How to Stand Out When Applying to a Competitive Surgical Residency Program

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The residency match process is simultaneously one of the most exciting and anxiety-inducing times during medical school. For students applying to competitive surgical specialties, the inherent difficulty of the match process is exacerbated by an opaque selection process. There are no standardized guidelines as to which personal attributes and scholastic achievements will guarantee a residency spot. While the application process has become more streamlined and transparent over the past several years, there is certainly a lot more work that needs to be done.

I applied and interviewed in the neurosurgery residency match during the 2011–2012 cycle. So, I’ll be using neurosurgery as an example. Many things have changed since then, but the key elements of a strong residency application have remained the same. The average applicant that secures an interview has excellent board scores, a laundry list of research publications, and jaw-dropping letters of recommendation. Despite these outstanding qualities, however, the applications become pretty monotonous. Therefore, I have compiled a list of the key features that will help polish your application and stand out to the selection committee.

Here are the main things we care about in your application, with commentary below:

  1. Academic performance:

  • USMLE Step 1/2CK Scores
  • Alpha Omega Alpha
  • Class rank in medical school
  • MSPE Letter

2. Research:

  • Involvement in neurosurgery-related research projects
  • Number and quality of publications
  • Presentations at major neurosurgical conferences (AANS, CNS, etc.)

3. Letters of recommendation:

  • Strong LORs from your home program and sub-internships

4. Interview performance

5. Expressing interest in the program

Academic Performance

This is pretty self-explanatory. It goes without saying that we want students who have achieved superior academic performance. To get an idea of the typical range of successful USMLE Step 1 scores, the National Resident Matching Program (NRMP) publishes some useful statistical data. If there are any weak points in your application, you should be prepared to discuss them during the interview. Although test scores are not the most important factor in an otherwise well-rounded application, they do show a number of key attributes:

  • ability to synthesize and retain a large volume of information
  • discipline to study for many hours without distractions
  • being able to perform at a high-level when the stakes are high

It is with these factors in mind that I recommend medical students start studying for the USMLE step 1 early. It is one of the most important tests of your life — do not take it lightly. Furthermore, induction into Alpha Omega Alpha, although not necessary, is a great boost to your application. It is a standardized way of knowing a medical student was at the top of his or her class. Other factors such as class rank and MSPE are also important, but not as heavily weighted as your board scores and AOA.

Bottom Line: You ideally want a USMLE step 1 score > 240 and AOA.

Research

Virtually all applicants have research experience and/or publications by the fourth year of medical school. Although getting a publication is not an absolute necessity, it is definitely a big boost to your application. My interest in neurosurgery started relatively late in my medical school career (middle of M3), so I actually took a dedicated research year between M3 and M4 to work with the neurosurgery department at my home institution. It was a great year and fortunately led to two first-author publications. This does not mean that you need to complete a similarly dedicated research year, but be aware that most applicants have research, several publications, and oral/poster presentations at major conferences. In fact, it has almost evolved to a “red flag” if an applicant has not engaged in at least some research project during medical school.

This is why I think it is essential to identify a solid mentor early on in your medical school career. If you are fortunate to be in a medical school with a strong home program, then it is probably advisable to stay and conduct research there. However, if your medical school does not have a strong program in the specialty in which you are interested, then you should consider working with a different department. There are research scholarships that exist for this exact purpose (Doris duke, HHMI, etc.). Having published research, rather than a bunch of ongoing research projects, demonstrates that you can see a task all the way through to the end. It takes an exceptional individual to start, finish, and ultimately publish their research.

Bottom Line: Identify a mentor in your preferred surgical specialty early on and get involved in research. If you are not able to secure a publication, then you should be active with oral/poster presentations in national conferences.

Letters of Recommendation

Strong letters of recommendation are key in a good application. You should have letters from your home neurosurgery department’s chairman, research mentor/PI, and a neurosurgery attending who can strongly advocate on your behalf. If you plan to complete sub-internships at other programs and secured a strong LOR, it is a good idea to include that too. A telephone call or e-mail from an attending can go a long way as well. If you lucked out and have control over the content of the letter, it would be beneficial to include things about your technical abilities in addition to your scholarly achievements. Strong LORs are extremely important. They are weighed heavily and can “make or break” your application.

Bottom Line: Your LORs are extremely important and carry significant weight in your application. From my experience, these should generally come from people who are “well known” in the field more so than new attendings who are fresh out of fellowship. If you wish to send a thank you note afterwards, e-mail, do not send handwritten letters.

Interview Performance

It’s amazing how an otherwise awesome applicant can be destroyed by an awkward or bizarre interview. In reality, all we are looking for is a relatively normal person who can hold a conversation. There are numerous websites that can give you tips and tricks to hone your interview skills; however, I feel the best way to practice is with another person who can provide constructive feedback. A good interview can definitely help your application, but not nearly as much as solid grades, LORs, etc. It is more of a “weed out” test.

Bottom Line: Unless you are a naturally gifted interviewee, make sure you practice on your own time with someone who can provide you unbiased, constructive feedback. Also make sure you have good questions to ask at the end of the interview.

Expressing interest in the program

If you cannot participate in a sub-internship at a program you are considering, you should definitely go back for a second-look visit. Not only is it viewed favorably, but it gives you a chance to see how things work behind the scenes at the institution. Ask yourself: do the residents seem satisfied or do they frequently complain? Do the ORs run smoothly? Do the attendings enjoy teaching? Are the residents collegiate or is the working environment hostile? These are all questions that are best answered on a second-look visit. Also, it is always a good idea to send a friendly thank you e-mail to the people with whom you interviewed. Although handwritten letters are a nice gesture, they frequently get lost and you are less likely to get a response.

Bottom Line: Sub-internships are the best way to express interest in a program. However, it is not realistic to do them at every program to which you have applied. Therefore, a second-look visit is a great way to show a program that you are highly considering them. It’s win-win in the sense that it simultaneously helps your application and allows you to learn more about the program’s workflow behind the scenes.

As I mentioned before, the application process has been made more transparent over the years. For example, the “Residency Navigator” developed by Doximity is an excellent way to gain concise, accurate, and straight-forward information on any given residency program. If you want a more-detailed overview of the benefits of the Residency Navigator, you can read my article here.

In the realm of neurosurgery, interested medical students should enjoy hands-on approaches to a wide range of central and peripheral nervous system pathologies, treating highly complex patients, work with state-of-the-art surgical technologies, and be involved with basic science and clinical research. Given the highly technical and sophisticated nature of neurosurgical procedures, we are only looking to recruit the best of the best to our ranks. We want applicants who are hardworking, altruistic, problem solvers, and have a high level of attention to detail. Despite the many years of training and long workdays, neurosurgery residency will be one of the toughest and best times of your life. You should be the type of person who thrives in high-stress environments and enjoys being a leader. The same qualities apply in almost any surgical specialty.

As you can imagine, selecting one or two exceptional applicants out of the large pool of outstanding applications is not an easy task. Therefore, there are steps any applicant can take to polish his or her application. Although nothing is guaranteed, following the key points I emphasized above should point you in the correct direction. Good luck!

Dr. Jonathan Rasouli, MD, is a sixth-year neurosurgery resident at the Mount Sinai Hospital in New York, NY. He is a graduate of the Albert Einstein College of Medicine and was elected to Alpha Omega Alpha during his senior year in medical school. His research interests include neurosimulation, translational medicine, healthcare informatics, and deep brain stimulation. He is a 2017–2018 Doximity Fellow.

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