Getting Into Radio

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The Successful Match: Getting into Radiology

October 10, 2010

Dr. Vicki Marx

By Samir P. Desai, M.D., and Rajani Katta, M.D.Authors of The Successful Match: 200 Rules to Succeed in the Residency Matchand 250Biggest Mistakes 3rd Year Medical Students Make And How To Avoid Them

Of the 4,455 total residents training in 188 ACGME-accredited radiology residencyprograms, 88.3% are graduates of U.S. allopathic medical schools, 7.6% are internationalmedical graduates, and 3.9% are osteopathic graduates.1 Dr. Vicki Marx is the director ofthe radiology program at the University of Southern California Keck School of Medicine,

and we asked for her insights into the radiology residency selection process.

After graduating from the Ohio State University College of Medicine, Dr. Marx remainedthere to complete her residency in diagnostic radiology. She then completed fellowships inabdominal imaging and interventional radiology at the Washington University MallinckrodtInstitute of Radiology in St. Louis, Missouri. Prior to joining the Department of Radiology atUSC, she held faculty appointments at both Washington University and the University ofMichigan. At USC, she also serves as the Vice Chair for Education.

At many U.S. medical schools, students are unable to take a radiology rotation untilthe beginning of their fourth year. How can medical students who have an early

interest in radiology explore the field?

This is a difficult issue. Currently, many medical students become captivated by thepuzzle-solving aspects and clinical importance of medical imaging as they progressthrough their core clinical clerkships. Based on this somewhat aesthetic perspective,some decide to go into Diagnostic Radiology without having a clue about what theresidency training process and work life are like. Two approaches can help provide thismissing information.

First, join a Radiology Student Interest group. This is an excellent way to get information

about the field. Such groups are active in most medical schools. If your school doesnthave one, start one! This not only will provide useful information for you, it is a citableactivity to add to residency applications. Make sure at least one session addresses what
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the professional work life is like after residency; many practice models exist and should beexplored.

Second, shadow a radiologist often. Shadowing practitioners through a clinical day asoften as possible is the best way to investigate the field. An interested student shouldobserve radiologists in multiple subspecialties to get a well rounded view. Although this

activity might be difficult to schedule while on clerkships that are time-intensive, it is worththe effort. In addition, radiologists work evenings and weekends, so shadowing can bedone outside the standard work week. Off-hours work in Emergency Radiology is aparticularly effective way to get an overview of the field.

A good way to begin the process of shadowing is to introduce yourself to the Radiologyclerkship director and/or program coordinator. Schedule some days to shadow. Show upon the scheduled clinical service and explain to the resident/fellow/faculty why you arethere and what you hope to learn. Pay attention. Stay until the work is done. Participate.When you get home, think about the experience and write down your impressions of thespecialty. Use the reflection as a resource for further career planning.

Securing a position in a radiology residency program requires that an applicanthave the numbers. In 2009, the mean USMLE Step 1 score among matched U.S.seniors was 238.2Many programs have established cut-off points for USMLEscores. According to a recent survey of radiology program directors, 79% ofrespondents reported having a target USMLE score.3What can lower-scoringapplicants do to improve their chances?

Id like to step back a bit first. Current medical school culture is Pass/Fail. Medicalstudents learn early in their educational process that P = MD. What medical students

may not realize in their pre-clinical years is that P !Residency. Competition forresidencies is fierce, particularly in some fields, including radiology. Competition is risingaccording to NRMP data (NRMP Results & Data, 2010 Main Residency Match, April 2010,www.nrmp.org). In the foreseeable future, it is possible that there will be qualifiedgraduates of US medical schools who cant get a residency position at all. So, whymention this? The time to begin preparing your medical school record for the match is onthe first day of medical school! Sustained effort over time to achieve a consistentlyexcellent academic record is the best way to keep all career options open.

Back to the USMLE Step 1 score: The reason this score is so important is that Step 1 isan easily accessible metric of pre-clinical performance and knowledge base. The rest ofthe preclinical transcript is typically hard to read and is nearly identical for all students. Allmedical students pass everything. With that background, the importance of a low USMLEStep 1 score is magnified, implying lack of knowledge, lack of intrinsic ability to learn, orlack of effort. In general, medical students are not poor test takers. This is especiallytrue now because medical schools teach to the test, and a large industry exists to producestudy aids for USMLE test preparation. An exception to this pattern is the USMLEperformance of the nontraditional student. Students entering medical school after aprevious career, or educational path, may do less well in the preclinical years and on theUSMLE Step 1 than students coming to medical school directly from college. Otheraspects of the application will make apparent the nontraditional students strengths.

The first thing I suggest to a student with a low Step 1 score is a moment of introspection.Is Radiology in the current competitive climate for you? Remember, all the rest of the


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people getting into Radiology residencies have really high Step 1 scores so the learningenvironment of all training programs is geared to that group. Next I recommend that astudent for whom a low Step I score is an aberration in performance explain theiracademic strengths very clearly up front in their personal statement. I recommend that thestudent work hard over a sustained period of time in the third year of medical school toexcel on clinical rotations. Clinical rotations scores of Honors and High Pass carry

significant weight in screening ERAS applications. So does a high Step 2 score. Finally,students with a low Step 1 score must apply widely to radiology programs all over thecountry in order to match in their chosen specialty. Success in the match is correlatedclosely with length of the rank list in the first choice specialty (Charting Outcomes in theMatch; Characteristics of applicants who matched to their preferred specialty in the 2009Main Residency Match; NRMP; 3rdEdition; August 2009).

Dr. Scott Pretorius, former radiology residency program director at the University ofPennsylvania, wrote that in this competitive market for radiology residency slots,medical students with research backgroundsallow themselves the opportunity tostand out in a field of increasingly highly qualified applicants. As an advisor ofmedical students, I routinely recommend that students intending to apply forradiology residency seek out a research mentor and undertake some kind ofresearch project.4Not all agree that research involvement is required, however. Inthe 2008 NRMP Program Director Survey, only 64% of programs cited involvement inresearch as a factor in selecting applicants.5What are your views on the importanceof research involvement in the residency selection process?

I see two types of research on applications for residency: 1) real research experienceleading to peer reviewed presentations and/or publications, and 2) simulated researchexperience that takes place in proximity to the due date for submission of the ERAS

application and does not lead to a peer-reviewed work product. Real research experiencehas a very positive influence on candidacy for residency particularly at institutions wherefaculty research productivity is high and where ongoing scholarly activity is highly valued,or even required of residents. Research done to pad an application is easily identified. Ithas no negative effect on the application because it is ubiquitous in the applicant pool. Ithas little positive effect either.

Absence of simulated research may have a negative effect on the ERAS application forstudents with mediocre academic records. My own opinion is that these students shouldput their energy into improving their core clinical skills rather than add another activity thatwill dilute the focus of their efforts.

Students with excellent academic performance throughout medical school, supported bydocumentation in ERAS, do not need to pad their applications to succeed in the match.Will some programs exclude them from an interview on this basis? Yes, but not many.

In a survey of radiology residency program directors, audition or away electives inthe field was ranked 15thin importance out of a total of 16 residency selectioncriteria.6While audition electives are not necessary for matching into the field, arethere times when you would recommend an auditionelective for a student?

The away rotation is a mixed bag because the student is in the position of beinginterviewed by the program over a period of weeks instead of minutes. For most peoplethis is great but for a few it isnt. The investment and anxiety are most likely to be


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worthwhile when the student has a well informed opinion that the program is where s/hewants to do residency. The drive could be geographic or academic. For instance, anapplicant with an interest or background in molecular imaging has an excellent reason todo an away rotation at an institution with a mature molecular imaging program. Morecommonly, a student of a culture where living close to extended family is a priority has avalid reason to investigate programs close to his/her family. The student should explain

the reasons for doing the away rotation openly and honestly with the clerkship director andthe residency program director early in the rotation. The rest of the clerkship should bespent in sustained effort to do a good job and to learn more about the program. Thestudent should meet with the program director a second time near completion of therotation as a courtesy and to remind the PD about his/her interest. We are old. If youdont remind us (politely and without being pushy) we will forget.

Dr. Sandra Oldham, radiology residency program director at the University of TexasMedical School at Houston, wrote that the personal statement is perhaps one ofthe toughest parts of the entire application processBut once you have acceptablegrades and have an USMLE score above our bar, the personal statement is thenext item on the agenda for scrutiny. After reading your statement, I should want tomeet you, and I should feel that I would actually enjoy working side by side with youat the workstationRemember, I am reading about 200 personal statements. Makeyours stand out.7Applicants recognize the importance of the personal statement,but often struggle to find ways to make it stand out. What advice can you offer toapplicants?

The personal statement is hard to write because no one gets taught how to write wellabout themselves. How can you write about yourself without seeming narcissistic orarrogant when your goal is to sell yourself to an audience you dont know? Egads, put that

way, writing a personal statement should be impossible. So you have to view the taskfrom a different perspective. The perspective that seems most useful to me is that of anewspaper article. In journalism class, I remember being told that a good article answersmultiple questions about the topic: who, what, where, when, and why. The objectiveERAS application components (transcript, MSPE, etc) do a pretty good job of explainingeach applicants who, what, where, and when. The personal statement gives you theopportunity to talk about your why, to explain your past, your stumbles, your dreams forthe future, your motivations for living the life you live, and your reasons for workingtowards the goals you have set for yourself. A successful personal statement answerswhy in a way that is sincere and succinct. You dont need quotes from obscureliterature. You dont need references to Wheres Waldo?. You do need honest reflection,

clear communication, and ruthless editing.

Dr. Gunderman, Vice Chair of the Department of Radiology at the University ofIndiana, wrote that many residency programs tend to interview students located ingeographical proximity, justified in part by a positive correlation between residentperformance and connection to the region. Therefore, if an applicant has aparticular interest in a program where they have been wait-listed, a telephone call orletter may be helpful to clarify that strong interest.8When and how should anapplicant with a strong interest in a particular program express their interest?


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The applicants primary goal is make sure the program director (or designee) knows thatthe student has a sincere and focused interest in this particular program. The secondarygoal is to avoid being annoying during this effort! Two points in the application processcreate natural opportunities for such interest to be brought to application screenersattention. The first is a focused personal statement where the interest in a particularprogram is clearly articulated for the reader. This strategy requires careful attention to

detail dont send a tailored personal statement intended for one program to all theprograms! The second is an email to the program director and program coordinator afterbeing rejected or waitlisted for an interview. The email serves the same purpose as thefocused personal statement: to articulate clearly the reasons the applicant has for beinginterested in the program and the willingness to interview on short notice should anopportunity become available. If no response comes to the email, a phone call to theprogram coordinator is a reasonable step to make sure the email was received. Thenyou wait. You may get an interview and you may not. There are no guarantees in thisdifficult process.

Speaking from my own experience as a program director, I do have a bit of advice aboutactions to avoid if you want to increase your interview opportunities. First, do not makemultiple phone calls to the department. Listen carefully to what is said in the first phonecall and live with it. Second, do not trash the program in question on a public internetforum. Your username may be less anonymous than you think! Finally, do not let one ofyour parents, or one of their friends who has connections with the institution, call thedepartment on your behalf. Those phone calls are uncomfortable for all involved and donothing to change the content of your application.

The transition from residency to practice is challenging. Dr. John Cronan, chairmanof the Department of Diagnostic Imaging at Brown University, cites the frenetic

pace of work, high volume, and stress associated with having to render the finalread as particularly difficult for most graduates.9In evaluating prospectiveradiology residency programs, how can applicants assess a programs ability toprepare graduates for practice?

This can be tough. The most reliable source of this information is a recent graduate of theresidency who currently has a real job. This person is unlikely to be present at theinterview. Interestingly, this information is becoming more available to programs thoughthe ACGME requirement to assess residency outcomes by using tools such as surveys ofgraduates. It is fair to ask about the results of such surveys but not all programs have amature survey process in place yet.

Residency training programs that prepare physicians for the frenetic pace, high volumeand stress of real life radiology practice are those that provide these opportunities duringresidency. Programs with high case volume and high expectations for residentperformance under appropriate faculty supervision are preparing residents for the realworld. Programs described by current residents as totally chill may be providing lessoptimal preparation. Applicants need to ask about case volume, system for providingresidents with feedback on performance, and level of on-call responsibilities to get a senseof the training opportunities available. On-call experience is particularly valuable. Duringthe standard work day, residents typically work alongside supervising faculty. At night,

residents have faculty back-up but it may be a phone call away. This is where the residentlearns to become independent in interpreting images. A resident who has never had torender a preliminary opinion on a CT study at 3am while alone in the Emergency


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interventional radiology, mammography and pediatric radiology) and a huge impact onpatient care. Maybe if we did a better job of demonstrating that to students during medicalschool, their perception of the specialty would be closer to reality.

References

1Brotherton S, Etzel S. Graduate medical education, 2008-2009. JAMA2009; 302 (12):1357-1372.

2Charting Outcomes in the Match, 2009. Available at www.nrmp.org. Accessed July 26,2010.

3APDR Program Director Survey on the Match, 2008. Available at www.apdr.org/index.cfm. Accessed on July 26, 2010.

4Pretorius E. Medical student research: a residency directors perspective.Acad Radiol

2002; 9(7): 808-809.

5Results of the 2008 NRMP Program Director Survey. Available at http://www.nrmp.org/data/programresultsbyspecialty.pdf. Accessed July 26, 2010.

6Green M, Jones P, Thomas JX. Selection criteria for residency: results of a nationalprogram directors survey. Acad Med 2009; 84(3): 362-367.

7Oldham S. Guide to the Radiology Match. Available at www.uth.tmc.edu/radiology/guide_to_radiology_match_2007_2008.htm. Accessed July 26, 2010.

8Ertel N, Gunderman R. Helping medical students to prepare for radiology residencyinterviews.Acad Radiol2006; 13(9): 1168-1171.

9Cronan J. My first job: the transition from residency to employment what the employerand employee should know. J Am Coll Rad2008; 5(3): 193-196.

10Roubidoux M, Packer M, Applegate K, Aben G. Female medical students interest inradiology careers. J Am Coll Rad2009; 6(4): 246-253.
http://www.uth.tmc.edu/radiology/guide_to_radiology_match_2007_2008.htmhttp://www.nrmp.org/data/programresultsbyspecialty.pdfhttp://www.nrmp.org/

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