Questions to Ask Yourself

You can begin to narrow your selection process and pick the programs to which you will apply by answering the following questions:

University-based or independent medical center program?

There are a number of fine independent medical center-based programs that will prepare you very well for surgical practice. In fact, a substantial proportion of practicing surgeons in all specialties today trained in these types of programs. The university-based programs will often require a year or more in research. University-based and medical school affiliated programs will include medical students, more full-time faculty and affiliations with public hospitals such as the Veterans Affairs (VA).
Do you plan on added training (a fellowship) once the core residency is completed?

Your surgery residency will prepare you to be a competent and capable surgeon in your specialty. That being said, additional fellowship training is available in most specialties. The competition for positions in some fellowship programs such as pediatric surgery can be tougher than the competition for positions in the core residencies. The number of subspecialty fellowships is increasing, and the majority of graduates from both university-based and independent medical center-based general surgery programs are continuing their training with fellowships. If you know you want to go directly into practice, the five- year clinical experience in most residencies will allow you to do so without feeling the pressure to do an additional fellowship. In fact, there is an increased need for broad-based surgeons in this country, and that may make a career choice in general surgery even more appealing. When you visit any surgery training program, it is wise to inquire what graduates from the past five years have done after residency and, if they chose to go directly into practice, whether they felt comfortable and prepared to do so.
Urban or rural?

Most surgeons find themselves practicing in an urban environment. However, if you are planning on practicing in a rural environment, you may be required to care for a broad range of patients with surgical illnesses and will be best served by a residency program that offers experience in all aspects of your specialty. For those who intend to practice in a developing nation or do missionary work, you may want to seek a residency in which you have the opportunity for extensive exposure to all aspects of surgery and/or consider an Acute Care Surgery fellowship.
Are you locked into a specific area of the country?

If you already know that you are going to practice surgery in a specific community or area, you should consider training programs that are well-known to the other people who practice in that same geographic area. This training decision will give you a head start over people trained in far-away places unknown to the community or to the referring physicians. This suggestion is probably a trivial point, as within three or four months of starting practice, you will be judged primarily on your affability, availability, and ability. An important corollary is the fact that, statistically, the leading predictive factor for where you will ultimately practice is where you do your residency. So be relatively sure that you, and especially your significant other, find the location of your proposed residency program at least acceptable.
What are your energy level and your level of personal and family commitment?

Are you the type of person who thinks that the only thing wrong with being on a night float team is that you miss half the good cases? Or do you find every-fourth-night call unacceptable because it interferes with your weekend plans? Your own and your family's requirements should seriously be considered when choosing a residency. You should remember that—especially in the junior years and the chief year of residency—you will be working approximately 80 hours per week and you will spend a large portion of your time at home sleeping. We cannot overemphasize the importance of these considerations. Perhaps the most important of all of our recommendations is to carefully consider these issues before embarking on a time schedule that might make you, and your family, chronically unhappy.
With my academic track record, where should I apply?

All programs try to attract the best applicants they can, and your academic credentials dictate your chances. Some institutions require that you have an advanced degree, several publications, and be elected to Alpha Omega Alpha (AOA). Others may be willing to review your record more broadly and value your other accomplishments as well, such as the fact that you worked your way through school and are involved in community activities. Evaluations from your clerkships and letters may also give the programs a feel for whether you are the sort of person they seek. They are looking for someone who treats everyone well and will remain calm and effective in the face of all the challenges a surgery resident may encounter during a hectic clinic or in the middle of the night.

If your record places you in the lower half of your class or if you scored below the mean on the United States Medical Licensing Examination™ (USMLE), you may not get many invitations to interview relative to the number of places you apply. Placement in the second quartile of your class or scoring at least a mean score on USMLE tests will make you competitive for many good programs. If you are in the top quartile of your class, have scores well above the mean on the USMLE examinations, and have some honors on your clinical clerkships, you will be considered at most programs. If you have been elected to Alpha Omega Alpha or the Gold Humanism Honor Society and have many major clinical honors, you should be competitive for any program in the country. We discuss this scenario further in the section below on our program grading guidelines.

Remember, you are obligated to go to the program to which you have matched. Switching programs later on is very, very difficult. Make sure that every program you select as part of your rank order list in the National Residency Matching Program (NRMP) will be satisfactory to you and your family. Never list a program that you do not want to go to—you might, to your dismay, find that this is the program to which you have matched.
Should I do a subinternship (“audition” elective) at an institution that I am seriously considering?

Our general advice to students is to take just enough courses within your specialty choice to make sure that you really want your career to be in that discipline. You should then spend as much time as possible in areas that you will not have further exposure—such as nephrology, cardiology, and radiology. You will find the American College of Surgeons handbook Successfully Navigating the First Year of Surgical Residency: Essentials for Medical Students and PGY-1 Residents to be quite useful in determining where your deficiencies lie. Arrange your electives accordingly. You can download a copy of the "Essentials" in PDF and Microsoft Word formats online, or order a printed copy by sending a request by e-mail to csherman@facs.org.

You might be able to improve your chances of matching at an institution, particularly one that is geographically or philosophically remote from your medical school, by taking a surgery subinternship and putting in a stellar performance. The more the surgical faculty get to know you, the better your chance of being selected. It also provides the opportunity for you to gain a deeper knowledge of the program and determine if it is a good fit for you. However, subinternships should be chosen carefully, generally no more than two programs. Consider utilizing time away from your home institutions to become familiar with programs where you have a reasonable chance of matching based upon your academic track record.
What about my interview?

You will not be considered for any good program without an interview, and you should not consider a program that does not require an interview. This is a time for you to obtain answers to questions that will guide your choice. Do not ask the faculty member who interviews you about the call schedule or benefits—get those answers from the program’s website or residents with whom you meet. The faculty expects you to be concerned about the educational aspects of the program. It's fine to ask about case variety and complexity, research opportunities, faculty and resident stability and morale, and what has become of the program's graduates, so include queries such as what is the "pass rate" on certifying board exams and how many graduates go on to subspecialty fellowships. While you are being interviewed for a residency position, you are also interviewing the residency to see if the training offered will meet your professional needs. The goal of the interview for both you and the program is to assess how you would “fit” into the program.

Should a conflict arise and you need to cancel a scheduled interview, it is essential that you notify the residency coordinator of the program with as much notice as possible. Cancelling an interview at the last minute inhibits other people’s opportunities for interviews, throws off complicated interviewing schedules, and can damage your medical school’s credibility.

Many suggestions about the interview process are found in the excellent section for medical students on this website.
What specific factors should I consider at each program?

How many cases has the average program graduate performed during residency? Each certifying board sets minimum requirements, and these must be met for the program to keep its accreditation by the RRC. Make sure the program provides at least that number of cases.
Is the case load sufficiently varied and complex? The good programs have an excellent mix of common and unusual or complex patients. Are the complex cases distributed equitably among the residents?
What are the outside rotations at affiliated institutions like? Do the residents in the program like these rotations and find them valuable? Is the level of supervision satisfactory?
Do residents complete rotations at geographically distant hospitals? Does the program offer appropriate resident support, including housing for outside rotations?
Is the house staff happy? Is the morale good? Is there a big turnover? These are very important issues. Remember, you're thinking about spending four to five years or more in this environment.
Do I fit in with these residents? Can I see myself spending time with the residents and faculty—inside and outside of the hospital? Can I envision myself working well as a team with these people?
Can current residents speak to the quantity and quality of faculty involvement, the opportunities for residents to make treatment decisions, collegiality between residents, and faculty and case variety?
Are there high-quality educational conferences and technical skills labs? Do the residents have protected time away from their duties to attend conferences and work in the lab?
Are the department and the institution stable? Many teaching hospitals have merged or even closed in recent years, and the "life expectancy" of a department chair may be less than the duration of your residency. Turnover of junior faculty may be a barometer of the department's stability as well.
Is there a dedicated research year or the opportunity to do one to two years of research? What resources are available for resident research? Is resident research primarily clinical or a mixture of clinical and basic science? Do surgical faculty have ongoing research, and are they willing to mentor residents on their projects? Are there local venues for research presentation?
Are subspecialty fellowships available? What is their impact on the residency program? The presence of subspecialty fellowships is an indication of a substantial educational commitment of the department and the depth of its faculty and research, but do the fellows take "all the good cases"? These are important questions to pose to the residents in the program when you meet them.
What are the possibilities for living arrangements for you and your family? Is the area near the hospital suitable, or must you commute? Long distance commuting is incompatible with a surgery residency at any stage!
Are the institution's fringe benefits satisfactory? Do you have access to important benefits such as day care, extended medical coverage such as long-term disability insurance, active mentoring opportunities, a social support network, and counseling services? Is attendance at yearly national conferences and/or review courses supported? If resident research is accepted for presentation locally or nationally, is additional time-off and funding available? Ask these questions of the residents you meet.
Are women and minorities comfortable in this program? The answer to this question can be found in the number of these groups enrolled in the program and their reaction to the climate provided by the program.

Letters of recommendation

Three or four letters in addition to your dean's letter (sent routinely to your application list on November 1 but not before) are optimal. More than this recommended number of letters is overkill. The most effective letters come from people who have worked directly with you and know your abilities, especially if the faculty member personally knows the program director where you are applying.

Most of the letters should come from surgeons. If you can get a strong supporting letter from a non-surgical attending or basic scientist who knows not only your clinical skills but also your human side, this type of support would be a great addition.
A letter from the department chair is potent, but only if the chair knows you personally or takes the trouble to speak with the faculty who know you well.
If you have done several rotations during your clerkship, a letter from the clerkship director synthesizing your overall performance would be helpful.

An untapped resource

By now, you have become acquainted with surgery residents at your medical school-affiliated hospitals. All of these residents know a lot about other programs; ask them about resident morale, who really does the cases, if the attending and resident staff are supportive or abusive, and so on. The postgraduate year 1 residents at your hospital were going through the same decision-making process that you are going through now, as recently as 12 months ago. Informal input from these residents, whose residency interviews and application processes are still fresh in their minds, can be very useful to you. Remember, though, that rumors abound and may or may not be accurate—so use your best judgment.

Another source of information is the Alumni registry at your medical school, which contains the current location of all graduates and their medical specialty. Alumni are usually very open to inquiries about their current residency and others that they considered. They also may provide an entrée, paving the way for future medical students from your medical school to become residents in their program.
Ranking programs on your match list

You've made all your interviewing trips, met all the right people, and asked all the appropriate questions. Now it's time to rank those programs. Here are some general principles to follow when doing so:

DON'T rank any program where you know you or your family would be unhappy; if you match there, you're required to go there.
DO include a couple of "dream" programs, where you're probably not competitive but "wouldn't it be great if...," at the top of your list. The matching plan favors your ranking, so it doesn't hurt to list those programs first. It won't hurt you in the long run, and the first program you list that also lists you highly will be the one to which you will be matched.
DO put a couple of "sure thing" programs, where you're slightly overqualified, at the bottom of your list. You DO NOT want to go unmatched. DON'T pay any attention to programs that say they have "guaranteed" you a spot. The way the match works, unless you and your significant other are in the couples match, telling you that you have a guaranteed spot is a violation of the rules.
If your sense is that you are not very competitive, you need to discuss the possibility of applying as a preliminary as well as a categorical resident with the program directors of your favorite programs. Again, you DO NOT want to go unmatched.

What are my chances of matching in surgery?

The number of categorical general surgery year 1 positions has been relatively stable at about 1,100 for several years. Other surgical specialties are also not adding significant numbers of residency positions. United States medical schools are preparing to increase enrollment by 30 percent in 2015. The ratio of US graduates applying to categorical positions approaches 1:1, while almost 100 percent of categorical positions are filled. As more students graduate from US schools, the competition for categorical positions will increase.

Students who feel they are not as competitive should apply for preliminary surgery positions as well as straight categorical slots. When resident attrition from categorical positions occurs, the openings are often filled by preliminary surgery residents. It behooves you to take a preliminary position in a program you like rather than to go unmatched.

Despite the challenges and long hours, rest assured that, like us, you're probably going to love your surgery residency and remember those years as some of the best of your life!