How to Choose (and Get Into) the Residency That Is Right For You

Choosing a residency is one of the most important decisions you will make in your professional life. The breadth of clinical exposure, the quality of residents and teaching, and the overall learning environment will play a major part in your formation as a physician. But how do you make that decision? To help, we've compiled this list of questions applicants commonly ask as they go through this process.

Q. When I look at residency programs it is hard to narrow down the choices. How should I start?
A. First, think about the location you would like to practice. Find out a little about the medical community. What kind of practice do people have? Is it full scope including obstetrics? Then you should look for a residency with strong obstetrics (like our program). Do they include inpatient medicine in their practice or mainly outpatient? Next, what do you want to do? Do you love procedures? Are you interested in teaching medicine? Do you want to be prepared for international work? Find a program that can tailor your training to help you reach your goals. Finally, where are the program’s current graduates? What type of practice do they have? Are they able to perform the procedures they want? It is possible -– but not likely – that you will be able to have a radically different set of hospital privileges than physicians who are already in practice in the location you choose.

Q. I’ve been told that I’m “too smart for family medicine” – should I still pursue it?
A. The real question is, “Are you smart enough for family medicine?” Dealing with the complexity of undifferentiated illness and practicing top quality family medicine takes smart physicians. If you’ve been hearing things like this, it just means you’ve been in a tertiary care medical center where they don’t really know what we can do. Family medicine is challenging and interesting because of its breadth and because of the variety of services we perform. Where else can you care for someone in the ICU, deliver a baby, do a colonoscopy, do a well-child check on an infant, counsel a woman regarding menopause, and discuss issues of aging with an elderly patient and their family all in one day? This variety also means you can emphasize the parts that you like more than others, creating a practice that fits your personality.

Q. When should I take my board exams?
A. While there is some merit to waiting to get more training and thus a better score on board exams, the results are also an important factor that residencies use in making decisions about interviews and ranking. It would be great to have Step I and II results back by October or November of your 4th year. Some programs may not consider you at all if your Step II exam results are not available by rank day.

Q. How many failures can I have on the boards and do the failures matter?
A. Absolutely. In Texas a physician cannot be licensed if they have failed any section ofthe USMLE or COMLEX exams, or any combination of both, three or more times. (There are a few exceptions to this, but no guarantees.)

Q. I had a hard time academically at first, but then “got my act together” and did better. Should I mention it in my personal statement or just see if someone notices?
A. It is always good to be open and honest about any struggles you have had and how you have overcome them. Learning from mistakes is a sign of maturity and a sign that you may be more likely to overcome adversity in the future. In contrast, applicants who try to minimize failures or low grades are less attractive as it appears they are trying to hide something. After all, we all have strengths and weaknesses and having a good understanding of what you most need to work on personally and academically increases your chances for success.

Q. Can I tell a residency that I am very interested in coming there?
A. Yes, absolutely. NRMP rules prohibit a residency from asking you how you will rank them, but they do not prohibit either side from expressing interest in each other. Don’t be surprised if a program director or faculty member is a little guarded in their response, though, as we work hard to avoid making comments that someone might interpret as a commitment to rank an individual highly. It’s still good to be enthusiastic if you genuinely feel that way.

Q. I think I’ve found the residency that is perfect for me. Is it ok to just rank one program?
A. NO! Emphatically not! It is always good to rank every program where you would be willing to work. Many things enter in to rank list decisions. You may not be as competitive as you think, and even though faculty and staff may like you, you might not match with them. Ranking multiple programs is always wise.

Q. What about doing a 4th year rotation. Does that help?
A. Yes, it often does. Extended time at a program gives you a much better picture of the organization and more opportunities to interact with residents of different year levels, see the morale, and get the feel of the place. If you have an academic weakness in your transcript, it may also help a residency be more comfortable about offering you a position when they have “seen you in action.”

Q. When should I interview? I was thinking of waiting until the end of January so that a program will remember me better.
A. We recommend interviewing as soon as you can after the dean’s letters are out (early to mid-October). It is fine to interview before that, but sometimes dean’s letters raise issues that need to be resolved, which is easier to do in person. Also as the interview season wears on, both interviewers and interviewees become weary. We see many more cancellations toward the end of January as people simply become tired of interviewing. You don’t want fatigue to be the deciding factor. Most US grads will need to interview in at least 6-8 places to find the spot that fits them best.

Q. Do I have to go back for a second look?
A. No. It’s nice to be enthusiastic about a program but most (ours at least) wouldn’t rank someone lower because they didn’t come back for a second look. We understand that people are busy and it can be difficult (and expensive) to travel repeatedly. On the other hand, it can be a great way to meet more people and get to see the residency in a little different light, without worrying about your interviews.

Q. What else should I do to prepare for an interview?
A. Think through why you are going into family medicine. Be able to articulate it. What excites you about being a family doc? Be ready to answer questions about any unusual items on your record. Get plenty of sleep if possible. You want to be bright and engaged during your interview.

Q. I thought the interview was just about a residency trying to “sell me” on their program and get me to come there. Is that true?
A. While there is some of that (a residency always wants to put its best foot forward), it is also important for you to sell yourself to theprogram. The residency wants to meet the real you and the interview is that opportunity. A good interview can improve your application; showing up late or seeming bored or disinterested can make you less attractive.

Q. I have a concern about the residency. How do I find out more?
A. The main thing is to ask. Most programs want you to know them well. As a program, we don't do ourselves or applicants any favors by sugarcoating a problem to get them to our residency and then having them feel like we weren’t honest. Every program has things they do very well and things they would like to improve upon. Part of your job is to find which program is the best fit for you.

Q. How do I make my decision?
A. Sometimes you’ll just “know.” For most of us, however, it helps to have some sort of organization to the process, making sure that you have answers to a basic set of questions for every residency you visit. Consider questions like: “Is there enough patient volume?” “What are the didactics like?” “Would I get along with the residents?" "How is the balance between supervision and autonomy?"

Q. I think I’ll go one place for my first year and then transfer to another residency if I don’t like it. Isn’t that ok?
A. Not a good plan. Some transfers between programs occur, but you shouldn’t count on it. It is disruptive to you and your family and difficult to jump in partway through. Also, if you were to quit at one residency and then not get a position at another, you might put your entire career in jeopardy. We receive many applications from individuals who didn’t think through their initial choice of residency well and then ended up in a research position or being a physician assistant because they couldn’t find another position. Every year that passes after medical school graduation makes it harder to obtain a residency position. You should also be aware that for board certification in family medicine you must complete your second and third year of training in the same program. Finally, it can be hard to come into a program in the second year and really feel like you are part of the team.

Q. What are things that would disqualify me from being considered?
A. Obvious ethical issues would be a major “red flag.” Also, anything that makes you unable to be licensed. In Texas, that would include having a felony conviction or “misdemeanor involving moral turpitude” or three or more failures on any section of the USMLE Steps or COMLEX licensing exams. The legal restrictions are more extensive and are available for download here on the Texas Medical Board website.   http://www.tmb.state.tx.us/page/board-rules

A full review of the licensing process, including the "substantial equivalence list" listing acceptable schools for medical training, can be found at: http://www.tmb.state.tx.us/page/full-medical-license

Q. What about my family? They like one place and I like another.
A. It is important to find out about the atmosphere of different residencies. Many residencies (including ours) have a lot of camaraderie outside of the academic program itself. Other spouses/significant others can be a great source of information and reassurance.

Q. How much time should I spend in town for my interview?
A. If you are interviewing in many places, you won't be able to afford more than just the interview day. But once you narrow your list, it is always great to spend an extra half day or day in a town where you are considering residency. I almost always wish I could have shown people around Waco more, so they could see things they are interested in: the zoo, if they have children, Cameron Park if they like to run or mountain bike, our two rivers and Lake Waco if they are interested in water sports or fishing, various cultural events at Baylor University or the two other colleges in Waco, or just nice parks and places to live.

Q. Don’t all residencies pay the same?
A. No, they don’t — and what is more important, the cost of living in a particular area may greatly affect how much of your paycheck you have left to spend after you have paid for essentials like housing, food, and clothing. It’s always good if you can see a few of the neighborhoods where residents live to get an idea of their style of living. Does it fit you? We do reviews every year to ensure that we are consistently in the top tier of salaries in Texas.

Q. I’ve heard that Waco FMRP is an FQHC (Federally Qualified Health Center). How does that change things for me as a resident?
A. There are many advantages to being an FQHC. First, it allows our organization to have a greater impact to underserved individuals in our community, reaching out to 49,000 individual patients in 2010 (234,000 visits) through our residency and satellite offices. Many of these satellites are the practices of our graduates who felt a connection to our mission and decided to stay with us after finishing residency. But there is also a financial incentive to practice with an FQHC. Through the National Health Service Corp's loan forgiveness program, residency graduates are eligible for an average of $25,000/yr. (tax free) in qualified student loan forgiveness. Second, being an FQHC and part of a larger organization provides a much more stable environment financially. Additionally, you are covered by Federal Tort Claims Act protection against malpractice cases for services provided through or sanctioned by our community health center. Finally, our larger size makes it possible for us to provide more complete services from lab to radiology and procedural services in the office, and a large in-house pharmacy. We also provide oral health (dental) services at multiple sites and behavioral health services via our Family Counseling and Children’s Services division and our two in-house psychiatrists.

Q. Are there other things I should ask about on my interview day?
A. There are many things, more specific to your situation, which you should ask. But one that may not occur to you is practice management training (Management of Health Systems). All residencies have it, because it is an ACGME requirement, but not all do it well. Even if you think you will be in a salaried position orpracticing overseas, these areas are important for you to learn about. We have an excellent, longstanding curriculum with both internal and external experts that bring you information and advice on many different topics, from contracting (led by both attorneys and practice management consultants), to financial management, malpractice, personnel management, retirement, and insurance issues. You will be taught by our own COO/CFO, human resource directors and program director, attorneys, practice management consultants, financial experts, insurance consultants and bankers, among others. During the 3rd year we also do mock depositions with Baylor law students which both residents and law students find extremely beneficial.