ERAS Round 2 - Readjusting Expectations

[mehc012]

Hey all,
I am a graduating USMD student who unexpectedly found myself having to SOAP into a preliminary PGY1 position. Frankly, I am still not entirely sure what the reason was for this, as I was considered by my advisors to be an excellent GS candidate with good chances at a strong surgical residency.

Obviously, this was a blow, and it has taken some time to adjust to my new expectations. I know that I will be applying for categorical GS positions again in the fall, and will have to go through all of the stress and expense of an ERAS cycle. What I'm not sure of is...what are reasonable/realistic goals going forward? As a preliminary resident, I know that many programs will not consider me on that basis alone. During this last cycle, it felt as if my options were fairly open...I was considering primarily academic programs, as I have some interest in the more competitive fellowships, though I also interviewed at several community programs. Now, I'm unsure. I don't want to set myself up for disappointment (again), so I was hoping that y'all could help give me an idea of what is realistically attainable for a preliminary PGY1 applicant.

App summary:
∙ ~260 on both Step 1 and Step 2 CK, first time pass on all board exams
∙ Honors in every clinical clerkship except Pediatrics (HP)
∙ Honors in 3 GS AIs
∙ One weak research experience/non-first-author publication in review at time of app
∙ Extensive global health experience and interest
∙ Strong letters (these were quoted to me frequently during interviews and referenced as a strength in my app)
∙ Decent PS (also discussed in multiple interviews, reviewed by multiple GS faculty including a PD prior to submission)
∙ 16 interview invites, 13 interviews attended (scheduling issues), ranging from community programs to well-known academic centers. Almost all of my interview invites were early, with interview dates beginning in October, concentrated in November, with only a few stragglers in Dec or later (mostly due to scheduling conflicts, not late invites).

I ultimately SOAPed into a PGY1 position at a top academic GS program which said it had actually considered inviting me during the main cycle, and was surprised to see me in the unmatched pool. No guaranteed retention of preliminary residents.

Possible negative factors:
- I did not have sufficient research for the sorts of institutions which sought out my board scores
- My school has a poor history of GS matches (~50% SOAPed the year prior to mine, low GS application numbers due to poor faculty support).
- I did not write thank you letters to most programs, and sent only one Letter of Intent (to my #1 program)
- I did not network, or ask mentors to reach out to their connections, etc.

Ultimately, I didn't play the game as I ought, perhaps because my hubris told me that I would at least Match somewhere, even without playing the game. Lesson learned.

Spoiler: Plan for the next cycle:

- My residency plans to put me on rotations with good attending exposure during the early months so that I can garner good letters. Obviously all of my letters will have to be from intern year.
- Attend every interview. Again, my residency is supportive of this, with a month's vacation during interview season and freedom to attend other interviews if they cannot be scheduled during that time.
- I plan to hit the ground running in intern year. My letters from AIs painted me as a hard worker and a valuable team member. This time, I plan to step that up to a new level, and also to be as prepared as humanly possible. I've already Anki'd a fair portion of the ABSITE review book and am going through the list of GME competencies for interns sent by my program, with plans to familiarize myself with all procedures, indications, etc. on that list prior to starting. I'm reviewing common intern calls, dosing of common floor meds, electrolytes and repletion, etc. I will stay late, get in early, and take whatever extra shifts need covering. My partner is supportive and understands that this is going to be a GRIND for both of us.
- New PS, though I do hope to borrow heavily from my current one, as that was not cited as an issue.
- Use EVERY contact I can possibly make. Ask for recs, calls, whatever it takes.

However, even with all of this, I know that my odds are even lower this time than they were the last. Given the above, I was hoping you guys would have some idea of what my new goals should be. My hope is to get a PGY2 categorical position, or failing that, a PGY1 categorical somewhere. I chose this prelim position as a stepping stone, with the hope that academic programs would still be open to me by taking this path. Is that realistic?

Thanks for reading the novel. Feel free to skim, but the first 12 responses are always asking for more information, so...here's everything I could think of to include from the get-go.

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[Dr.LeoSpaceman]

Wow. Sorry to hear this. As you probably know, based on the stats you're in the 1%...unfortunately it's not the good 1%.

As for what happened, tough to tell but a few thoughts.
1) Issues with interviews. Honestly this is often the most likely. If you got a prelim at a place that interviewed this seems less likely, but you need to try and figure out if there's something you said/did at interviews that raised eyebrows.
2) Your letters were good, but you came from a place that isn't a "known quantity". The fact that your school has had issues matching people to surgery in the past makes me think this could be an issue.
3) You got stuck in a situation where you didn't quite make the cut at academic programs due to the research, but community programs thought you were "too good" or that you weren't really interested in a community program.

I think you have a good plan, and it's great the prelim program is going to help you out. I'd definitely make sure they know you're open to taking a prelim PGY2 spot if that's what it comes down to.

Fortunately, #2 should be addressed by being at a program that will give you the bona fides you may have been lacking.

#3 can be addressed by trying to get some chip shot clinical research papers done early, though they likely won't be on your CV prior to application. I think you also need to make sure you're consistent in your message to programs during interviews.

#1 is the toughest to address. I'd see if your current PD is willing to share general feedback from their interview process.

Work hard, be a team player, and don't rule out any options. Good luck!

 

[mehc012]

Wow. Sorry to hear this. As you probably know, based on the status you're in 1%...unfortunately it's not the good 1%.

As for what happened, tough to tell but a few thoughts.
1) Issues with interviews. Honestly this is often the most likely. If you got a prelim at a place that interviewed this seems less likely, but you need to try and figure out if there's something you said/did at interviews that raised eyebrows.
2) Your letters were good, but you came from a place that isn't a "known quantity". The fact that your school has had issues matching people to surgery in the past makes me think this could be an issue.
3) You hit stuck in a situation where you didn't quite make the cut at academic programs due to the research, but community programs thought you were "too good" or that you weren't really interested in community program.

I think you have a good plan, and it's great the prelim program is going to help you out. I'd definitely make sure they know you're open to taking a prelim PGY2 spot if that's what it comes down to. Fortunately, #2 should be addressed by being at a program that will give you bona fides you may have been lacking.

#3 can be addressed by trying to get some chip shot clinical research papers done early, though they likely won't be on your CV prior to application. I think you also need to make sure you're consistent in your message to programs during interviews.

#1 is the toughest to address. I'd see if your current PD is willing to share general feedback from their interview process.

Work hard, be a team player, and don't rule out any options. Good luck!

I was offered a prelim at a place where I interviewed during the main Match, but ultimately went elsewhere. During the phone interview for SOAP, the PD from that program said that they had really liked me, but figured I would go 'somewhere bigger', so they did not rank me very highly.

My school is a known quantity for IM and surgical subspecialties...it's specifically GS that they seem to have an issue matching. It's pretty common for the ortho or ENT Matches to outnumber the GS ones, and for NSG/CT/Ophtho/Plastics combined to outnumber them as well. My letter writers were admittedly not very connected, and there is nobody at our school who has a track record of really supporting the GS applicants. The prior 'go-to' person that our administration recommends getting AIs with for the letter has stopped really paying attention to student applications, to the point where they either did not write comments or wrote comments incongruent with the evaluations for several of my cohort...they gave me Honors, but no eval, and they gave my classmate (who is smarter and harder working than me in every way) an amazing eval and a LOR offer...but a HP, causing them to scramble for a last-minute AI to course correct.

I will of course address my interview prep as I go ahead with this next cycle. My gut feeling and what feedback I've gotten is that this was not the primary issue. I am generally fairly personable, and I did a large amount of prep work, including multiple practice interviews with GS faculty (one a PD). My biggest downfall in interviews was likely my general tendency to err slightly on the side of friendly and casual rather than formal, but overall I got good vibes and feedback from interviewers.

Hopefully improvements to #1 and #2 will be sufficient, because I really don't see much hope of research productivity to address #3 while I am navigating the early parts of a prelim intern year. The program I am attending is tough, and will be an amazing educational opportunity...and it will require my full attention and effort to distinguish myself.

Thank you for the advice!

Do you think a mid-range academic program is out of my reach for this next cycle?

 

[Dr.LeoSpaceman]

Do you think a mid-range academic program is out of my reach for this next cycle?

I'd like to say "yes", but given your experience I'm hesitant to make any sweeping generalizations. Not because you don't seem qualified, but because as you've found out, it's all cold comfort if you don't match. But I think with strong letters out of your prelim program, it should certainly be possible.

As for research, you are right. The only thing worse than doing nothing is trying something only to not follow through or let your clinical performance suffer. The chances of you getting a first author publication are probably low. But an abstract/presentation could be feasible. The other piece of advice is to seek out the senior residents/fellows who have been productive. They are almost certainly looking for someone to do some piece of a project in exchange for "somewhere in the middle" authorship.

When it comes to interviews, it can be a fine line. If you are personable and easy going, that's fine. And in reality, this is usually better than the alternative...no one likes a cold fish. The key is to know your audience. You have to be able to feel out the interview to know when you can be easy going and when you need to be serious. I'd also say you should have a bulletproof answer to the question "Why do you think you didn't match, and what have you done to improve?" that is more substantial than "I was just unlucky." (Not suggesting that's what you would say.)

Finally, you mentioned global health. If you are going to talk about this at academic programs, you need to be able to do so intelligently. My experience has been that this has become a hot buzzword for applicants to talk about, but then when you probe, there's no depth. If you have experience, that's a benefit. But you need to be able to translate that into how it fits into an academic career.

 

[mehc012]

Finally, you mentioned global health. If you are going to talk about this at academic programs, you need to be able to do so intelligently. My experience has been that this has become a hot buzzword for applicants to talk about, but then when you probe, there's no depth. If you have experience, that's a benefit. But you need to be able to translate that into how it fits into an academic career.

Sure, I've found this to be true as well. My interest is fairly well developed and demonstrated by my activities - both in medical school and on my own time. I've spent months living and volunteering abroad, followed it up with medical language courses for credit through my school, and used those language skills on the wards, as well as an international elective during which I acted as translator for rural primary care. I founded and ran the global surgery group at my school, and have a good idea of how I would want international work to fit into my eventual academic career in a way that is responsible to the areas I'm supposedly helping.

*sigh* sorry. I know that I'm being difficult. Frankly, it's why I'm on here...because I know that it's going to be difficult to adjust my expectations and be appropriately humble, and I need practice at readjusting.

 

[Thanatos]

Hey all,
I am a graduating USMD student who unexpectedly found myself having to SOAP into a preliminary PGY1 position. Frankly, I am still not entirely sure what the reason was for this, as I was considered by my advisors to be an excellent GS candidate with good chances at a strong surgical residency.

Obviously, this was a blow, and it has taken some time to adjust to my new expectations. I know that I will be applying for categorical GS positions again in the fall, and will have to go through all of the stress and expense of an ERAS cycle. What I'm not sure of is...what are reasonable/realistic goals going forward? As a preliminary resident, I know that many programs will not consider me on that basis alone. During this last cycle, it felt as if my options were fairly open...I was considering primarily academic programs, as I have some interest in the more competitive fellowships, though I also interviewed at several community programs. Now, I'm unsure. I don't want to set myself up for disappointment (again), so I was hoping that y'all could help give me an idea of what is realistically attainable for a preliminary PGY1 applicant.

App summary:
∙ ~260 on both Step 1 and Step 2 CK, first time pass on all board exams
∙ Honors in every clinical clerkship except Pediatrics (HP)
∙ Honors in 3 GS AIs
∙ One weak research experience/non-first-author publication in review at time of app
∙ Extensive global health experience and interest
∙ Strong letters (these were quoted to me frequently during interviews and referenced as a strength in my app)
∙ Decent PS (also discussed in multiple interviews, reviewed by multiple GS faculty including a PD prior to submission)
∙ 16 interview invites, 13 interviews attended (scheduling issues), ranging from community programs to well-known academic centers. Almost all of my interview invites were early, with interview dates beginning in October, concentrated in November, with only a few stragglers in Dec or later (mostly due to scheduling conflicts, not late invites).

I ultimately SOAPed into a PGY1 position at a top academic GS program which said it had actually considered inviting me during the main cycle, and was surprised to see me in the unmatched pool. No guaranteed retention of preliminary residents.

Possible negative factors:
- I did not have sufficient research for the sorts of institutions which sought out my board scores
- My school has a poor history of GS matches (~50% SOAPed the year prior to mine, low GS application numbers due to poor faculty support).
- I did not write thank you letters to most programs, and sent only one Letter of Intent (to my #1 program)
- I did not network, or ask mentors to reach out to their connections, etc.

Ultimately, I didn't play the game as I ought, perhaps because my hubris told me that I would at least Match somewhere, even without playing the game. Lesson learned.

Spoiler: Plan for the next cycle:

- My residency plans to put me on rotations with good attending exposure during the early months so that I can garner good letters. Obviously all of my letters will have to be from intern year.
- Attend every interview. Again, my residency is supportive of this, with a month's vacation during interview season and freedom to attend other interviews if they cannot be scheduled during that time.
- I plan to hit the ground running in intern year. My letters from AIs painted me as a hard worker and a valuable team member. This time, I plan to step that up to a new level, and also to be as prepared as humanly possible. I've already Anki'd a fair portion of the ABSITE review book and am going through the list of GME competencies for interns sent by my program, with plans to familiarize myself with all procedures, indications, etc. on that list prior to starting. I'm reviewing common intern calls, dosing of common floor meds, electrolytes and repletion, etc. I will stay late, get in early, and take whatever extra shifts need covering. My partner is supportive and understands that this is going to be a GRIND for both of us.
- New PS, though I do hope to borrow heavily from my current one, as that was not cited as an issue.
- Use EVERY contact I can possibly make. Ask for recs, calls, whatever it takes.

However, even with all of this, I know that my odds are even lower this time than they were the last. Given the above, I was hoping you guys would have some idea of what my new goals should be. My hope is to get a PGY2 categorical position, or failing that, a PGY1 categorical somewhere. I chose this prelim position as a stepping stone, with the hope that academic programs would still be open to me by taking this path. Is that realistic?

Thanks for reading the novel. Feel free to skim, but the first 12 responses are always asking for more information, so...here's everything I could think of to include from the get-go.

Your stats look pretty good, and it seems unlikely you blew the interview. It's hard to say for sure....

One thing I've seen before is that people can find themselves in an unfortunate mathematical never-never land.....for example you got 16 interviews and went on 13. If all 13 of those places were some of the best programs in the country, and each one takes 6 applicants, you could have been number 7 on each list. If the 6 people ahead of you all picked that place as #1 you fail to match, even though your stats are good. Each program could have liked you but had a few people that had more research publications, did an away rotation there, had strong faculty support or attended their medical school and so placed a few spots ahead of you. So overall in the pool of applicants you're in good shape....but at those handful of places you just missed the mark.

Certainly having a lack of faculty support hurt you, but that's something you can work on this year. I think people don't appreciate that....getting an email from a faculty member (even if I don't know them) is usually enough to at least get you an interview. If someone known to me highly recommends you that's solid gold and I'll probably fight like hell for you at a rank list meeting.

Did you have any safety net programs on your list? And I mean real safety places most people don't want to be.....undesirable cities or etc? The problem with applying to these places is you need to have some sort of narrative as to why you would want to be there....if they sniff out you're using them as their backup date to the prom they'll be pissed and that will hurt you.

When you re-apply you may need to drastically broaden your application.....I've seen this a few times where a solid applicant doesn't match.

Work really hard next year, some people will pick up an all-star prelim if one of their categorical residents quit. I saw several prelim residents over the years find a spot, especially the good ones.....

 

[droliver]

Your best chance is for 1) the program you are in to take you or 2) your prior medical school quite frankly.

 

[mehc012]

Your stats look pretty good, and it seems unlikely you blew the interview. It's hard to say for sure....

One thing I've seen before is that people can find themselves in an unfortunate mathematical never-never land.....for example you got 16 interviews and went on 13. If all 13 of those places were some of the best programs in the country, and each one takes 6 applicants, you could have been number 7 on each list. If the 6 people ahead of you all picked that place as #1 you fail to match, even though your stats are good. Each program could have liked you but had a few people that had more research publications, did an away rotation there, had strong faculty support or attended their medical school and so placed a few spots ahead of you. So overall in the pool of applicants you're in good shape....but at those handful of places you just missed the mark.

Certainly having a lack of faculty support hurt you, but that's something you can work on this year. I think people don't appreciate that....getting an email from a faculty member (even if I don't know them) is usually enough to at least get you an interview. If someone known to me highly recommends you that's solid gold and I'll probably fight like hell for you at a rank list meeting.

Did you have any safety net programs on your list? And I mean real safety places most people don't want to be.....undesirable cities or etc? The problem with applying to these places is you need to have some sort of narrative as to why you would want to be there....if they sniff out you're using them as their backup date to the prom they'll be pissed and that will hurt you.

When you re-apply you may need to drastically broaden your application.....I've seen this a few times where a solid applicant doesn't match.

Work really hard next year, some people will pick up an all-star prelim if one of their categorical residents quit. I saw several prelim residents over the years find a spot, especially the good ones.....

I do think I had difficulty convincing my safeties (and I do feel that I had several among my interviews) that I wanted to attend. One tried very earnestly to recruit me in SOAP and was pretty clear that they had ranked me low expecting me to go somewhere bigger.

 

[Jolie South]

Have you gone over your application with your medical school dean? That might just reassure you there are no glaring things in your LORs/Deans letter/evals that you are unaware of.

I think sometimes the holes in the Swiss cheese just line up enough that you get screwed. It happened to me when I applied to urology. I got interviews like 75% of places I applied. Everyone I talked to said my app was great and didn’t match and no one could say why. I think that was almost worse than having a known deficiency to address.

Obviously, I didn’t reapply to urology, bc I ended up realizing it wasn’t right for me, but as a surgery prelim applying to gen surg, I worked HARD on wards. I applied broadly and went on every interview I could. Your best chance of a match is likely where you will be a prelim bc you will be a known commodity. You may have to repeat intern year to match there categorical. At the same time to
prepare for the worst, I would do everything to work hard, take care of patients, and get good letters to better your application for outside programs.

 

[mehc012]

Have you gone over your application with your medical school dean? That might just reassure you there are no glaring things in your LORs/Deans letter/evals that you are unaware of.

I think sometimes the holes in the Swiss cheese just line up enough that you get screwed. It happened to me when I applied to urology. I got interviews like 75% of places I applied. Everyone I talked to said my app was great and didn’t match and no one could say why. I think that was almost worse than having a known deficiency to address.

Obviously, I didn’t reapply to urology, bc I ended up realizing it wasn’t right for me, but as a surgery prelim applying to gen surg, I worked HARD on wards. I applied broadly and went on every interview I could. Your best chance of a match is likely where you will be a prelim bc you will be a known commodity. You may have to repeat intern year to match there categorical. At the same time to
prepare for the worst, I would do everything to work hard, take care of patients, and get good letters to better your application for outside programs.

Yup. Read the MSPE through with them in person and did final tweaks together. They assured me I had strong LORs, which is backed up by the comments I heard at interviews. All evals are visible to us, and were something I actually pointed out at most places as a strength of my application.

Honestly, I'm either much, much worse at interviews than I think, or else incredibly unlucky. (Or, more likely, a little of both).