What is in this Complete Residency Guide, Updated for 2022/23?
Applying to a medical residency through the match process is a tedious process that requires plenty of forethought and planning. The key to applying and matching well starts by understanding the process by which medical students apply to residency, and how they match. This guide will help you through many of the following questions!
Table of Contents
- How should one choose the speciality they apply to during the match process?
- How does the match process work? What is the ERAS application?
- What is the ERAS Timeline? When do programs start reviewing applications?
- What is the difference between The National Residency Matching Program (NRMP) and the ERAS?
- How does the Match algorithm work?
- How should I plan 3rd and 4th year rotations for the match and ERAS?
- What are the parts of the ERAS application?
- What is an example of an effective personal statement for residency?
- What type of questions are asked during the residency interview?
- How do I make a rank list order?
- Can I apply to multiple specialities in the match?
- What is the ERAS supplemental application?
- What happens during the month of match?
- What is the SOAP program? What do I do if I do not match?
- A Special Note for International Medical Graduates (IMGs)
How should one choose the specialty they apply to during the match process?
Before we jump into the entire process of how you apply to residency and how the matching process works, it’s worth first discussing how to choose a specialty or specialties to apply to. There are a few basic principles in tackling this fundamental question.
- Set Realistic Expectations
This discussion requires honesty and a certain degree of bluntness. No matter how much you might love Dermatology, Plastic Surgery, or other highly competitive specialties, if you don’t have the academic performance to stack up to the competition, it’s just not realistic to “go for it.”In 2019, the average USMLE Step 1 score for applicants that successfully matched into plastic surgery was 249 and USMLE Step 2 CK was 254. The average amount of presentations, publications, and abstracts was 14 – and 40% of those that matched had Alpha Omega Alpha (AOA) designation.If you’ve got no relevant research experience, and low board scores, applying to Plastic Surgery just is not realistic. For brand new medical students, keep this in mind, to be able to practice in these highly competitive specialties, you must start out early building your resume. Reference the Charting Outcomes in the Match data (nrmp.org/main-residency-match-data) to find out more about the statistics for each specialty to see how you compare to the competition or what you need to do to get there.Note: At the beginning of 2020, the USMLE announced that no sooner than January 2022, the USMLE Step 1 will become a pass/fail test. Practically speaking, this means that Step 2 CK will become the new Step 1. Every effort should be made to excel on Step 1 and pass, but an exceptional performance on Step 2 CK will be a major deciding factor on residency selection.
- Understand What You Want
Some students go into medical school already knowing what they want to practice and go through with it. Others start out with a goal in mind and veer off on a completely different path. Some students have no clue until their third-year rolls around.Some basic principles are involved in understanding what kind of medical practice best suit you:- Do you like the idea of a nice quiet office where you clock in and clock out? Outpatient practice suits you well.
- Do you like the idea of fast paced medicine with a bustling hospital? Inpatient practice is your game.
- Do you like the cool, sterile feel of an operating room with scalpel in hand? Surgical specialties sound about right.
- Do you want to work in the public health arena? Consider preventive medicine.
Thinking about big picture ideas of practice will help narrow down your choices. For some people, the kind of medicine is most important, and for others the lifestyle that practice comes with is more important. Take time to think deeply about these choices and spend time during your pre-clinical and clinical years observing doctors in these fields to get an eyes-wide-open view of what it truly looks like. On that note, make sure you spend time with residents as well as attendings to see the full scope.
Suggested Read: The 10 Most Popular Residency Specialities
How does the match process work? What is the ERAS application?
Most residency positions are offered through the Electronic Residency Application Service, or ERAS. The timeline each year varies, but generally follows the same month structure that starts in June and culminates with “The Match” in March of the following year. You can reference the 2019 timeline to prepare for your own application cycle.
What is the ERAS Timeline? When do programs start reviewing applications?
While exact dates change from year to year, here is a general timeline for the ERAS application:
June ERAS Begins – Applicants can register on MyERAS and begin working on their application. Visit: apps.aamc.org/account. | September Applicants start applying to ACGME-accredited residency programs only. | October MSPEs released to residency programs. | March National Residency Match Program (NRMP) main residency match results are available. Visit nrmp.org. |
Programs typically will start reviewing applications at the end of September into early October. Interviews happen from October through February of any given year.
While most programs operate in this way there are several programs that operate outside of this structure or alongside it:
- The Military Match – Applicants apply through ERAS as above, but complete a rank order list and match through a system called the Military Operational Data System, or MODS. Application to programs ends August 31st, and rank lists are due October 15th. Match results are released around December 12th. Notice, there is no involvement of the NRMP.
- The Urology Match – Applicants apply through ERAS and rank lists are due January 3rd. Some programs use NRMP, and some use a urology match program. Match Day is around January 18th. More information can be found at the American Urology Association website.
- Ophthalmology Match – Applicants apply through the Central Application Service (CAS) and match through the SF Match in January. More information can be found on the American Academy of Ophthalmology website at aao.org.
- Preventive Medicine – Applicants must contact individual programs to determine their process. Some use ERAS, and some use a preventive medicine residency application service. Most use a separate matching service outside the NRMP called the Standardized Acceptance Process, or SAP. However, some use NRMP. The SAP deadline for rank lists is on January 10th. Match Day is around January 20th. More information can be found on the American College of Preventive Medicine website at acpm.org.
What is the difference between The National Residency Matching Program (NRMP) and the ERAS?
It is important to understand that the application process and the matching process are two separate entities. You’ll need to register for both systems for most residency applications in order to match. ERAS allows you to package your application and get it to programs which in turn will offer you interviews. NRMP allows you to rank those programs in order from most to least desirable, then submit that ranking so their algorithm can match you into a program. The NRMP publishes calendars each year with deadlines for the process which can be found here. In general, NRMP opens in September, the registration deadline is in November, and rank order lists are due in February.
How does the Match algorithm work?
The Match is basically an algorithm that takes rank order lists of applicants’ programs and compares them to the rank order lists developed by programs that rank the applicants. The algorithm attempts to pair these together as best possible taking into consideration every applicant at the same time.
To learn more about how the matching algorithm works from the NRMP, check out this helpful video: nrmp.org/matching-algorithm
Applicants often wonder why you don’t just apply, interview, and get acceptances to programs like you did for medical school. If you’re interested, read on for some history and rationale!
This algorithm-driven process was invented to solve a very specific situation. Before the match, hospitals were under a great deal of pressure to try to fill their programs, which meant as time went on, hospitals would reach out and extend offers to medical students sooner and sooner – often in their 2nd and 3rd years. Students would snatch up these offers and hospitals would start filling their programs early to secure their futures.
As the process became more competitive, it also became less fair, with students and hospitals accepting and filling programs at will through the year. To standardize this, the powers that be invented this matching algorithm to pair up applicants and programs at one point-in-time in the 4th year – to even the playing field. Interestingly enough, the research used to create this algorithm even won a Nobel prize!
How should I plan 3rd and 4th year rotations for the match and ERAS?
Before the actual application process begins, a successful bid for residency requires careful planning of the second half of third-year and the first half of fourth-year. The important parts here are away rotations and use of electives.
Away rotations are particularly useful for you to find out more about a program, while at the same time, showcasing your talents. These are essentially working interviews, or audition rotations. For this reason, away rotations should be chosen based on your interest of matching into one of these locations. Plus, you can use them as a required rotation. For instance, when using an away rotation as an elective or a Sub-Internship rotation, you’ll also get a free interview out of the rotation without having to travel back for another visit.
Do keep in mind that nearly every medical school has set-aside time for you to do interviews in your fourth year, so you don’t need to feel compelled to get all your interviews done through away rotations.
In general, it is not wise to do your first core rotation as an away rotation at a program you’re interested in. So, if you haven’t done Internal Medicine yet, don’t show up to an audition rotation for internal medicine. Sure, you’ll learn a ton about the program, but you won’t make much of a strong impression. You want to show up to audition rotations looking strong, so usually this means doing a Sub-I or just an elective in that specialty late in your third-year or early in your fourth year.
Regarding timing, there is no right time to do your audition rotation, just a wrong time. One wrong time is early in your third year when you’re not strong clinically. The other wrong time would be too close to your rank order list being due in February. That makes the ideal time anywhere from late Spring of your third year through the end of that calendar year.
Practically speaking, you cannot use all your electives and away time to do audition rotations. Your school will have limitations, but also you also don’t want to spend your whole fourth year just doing the same rotations at different hospitals. You’d be shortchanging your clinical education. Most applicants can afford to do one or two of these, and the rest of exposure to these programs will come from interviews. Every school is different, so make sure you sit down with your deans to find out how many aways you can do, when you can do them, what specialties you can do them with, and how much time is set aside for electives.
What are the parts of the ERAS application?
Just as it is wise to start prepping your medical school application in advance of the season, applicants should prepare their application well before ERAS opens in the beginning of June.
Start by preparing a comprehensive CV (curriculum vitae) to structure your experiences. You will take that CV and expand on each topic to write small paragraphs for each section of research, volunteer activity, clinical activities, and employment. Since the application assumes you have completed your entire medical curriculum (or will) it is not beneficial to write about rotations unless they were particularly meaningful. If you decide to write about a rotation, pick just one.
ERAS allows for a personal statement about five pages long. You should aim for just about a page and a paragraph. You should not need five pages, nor do admissions committees want to read that much. Describe why you want to pursue your residency of choice and what will make you exceptional at it.
Now review the format for both the Activities and Personal Statement sections.
Gather a Dean’s Letter/Medical Student Performance Evaluation (MSPE)
To begin the Dean’s letter, you’ll need to start by talking to your Dean. Each school has different policies on how this is conducted, but the school will notify the applicant and ultimately generate the letter and upload it to ERAS.
Most schools will automate this and there will be set deadlines from your Dean. Your school will likely require you to attend a meeting before writing the Dean’s Letter/MSPE and will require you to present three noteworthy characteristics.
Dean’s Letter/MSPE Instructions Example
The medical school transcript must be uploaded to ERAS directly from the medical school.
Collect Letters of Recommendation
If an applicant has 2-3 Letters of Recommendation (LORs), this should satisfy most program’s requirements. Do not wait until right before the application process to request letters. If you connect with an attending and perform well, ask them if they would be willing to write a letter about 75% of the way through the rotation. Then ask them for the letter at the end of the rotation.
Collect your letters right away through a 3rd party service like Interfolio so you can store them ahead of time and then upload them when the application process opens.
To use ERAS to request letters, you’ll need to wait until the service opens in June. The applicant has to enter the LOR writer’s name and information and then can generate a letter request form to be sent to the letter writer.
After this step, the applicant must confirm the letter of recommendation.
Once the letter is received in ERAS, then they can assign it to the program of choice.
For extended information on letters, the AAMC has details about the format of the letter (https://www.aamc.org/services/eras-for-institutions/lor-portal), and this UCSF has great information on what the letter should include (https://meded.ucsf.edu/md-program/current-students/student-services/advising-career-development/letters-recommendation).
What to write on your ERAS/residency personal statement?
Applicants should start writing their personal statement far in advance of the application. If you know you want to be a general surgeon halfway through your 2nd year, go ahead and start then. Do not wait until the application season to start your personal statement. Applicants are allotted 28,000 characters with spaces.
If you will be applying to more than one specialty, you’ll need a separate personal statement for each program. Technically, you could write a different personal statement for every program, but this is not necessary. You will have the option to assign a specific personal statement to each program.
Writing a strong personal statement starts with structure. A clear format breaks the essay into manageable pieces for the reader to read and for you to write:
- Introduction – Open with an anecdote, story, or other creative writing technique to draw the reader in. End this paragraph by introducing your theme(s) to be explored.
- Body paragraphs 1 to 3 – Explore your theme(s). Focus on traits that will make you a good physician or otherwise prepare you to excel in medical school and beyond. Do not tell more stories here, and do not rehash your resume/work and activities section. Introduce activities only to provide context to how they’ve shaped you. Pick a theme and use two activities to prove that you possess the skill/trait. In this way, you show that the activities are an expression of yourself, not a simple lesson you learned from an experience. Why two? Because one doesn’t provide enough evidence and three or more sounds like a list. Two is the sweet spot.
- Content – To make a personal statement truly unique, you need to look beyond your activities. Write about something you are passionate about. It doesn’t have to be medicine. I’ve read great personal statements that talk about the lessons the writer learned as a dancer, as a baseball player, or as a teacher. They show how they’ve learned humility, compassion, perseverance, diligence, patience, and all sorts of characteristics that apply to medicine. Picking something that you’re passionate about allows you to demonstrate how these characteristics are woven into aspects of your life – not that you learned them by being involved in an activity, but the activity is an expression of the underlying characteristic.
- Conclusion – Wrap it up and end on a catchy or more emotional note. If the introduction serves to draw the reader in, then the conclusion will help leave a lasting impression on the reader.
What is an example of an effective personal statement for residency
“I began my family medicine clerkship in a community clinic dedicated to the less fortunate. There I found a group of family physicians, each with their own niche, working together to form an incredibly comprehensive team. One physician in particular specialized in the behavioral sciences, amongst other things. He saw the kinds of patients I found so fulfilling to treat on my psychiatry rotation, but he also saw just about everything else under the sun. From depression, to skin cancer, to a well-woman exam, I found the pace and surprise of the daily schedule invigorating. What truly impressed me was how he applied the same principles of the one-on-one real, personal connection required in mental-health to every patient. He laughed, he joked, he hugged, he spoke with authority, and to me it seemed like every patient was a member of his own extended family. To me this is what family medicine really means and I will strive to make every patient leave feeling as though they were listened to, understood, and given the best possible medical care available.”
WARNING: Try to weave description and content together. Most applicants use a paragraph to tell a story and then use a sentence or two at the end to reflect on it (which is perfect for a work/activities section, but not for a personal statement). When I see this as an admissions committee member, I just start skipping the story and reading the last sentence of each paragraph.
Don’t think activities. Think THEMES. Think YOU. Here’s some questions to get you thinking:
- What are you great at?
- What are you passionate about?
- What do you like to do?
- What do you have that other applicants don’t have?
- Do you have a unique approach to problem solving?
- Do you have a unique way of thinking in general?
- Do you have a unique perspective?
- What values are important to you?
ERAS Activities Section
The applicant can enter as many experiences as they would like to. Be sure to aim for quality, not quantity.
Should you write out your description in bullet form or paragraph form? If you go with bullets, don’t make each bullet a paragraph. If you go with paragraph form, you need to use complete sentences.
I prefer the paragraph form because you can be more reflective. Consider that most applicants will have many similar activities – like participating in an interest group for example. Let’s look at two approaches to illustrate a few advantages of the paragraph form.
Notice there’s just so much more you can say with a paragraph. Suppose both applicants had the exact same resume and both chose bullet form. How would the program director decide which was a better applicant? Choosing to write in paragraph form allows you to identify and highlight all the unique aspects and attributes of your application to help you stand out.
The experience format is as follows:
Program Lists
Due to the vast number of programs offered for each specialty, we are not able to offer detailed program list selection help. The applicant should start by entering their information into residencyexplorer.org. This site will give an idea of where the applicant is competitive based on multiple factors, and they can filter the results based on location and program type. Your adviser will help you to determine which programs are a best fit for you in broader strokes.
Residency Explorer is to residency applications what the MSAR (medical school application requirements) is to medical school applications. It has vast amounts of data on each individual program. Everything from average step scores to the total number of residents and which schools they come from.
Note that you can only enter your scores in Residency Explorer three times, so applicants should not “play around” with different score scenarios, otherwise they will lock out the account – you can still access the information, you just can’t change the numbers.
Helpful Tools in Creating a Program List
There are several different tools to help you understand and navigate the residency application process.
- AAMC’s Apply Smart Tool – this tool allows applicants to see how many applicants applied with a given Step 1 score and what percent matched. It also provides data on the point of diminishing returns. This is a statistical point where 1 more program applied to does not confer a significant advantage in return. It does NOT mean that applying to more schools decreases your chance of matching, just that the rate of return is lower.Visit https://bit.ly/AAMC-apply-smart
- Interactive Charting Outcomes of the Match – this tool allows the user to identify specific categories (step scores, research experience, volunteer experience, etc.) and see exactly what percent of applicants matched with these characteristics. By plugging in numbers, one can see their statistical chance of matching similar to the MCAT/GPA grid utilized for pre-meds.Visit https://bit.ly/charting-outcomes
- Main Residency Match Data – Every year, the NRMP publishes all data on the match. This is where every piece of data can be accessed. The SAP Crystal report (Item number 2 at the top under Data Reports) is particularly useful. You can see in each state, how many applicants there are for each specialty and how many match from DO, MD, IMG, and US-IMG. This is particularly useful in structuring applications based on geography to make sure your degree, citizenship, location, and specialty choice are all compatible.Visit https://www.nrmp.org/main-residency-match-data/
What type of questions are asked during the residency interview?
Interviews typically start rolling in around late Fall and early Winter. Aim to interview at as many programs as you can afford to attend. Preparing for interviews should start with becoming familiar with typical interview questions. You can expect to find these questions and prompts in a typical interview:
- Tell me about yourself.
- Why did you become a physician?
- What makes you want to be a ____? (fill in the specialty)
- What are your greatest strengths?
- What are your greatest weaknesses?
- Describe a time when you overcame a great challenge.
- Where do you see yourself in 5 years? 10 years?
- Describe a research project you were involved in?
- Name 3 things wrong with the U.S. healthcare system and propose some fixes.
- What is your interest in this program?
- How do you manage stress?
- How do you handle interpersonal conflict?
- Describe a time where you disagreed with someone or something and how you handled it
- Describe an accomplishment you are most proud of.
- What are you looking for in a residency program?
- What do you like to do outside of medicine?
- What other specialties did you consider?
- What is the most interesting case you have encountered?
- How would you handle a non-compliant patient?
- What would you do if you saw a senior resident or attending do something wrong?
- Please explain any gaps or discrepancies in your education.
- What elements do you think make a great ____? (fill in specialty)
- What 3 words would your patients describe you with?
- What 3 words would your colleagues describe you with?
General tips on interview day:
- Attire – Dress professionally, and remember this is not a fashion show. If you happen to be up to date on the newest fashion trends, just remember that your interviewer might not. Interview day is probably not the best day for an ironic tie or pink gator boots. Your clothes should be neat and presentable, and should not distract from the content of your message. The same goes for jewelry. Try not to wear anything that draws the attention away from you.
- Stature – Sit upright and lean in just like you would when speaking to a patient. Body language conveys interest, so leaning back with crossed arms may send the wrong message.
- Ask Questions – Every interview will end with the same question: What questions do you have for me? The only wrong answer is to walk away without asking questions. Rather than reinvent the wheel, check out the extremely exhaustive list the American Academy of Family Physicians prepared on this topic: https://bit.ly/AAFP-questions
How do I make a rank list order?
It is helpful to review exactly how the matching algorithm works in order to understand how to create a rank list and how programs are creating their own lists. According to the National Resident Matching Program:
The NRMP uses a mathematical algorithm to place applicants into residency and fellowship positions. Research on the algorithm was the basis for awarding the 2012 Nobel Prize in Economic Sciences. To make the matching algorithm work best for you, create your rank order list in order of your true preferences, not how you think you will match.
Creating a rank order list is stressful but is actually very straight forward. The AAMC specifically states that you should order your programs in the order YOU value the program, not how you think the program will rank you. While this is sound advice, it also stands to reason that you should not highly rank a program you love that you don’t have a realistic shot at attending. If you are listing a program at Harvard that you did not rotate at or interview with, you should not rank that as your number 1 program.
The final rank order list is due at the end of February to prepare for the match in March.
Can I apply to multiple specialities in the match?
Some applicants are not 100% sure on what specialty they are ready to enter, and others may include ‘backup specialties’ to fill their list. There are certain benefits and drawbacks to creating non-contiguous lists. The term ‘contiguous ranks’ refers to the number of specialties that appear in a row. For example:
Applicant A:
- Derm program 1
- Derm program 2
- Derm program 3
- Family med 1
- Family med 2
Applicant B:
- Derm program 1
- Family med 1
- Derm program 2
- Family med 2
- Derm program3
Notice that both applicants have three Derm programs and two family med programs. Applicant A has three contiguous ranks for Derm and two contiguous ranks for Family Med. Applicant B has no contiguous ranks.
The number of contiguous ranks is very important, and there is data in Charting Outcomes in The Match (nrmp.org/main-residency-match-data) that provides more detail. For example, of the derm applicants in 2019 that had one contiguous rank for Derm, 30% matched. Of the derm applicants with 12+ contiguous ranks, 100% matched. How you organize your rank list is clearly very important.
That doesn’t mean that you can’t rank multiple specialties though. That is a separate piece of data. In 2019, of the derm applicants that ranked one specialty, 89% matched, while 80% of those that ranked three specialties matched. This is true of other specialties, but not all. In the case of orthopedics, there was an 87% match rate for applicants with one specialty, but that number drops down to 52% with two specialties. Having backup specialties is neither good nor bad across the board, it is specialty specific, and should be a carefully researched decision based on your specialty of choice.
What is the ERAS supplemental application?
The main ERAS application consists of the personal statement and the activities, but there are also now supplemental applications for residency. In 2022/23, there are now 16 specialties that utilize the ERAS® supplemental application. These questions are very short, and free to fill out, and are utilized to help applicants share more information about themselves with programs that they maybe interested in.
Related Read: Our Guide to the ERAS Supplemental Application
What happens during the month of match?
The Match occurs over the process of one week in March – Match Week – and culminates on Match Day, which is on a Friday.
Applicants are notified the Monday of that week to let them know if they matched or not, but there are no specifics on where they match.
If you match, you get to participate in a big ceremony at your medical school where typically students walk to the front of a crowd, open up a sealed envelope, and announce their match. If you find out on Monday that you did NOT match, there’s more work to be done. You’ll need to work through the Supplemental Offer and Acceptance Program (SOAP).
What is the SOAP program? What do I do if I do not match?
The SOAP program is designed to fill in the gaps left by the algorithm. If you didn’t get paired up, this is the chance to remedy that. The Friday before Match Week kicks off, applicants are notified if they are eligible for the SOAP. This has nothing to do with whether you matched or not. To be eligible for SOAP, you must be registered in the main match through NRMP, be available to start residency in June, and be unmatched. (You find that out the Monday of Match Week).
SOAP works in a completely different way than the NRMP. There is no algorithm this time. If you find out you don’t match on Monday, you obtain access to a list of all unmatched programs through the NRMP website. Through that website, you can select and apply to as many as 45 programs. Now the ball is in the programs’ court. You are not allowed to contact programs at this time. You must wait for them to contact you. They will call and interview you over the phone over the next several days.
SOAP offers are extended in three rounds which start that Wednesday. There are two rounds on Wednesday morning and one round on Thursday. Most positions are filled in that first round. Programs extend offers during those rounds which are valid for only two hours. If you do not respond in those two hours, any acceptances in that round are forfeited and will not be extended to you in other rounds. So, you can either accept, reject, or do nothing. If you reject an offer, it is the same as letting it expire – you can’t come back to it in other rounds.
On Thursday afternoon, the SOAP offers end. If you still have not matched at this point, you still have access to that updated list of unfilled programs and now the rules change. At this point, you can contact the programs on that list and ask for interviews. If they like you, they can extend an offer to you at any time. This process is available from that Thursday during Match Week until May 1st.
A Special Note for International Medical Graduates (IMGs)
International medical graduates are inherently at a disadvantage compared to American Medical Graduates (AMGs) for multiple reasons. Broadly speaking, this is because most program directors are familiar with and confident about the medical education AMGs receive. Since IMGs are somewhat of an unknown to many programs, and because there is a large pool of applicants applying for a smaller group of positions, IMGs always need to have more competitive stats. That means higher USMLE scores, more research, and more volunteer activities. This helps give them the edge with applying.
All the same principles for a successful application apply to the IMG whether you’re from the U.S. or not. One note that is particularly important is selecting IMG “friendly” states. For instance, if you were an IMG interested in Anesthesiology and applied to all programs in Alabama, you simply will not be successful. Why? The reason is that the data shows (for 2019) that no IMGs were matched into any Anesthesiology positions in the state. This data is available in the SAP Crystal Report. Using this report should be the first step in identifying programs to apply to as an IMG.
Once you’ve identified which states match IMGs into the specialty of your choice, the next step is to look at the Residency Explorer app to specifically find out how many IMGs match into specific programs.
The residency application process is a long road requiring a well-planned out approach. From carefully selected audition rotations all the way until Match day, staying ahead of the curve by being prepared is the key to success!
