Acad Psychiatry 30:239-247, May-June 2006
doi: 10.1176/appi.ap.30.3.239
© 2006 Academic Psychiatry
Applying to Psychiatry Residency Programs
Mina K. Bak, M.D.,
Alan K. Louie, M.D.,
Lowell D. Tong, M.D.,
John Coverdale, M.D., M.Ed., FRANZCP and
Laura Weiss Roberts, M.D., M.A.
Dr. Bak is affiliated with San Mateo County Mental Health Services, San Mateo, California. Dr. Louie is affiliated with San Mateo County Mental Health Services, San Mateo, California, and the University of California, San Francisco, California. Dr. Tong is affiliated with the University of California, San Francisco, California. Dr. Coverdale is affiliated with Baylor College of Medicine, Houston, Texas. Dr. Roberts is affiliated with the Medical College of Wisconsin, Milwaukee, Wisconsin. Address correspondence to Dr. Louie, 222 West 39th Ave., San Mateo, CA 94403; alouie{at}co.sanmateo.ca.us (E-mail). Copyright © 2006 Academic Psychiatry.
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INTRODUCTION
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The purpose of this article is to provide some practical ideas to help senior medical students understand and navigate the process of applying to a psychiatry residency. Individualized advice on how to find the best fitting program for a particular student is beyond the scope of this article. The comments are intended to provide guidance, but are not meant to be a rigid recipe. Perspectives were integrated from a recently matched psychiatric resident (Dr. Bak), a director of a psychiatry residency (Dr. Louie), a medical student career adviser (Dr. Tong), a medical educator (Dr. Coverdale), and a department of psychiatry chair (Dr. Roberts).
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Preparation in Medical School
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The core clerkship in psychiatry is often the first clinical introduction to psychiatry for most medical students and an opportunity to see whether the specialty would be a good fit. In the event that psychiatry becomes a serious consideration, the student should survey the residents and attendings on their decision to pursue this specialty. At the end of the rotation, the student may choose to ask for a recommendation letter, especially while the student’s performance is fresh in the attending’s memory.
Receiving the top grade (e.g., honors) in the core psychiatry rotation is not essential for matching, but it is noticed by selection committees. In many medical schools, the top grade in the core psychiatry rotation has stricter criteria than the top grade in an elective or advanced psychiatry rotation and is therefore of special note. Students not receiving honors in a core psychiatry clerkship may augment their transcript by exceptional performance in subsequent advanced psychiatry rotations.
In order to verify a good fit with psychiatry, medical students should plan one fourth-year psychiatry elective. A psychiatry "subinternship," during which the student has primary responsibility for the management of patients, is advised. A second psychiatry elective might be scheduled if the applicant wants to sample a subspecialty of psychiatry (e.g., child, forensic, or addiction psychiatry). Some student advisers suggest taking no more than two psychiatry electives in order to leave time to explore other areas of medicine prior to graduating. Applicants should attempt to complete the psychiatry electives and a medicine subinternship (desirable for competitive programs) before November so that those do not interfere with interviewing schedules and to enable associated grades and potential letters of recommendation to be available to programs.
A psychiatry externship at a program outside the student’s medical school affords a student more accurate information about a program, and vice versa. Doing so is not, however, necessary in order to match at such programs since it is well understood that it is inconvenient to do away with electives. If applicants are considering a fourth-year externship, they should request these applications promptly (Appendix 1); programs require applications, sometimes with a fee, transcript, and/or a letter of reference.
Most residents, even at top academic programs, primarily tend to become clinicians; thus, research experience is not essential for applicants to successfully match. Nevertheless, medical school is an excellent time to pursue to psychiatric research as an educational credential and to consider a research career. Applicants who are interested in future research should inquire about time that will be protected for research opportunities and established research tracks.
Students should look into or start a psychiatry interest group at their medical school and consider joining APA; medical student membership is free and comes with an online newsletter and subscription to the American Journal of Psychiatry. Of note, their website features a "Guide to the Match in Psychiatry" (1). The APA website also features links to a collaboration of various interest groups, including ones that target women, minorities, medical students, and gays, lesbians, and bisexuals (2). The websites of national medical student organizations also may be informative.
Selecting Programs
Applicants should research psychiatry residencies approved by the Accreditation Council on Graduate Medical Education (ACGME) (3). A user-friendly source of information is the Fellowship and Residency Electronic Interactive Database (FREIDA) (4), which lists data about all of the ACGME-accredited medical education programs, as well as ACGME-approved combined specialty programs. This database may be searched according to specialties or states. The statistics available on this database are of limited value, and applicants will have to visit the websites of specific programs for more details; links are usually provided by FREIDA. The APA also publishes a directory to psychiatry residency training programs.
There is significant variation in training emphasis among psychiatry programs, so applicants will need to learn about the differences between programs. They should first speak with a psychiatry training director or a career adviser in psychiatry at their school for suggestions on programs. The most current information may be obtained by networking with recent graduates from their medical schools who are in psychiatry residencies, with other applicants who have visited programs, and with attendings who came from other programs. Applicants should then review their preliminary list of residencies with their medical school’s psychiatry adviser to determine whether their list is compatible with the applicant’s goals and likely ability to match.
Psychiatry Residency Application Process
Programs use the Electronic Residency Application Service (ERAS), which was developed by the Association of American Medical Colleges and uses the Internet to transmit application materials from medical schools to programs, including medical student performance evaluations, personal statements, letters of recommendation, transcripts, and other documents. Applicants must register separately for the National Residency Matching Program (NRMP) (http://www.nrmp.org/res_match/index.html) and the ERAS; registering for the former, which is a residency matching service, does not automatically register the applicant for the latter, which is an application information transmittal service. Applications should be sent in to ERAS (http://www.nrmp.org/res_match/about_res/application_process.html) soon after it begins accepting them. Appendix 1 provides an application timeline (5, 6, 7). Exact dates, which are available at the NRMP website, are not listed since they vary annually.
Documents Submitted With the Application
Selection committees look at the entire application and the individual; thus, applicants should pay diligent attention to all aspects of the application. Generally, these committees do not focus solely on core clerkship grades, USMLE scores, or personal statements. The exception to this would be programs that use grades or scores in a first-cut screening process.
The following are required documents to be submitted by US medical school applicants (international medical school applicants may need additional documents).
Application
As honesty and accuracy are fundamental elements of professionalism, they are essential throughout the application process. For example, exaggerating accomplishments or capabilities in the application may become evident during the interview; if the applicant claims "fluency" in Spanish, the interviewer may want to converse in Spanish.
Curriculum Vitae
ERAS has a template for the applicant’s curriculum vitae (CV). Descriptions of academic training, employment and extracurricular activities should be concise; applicants will have opportunities to expand further upon this information during their interviews. The dates of various education, work and personal experiences should be clear and allow the reader to construct a continuous timeline of activities since high school. Gaps in this timeline are red flags and require explanation, usually in the personal statement. Applicants should outline the depth and breadth of their experience to date, but should avoid listing minor awards or activities, which may look more like padding and be more distracting than helpful. An adviser can provide personalized help on what information to include and where. In the case that honors occur after the application is submitted, such as election to the Alpha Omega Alpha (AOA) Honor Medical Society, the applicant should send separate notification of this directly to programs.
Personal Statement
Instead of being a repetition of the information in the CV, the personal statement should bring to light information about the applicant not found elsewhere in the application.
Many applicants begin their personal statements by explaining why they are interested in psychiatry. In doing so, applicants frequently write about an experience with a patient that encouraged them to pursue psychiatry. Though this is adequate, it is also common, so one should spend no more than a brief paragraph about such a vignette. Readers want the statement to give a sense of the applicant as a total person. Thus, applicants should feel empowered to expand on "how," in addition to "why," they ended up applying to psychiatry. For example, if the applicant has an advanced degree (e.g., M.B.A., Ph.D.), he or she should explain how this aided development and how it might be integrated into a career in psychiatry. Some creativity is warranted in expressing oneself; while keeping in mind that personal statements should not be literary or poetic works, there should be an appropriate balance of individualization with professionalism.
Applicants should be aware that the reader may be looking for particular information like an explanation of any gaps in education, academic difficulties, or unusual circumstances. The applicant should not try to obscure such information and should consider mentioning it in the personal statement, providing an explanation for and indicating what was learned from it. The type of program the applicant is seeking may be worth addressing. Applicants who have specific reasons for applying to particular programs may customize the personal statements going to those programs—ERAS allows this, but applicants are advised strongly to ensure they are sending the right statement to the corresponding program. Finally, the readers may like to have an idea of applicant’s goals, such as future type of practice or intentions for further training after residency.
Selection committee members read many personal statements each year, so well-written and concise statements are essential. Longer is not necessarily better. Applicants should have some colleagues and faculty who are excellent writers (including some who do not know them too well) to review drafts of the personal statement. Many medical schools also provide workshops on writing CVs and personal statements.
Medical Student Performance Evaluation (MSPE)
Medical Student Performance Evaluations, formerly called the "Dean’s letters," are released on November 1st. MSPEs first mention time gaps in training and disciplinary actions. They describe the applicant’s background, performance in medical school, especially in the five core clerkships (psychiatry, medicine, surgery, OB/GYN, and pediatrics), and involvement in extracurricular activities. Though the most important evaluations are the ones from psychiatry, those from the other core clerkships are also noted, especially those from internal medicine and primary care rotations. Along with the actual grades recorded, the MSPEs will include quotes from faculty and residents about the applicant’s competence, interpersonal skills, and professionalism. Some MSPEs will break down the grades into the contribution from the written final exams and the clinical performance, which is helpful to applicants who are not good test takers. MSPEs will also include a summary statement of the overall performance, usually in the last paragraph where an adjective (e.g., outstanding, excellent, very good, etc.) is assigned or, in the case of a few schools, a numeric ranking based on a formula of grades unique to each school is assigned.
Transcripts
The transcript should be up-to-date and include any recent elective rotations in psychiatry. Red flags are any "incomplete," "repeated," or "failed" rotations.
Letters of Recommendation
Applicants are expected to obtain three to four recent letters of reference from direct supervisors (usually two from psychiatry rotations). A few programs require one letter to be from a nonpsychiatrist. Applicants should use letters from senior or chief residents only if in an acting attending role.
When selecting references, applicants should reflect on who would know them best and be able to discuss their qualities in detail. Applicants should communicate with each of these letter-writers by August or September, to give them enough time to compose the letters. To assist the reference, the applicant should offer a CV and a version of their personal statement, even if it is a preliminary draft, and remind the writer of memorable cases seen with them. Letter-writers should be given a specific deadline before October 1st and a reminder a week prior to that date.
Most letters are quite similar and do not help in differentiating applicants unless they include specifics about particularly outstanding performance. The most effective letters say something specific about the applicant, such as, "This applicant is the one of the top three applicants I have ever supervised" and list reasons why. Letters from a research mentor should be included, especially if the applicant is contemplating a research career. Letters from well-known psychiatrists, the chair of psychiatry, or senior professors are of little benefit if the writer does not know the applicant well enough to make meaningful and specific remarks.
USLME Scores
The usefulness of USMLE scores is limited to being a measure of knowledge. Though an imperfect metric, it is the only measure included in the application which is standardized across the country. While top USMLE scores are helpful, they are probably less crucial in psychiatry, compared to other subspecialties, since evaluation of the whole person is emphasized.
USMLE is of practical importance because passing is required for licensure as a physician and surgeon in most states. Directors want to feel confident that applicants will be able to pass Step 3, which is taken after the first year of residency, because failure to pass Step 3 in a timely manner may prevent the resident from obtaining a medical license and progressing in the residency.
USMLE Step 1 scores must be included in the application. USMLE Step 2 scores are not required by many programs, although those who scored below their potential on USLME Step 1 may want to take Step 2 earlier to show a better performance in their application. The selection committee will be especially interested in the applicant’s Step 2 scores if at a medical school in which passing Step 2 is a criterion for graduation, because the residency does not want to be in the position of matching applicants who are not guaranteed to graduate from medical school on time. Applicants with multiple failures of Step 1 or 2 should list these failures on their applications and consider explaining them in the personal statement.
Photograph
ERAS does not release photographs to the residency until the applicant has been invited for an interview. Photographs are essential memory prompts for the selection committee and help safeguard against interviewees being accidentally confused with other applicants. Photographs should convey a professional look, but do not need to be absolutely formal.
Interview
Interviews, perhaps the most important part of the selection process, occur from late October to the end of January. After being invited, applicants should call back within 1 week to schedule interviews. Competitive programs sometimes run out of interview slots and have to turn down applicants who are highly qualified. When the applicant is seen during the interview season is not crucial. Early in the season, the applicants and interviewers are fresher; during the middle of the season, the applicants are more practiced; and by the end of the season, both applicants and interviewers tend to be more tired, but applicants are remembered better by interviewers. Applicants should interview at their favorite programs before January, thus leaving the option to revisit the program. Limiting the number of interviews decreases "burnout." Scheduling more than three interview days in a week is inadvisable because applicants may start to mix up programs and may not have time to prepare sufficiently for each interview day. Any applicant canceling an interview should call the program as soon as possible. Programs commit the time of several faculty members for interviews of each applicant, and to simply not appear, without canceling, is highly unprofessional. Timely cancellations will also allow other applicants on a wait list to be scheduled.
Though being relaxed and rested is best, preparation is prudent. In order to maximize the usefulness of the interview day, applicants should spend some time beforehand reflecting on their goals and expectations for the interview day, as well as on the most important characteristics they seek from the program. Applicants should devise lists of questions they anticipate being asked, and lists of questions to ask of interviewers and current residents, like the sample ones in Appendix 2 (1, 5). In order to ask informed questions about the program, the applicant should become familiar with the program beforehand, by carefully studying the program’s website and, perhaps, by reading about some of the faculty members. Applicants should thoroughly review every component of their application prior to interviewing and then bring a copy of their application, along with literature about the training program to reference during breaks.
On the actual day of the interview, applicants should arrive early and be dressed professionally and comfortably. The definition of professional attire depends on the type of program and the geographic location, ranging from business-casual to a black suit. Nevertheless, the applicant’s clothes should reflect his or her personality and feel natural—it should not be the first time the outfit and shoes have ever been worn. During the interview, the applicants should be sharp and engaged, but they also need to "be themselves." The optimal interview will supply insights, for both the applicant and interviewer, about the degree of fit between the applicant and the program, so candor is important. What is the "best training" must be evaluated relative to the particular applicant’s career goals. For one applicant the best program may be the one with the most research grants, while for another it is the diversity of the patient population. The process of interviews at multiple programs may serve as a time for self-reflection, looking back at one’s reactions to various medical school experiences, and predicting what will be most gratifying during residency and beyond.
Interviewers will sometimes ask questions that are inappropriate or even illegal during an interview. Many are not aware that one may not ask about family status, age, creed, pregnancy, race, or physical status (8). Such questions put the applicant in a difficult position. Questions should relate in some way to how the applicant will perform in the job being discussed. An applicant might consider reframing a question and then providing an answer in this vein. If the applicant feels sexually harassed by the interviewer, the applicant should diplomatically terminate the interview, report the incident to the department chair, and write down details of the harassment (8).
Every program has its own protocol for the interview day. Faculty members tend to be interviewers, but more senior residents may also be utilized. Interviewers have sometimes read the applicant’s materials (not blinded interviews), but others have intentionally not (blinded interviews). Interview rating systems are devised by each program. Published accounts describe interviewers assigning scores for dimensions like "empathic quality, academic potential, clinical potential, team player, and overall rating" (9) or "personality factors, psychological mindedness, ability to communicate, and performance in the interview" (10). Of note is the emphasis on interpersonal qualities and personality. Psychiatry residencies view interpersonal and communication skills as essential and, other than secondhand reports from recommendations, interviews are the primary means of assessing these skills.
The interview day is also a chance to meet residents at the program. Applicants ought to get a sense of whether these are the types of people with whom they want to spend time. Residency is a form of employment and working with people is different from going to school with them. Instead of just asking questions about the program, applicants should use some of the time to get to know a few residents. Do they share similar values, goals, and work styles? If a program does not have a social hour at the end of the interview day, the applicant should ask if he or she may interact with residents at lunch or a seminar.
After an Interview
Applicants should record their impressions after each interview. Some maintain a chart listing important characteristics (Appendix 3) which they use to rate programs. Though optional, it is generally courteous for applicants to send a thank you letter or card within a few days of the interview to the training director. It is not necessary to send notes to every interviewer. At the end of the interview season, some medical schools will hold a meeting of all students applying in psychiatry, at which a faculty member facilitates discussion of interview experiences.
Communicating With the Training Director
If an applicant is seriously considering a program, the interview should not be the last communication with the training director. Most applicants send an e-mail to the few programs about which they are most serious to indicate their interest. Similarly, if the program is highly interested in the applicant, the training director may contact the applicant and ask whether the applicant has any further questions. If the applicant is truly interested, having additional questions and, if practical, revisiting the program can affirm whether it is a good fit. A few programs will routinely call applicants several weeks after their interviews to provide feedback. In contrast, some training directors may wait until most interviews are complete before calling top applicants; follow-up calls from these residencies may not come until January or February. One cannot draw any clear conclusions if a program calls late in the process or not at all.
Applicants and programs making any "deals" or verbal or written contracts prior to the submission of rank order lists is a violation of the NRMP rules (11):
"Both applicants and programs may express a high degree of interest in each other and try to influence future ranking decisions in their favor, but must not make statements implying a commitment. It is a material breach of [the Match Participation Agreement] for a participant in the Matching Program to make any verbal or written contract for appointment to a concurrent year residency position prior to the Matching Program. In addition, although applicants or programs may volunteer how they plan to rank each other, it is a material breach of this Agreement to request such information."
It is, however, useful for both parties to indicate interest if it is sincere since selection committees generally prefer applicants who are enthusiastic about their program. Interviewers become adept at picking up on disingenuous or contradictory comments.
Within these rules, a training director may volunteer a program's sincere interest in an applicant. Though such expressions are informative, the applicant must not over-interpret them. Statements like, "We plan to rank you highly," "We feel you would be a good fit," or "We would be delighted if you matched here" in no way guarantee matching with that program. Additionally, since training directors don't know how far down their rank list they will be taking applicants, they don't usually know the probability of matching a specific applicant, even if highly ranked. A special situation arises for applicants in the couples match. Applicants should inform training directors about how matching of their partner may influence their interest in a program. If the partner is applying to another department in the same institution, the training director may, on occasion, call the other department to express the great desire to match the applicant and to have the couple in the same city.
Rank List
Applicants and programs will enter their ranks lists via the Internet by mid-February of each year. Appendix 3 lists some characteristics that applicants may want to consider when formulating their rank list. The match endeavors to match the applicants’ highest choices with the residencies’ highest choices. Thus applicants should rank programs from most desired to least desired, independent of how they think the programs are ranking them. For instance, if the training director at program "Z" volunteers that an applicant will be ranked number one, this should not objectively affect the applicant’s rank list of programs. If the applicant still prefers programs "X" and "Y," he or she should still rank "X" and "Y" higher, and rank "Z" number three. The applicant will still have the same chance of matching at program "Z," but only when not matching at programs "X" or "Y" first.
By submitting a rank list, applicants are agreeing to join the program to which they match. Violation of the Match Participation Agreement may result in serious consequences for the applicant, including being barred permanently from subsequent NRMP matches (12). Therefore, applicants should be sure they are willing to attend each and every program that they rank and not rank any program they would not join.
Applicants should give significant weight to how comfortable and compatible they felt at each program. Applicants need to realize that picking a residency is different from selecting colleges or medical schools. The residency will be their place of full-time employment for some time, and the quality of the work environment is important in any job choice.
The Match
The results of the match are released in March, on "Match Day." A few days prior to the release of these results, their school will notify applicants who have not successfully matched anywhere. The following day, a list of programs with unmatched positions is released, and unmatched applicants then "scramble" by calling the programs for these positions.
Match Day is a positive experience for most students. In 2005, nearly 83% of all applicants matching in all subspecialties were assigned to one of their top three residency choices (13). Our hope is that this article will assist senior medical students in navigating the application process.
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REFERENCES
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- Guide to the Match in Psychiatry. Available at http://www.psych.org/edu/med_students/psychmatch.cfm. Accessed February 6, 2006
- APA Interest Groups. Available at http://www.psych.org/mem_groups. Accessed February 6, 2006
- American Medical Association, The Graduate Medical Education Directory. American Medical Association, Chicago, annual publication
- American Medical Association. Available at http://www.ama-assn.org. Accessed February 6, 2006
- Miller LT, Donowitz LG: Medical Student’s Guide To Successful Residency Matching. Lippincott, Williams & Wilkins, Philadelphia, 2001
- NRMP 2006 Main Match Schedule. Available at http://www.nrmp.org/res_match/yearly.html. Accessed February 6, 2006
- ERAS 2006 Timeline for Residency Programs. Available at http://www.aamc.org/programs/eras/programs/timeline/timeline_res.htm. Accessed February 6, 2006
- Dawkins K, Ekstrom RD, Maltbie A, et al: The relationship between psychiatry residency applicant evaluations and subsequent residency performance. Acad Psychiatry 2005; 29:69–75[Abstract/Free Full Text]
- Rao NR, Meinzer AE, Primavera LH, et al: Psychiatry residency selection criteria for American and foreign medical graduates, a comparative study. Acad Psychiatry 1991; 15:69–79[Abstract]
- Gibson RH, Roberts LW: Interviewing for an Academic Press Positionm, in Handbook of Career Development in Academic Psychiatry and Behavioral Sciences. Edited by Roberts LW, Hilty DM. American Psychiatric Press, Washington, DC, 2006, p61-70
- NRMP Match Participation Agreement for Applicants and Programs—Restrictions on Persuasion 6.0. Available at http://www.nrmp.org/res_match/policies/map_main.html#apps_matchviolations. Accessed February 6, 2006
- NRMP Match Participation Agreement for Applicants and Programs—Consequences of Confirmed Violations Applicants 7.2.1. Available at http://www.nrmp.org/res_match/policies/map_main.html#consequences. Accessed February 6, 2006
- National Resident Matching Program Press Release. Available at http://www.nrmp.org/2005pressrelease.pdf. Accessed February 6, 2006
This article has been cited by other articles:
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K. Edenharder
Practical Knowledge for Academic Psychiatrists
Acad Psychiatry,
June 1, 2006;
30(3):
238 - 238.
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INTRODUCTION
Preparation in Medical School
