My wife recently emerged from a seven-year slog through medical school and residency and landed her first “real” job at an outpatient clinic in Minneapolis. Needless to say, it was a huge step for her career and a watershed in our lives.
It also didn’t happen overnight. My wife began laying the groundwork for her residency training and employment several years earlier. During the fall and winter of her last year of medical school, she interviewed with at least a dozen U.S. residency programs in four time zones.
If you plan to work as a licensed physician anywhere in the United States, your ordeal could well be longer and tougher than my wife’s. She specializes in family medicine, which has a three-year residency and relatively forgiving hours. In many surgical specialties, seven-year residencies and 80-hour-plus work weeks are the norm.
If you’re an aspiring physician, let the following be your guide to the first phase of the residency-selection process: choosing a specialty and deciding where to interview. This is the first in a three-part series on the subject; the second and third parts cover interview strategies and navigating the dreaded Match process, respectively.
Choosing Your Specialty
My wife knew she wanted to practice family medicine from an early age. She never had to apply her formidable analytic skills to choosing the best medical specialty for her — a tough decision that most of her peers made far later.
It’s not a decision to make lightly; your specialty affects your likely career path, lifetime earning potential, and work-life balance. These are among the major factors you’ll want to consider as you narrow down your options.
1. Your Medical Degree
Residency programs in competitive specialties, such as orthopedic surgery and dermatology, prefer allopathic doctors (MDs) to osteopathic doctors (DOs). If you’re pursuing a DO degree, you’re likely to struggle to match into — or even land interviews at — these uber-selective programs.
A friend of ours pursuing a DO degree, who I’ll call “Anna,” has wrestled with this herself. Initially inclined to pursue a more competitive specialty, she narrowed her target list to OB-GYN and family medicine residencies. As a resident, she thought seriously about post-residency fellowship options, a common track for less-competitive applicants looking to back into selective specialties and increase their earning power.
2. The Strength of Your Application
Competitive specialties attract competitive applicants. If you’re enrolled in a top-tier medical school, blessed with fantastic board scores, and brimming with letters of recommendation from distinguished faculty, why not pursue a specialty that rewards your decade-plus trek through med school and residency with a $500,000 starting salary?
Not every young physician is so lucky. “Claire,” an MD friend we met in medical school, lacked the board scores to match with her preferred surgical specialty. Fortunately, she matched into her top family medicine residency program. Five years later, she’s part of a thriving small-town practice and doesn’t regret how things turned out.
If you’re a DO, you’ll have to decide early on whether to take the U.S. Medical Licensing Examination (USMLE) in addition to your American Osteopathic Association board certification exams. The added expense is considerable; the total for the first two USMLE tests, or “steps,” is well over $2,500, according to the National Board of Medical Examiners. But DOs who take only the Osteopathic Board Certification are far less competitive residency applicants. Anna recalls a DO colleague of hers who matched into her second-last residency choice after skipping the USMLE exam.
3. Your Preferred Practice Setting
Do you prefer to work in an outpatient clinic? An outpatient surgery center? An inpatient facility?
Although specialty and practice setting aren’t inextricably bound, there’s usually a correlation. For instance, trauma surgeons are likely to work in hospitals and exclusively serve inpatients, whereas dermatologists are more likely to work at outpatient clinics or specialty centers and primarily serve outpatients.
That said, few specialties require physicians to choose between the hospital and the clinic. My wife went into family medicine in part because she dislikes hospital work and knew she could easily find an outpatient-only job after graduation, but most of her residency colleagues now split their time between hospitals and outpatient clinics.
4. Your Tolerance for the Surgical Suite
If you don’t enjoy surgery, you obviously won’t pursue a surgical specialty or subspecialty. However, some specialties that laypeople don’t closely associate with the surgical suite, such as OB-GYN, do involve inpatient surgical procedures.
Get a feel for your surgical tolerance soon after beginning clinical rotations in your third year of med school. It took just one clinical day to quash Anna’s enthusiasm for OB-GYN. “On the first day of my OB-GYN rotation, we had to go into surgery,” she says. “It was immediately obvious that this wasn’t the path for me.”
5. Your Tolerance for Patient Interaction
Are you a people person? If so, you’ll want to pursue specialties with ample opportunity for close patient interaction. If bedside manner isn’t your strong suit, consider a more solitary specialty, such as radiology or pathology.
6. Your Preferred Degree of Specialization
How narrow would you like your practice to be? If you’re daunted by the vast universe of issues internists and family medicine doctors address, pursue a narrower specialty or subspecialty. You’ll almost certainly earn more by doing so.
7. Your Post-Residency Salary Goals
Although all physicians are well-compensated, the earnings gap between generalists (family medicine physicians, internists) and in-demand specialists (cardiologists, plastic surgeons) is shocking. According to the Medscape Family Physician Compensation Report 2018, the average U.S. family physician’s salary is $219,000, while the average plastic surgeon’s salary is $501,000. Physicians in concierge practice typically earn even more.
Aspiring physicians with crushing student loan debt might naturally feel pressured to pursue higher-earning specialties.
Pro tip: If you’re dealing with massive student loan debt, you might want to consider refinancing. Companies like Credible will provide you with quotes from multiple lenders so you can make sure you get the best rate. Credible is also offering Money Crashers readers up to $750 when they refinance their student loans.
Deciding Where to Interview
During your fourth year, your medical school will give you some time and money to travel to residency interviews, but it won’t be enough, so you’ll need to eliminate some residencies right off the bat. Let these considerations guide you.
Like elite colleges and universities, top-tier medical residencies’ reputations precede them. However, just as it’s debatable whether it matters where you go to college, your medical residency’s reputation probably won’t make or break your career. You can still land a great job and go on to do great things in your field out of a mediocre residency.
Residency competitiveness does matter to applicants, as selective residencies simply decline to interview less-competitive applicants. There’s no sense wasting time and money to apply to residencies that aren’t likely to consider you. As you probably did when applying to undergrad and medical schools, order your choices into three categories:
- “Safe” residencies that are highly likely to grant your interview request
- “Target” residencies that have a good chance of granting your interview request
- “Stretch” residencies that may or may not grant your interview request
Before whittling down your choices and sending off applications, consult with your academic advisor about the subjective metrics that may strengthen or weaken your applicant profile, and review publicly available data about each residency’s selectivity. The National Resident Matching Program (NRMP) has a slew of information about medical residency programs, some of which — such as first-year residents’ average board scores — is directly relevant to evaluating program competitiveness.
Lastly, remember that timing plays a role. Residencies typically grant interviews on a rolling basis, depending on when they receive your application, and may grant last-minute interviews to waitlist candidates toward the end of interview season.
2. Geographic Location & Proximity
For many medical students, residency location is paramount. You might be inclined to limit your residency search to a specific part of the country for reasons such as:
- Social Network. If you have deep family or social roots in a particular city or state, why not remain nearby? Although you can’t bank on matching at a residency in your current hometown, you’ll almost certainly find enough choices within a few hours’ drive.
- Travel Logistics. Even if your medical school provides a generous interview travel stipend and plenty of time off, you may find that you lack the means, capacity, or inclination to crisscross the country for interviews. My wife’s interview travel schedule was complicated by our geographical isolation during her third and fourth years; we were five hours’ drive from the nearest major metropolitan area, and the local airport had only a handful of commercial flights per day. Toward the end of interview season, she declined several interviews at otherwise promising residencies for this reason.
- Post-Residency Career Opportunities. Where do you want to end up? Many physicians stay put after residency, so this isn’t an idle question. If your specialty isn’t common and demand for it isn’t geographically uniform, you need to make sure you can find a job in or near your residency city — or, more likely, the city in which you complete your subspecialty fellowship — unless you want to move again after your residency ends.
- Amenities. If you value certain natural or cultural amenities, you’ll gravitate to places that have them in abundance. This was a key consideration for Anna and my wife, both of whom love the outdoors. My wife’s top three residencies were all in places renowned for outdoorsy culture and amenities: Colorado, Washington state, and Minnesota.
- Setting. Do you want to live in a big city, rural vacation town, or college town? Your setting matters for your household budget — big cities are generally more expensive than small towns — your spouse’s career prospects, your kids’ education, and your overall well-being. Favorable amenities notwithstanding, both Anna and my wife passed over small-town residencies that they worried might grow claustrophobic. “I hemmed and hawed about small towns, but ultimately decided I didn’t want a super rural program,” Anna says.
- Climate. Residencies in places like Florida and California owe their popularity, in part, to warm weather. If you’re worried about cold winter weather compounding the torture of 80-hour work weeks for the next three to seven years, choose a place with a sunnier climate.
3. Specialty & Subspecialty Training
If you plan to pursue a particular specialty or subspecialty, you may need to complete a fellowship after your residency. For example, neurosurgical fellowships covering recognized subspecialties include pediatric neurosurgery, spinal neurosurgery, and cerebrovascular neurosurgery. Internal medicine specialties include cardiology, endocrinology, and geriatrics.
Additionally, many residency programs incorporate subspecialty training, practice management training, or both into chief years, usually in the program’s final year. The chief year is an opportunity to work closely with subspecialist faculty in preparation for a fellowship or career-track position.
Regardless of your exact career path, you’ll need to choose a residency that offers plenty of training in your preferred subspecialty, assuming you know when you apply what that subspecialty will be.
4. Research Opportunities
Like specialty and subspecialty training, research opportunities vary widely by residency. The Johns Hopkins Neurosurgery Residency program offers two “protected years” for resident research, while the Duke Neurosurgery program offers only one general “academic year” during which residents may conduct research or pursue clinical education tracks that may benefit their practice (although Duke allows residents to continue research initiated in their fourth years through their seventh and final years). Both programs are highly regarded, but applicants more interested in research than clinical work may prefer Johns Hopkins.
5. Cohort Size
Residency cohort (year) size is a key determinant of residency quality and residents’ subjective experiences. Among other program attributes, cohort size may influence:
- Working Hours. Larger cohorts generally — although not always — allow for more favorable scheduling.
- Faculty Ratio. All residencies have low faculty-to-resident ratios, but smaller cohorts allow for more one-on-one attention. Residents who prefer to fly under the radar may prefer larger cohorts.
- Social Dynamics. Strong or outright toxic personalities are more influential in small cohorts, while lower-key residents may struggle for attention in large cohorts. While my wife focused on smaller programs, Anna’s ideal residencies were moderately sized. “I thought a small program might be [socially] weird, and I didn’t want to get lost in a larger program,” she says.
Bear in mind that cohort size is relative. General practice residencies, such as internal medicine and pediatrics, tend to be quite large; cohorts of several dozen aren’t unusual. Cohorts tend to be quite large in popular specialties as well.
6. Faculty Quality
Residency faculty — the residents’ physician supervisors — should be excellent at what they do. But quality isn’t just about a demonstrated ability. Subjective factors matter just as much, if not more. These include:
- Academic Rigor. Are residency faculty up to date on the latest research? Do they exhibit a strong bias toward the evidence? Are they good communicators? This was a big consideration for my wife, who excluded one particular residency because she got the sense that evidence-based teaching wasn’t the program’s strong suit.
- Personability. You’ll be spending a lot of time around your program’s faculty. Make sure you actually want to.
- Mentorship. Can you identify at least one faculty member from whom you’d like to learn? More generally, do faculty seem interested in mentoring and nurturing residents? Residency culture is notoriously tough, but that’s not to say faculty should be allergic to working closely with residents.
- Concern for Patients. Some residencies are more patient-focused than others. My wife’s residency centered around a family medicine clinic where faculty showed real care and concern for their patients. Indeed, my wife’s clinic time defined her residency experience and made her the physician she is today. I’m not sure she would have done as well in a less patient-centric program.
It’s tough to evaluate faculty quality without visiting the program and seeing the whole team in action, but you can start by reading about the program in medical student forums, looking up faculty on neutral evaluation resources like Healthgrades, and reaching out to current and former residents directly.
7. Your Degree
Fairly or not, most residency programs prefer allopathic doctors (MDs) to osteopathic doctors (DOs). If you’re working toward your DO and targeting a competitive specialty, plan accordingly.
“Competitive residencies don’t consider DOs unless they’re really strong candidates,” Anna says. Worried about landing enough interviews, she applied to nearly 30 residencies. It paid off; she’s now happily plugging away at her first-choice program.
Finalizing your interview list is not the last step in the residency-selection process. Nor is it the most difficult part of the ordeal, unfortunately. That honor goes to the interview process itself, including the painstaking preparations you’ll need to make to ensure you put your best foot forward at each interview.
Not that this should come as a surprise. You chose this path and have an idea of what’s involved. And the silver lining is that the first phase of your medical training — medical school — is nearing completion. Every morning, you’re one step closer to realizing your dream.
Are you weighing your residency options? What’s factoring into your decision?