Unsolicited Advice to Residency Applicants.

A medical student recently told me that he wants to become a psychiatrist.

“What should I look for in residencies?” he asked.

I wrote the following in September 2007. Though I am now a few years out of training, I believe much of the information still holds true. If you will be applying for a residency slot later on this year (regardless of specialty), you may find the suggestions below useful.

So, you are in your final year of medical school and will soon begin life in post-graduate training (because overeducation will help you lose weight! have more confidence! get you a lot of dates!). You’ve selected a specialty. What are some things to look for while you attend your interviews in your black suit while clutching your black, leather-bound folder? What are questions to ask of the people you meet? What are some things you ought to consider that may significantly impact your training experience?

How many clinical sites are in the program? The more clinical sites generally means more exposure to clinical diversity. If you train only in a community hospital, you’ll learn to manage common medical events, but you’ll miss out on more exotic cases. If you only train in a private sector hospital, you’ll become familiar with the medical problems of people who have money and/or insurance, but miss out on the indigent population and people who can’t afford healthcare (which includes a lot of people). The number of clinical sites will affect your clinical experience and “fund of knowledge”.

However, the practical aspects of clinical work become complicated with each additional clinical site. If you are in a specialty that includes an outpatient component, your clinic may be at Orange Medical Center, but you may be on an inpatient rotation at Apple Hospital. Getting from Apples to Oranges could be frustrating, particularly if you cannot chart for Apples while at Oranges. Keep in mind the practical aspects of travelling from one site to another: Is there a shuttle system? How reliable (and efficient) is public transportation? If you drive, how is traffic between Site One and Site Two? What about parking?

Furthermore, the more hospitals involved in the residency program could potentially mean more call. Although the number of residents in any given program is directly proportional to the number of medical centers in a residency, that doesn’t mean that there are necessarily enough residents to permit a decreasing call burden as one advances in the residency. (For example, there are many psychiatry residents in the country who do not take any call as third- and fourth-year residents. This sounds almost obscene to those of us who do did.)

What do the current residents have to say about the residency program director? If the residents generally malign the program director, then this does not bode well for the residency. Find out the reasons for the disdain: Does the program director ignore resident comments and complaints? Is the program director more concerned about his/her status in the academic hierarchy rather than resident welfare? Has the program director repeatedly refused to advocate for residents?

If the residents say little about the program director (“who?”), this is also worrisome: Does this mean that the program director is never around? Does s/he (purposely?) limit contact with residents? How do residents deal with residency-wide problems?

Obviously, not everyone is going to like everyone else (including the program director), but you want to look for a program where people respect the residency director.

How involved is the department chair in resident education? This is difficult to suss out and doesn’t seem entirely relevant, but the department chairperson does indirectly affect the resident experience. If the department chair doesn’t care about resident education, that means that the chair will not support the residency director. (See the previous point.) If there are attendings who are atrocious towards residents, but are nonetheless producing excellent research or are otherwise bringing in The Big Bucks, these attendings will continue to participate (or not, if that’s the problem) in training residents.

If the chairperson meets applicants during residency interviews (whether formally or not), this is encouraging. If the chairperson interviews applicants, this is also encouraging.

Do the residents like each other? This is obvious. You don’t want to work with people who can’t tolerate each other.

Does the residency try to make your life easier? Much of this may actually depend on the School of Medicine, as that is where each residency obtains much of its funding. This is what I mean by “make your life easier”:

  • Do you have to pay for your own meals while on call? Does the residency reimburse you for meals? Do residents have a “meal card” that they can use with ease while on call to get food?
  • Do you have to pay for parking? (This adds up.) How far are the resident parking lots from the hospital and clinics? Does the residency offer a voucher for public transportation (bus pass, etc.) so you can travel at a discount or, even better, for free?
  • Does the residency provide (cheap) options for health insurance? dental insurance? life insurance?
  • Are residents permitted to participate in a savings program? Will the institution match the donations you invest?
  • What provisions are in place to maximize your safety? Will security officers walk you to your car at your request if you’re leaving the hospital at a late hour? Can you get a ride to a safe bus stop?
  • If an electronic medical record is in use, does the IT department want your feedback? Can you chart from your computer at home? If not, why not? If so, do you need extra software, security clearance, etc.?
  • Do residents have an “education fund”, where the residency provides money for the residents to purchase books or attend conferences? How much is in that fund? Does it roll over with each year?

What is the balance between service and education? Ask the residents how the residency provides education. (The incorrect answer is: “Oh, we kinda run the hospital.”) Is there dedicated time for residents to attend didactics? Do these formal teaching sessions occur on a weekly basis? monthly basis? as needed harangued basis? Who teaches the residents? Are the attendings in clinical settings invested in resident education, or merely invested in scutting out residents? Are there case conferences? journal clubs? Who organizes them? Who attends them? (It doesn’t count if the residency “offers” them, but the residents feel too saddled with work to actually participate in them.)

Do you want to moonlight? Most people don’t go into residency with this question in mind and perhaps I am not in the best position to address this: I do did not moonlight, as I much prefer having time over money. However, if you have plans to start a family, want to pay off your loans as soon as humanly possible, desire to purchase property, or otherwise want to bring in the BLING BLING to charm the ladies (…), inquire into moonlighting opportunities and difficulties. Some residencies (or, more commonly, the associated Schools of Medicine) won’t let you moonlight within the clinical institutions in which you work (e.g. the ER). Some residencies won’t let people moonlight within a certain geographical distance. Driving fifty miles to work on a weekend sucks. (Refer back to the first point about clinical sites: These other psychiatry residents who do not take call as senior residents are often moonlighting within the clinical institutions and thus are (1) providing call coverage anyway and (2) making BANK while doing so.)

What do you like to do when you’re not working? Do not be mistaken: As an intern, you won’t be doing much other than working, sleeping, and performing necessary ADLs (Activities of Daily Living—bathing, eating, etc.). However, as you progress in your training, you should have more time away from work. If you love to fish, attending a residency in a land-locked area is not a good idea. If museums and viewing plays are sources of joy in your life, a rural residency probably won’t sustain you.

Of course, you can cultivate new hobbies wherever the Match sends you. The opportunity to immediately continue your interests upon relocation, however, allows you to build your (non-medical) social network rapidly. And you may find that your non-medical friends, in engaging you in your non-medical hobbies, offer invaluable support when the fangs of medicine have latched onto your soul and are draining you of your Life Force.

Now that it’s four years later, I would add two more things:

Where do the graduates of the residency go and what are they doing? Everyone has their own interests, of course, but this information can at least suggest how the residency has trained people for “real life”. If graduates end up throughout the country in a variety of positions, this could mean that the residency provided excellent training that prepared graduates for different jobs. (It could also mean that graduates disliked living in the city where they trained and wanted to get out as soon as possible.) If graduates all end up working in the clinics and hospitals associated with the residency, this could mean that graduates couldn’t get jobs anywhere else. (It could also mean that they didn’t want to work anywhere else, which could reflect well on the academic center.) If graduates end up not practicing medicine… well, you get the idea.

Is there stability within the administration? Things change all the time, though significant change within higher levels of administration (chairs, vice chairs, chiefs of service, etc.) can make the lives of residents more stressful. When leadership changes, that can lead to changes in policies and practices that can directly affect training experiences. The balance between service and education could shift. The number of training sites could increase or decrease. Call schedules could change. Faculty turnover might suddenly increase. These changes may be long overdue and everyone might welcome them with open arms, but change—even for the better—can still lead people to feel anxious or uncomfortable. Leadership instability isn’t reason alone to avoid a residency, though you might want to ask more questions to learn more about the reasons behind the changes.

Best wishes to the medical students who will be applying for residency slots. May you be offered way more interviews that you can attend and courted with enthusiasm and vigor. The Match will come sooner than you think.