Dermatology Online Journal

Advice for fourth year medical students beginning the dermatology residency application process: Perspectives from interns who matched
Ali Alikhan MD¹, Raja K Sivamani MD², Misha M Mutizwa MD³, Lesley M Felsten MD¹
Dermatology Online Journal 15 (10): 3

1. MacNeal Hospital, Berwyn, Illinois. alialikhan1@yahoo.com
2. Santa Clara Valley Medical Center, San Jose, California
3. Albert Einstein Medical Center, Philadelphia, Pennsylvania

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Introduction

Getting a dermatology residency positionis a difficult hurdle. This article is targeted to fourth year medical students beginning the application process to dermatology residency programs. We discuss the application itself, the interview process, and the ranking process. We also discuss avenues to take if one does not match into dermatology but remains interested in the field. We summarize the perspectives of four recent medical school graduates, now interns, who matched into dermatology in the 2008-2009 cycle. It is important to remember that this is simply one pooled set of suggestions, and that decisions should ultimately be made by the student.

Discussion

Applying

Applying in dermatology can be an anxiety-provoking process, given the limited number of positions and abundance of well-qualified candidates [1]. The Electronic Residency Application Service (ERAS) application requires several parts: a detailed listing of activities (extracurricular, research, publications, time off, memberships, leadership, hobbies), a personal statement, letters of recommendation, academic transcripts, United States Medical Licensing Exam (USMLE) Step scores, and Dean's Letter.

It is difficult to address the question of how many programs to which one should apply – there is no penalty for applying to all programs except for expense. It is generally suggested that applications be submitted to at least fifty programs given the limited number of positions available. When deciding how many programs to apply to, balance the strength of your application (grades, scores, research, leadership), location desirability, family/spouse issues, and cost. However, given how strong dermatology applicants are, never be too confident. You will likely find yourself applying to many more programs than your friends who are applying in different specialties, even if you are a much academically stronger medical student than they are. Conventional wisdom is that the "average" (by dermatology standards) applicant should apply to as many programs as is financially feasible. This being said, one can save hundreds of dollars through a simple review of the past several years' match lists on the dermatology forum of the Student Doctor Network website (or through individual departmental websites). Discussion with past dermatology applicants who are familiar with the trends of particular institutions is also helpful. There are certain programs that typically take either medical students from that particular institution or region or individuals who have completed research fellowships at the institution. Applying to these programs may not be an efficient use of time and money.

The issue of where to apply is one worth discussing with your mentors, your program director, and other faculty members. In any case, it is better to err on the side of too many rather than too few applications. Though more interviews typically come from regional programs, this is not always the case. One author received almost all of his interviews in states other than his own and most of his interviews were not even in his region. Keep in mind that the programs you find desirable, be it for location, reputation, or another factor, will likely be highly sought after by your colleagues as well. Applying to some smaller, less centrally located programs may improve your chances of receiving an interview, simply because there will be less competition. Try to submit your application as close to September 1st as possible, but it may be important to delay slightly if this means that newly submitted papers can be included. Within dermatology departments, applications are not usually reviewed until October, November, or even December. Be aware that some programs require application submission before the typical November 1st deadline. For example, the earliest application deadline during the 2008-2009 application cycle was in early October. This information is almost always available on individual programs' websites.

Hopefully, over the past four years you have been keeping track of organization memberships, activities, research, and academic or leadership positions. All of these will be essential in completing the application. Additionally, the time spent per week or month and a brief (but clear) description of specific responsibilities will be important. Some judgment as to what to list is also important. Include activities that were meaningful and required a significant amount of involvement and time are important to include. Remember, anything on the application is fair game as an interview question. List activities about which you are passionate and can describe acurately. Avoid listing only things that are medically relevant – any hobbies or activities that demonstrate what kind of person you are should be included. Several of the authors participated in non-medical activities, ranging from environmental conservation to traditional Indian music. These kinds of things set you apart and make you unique. Always remember to be honest about everything you list – if you are not, it may come back to haunt you. This is particularly true for listing research publications; faculty at a particular program can call journals to inquire about the validity of a submission listed on an application [2].

The personal statement is another important component of the application. It is your chance to describe yourself outside of your grades, test scores, and CV. Although a phenomenal personal statement will probably not be the sole determinant in obtaining an interview, a poor personal statement may exclude you from interviews. Thus, a conservative approach, which still speaks to your interests and passions, is called for. It is important to discuss what attracted you to dermatology, what you hope to accomplish as a dermatologist, and why you will be an asset to a program. However, remember that every other applicant will be addressing these same issues. Your personal statement should address these issues briefly, but leave the reader with a unique and positive impression of your character.

Avoid clichés to the effect of "I am a visual person" or "I like that in dermatology you can be an internist, a surgeon, and a pathologist all in one!" Although there is certainly some truth to these points, they are likely to be true for virtually all applicants and thus will do little to make your application seem interesting [3]. It is important to keep your personal statement less than one page – with hundreds of these to read, multiple pages can turn a reviewer off. A different personal statement can be sent to each program. Therefore, it would be reasonable to use a few lines of the personal statement to highlight any specific interests in you have in a program (e.g., a particular mentor or research arena) or links you have to the particular geographical region where a program is situated. After creating a first draft and editing extensively, have several people look at it including your program director, chairman, other dermatologists and physicians, friends, family members, and classmates.. Essay editing services are available online for unconfident writers. Clearly indicate your motivation and your objectives.

Like a personal statement, letters of recommendation can also offer a personal glimpse of an applicant, beyond activities, grades, and scores. Strong letters from non-dermatologist physicians may also be helpful. Supporting letters from specialists in medicine, pediatrics, and surgery may be helpful if they are excellent. Several dermatology programs ask for a non-dermatologist letter (they prefer supervising physicians from an inpatient rotation). Furthermore, preliminary and transitional year programs almost always want such a letter (or two).

As far as dermatology letters go, the most valuable letters are from the people who know you best and who spent the most time with you. Dermatologists with whom you conducted research or worked with extensively over the years, especially mentors, can write letters that are very detailed and powerful. After this, your program director and chairperson (if your school has a dermatology program) are important. Finally, other dermatology faculty at your institution or at away institutions should be considered. Only four letters are acceptable in the ERAS application. Simply having a letter with the name of a well-recognized dermatologist is not as important as a letter from someone who can vouch for your abilities, discuss your interpersonal communication, and demonstrate that they know you personally. If this person is also well-recognized in academic dermatology, that is ideal. When it comes to asking for the letter of recommendation, try to do this in person. Make sure to ask the writer if he/she would feel comfortable writing a strong letter of recommendation; an average or standard letter will not be helpful. This gives the potential letter writer the option to say "no," saving the letter writer time energy and the applicant from having a lukewarm letter, which can be detrimental.

Sending out an email to request a meeting is an appropriate way to do this and it will ensure protected time dedicated to discussing your letter. Be prepared to provide your letter writers with a copy of your personal statement and your CV; this will help them fill in important details they may not know. Remember to give letter writers at least one to two months notice – they are busy people, and need advanced notice.

When deciding which letters to send to which programs, several factors may be of import. These include: 1.how well a particular letter writer knows you 2.the connections that a letter writer may have at a particular program 3. the emphasis of particular programs- clinical versus research. The dean's office at one author's home institution had access to viewing the letters of recommendation as they were uploaded to ERAS and was able to provide guidance about which letters were strongest. Not all medical schools will do this for their students, but it may be worth your time to ask.

Finally, the Dean's letter is considered by some to be critical in the interview offering process. Many programs will not begin looking at applications until the Dean's letter arrives (typically November 1st). Although the major content of this letter is not in your control, most universities allow their students to participate in its production. When a first draft is sent to you, read it carefully. Make sure that it represents your character and what is important to you. If you feel that something is not discussed or discussed incorrectly, notify the writer as soon as possible. This letter should accurately portray you and your accomplishments during medical school. It is important that it contains evidence to support any subjective statements that are made.

Ultimately seek advice from those who have guided you and those involved in medical education (e.g., your program director or chairperson) when compiling your application. Ask them where to apply and what activities to include; have them read your personal statement and ask them which letters to send to which programs. Experience is key. For instance, your program director may tell you to apply to a particular program in another state (which you may not have done otherwise) because that program has a strong track record of interviewing and admitting candidates from your school.

The use of Online Forums

By now, most readers are probably aware of the existence of several online discussion forums targeted primarily at dermatology applicants. Decide early on whether you want to make use of these forums during interview season. These sites can provide invaluable information and services to applicants (e.g., a listing of when various programs make interview offers or send out rejections, a listing of applicants interested in trading interview dates, and so forth). These forums are also useful in that they allow for exchange between current applicants, residents, and faculty members. Some applicants find these types of sites overly stressful and choose to avoid them. Anyone who does choose to use these sources should be aware that some of the information provided by anonymous posters is, unfortunately, designed to mislead. Everything you read on any of these forums should be taken with a grain of salt. One should particularly avoid reading too much into posts regarding applicant statistics (e.g., board scores, AOA status, number of publications). These are often used to intimidate other prospective applicants.

Interviewing

Many of you have not interviewed for any position since applying to medical school and this can be a strange and sometimes nerve-wracking experience. Fortunately, anxiety decreases after the first few interviews when you begin to feel more comfortable with yourself and with your answers.

Getting interviews for dermatology residency positions is challenging and many programs may only offer one or two interview dates. This becomes a dilemma if your interview invitations are from programs with overlapping interview days. Scheduling interviews for dermatology is a test of speed because they are scheduled on a first come-first serve basis for the dates. Apart from the few programs that personally call or send snail mail offers, most programs will send mass email interview offers. Because of this, you may find yourself in the predicament of having to schedule two interviews for the same date. Consider investing in a mobile phone with email capabilities, so that you are able to check throughout the day. While this may seem excessive, be aware that the majority of your fellow applicants will be doing this. In one author's experience, particular interview dates have filled within an hour of when an email was sent out. Also, it is wise to schedule as many interviews as possible in December because the majority of interviews occur in January when scheduling conflicts are most likely to arise. Weekend dates, when available, are also good options; the vast majority of interview dates will be during weekdays.

Should there be a conflict between interview dates, one option is to ask the coordinator at either school to put you on a waiting list for another preferred date. Remember to be polite and considerate to the interview coordinator because they may have some influence about your application (usually only if there is a negative experience). Being perceived as pushy or needy or simply annoying to the interview coordinator could well be the kiss of death for any chance of acceptance at that program.

An alternative option would be to find another interviewee at that school who will be willing to switch dates. This can be done by posting your request anonymously on online dermatology forums, specifically the dermatology forum on the Student Doctor Network webpage. In the chance that you are unable to switch either of the conflicting interviews, one must be cancelled. Do this as soon as you know you will not be able to attend an interview because this may permit another applicant to interview.

The majority of programs conduct pre-interview dinners where applicants are able to converse with residents and, rarely, faculty. Make every attempt to attend these dinners if you are able; this is the best chance to get a feel for a particular program and its residents. It may also be an important component of the applicant evaluation process at that program. Oftentimes faculty at the formal interview will ask about the dinner and being able to talk about your experience shows you are serious about their program. Whereas you may be aware that you are being informally evaluated at these dinners, be yourself. Keep this in mind when interacting with residents and, just as importantly, other applicants. In general, individuals who are outgoing without being overbearing or obnoxious do the best in these situations. If you are a wallflower, make an effort to be more outgoing without seeming disingenuous. Similarly, if you are an extrovert, avoid dominating conversations. There are certainly topics that should be avoided during pre-interview dinners. It is fine to compare your experiences at other institutions with other applicants and residents, but avoid saying anything overly negative about individuals or programs. It is also wise to avoid discussing the number of interviews you have received (as well as grades and scores) or asking residents questions that may be perceived as being too intrusive.

The interview day will be different at each program. Know where and when to be somewhere; showing up late would be poor form. Interviews may last as few as ten or up to forty-five minutes. Most interviewers will opt for a casual conversational approach. Others may have a pre-set list of questions and will conduct a more formal session. Make sure you have thoroughly reviewed your application, including your personal statement, CV, and extracurricular activities. It is particularly important to be intimately familiar with the details of each research pursuit included on your application. Remember, anything listed is fair game for discussion. Also, think about anything that may have changed in your application since submitted; there may be an opportunity to discuss a new publication, research project, or leadership position. Anticipate some potential questions and think about how to answer them. Why do you want to be a dermatologist? Why did you apply to our program? What is the last book you have read? Tell me something about you that is not on your application? This may sound elementary, but answering questions clearly and thoughtfully is important. If you have not thought through such simple questions recently, you may find yourself tongue tied or rambling during the interview. Also, be aware that some interviewers will ask you bizarre questions or very technical questions about dermatology. Be aware that these types of questions are generally designed to assess your stress response – take a few seconds to think about your responses and remember to smile. A great resource for basic interviewing skills and answers to common interview questions is Iserson's Guide to Residencies.

Many interviewees are unsure of the etiquette surrounding thank you notes after interviews. Some of the authors routinely wrote thank you notes, but others did not write any. As a general rule, thank you notes are unlikely to affect your position on a rank list. If you feel uncomfortable not sending a thank you note, by all means you should do it. However, be aware that some programs instruct not to send thank you notes to their faculty. If so, follow these instructions. Be aware that at some programs interviews will be with more than ten faculty members. There are certainly candidates who sent thank you notes to every interviewer they encountered on the trail, but a reasonable approach with larger programs is to send thank you notes only to the interviewers with whom you had the most meaningful conversations. Alternatively, some candidates only sent thank you notes to the program director and/or chairperson.

Ranking

Once interviews are over, applicants are faced with the task of creating a rank order list. Some authors created a list of pros and cons for each program; others sorted their lists simply by gestalt. Some chose to rank based on the perceived prestige of the program. Whereas there is no right or wrong way to make a rank list, conventional wisdom is to trust your gut. Rank list ordering is facilitated by asking the right questions of residents during the interview day or at the pre-interview dinner. It is advisable to compile notes about each particular program immediately after the interview day; it will be difficult to remember some important details when it comes time to compare and contrast programs several weeks later. Remember that the match will always work in the applicant's best interest. Whether or not a program ranks you highly on their list should not affect how you rank them.

Once you have finalized your rank list, the final thing that should be done is to let your #1 choice know that they are your #1 choice. According to the NRMP rank list rules, the dermatology program or the candidate may voluntarily divulge their interest in the other as long as they do not solicit the other party's interest. Therefore, it is well within the rules to let a program know that you are very interested in them. Make such communication brief and concise. Making a particular program aware that you have ranked it first will not necessarily improve your chances of matching there, but in general it can do no harm; programs want residents who are enthusiastic about them.

Dermatology is a small field and many of the academic dermatologists know each other. If you have built up a strong or close relationship with a particular mentor, it may be reasonable to have that mentor place a call to the program(s) you like best. This should be done carefully, if at all, and only to places you are serious about after the interview. A special case in which you may have your mentor place this call before the interview is if you are declined an interview from an institution in which you were exceedingly interested. In this case, your mentor may make the difference in helping garner a precious interview.

With regards to ranking preliminary programs, the NRMP allows you to make two distinctions on your rank order. There is a primary rank order and a secondary rank order. The primary rank order is the main list where the NRMP match algorithm will start in trying to match you into programs. You can place any program, be it a dermatology program, a preliminary program, or a transitional program on this list. The secondary rank order is for ranking your intern year programs. This can be a combination of preliminary and transitional year programs. You can make a separate secondary list for each program on the primary list. Secondary lists are required only for programs that require you to find your own internship, such as an advanced dermatology program. The NRMP website will not allow you to attach a secondary list to programs that already have the internship included.

One point of confusion that arises is the difference between a "preliminary year" and a "transitional year." Both are one-year internships. Preliminary years have more focus on a certain field, such as medicine, surgery, or pediatrics. A transitional year is a "rotating internship" where the experiences tend to be more varied and time will be spent in surgery, internal medicine, pediatrics, and ob-gyn. There is also more specialty elective time. It is advisable to place a reputable preliminary medicine year on your primary rank order list as a backup should you fail to match in dermatology. Most clinical fellowships require an internship and dermatology residency programs tend to prefer candidates who have completed an internship in internal medicine because they are viewed as being more rigorous than other types of internships. It can certainly be argued that there is great value in a transitional year for individuals interested in dermatology; in these there is the opportunigy to spend months on subspecialty rotations that are more relevant to dermatology (e.g., rheumatology, infectious disease, plastic surgery). Indeed, all four authors are currently completing transitional year internships. However, avoid ranking transitional programs as a backup if you go unmatched; these internships tend to be looked down upon by faculty at many programs. Be aware that you will be asked what you plan on doing for your internship during interviews; be prepared to answer this question.

In case you do not match

If you do not match into dermatology, it is not the end of the world. In fact, many dermatologists and dermatology residents did not match on their first try. Begin looking into alternatives around the time of submitting your ERAS application.

Before you submit the application, think long and hard about what you want for your future. If becoming a dermatologist is the only thing that will make you happy in life, then put yourself out there and feel confident in your decision. However, many of you may have other interests outside of dermatology. If there is another field in medicine that interests you, it is worth your time to consider dually applying to both dermatology and another field. Although this is not an easy task to do (it requires a separate personal statement, separate letters of recommendation, and potentially twice as many days to interview), it can be and has been done before. If you decide to double apply, keep this information to yourself as much as possible. Do not apply to two different programs in the same institution. Program directors for either specialty may not take you seriously if they know you are not 100 percent committed to their field. However, it is your right to do this if you so choose. It may be comforting to know that if you do not match into dermatology, you may still match into something else you enjoy.

If however, becoming a dermatologist is the only reason you live and breathe, begin to consider alternative options should you not match into dermatology. Several possibilities exist: 1) Complete an internship in medicine, pediatrics, or surgery and then reapply during the next application cycle. 2) Conduct a year of research and apply again during the next cycle (be aware this option is more appropriate for those with basic science interests; most clinical research fellowships require prior completion of an internship). 3) Complete an internship followed by a pre-dermatology residency fellowship and apply again in two or three cycles (depending on the length of the fellowship). Such fellowships, improve the chances that one will match during his/her next go-around [4], oftentimes at the institution where he/she is participating in the fellowship. However, be aware that these fellowships do not typically "guarantee" a residency slot. Hard work, perseverance, productivity, and above all, interpersonal skills are essential during these fellowships. Be on the lookout for fellowship opportunities on the dermatology page on the Student Doctor forums, the message boards at derminterest.org, and the websites of individual dermatology programs. These fellowships are typically competitive so it is advisable to contact fellowship coordinators early and have your mentors and faculty send letters, emails, and/or make phone calls in your support. Try and pick programs with a good track record of matching their fellows into dermatology residencies. The best way to find out which programs fall into this category is through word of mouth – ask past applicants and faculty members at your institution. The time to contact these fellowship sites would be right after the match results are posted.

For those who want to start an internship and then apply again in the next cycle, ask yourself "what will be different this time?" In other words, evaluate how the application has changed since the unsuccessful match? Perhaps you were able to submit several papers, present a poster, give an oral presentation, or win a major award. Realistically evaluate the changes and consider whether or not a year of research (e.g., such as pre-dermatology fellowship described above) could help more. Remember, each time you apply, your chances of successfully matching decrease.

Finally, you may decide if you do not match that you would like to conduct a year or two of research and reapply for dermatology in the next cycle or in two cycles (delaying graduation in other words). The first step is to make sure your school is approves this. The second step is to find a suitable research mentor and suitable project ideas. Remember that productivity in such a year is crucial to a successful retry of the match process. Select a mentor who is well-published and whose students have a strong track record of matching into dermatology residencies. For more information on mentor selection, see our first article [5]. If you think you'd rather not begin a transitional or preliminary medicine year if you do not match into dermatology, remember to make your intern year contingent upon matching into dermatology on the NRMP website. Otherwise (e.g., if you rank intern programs below dermatology programs on your primary list), you may match into a preliminary medicine or transitional year program without matching into a dermatology program. Remember the NRMP is a contractually binding agreement and it is not acceptable to say "no" to a program after you have matched there.

If you decide that you would not like to apply for dermatology again, or have applied several times unsuccessfully, but still love studying cutaneous disease, do not worry. Many family practitioners and general practitioners also practice a great deal of dermatology. During and after a family medicine and internal medicine residency, there are opportunities to work with dermatologists to learn, in greater detail, about diagnosis and treatment of skin disease (including procedures) [6].

Conclusion

There are clearly many factors to consider when applying to, interviewing at, and ultimately ranking programs. Careful consideration of the issues discussed above is crucial to a successful outcome. Nevertheless, in many cases, even the most qualified applicants fail to match on their first try. With persistence and dedication, a successful match is certainly attainable. The key is to plan early, be organized, stay positive, and discuss any concerns or issues with mentors, residents, and faculty members at your institution and institutions where you have rotated. Although it is important to take the application process seriously and to stay focused, try to enjoy yourself and the company of your future colleagues!

Acknowledgments: We thank Dr. Steven R. Feldman and Dr. Andrew Lee for their valuable editing, suggestions, and ideas.

References

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3. Heymann WR. Advice to the dermatology residency applicant. Arch Dermatol. 2000 Jan;136(1):123-4. [PubMed]

4. Wasong SJ, Miller JJ, Zaenglein AL. Does a predermatology fellowship increase the chance to match in dermatology? J Amer Acad Dermatol. 2008 Sep;59(3):535-6. [PubMed]

5. Alikhan A, Sivamani RK, Mutizwa MM, Aldabagh B. Advice for Medical Students Interested in Dermatology: Perspectives from Students Who Matched. Dermatol Online J. 2009;15(7):4.

6. Kosari P, Alikhan A, Yentzer BA, Lynch PJ. The Role of Family Practitioners in Skin Care. Skin & Aging. 2009;9(4):48-51.

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