Sophia K. McKinley MD, EdM; John T. Mullen, MD, FACS; and Roy Phitayakorn, MD, MHPE, FACS
In 2018, approximately 7 percent of U.S. senior medical students who applied for a residency position exclusively in general surgery did not obtain a categorical position.1 Neurosurgery, orthopedic surgery, and plastic surgery are even more competitive; more than 10 percent of U.S. medical students who applied to these specialties found themselves without a position.1 The competitiveness of the residency selection process, commonly referred to as the Match
Residency selection can be divided into three phases:
This RISE article focuses on the interview phase, including its importance and its pitfalls. Finally, we describe our method of preparing students to succeed in this important part of their professional journey towards becoming a surgeon.
United States Medical Licensing Examination (USMLE) Step 1 scores have been identified as one of the most important determinants of an interview invitation.4,5 However, once an applicant enters the interview phase, his or her performance on the interview day is critical. In a survey study of surgical program directors, the interview was found to be the most important factor in determining the rank list, contributing up to 25 percent of final rank list determination.5,6 The importance of the interview is confirmed by National Resident Matching Program (NRMP) data, which indicate that the top four variables in determining an interviewed applicant's position on the rank list are grounded in their interactions with faculty, staff, and residents on the interview day.4
The interview is also significant in terms of its financial burden and strain to both residency programs and applicants. Surgical residency programs spend more than $1,200 on average per interviewee.7 Applicants spend several hundred dollars per interview, which adds up to thousands of dollars across an interview season.8 Because surgical specialties are especially competitive, applicants to these fields may seek a higher number of interviews, further driving up the cost of an already expensive endeavor.8 This combination of both high expense and importance for positioning on a program’s rank list of applicants ensures that the surgical residency interview is a high-stakes activity that requires careful preparation for medical students pursuing a career in surgery.
Besides being both expensive and important, the surgical residency interview offers a number of challenges and potential pitfalls to aspiring surgeons. One of the greatest challenges is that programs adopt a wide variety of approaches to the residency selection interview, requiring that students adapt their interview approach on a program-by-program basis.9 Furthermore, interview performance is often subjectively scored and not standardized. There is evidence that bias can exist on a number of fronts, including compatibility of interviewer and interviewee personalities as well as student gender.10,11 Even more concerning is a repeated finding in the literature that women applicants are more frequently the subjects of illegal questioning during residency interviews.10,11 A survey of general surgery program directors found that use of blinded interviews and standardized interview questions remain uncommon, leaving room for subjectivity and bias to play a role in applicant evaluation and, ultimately, how that student is ranked for a position.6 Other challenging interview situations that our students have encountered include the unprepared interviewer who is unfamiliar with their application package or who confused them with another applicant, and the interviewer who is hostile about their clinical and professional interests.
Student behavior outside of the formal interview setting but during the interview visit (for example, during the pre-interview get-together) is another potential pitfall. The pre-interview reception can be stressful to applicants who feel that their behavior in this setting is also being judged and evaluated by the residents and faculty in attendance.12 Alcohol is nearly ubiquitous at these events, and while the majority of students may not believe that their consumption of alcohol has a negative impact on their interview performance and subsequent evaluation, it is not difficult to imagine that the consumption of alcohol may be detrimental to at least some students. During the interview day itself, some students may be unaware that their informal interactions with administrative staff and residents in between their formal interviews also frequently contribute to their overall evaluation.4
Given its importance, cost, and potential challenges and pitfalls, we offer medical students at our institution a workshop designed to better prepare them for surgical residency interviews. The format of the workshop is based on Kolb’s experiential learning model (see Figure 1).13 The ultimate purpose of this workshop is to provide students with the knowledge and experience to perform at their highest levels in order to improve their chances at matching at their preferred training program. This workshop includes instruction on potential interview pitfalls while also providing applicants with the opportunity to practice and receive feedback on their interviewing skills in a simulated interview situation.
Figure 1. Kolb’s experiential learning cycle
To prepare for the workshop, students send their Electronic Residency Application Service (ERAS) application, which includes a curriculum vitae, personal statement, and USMLE step scores to a faculty surgeon (author R.P.). This surgeon has extensive experience with interviewing surgical residency applicants, but no longer interviews for the MGH department of surgery to avoid any conflicts of interest with this workshop. The surgeon reviews the student’s materials as if he or she were preparing for a residency interview. Students arrive at the simulated interview dressed as they would for a real interview. Students participate in the workshop in small groups of two to four.
Each student takes a turn completing a simulated interview that lasts approximately 15 minutes with the surgeon. The surgeon begins with traditional open-ended questions regarding student motivations for entering the surgical profession and then transitions to questions about specific experiences on the student’s CV. The surgeon asks the student at least one “stressful” interview question. Finally, the student gets the opportunity to ask the surgeon questions, just as he or she would during a typical residency interview. The entire interview is recorded on the student’s phone and forms a concrete learning experience as highlighted in the first part of the Kolb learning cycle.
After the student finishes the interview, the student moves along the Kolb cycle. He or she reflects on the interview and assess his or her own performance. Importantly, the other students who have observed are also asked to reflect and provide feedback to their peer. This part of the workshop allows for vicarious learning among all of the non-interviewed workshop participants. Finally, the surgeon and any surgical residents assisting with the workshop also provide feedback. Feedback is focused on potential improvements to answers and how various answers may be interpreted by faculty interviewers. The group also discusses any verbal or physical tics that the student may exhibit and identifies responses or behaviors that were particularly positive. The entire group discusses alternative ways that the interview could have gone, including scenarios of an unprepared or skeptical interviewer, or the interviewer who asks “illegal” questions. Students practice their responses to these alternative scenarios and receive feedback for this part as well. The first two parts of the Kolb cycle then repeat for all of the students who want to have a simulated interview.
At the end of the workshop, the group discusses interview challenges and pitfalls. Particular emphasis is placed on appropriate dress and behavior during the pre-interview reception and the interview itself. Students are also reminded of the importance of their behavior and informal interactions with residency staff and residents in between their formal interviews with surgical faculty. The workshop concludes once all student concerns and questions have been discussed and addressed.
During the next part of the Kolb cycle, the students can create some conclusions regarding what they have learned during the workshop. Students receive a list of difficult interview questions and are encouraged to practice with each other to complete the Kolb cycle. The workshop is summarized in Figure 2, with common themes of student interview improvement presented in Table 1.
Figure 2. The Massachusetts General Hospital (MGH) Interviewing for Surgery Residency Workshop
Table 1. Common themes discussed with medical students to improve their surgical residency interviews
Students receive feedback on optimizing the content of their interview, including:
Students receive feedback on concerns and assumptions regarding the interview process, including:
While we have not studied this workshop formally, feedback from students over the past three years has been extremely positive. Anecdotally, the workshop is particularly helpful in demystifying the interview process for students who come from a diverse range of backgrounds, whether that be a military background or from historically underrepresented and disadvantaged groups. This workshop may also help level the playing field for those students who don’t have parents working in the surgical field or other sources of insider knowledge, but are qualified for a residency position.14,15
The interview is a costly but important part of the surgical residency selection process that can present a number of challenges to applicants. We describe a residency interview workshop based on the Kolb experiential learning cycle to help prepare medical students applying to surgical residency to perform their best during the interview day in order to maximize their chances of receiving a position at their training program of choice. The workshop is designed to educate students regarding potential interviewing pitfalls and provide students with the opportunity to practice and receive feedback confronting a number of interviewing challenges. All of the workshop activities take place in a supportive environment prior to completing any high-stakes residency interviews. Other institutions may wish to adopt and modify this workshop structure to support students who have committed themselves to a surgical career.
Sophia K. McKinley MD, EdM, is a resident physician and surgical education research fellow in the department of surgery, Massachusetts General Hospital, Boston, MA.
John T. Mullen, MD, FACS, is associate professor and general surgery residency program director, department of surgery, Massachusetts General Hospital, Boston, MA.
Roy Phitayakorn, MD, MHPE, FACS, is associate professor, department of surgery, Massachusetts General Hospital, Boston, MA.