Medicine From The Trenches

Experiences from undergradute, graduate school, medical school, residency and beyond.

Applying for Residency

Each year since 1952, seniors in US medical schools have applied for first-year, post-graduate-1 (PGY-1) positions through the National Resident Matching Program (NRMP). Prior to 1973, these positions were termed “internships” but now, the term PGY-1 (and in some cases PGY-2) positions are more accurate. This service is open to several applicant types who are divided into the following categories: seniors of US medical allopathic medical schools, previous graduates of US medical schools, student graduates of Canadian medical schools, student graduates of osteopathic medical schools , US citizen IMGs and Non-US citizen IMGs and student graduates of fifth-pathway programs. In the last year (2012) that the match was held, there were more than 26,000 positions offered with about 38,000 registrants vying for them. Most of the positions were for PGY-1 positions and a small number were for PGY-2 positions.

By far, US graduates were successful in terms of securing a position (more than 95%) and this meant that fewer positions were left over for the scramble [now SOAP] (open to those who were not able to match). This also meant that US graduates held a distinct advantage when it came to securing positions in the SOAP. It also means that applicants who enter then 2013 application and match need to be very savvy in terms of making sure that they are competitive for the specialty that they seek, that they are competitive for programs within that specialty and that they don’t make any mistakes in their applications that might cost them a position.

The “lifestyle” specialties, Anesthesiology, Dermatology, Emergency Medicine, Radiology and Orthopedic Surgery had fewer than 10 unfilled positions and far more applicants vying for those positions. These specialties filled almost 100% with US graduates who had USMLE Step 1 Board Scores well into the 230+ range (three-digit score) which is considerably above average in terms of performance on that exam. Also key to being successful in matching into the more competitive specialties was membership in Alpha Omega Alpha (AOA) which indicated a high level of scholarship in medical school.

With the numbers of applicants higher but the number of post-graduate positions staying about the same, would mean that academics, grades/USMLE scores are very important for securing a position in the match.  Additionally, making sure that one obtains the best advice from reliable and trusted resources at your medical school become crucial in this process. To go into the process of residency application without the best and more reliable advising can mean costly mistakes that will affect a process that is more crucial to your career as a physician-more crucial than selection of a medical school in the first place.

The other aspect of the application process is that an applicant has to be as realistic as possible in choosing a specialty and program for postgraduate medical training. Similar to medical application, seeking and applying to residency programs where you are far from competitive doesn’t enhance your chances of securing a PGY-1 position in the Match. While it’s great to “dream” of entering a particular specialty or program, you have to make sure you are 1) competitive and 2) suited to a particular specialty or program.

If your medical school academics, licensure board scores and general performance are less than those of people who generally match into a particular specialty, you are not going to secure an interview or secure a match. If you are choosing a specialty because of “what you heard” without regard for whether you have the interest, ability and temperament for said specialty, you may find that you are in for a miserable time and career.

Specialty choice is the most subjective portion of your career in a couple of significant ways. First, you choose a specialty that you know you will love for the rest of your career. This means that you have to love that specialty at 3AM when you are exhausted. This means that you love the scope of practice and the patient population that you will treat. Second, you have to be a good “fit” for the reasons that I have outlined above. You have to be able to enter a training program and thrive in the learning environment that is provided. This means that you have to be suitable for a particular program and they have to be suitable for you. Your medical school may open some doors in this process but in the end, you have to like the program and they have to like you (and your application).

If you are a pre-med student, this post has little reference or impact on what you need to be getting taken care of. Your first task is to get into a medical school where you can thrive in the atmosphere of learning provided by that medical school. Looking at match lists and specialties of the graduates of a school that you have yet to enter will have no impact on your career. Your performance in medical school and on licensure exams is not tied to previous graduates of a particular school. Work on your application/undergraduate coursework and leave specialty/residency selection/residency application for a more appropriate time. If you don’t get into medical school, specialty/residency selection/residency application won’t figure into your life.

If you are a first-year medical student reading this post, your immediate job is to make sure that your academics are as strong as possible. If you are struggling with coursework, you have to get your coursework under control before worrying about what residency you can get into at this point. In short, you have to take care of the tasks that are immediately on your plate at this time.

If you are a second-year medical student, you need to keep your academics strong and make sure that you enter third-year with an open mind. Keep in mind that you may have an idea of what you might like in a specialty but you may find something that you love more once you get to the clinical years. You also need to be thinking about your timing for reviewing and taking your licensure board exams (USMLE or COMLEX Part 1). You don’t want to take this exam too late to have a passing score before you enter third year or too early so that you don’t do well.

If you are a third year medical student, you should have some idea of what you want to do and you should be “scouring” your medical school for as much information as you can find on the residency application process. If you haven’t chosen a specialty at this point, I would encourage you to seek out trusted faculty advisers who can get your selection process underway. I would also encourage any third-year student not to make a specialty choice because they had a “good time” on a particular clerkship.

To Recap:

  • Take “dreaming”, “wishing” and “hoping” out of this process and replace these items with “research”, “realism” and “sound advice”.
  • Make sure that you have comparable or that you exceed the characteristics of applicants that have been successful in matching into a particular specialty/residency program or choose something else.
  • If you are currently in medical school, be proactive about learning as much about the specialty selection process, residency application process and keeping your academics strong.
  • Resist the urge to choose a specialty based on its competitiveness or lack of competitiveness because you just want to impress others or “get a job” because you don’t have any “do-overs” in this process. You have to choose something that you love and for which you are competitive.

14 February, 2013 - Posted by | applying for Residency, residency, summer school | ,


  1. Dear drnjbmd
    I need some advice. I am a 2007 fmg ( green card holder – recently applied for citizenship). I have failed step1 with a 74 on first attempt. Since then I have sat all steps and passed on first try. 83/79/83 I took step 3 in 2011.

    After graduating med school I wanted to take time off to have my kids and sit step 3 before applying for residency. Back then I wanted to do pediatrics ( to specialize in heme/onc) but after having my son I wanted to do pathology because it seemed lend more room to allow me to also balance family into the picture, not to mention that I also love pathology ( choosing heme/onc was giving me the best of both worlds- clinical mixed with pathology).

    So I initially intended to take 1-2 yrs off however when I applied to pediatrics in 2009 I got 3 interviews and did not match. I had applied without my step 3.

    Now that I want to do pathology, I don’t know where to begin- I have been a stay at home mom since graduation, I tried looking for research to volunteer at hospitals but no luck. I don’t know what my options are to improve my cv. I only have 3 letters of recommendations: 2 are from pediatrics (general pediatrics and pediatrics heme/onc) and 1 from internal medicine( heme/onc).
    In 2010 I worked closely on a case study and did a lot of work to write it up for publication. I was given to the attending (heme/onc) but later she said that the patient didn’t want to cooperate for the last bit of info needed to submit it for publication- so it was not submitted 😦

    I guess my most basic question is- how can I improve my cv to be desirable for pathology scramble 2014? Any advice at all would be appreciated, please. I’m clueless but trying.

    Comment by Zoe | 25 November, 2013 | Reply

    • See reply to your other post

      Comment by drnjbmd | 25 November, 2013 | Reply

  2. Would you please elaborate about appealing failing USMLE scores? I was diagnosed with a learning disorder late in my third year of medical. Unfortunately this was after multiple Step 1 failures and difficulty in clerkships.
    Obviously I am nervous about matching. I am attending a US medical school and am a citizen. I want to place myself in the best possible place to match into Primary Care. Is there a difference in competitiveness between Family medicine or Pediatrics? Should I take a year to do research in gastroenterology (my dream job) or get an additional degree, before beginning my fourth year of medical school?
    I am incredibly determined to practice medicine although my road has been tenuous and rocky. Any advice you have to help me on my journey will be appreciated!

    Comment by Keepon Swimming | 14 June, 2013 | Reply

    • To Keepon Swimming:
      Since your diagnosis was past your USMLE failures, you likely can’t “appeal” your USMLE scores. If you were diagnosed before your attempted USMLE and there were no accommodations, you might have the basis for an appeal. What you do need to have is letters from your Dean and faculty that state that you have overcome your learning disability and that you have successfully re-mediated your clerkship work and that you will no longer have problems with licensure boards/clerkship exams/performance. Residency programs are reluctant to take anyone who is going to struggle with in-training exams and passing specialty boards. If you are now diagnosed (and accommodations/treatment have been completed), you need to make sure that everything you are doing now (clinical work) and end of rotation exams, licensure exams are all taken and passed without exception. In short, a residency director should see a clear difference in your performance before and after diagnosis and treatment. It doesn’t make much difference to have a learning disability diagnosed if your don’t get the proper tools to overcome it. Ahead of you will be more licensure exams (Step II CK and CS, Step III + yearly inservice exams during residency + specialty board exam). If you can’t show that you can pass these exams, a residency program isn’t going to want to take a chance on you. There are programs available for professional students with learning disabilities (HELP program at Marshall University in West Virginia) who can help with strategies in mastery of professional exams. If you have completed one of these types of programs, then you need to make sure that your residency application reflects this. No amount of research or extra degrees will overcome poor academics/board exams if you have not re mediated/corrected your learning disability and can show that you will not struggle through residency. Good luck.

      Comment by drnjbmd | 15 June, 2013 | Reply

  3. Another one, Does the ECFMG Certified IMGs, can not re-apply to the USA Medical schools.once you get the ECFMG cert. that’s an indication to be not eligible for US medical school even if you have a high MCAT Score.

    Comment by Matwa | 24 February, 2013 | Reply

    • To Matwa,
      Most medical schools in this country will not consider a graduate from a foreign school for admission. You can contact individual schools but the AMCAS (centralized application service) will ask if you have previously attended medical school. Most schools will automatically screen out anyone who has previously attended and graduated from medical school. The only exception to this rule would be a transfer (rarely happens under the best of circumstances) between LCME-accredited schools where the student is in good standing.

      Comment by drnjbmd | 25 February, 2013 | Reply

  4. Would you please tells us what could happen for the candidates who fail the USMLE twice in ck. is this mean that they will not get any Residecies invitations. Or what they have to do? Please write to me on my email what will be the answer?

    Comment by Matwa | 24 February, 2013 | Reply

    • To Matwa,
      I don’t answer personal replies but two failures on any step of USMLE is quite problematic if you are attempting to enter residency here in the United States from a foreign country. You have to pass USMLE and you can’t take USMLE until you are certain that you will pass. To keep failing USMLE and retaking makes it quite difficult for you to match into a residency program. In many specialty programs, IMGs have to meet a minimum two-digit score and not have any failures at all. Thus you see, two failures will be problematic. You can search out programs that don’t mind your failures but these are getting very rare because of the increased number of applicants in general. Do some research in terms of programs and find out if there are some that don’t care about your failures as long as you eventually pass. Most important, don’t take any more USMLE steps until you are sure that you can pass.

      Comment by drnjbmd | 24 February, 2013 | Reply

      • That’s Auwsom, thanks for the immediate reply. I have another question how I can know about the programs that does not use the match to fill there spots. I am suffering already from this failures. The problem that I have a 4 years experience in on of the highly competitive speciality. I am in a very critical situation I might not get into my speciality again. Please advice me where I can find the hospitals that does not use the match to fill their positions.

        Comment by Matwa | 24 February, 2013

      • To Matwa,
        You have to research individual residency programs to find out if they accept applicants outside of the MATCH.

        Comment by drnjbmd | 25 February, 2013

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