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Throughout the year, we see a lot of posts from students who want to know about otolaryngology and want to know if they are competitive enough to match in otolaryngology. So, I crafted this post for those of you who want to know what they should do in order to maximize your chances of getting into a residency program. By way of this post, you should be able to judge whether you are competitive or not.
What to do if you are "premed."
I am of the opinion that you should spend your college years wisely. This means balancing your academic pursuits with the "experience" of being in college and being away from your family for what is likely to be first time.
There is no particular major in college that makes your more likely to be evaluated more closely during the residency application process. So, major in whatever you want. You should choose wisely, however, because getting into medical school isn't a guarantee. Choosing a major that will help you get a job in multiple career pathways is always a good thing. Of course you'll have to master to core material required of every premedical student and score well on the MCAT (or whatever the entrance exam is these days). Having a diverse or "liberal" education is going to help you as you go through life, so unless you really like biology, biochemistry, physics, or chemistry, don't shy away from majors in English, economics, history or business. These backgrounds will always help you , and it will be a long time before you can "go back" and take that 18th Century French Poetry class you wished you had taken instead of racking up huge hours in the library trying to master theorems or fiddling with those utterly stupid 3D organic chemistry molecules.
Do whatever it takes to maximize your performance on your premed classes, however. Do not take the entrance exam(s) lightly, because not only will poor performance on this affect your chances of getting into that top tier medical school, but poor performance may possibly prevent you from getting into medical school at all.
Do not feel compelled to get a job or do research that is medicine-oriented. It's fine if you do, of course, but I've had more interesting conversations with applicants who were cab drivers to the Stars, spent summers on commercial fishing boats or interned at the White House (or whatever).
What I feel may be helpful to you is volunteering in some health care capacity or shadowing a doctor. Volunteering in the emergency room, at a clinic, at a shelter, at a hospital entrance or a nursing home offers you a means of interacting with people who provide health care as well as those who receive health care. This will position you early to see that sometimes being in the health care field isn't like Grey's Anatomy or Life in the ER. Beyond this, if you can identify a local physician (private practice or university) who will let you spend a few days of the week in clinic with him or her, then you should do it. If it isn't ENT, so what. You'll see what medicine is really like for the majority of people and you'll get a flavor of what it takes to run a busy practice and deal with people with multiple problems – social, economic and medical.
So, you got into medical school. Now what?
Congratulations. You're not even close to the finish line. I've likened medical school to a marathon, and if you want to get into otolaryngology, you have to be ready to sprint when necessary. If you are sure you want to go into otolaryngology – I mean, really sure – then good for you. You can start really early. For those of you (the majority) who do not know what you want to go into, don't worry about it. You really need to keep your minds open at this point. Medicine is really broad, and what may interest you at one stage may be completely the opposite of what you go into. I did a study as a first year student and as a fourth year student about medical student goals and objectives. If found through directed surveys that 47% of my class chose a field of medicine (e.g., surgery -> PMR) that was very dissimilar to what they originally stated they were going to shoot for. About a third chose a related field (surgery -> orthopedics). The rest weren't sure at the beginning. Really simple work, but people change.
What's my point? My point is that if you originally feel like family medicine is your pathway of choice and late in your third year you decide otolaryngology is what you want to do, you ain't getting in with your "passes" and your 209 USMLE score.
Move forward in a manner that will keep ALL possible pathways open. The moment you slack off is the moment you close doors.
MS1
This year undoubtedly sucks. It seems like nothing you do is remotely related to medicine other than gross anatomy. Frankly, much of it is bull****. But, that doesn't really matter. Even though I couldn't tell you the steps of the Kreb's cycle now, I knew it backwards and forwards and blindfolded with two hands tied behind my back when I was a first year. I woke up at 5:30 every morning, went to the gym, had breakfast, went to the library to study, went to class, went to the library, went home and went to bed. But what about enjoying the city? What about enjoying some traveling? Didn't you go out at all? Sure. But that's not why I went to medical school. You can throw the phrase YOLO at me all you want. You might be right. I could die tomorrow. But, I achieved my goal of getting the career of my choice. I could have done plastics, neurosurgery, urology, orthopedics – you name it. I had the grades and the scores to make me "competitive."
Your first year grades are not so important in the grand scheme of things, but they may possibly relate to how well you perform on your USMLEs; I'll get to that later. So, do your best during your first year.
As someone who interviews students three times per year for residency spots, I really don't look at MS1 grades. But I do look at USMLE scores…heavily.
I'm going to throw in the issue of research during your MS1 year. Some attendings on this forum may disagree with me, but you should do research in some fashion between your MS1 and MS2 year. It doesn't have to be ENT, but you should start getting involved. I'll put it this way: the AVERAGE medical student applying to ENT has some research experience. I didn't say it was great experience, but it is experience. So, if you don't do any research, you are a below average performer when it comes to application time. Go out and collect data on women's health in poor communities with the family medicine residents. Go make up reagents in some genetics lab. Segment CTs or MRIs for some neurologist. If you are positive you want to get into an ENT residency, seek out one of the otolaryngology attendings in your medical school. The vast majority of us LOVE to have eager students come meet us and tell us they're interested in otolaryngology. If we have projects going on, we can almost always find something for you to do. And if there is nothing going on, ask politely if you can shadow that attending over the summer when you have time. I shadowed a general surgeon between my MS1 and MS2 year, and I scrubbed into cases and often stapled skin, cut sutures and even got to get my hands bloody a few times by "running the intestines." Whatever you do, don't waste time during the summer. If you need to make money by getting a job, that's understandable. See if there's a paid internship or lab job out there first. If you have to deliver pizza or whatever, try to find time to shadow or do some small project. Another reason to start it now is because this is the last vacation you'll take until the end of your 4th year, and in some respects, that will be the last real vacation you take until you've finished residency/fellowship and take that job you've always wanted (and fully noting that your college buddies have been working for 10 years and have 401ks that are larger than your medical student loans.
Get involved in your ENT interest group. Often there will be upper level medical students who will have met a handful of the otolaryngology attendings or pass along pearls that will help you navigate your system and how to maximize your chances. This is part of the process of networking that you will need to be prepared to do for the next several years. You're not too young to start it.
The main thing is to buckle down.
MS2
Time is short. USMLEs are right around the corner. Your classes have that hint of something that smells like medicine or surgery, and things are starting to make a lot more sense as time goes on.
From an academic standpoint, treat this year as even more important than your MS1 year. You need to remember everything you learn this year, because it could very well be on the USMLE. You may be subjected to lectures from the administration about the impending USMLEs. At my school, in order to assuage some anxiety of the collective student body, the dean and vice dean would frequently remind us of what the passing score was for the USMLE and that we should concentrate on "concepts" during our second year.
Nonsense.
Concepts and barely passing won't get you into much at all when you finish medical school, and it certainly won't get you into otolaryngology. In my opinion, those lectures did a huge disservice to many students who felt their options would be open if they continued their journeys under those provisions. It may have been that way in the 70s and 80s, but it isn't that way now.
As I said before, I really don't pay attention specifically to MS2 grades. Most ENT applicants have MS2 grades that parallel their MS1 grades – the average person does very well (As/Bs or H/HPs). I can't say I've ever encountered a situation in which we have candidates so similar that we've gone back to compare their MS1 and MS2 grades, so we never look at them with that much scrutiny. However, if grades are an early indicator of USMLE performance, then you better do well your MS2 year as well.
Continue your work with the ENT interest group.
Continue to look for those volunteer or shadow positions through the year.
Continue to look for research projects such as case reports, simple data analysis/collection, chart reviews or journal queries. Remember, the average ENT applicant has some sort of research experience under his belt. You should too.
USMLE Step I
I cannot overstate how critical this is. This test does only one thing for you: It closes doors. You can keep those doors open by doing well – very well.
First, a word about scores and what they mean. No one in my program looks at the 2 digit score. We look at the three digit score. It's more meaningful. When I was applying to residency, the national average was 215 (232 for ENT) and the standard deviation was 20 points. Last year, the average USMLE score of a medical student getting into ENT was 240. It has risen predictably over the last ten years.
If you score a 240 on the USMLE Step I examination, you have achieved the mean score of medical students matching into an ACGME accredited program. I don't know what the standard deviation is for ENT matches, but logically thinking, some applicants score above this and some score below this. May programs have a cutoff of 220 to interviews, so for all intents and purposes, it would seem POSSIBLE that the standard deviation is 10. If you are within 2 standard deviations of this, you have a USMLE score that could conceivably make you competitive for the match.
This is thinking liberally.
If you are more conservative, I would put the standard deviation around 5 points. Most applicants that hit my desk have scores between 230 and 250. Some crazies have 260+ and some poor souls are in the 220s. So, I would shoot for 240. But know that a score between 230 and 250 is likely to make you competitive for most programs.
I can't tell you how to get a 240 on the USMLE Step I exam. I did it by busting my ass my first two years and doing Kaplan Q bank. (I think that came out my year and it was very helpful.) I got all the review books. I dictated myself reading these review books and played them back while jogging every morning (nothing is more hideous than listening to yourself talk while exercising). I probably went overboard, but I did match. So, it's just my perspective.
I don't think there's a single attending on this forum who will disagree that Step I is critical. You should treat it that way.
So, no more posts about USMLE scores and whether it's competitive. The answer is in this post.
I don't recommend cramming the night before the test. You're not likely to learn (or relearn) anything new. Don't underestimate the epic fail you can achieve by not getting enough quality sleep. If you're too jazzed up to sleep, then watch a couple of movies or work-out.
After the exam, I wouldn't concern myself with going back to rehash questions with your buddy or look up the answers. There's nothing you can do about it. Celebration is in order; you've earned it – even if you tanked Step I.
After you've recovered from your hangover, many students typically have some time before they start their third year. If you have a relationship with an otolaryngologist, use your time wisely to build up that resume. If you are really sure you want to go into otolaryngology, meet up with the program director and find a mentor. Getting guidance is critical for young careers. I still seek it from my older colleagues. The knowledge you gain from those with more experience is priceless. Note: this knowledge can tell you as much of what to do as it does what not to do. It goes both ways.
MS3
Now you feel like a doctor, only it's clear to everyone around you that you don't know ****.
You have a single job your third year: honor your core rotations. If your school only has PASS or FAIL (weak), you need to do something that stands out and helps beef up your dean's letter, which is basically a summation of the comments you got on your evaluations for your third year rotations.
Again, I am going to say something the others may disagree with, you but you should try to honor all your core rotations. Why? Doors are open. Yes, we see plenty of applicants with HIGH PASS scores in rotations, and that's OK. But, the majority of applicants honor most of their core rotations. That should start molding your perceptions of your competitiveness. If you are all HIGH PASS, you're coming into the game with weaknesses and are below average.
We look primarily at the third year core rotation grades: surgery, medicine, OB/GYN, pediatrics, family medicine and psychiatry. In some cases it is neurology. The more you honor, the better. But, we look more positively on those who honor surgery and medicine and HP everything else than we do the person who honors psych and FM and only HP'es medicine and surgery. Clearly the latter are much more robust and difficult rotations.
If you honor a surgery rotation, stay in touch with the surgeons you work with. We value good letters of recommendation from all faculty, but we value recommendations from surgeons more than others because most surgeons understand what it takes to make a good surgical resident. Although we value ENT letters more, a letter from a surgeon (IMHO) carries some weight.
It's nice to get letters from your rheumatologist who thought you were God's gift to arthritis or the pediatrician who thought your 10 page progress note for the "little guy" with Kawasaki disease was the bomb. But don't package those letters at the expense of more meaningful letters.
EXCEPTION: letters from lab MDs or PhDs. If you spend time in a lab, particularly at some Howard Hughes fellowship or the NIH or whatever, I would (and many others) would expect a letter from one of those mentors. This is going to give us insight into how you manage time, assimilate date, write, think critically and work in a group. Highly valuable.
Away Rotations Part 1
For those of you who have known me a long time, I have never advocated that you do away rotations. I'll speak more about that later. I do understand, contrary to many opinions, the value of doing these rotations, however.
If you are going to do away rotations, start thinking about them – the sooner the better. Many programs have limited spots, and many programs are so popular that they fill up quickly.
I recommend selecting a program that seems like a fit for you. How do you know? You ask your matched buddies and your ENT attendings at your home institutions. Sit down with them and brainstorm your goals and where you want to be. Does your husband/wife want to be in the big city or are they married to a career where you are now? Don't rotate at Hopkins because you want a letter from Cummings because you think that'd be awesome and would get you in anywhere. I see so many letters from so many chairs and famous people that are absolutely meaningless – they either are form/stock letters or clearly show that they don't know you apart from their own grandchildren or wouldn't recognize you if you passed them in the hallway 5 minutes after you're off their service. Sorry to burst your bubble, but that's the way it is most of the time. Go to programs that will give you a good taste of a well rounded program, and get letters from people you spend an appreciable amount of time with.
MS4
Repeat MS3.
Honor your ENT rotations. Anything less is a red flag.
Since you have more time, you better produce some research.
USMLE Step II
You have to do well on this test. Although it is commonly seen as the lesser important exam, it is quickly becoming more important than it was in the past.
You cannot score significantly less on this exam than you did on the USMLE Step I. If you feel you are at risk for this, delay your Step II as long as you can. If you scored 230 or more on Step II CK, you are probably in good shape; however, I've seen a shift if mentality over the past few years. In the past, we never really paid attention to Step II, mostly because of the early match. When ENT became a regular match, Step II all of a sudden became a factor. So, it reflects poorly on you if you score lower on Step II than you did on Step I. That obviously creates a challenge for those of you who scored 2SD or greater on Step I. As long as Step II is close to Step I, we see it as performing consistently.
For those of you who scored "poorly" on Step I, Step II provides you with an opportunity to show us that you can redirect yourself and achieve to what we consider to be the highest standards of those who match into otolaryngology. So, for every 10 points below the mean on your Step I exam, I would shoot for 10 points higher on Step II (e.g., if you scored 230 on Step I, shoot for 250 on Step II).
The Step II CS exam is important. It may seem like the collective joke, but if you fail that exam, it looks really bad.
The majority of people applying to our program pass the CS exam and score >230 on Step II CK.
Away Rotations Part II
I firmly believe that Away Rotations (Sub-Is, AI's, whatever) are the best forum for showing programs how terrible you are. You're supposed to keep this a secret, but these rotations much more often than not reveal all the reasons why programs shouldn't take you.
It continues to surprise me that students so frequently shoot themselves in the foot during these rotations. Here's a list of why students perform terribly on rotations:
Here's a short list of medical student habits that have impressed me over the years
Letters of Recommendation
In a nutshell, shoot for the associate professors and the professors. They are more likely to be known nationally. Try to get letters from people you have interacted with during the course of your rotation. You want a positive, in depth letter that is meaningful to the reader. I want to know as much about you as I can if I'm going to offer you an interview. If the super duper chair at XYZ university writes you a letter and it's a paragraph long and tells me what your grades were and your usmle scores were, that letter is completely wasted. Your home institution chair is likely to write you a decent letter. The chair from an away rotation is not likely to do so. Too little time to get to know you.
Applying to Residency Programs
Apply broadly. Eat the cost. You'll regret it later if you don't get any interviews and you could have applied to more programs. This is where you need to drop your arrogance at the door. We've turned away people with >260 on their USMLEs because of bad letters or shot them down on site because they were bad fits. If your scores are low, you definitely need to apply broadly. If you have great scores, you still should apply broadly. Remember: you may be number 3 out of 50, but if the program takes only 2, you ain't getting in.
Don't pester the residency program coordinator. Our coordinator is so busy managing our own residents and visiting medical students that she doesn't have time to field your 100th phone call about whether the application was received or how you want to switch interview dates with this person or that.
I am in a osteopathic program. Can I match in an allopathic program?
This section of information shouldn't serve as a forum for comparing the two types of medical education. If you are in a DO program and want to apply for the match in an allopathic otolaryngology program, I will say that chances of matching are not impossible, but extremely improbable.
Having said that, if you are going to apply despite the overwhelming odds, I would charge you with the task of building up your resume in such a manner that any one of the programs out there must unequivocally match you and you alone. This means that you cannot simply be the "average" applicant (honors/HP, 240 Step I, great LORs, some research, interviews well). You have to be better than the average allopathic applicant in order to overcome the biases many programs will have simply because of those two letters that will follow your name. I cannot say what expectations will be required of you since there are so few data on DO matches into MD programs. Remember that the matching process is a game, and you win the game by playing it to your advantage.
If you are an osteopathic medical student and wish to match into an osteopathic otolaryngology residency program, then I suggest you read this very excellent thread on osteopathic residency programs and experiences. There seem to be a number of very dedicated DO students/residents who have researched this topic very well and can say more about DO programs & requirements than I could ever speak to. However, I'm sure these DO Otos would pretty much say the same thing about what you must do to get into a DO residency. Given the number of programs and spots, I'd venture a guess that it would be more competitive than getting into an allopathic program.
Interviews
This is the last of the line for you, and in many ways it is the most important. Get advice. Talk to your program directors and the residents. They have been through this before. They may have really good advice about programs and what really goes on there.
Be patient with those that interview you. Every year I screen many applications. Before each interview period, I read up on about 20 residents (and I do this three times during the season). I do this in addition to everything I have to do for my own practice and my family. So, if I don't remember the details about you, it's generally not because I (or we) are disinterested in you. We may simply have forgotten. So, don't sigh and say things like "As I said earlier. . .." We're just trying to get to know you. (At least most of us are; true, there are some jerks during the interview who are trying to stress you out.)
Expect me to ask you about anything. I'm sure many of you will perk your heads up and say: "you can't ask me about x, y, and z – those are match violations." I personally don't know what all the "match violations" are. If I did, I wouldn't ask them. If I ask you a question, it's because I'm genuinely interested in the answer. I'm interviewing you to work with me for 5 years; I don't want any surprises.
Expect me to ask you about your background: where you grew up, what mom and dad were like, how you passed your time in childhood, high school, college, jobs, friends, likes, sports, travels and the future.
Expect me to ask about that PASS you got in surgery when all the other core rotations were HP and H.
Expect me to ask about your research. There are many cases over the years during which students have been completely unable to talk to me about what they did for their research, what the goals were, what the implications were or what further involvement they will have in their projects. Frankly, if you can't talk about it, you did nothing for the project.
Expect me to ask you about some hypothetical ethical dilemma you will experience during residency. It's a test of character.
Expect me to ask you why you want to come to my program. The answer is not "I want a medium-sized residency program that is well-rounded and will get me into a great fellowship" or "I love NYC!" You need to say something about my program that is compelling to you. This tells me that you really are interested in this program and that it isn't just another stop on the trail.
Make eye contact. Wear bland clothing. Nothing flashy, trendy or provocative. Sell your mind, not your fashion.
Shake firmly.
Thank everyone.
If you have a social event with the residents, this is not the time to let it all out and treat the residents like you've known them for a long time (unless you have, of course). They are evaluating you during this time for compatibility. I've been a part of a dysfunctional residency program before, and it is a disaster. You simply can't work effectively with someone who is not a fit for the program. We take our residents' comments and experiences very seriously.
Thank you letters
If you were raised to send thank you letters, then send thank you letters. If you are writing letters to thank people because deep down you know this is going to earn you extra points, don't waste your time and money. 9/10, we've ranked you before you've finished your lunch on the day of the interview.
That's what I think will make you competitive.
Good luck.
What to do if you are "premed."
I am of the opinion that you should spend your college years wisely. This means balancing your academic pursuits with the "experience" of being in college and being away from your family for what is likely to be first time.
There is no particular major in college that makes your more likely to be evaluated more closely during the residency application process. So, major in whatever you want. You should choose wisely, however, because getting into medical school isn't a guarantee. Choosing a major that will help you get a job in multiple career pathways is always a good thing. Of course you'll have to master to core material required of every premedical student and score well on the MCAT (or whatever the entrance exam is these days). Having a diverse or "liberal" education is going to help you as you go through life, so unless you really like biology, biochemistry, physics, or chemistry, don't shy away from majors in English, economics, history or business. These backgrounds will always help you , and it will be a long time before you can "go back" and take that 18th Century French Poetry class you wished you had taken instead of racking up huge hours in the library trying to master theorems or fiddling with those utterly stupid 3D organic chemistry molecules.
Do whatever it takes to maximize your performance on your premed classes, however. Do not take the entrance exam(s) lightly, because not only will poor performance on this affect your chances of getting into that top tier medical school, but poor performance may possibly prevent you from getting into medical school at all.
Do not feel compelled to get a job or do research that is medicine-oriented. It's fine if you do, of course, but I've had more interesting conversations with applicants who were cab drivers to the Stars, spent summers on commercial fishing boats or interned at the White House (or whatever).
What I feel may be helpful to you is volunteering in some health care capacity or shadowing a doctor. Volunteering in the emergency room, at a clinic, at a shelter, at a hospital entrance or a nursing home offers you a means of interacting with people who provide health care as well as those who receive health care. This will position you early to see that sometimes being in the health care field isn't like Grey's Anatomy or Life in the ER. Beyond this, if you can identify a local physician (private practice or university) who will let you spend a few days of the week in clinic with him or her, then you should do it. If it isn't ENT, so what. You'll see what medicine is really like for the majority of people and you'll get a flavor of what it takes to run a busy practice and deal with people with multiple problems – social, economic and medical.
So, you got into medical school. Now what?
Congratulations. You're not even close to the finish line. I've likened medical school to a marathon, and if you want to get into otolaryngology, you have to be ready to sprint when necessary. If you are sure you want to go into otolaryngology – I mean, really sure – then good for you. You can start really early. For those of you (the majority) who do not know what you want to go into, don't worry about it. You really need to keep your minds open at this point. Medicine is really broad, and what may interest you at one stage may be completely the opposite of what you go into. I did a study as a first year student and as a fourth year student about medical student goals and objectives. If found through directed surveys that 47% of my class chose a field of medicine (e.g., surgery -> PMR) that was very dissimilar to what they originally stated they were going to shoot for. About a third chose a related field (surgery -> orthopedics). The rest weren't sure at the beginning. Really simple work, but people change.
What's my point? My point is that if you originally feel like family medicine is your pathway of choice and late in your third year you decide otolaryngology is what you want to do, you ain't getting in with your "passes" and your 209 USMLE score.
Move forward in a manner that will keep ALL possible pathways open. The moment you slack off is the moment you close doors.
MS1
This year undoubtedly sucks. It seems like nothing you do is remotely related to medicine other than gross anatomy. Frankly, much of it is bull****. But, that doesn't really matter. Even though I couldn't tell you the steps of the Kreb's cycle now, I knew it backwards and forwards and blindfolded with two hands tied behind my back when I was a first year. I woke up at 5:30 every morning, went to the gym, had breakfast, went to the library to study, went to class, went to the library, went home and went to bed. But what about enjoying the city? What about enjoying some traveling? Didn't you go out at all? Sure. But that's not why I went to medical school. You can throw the phrase YOLO at me all you want. You might be right. I could die tomorrow. But, I achieved my goal of getting the career of my choice. I could have done plastics, neurosurgery, urology, orthopedics – you name it. I had the grades and the scores to make me "competitive."
Your first year grades are not so important in the grand scheme of things, but they may possibly relate to how well you perform on your USMLEs; I'll get to that later. So, do your best during your first year.
As someone who interviews students three times per year for residency spots, I really don't look at MS1 grades. But I do look at USMLE scores…heavily.
I'm going to throw in the issue of research during your MS1 year. Some attendings on this forum may disagree with me, but you should do research in some fashion between your MS1 and MS2 year. It doesn't have to be ENT, but you should start getting involved. I'll put it this way: the AVERAGE medical student applying to ENT has some research experience. I didn't say it was great experience, but it is experience. So, if you don't do any research, you are a below average performer when it comes to application time. Go out and collect data on women's health in poor communities with the family medicine residents. Go make up reagents in some genetics lab. Segment CTs or MRIs for some neurologist. If you are positive you want to get into an ENT residency, seek out one of the otolaryngology attendings in your medical school. The vast majority of us LOVE to have eager students come meet us and tell us they're interested in otolaryngology. If we have projects going on, we can almost always find something for you to do. And if there is nothing going on, ask politely if you can shadow that attending over the summer when you have time. I shadowed a general surgeon between my MS1 and MS2 year, and I scrubbed into cases and often stapled skin, cut sutures and even got to get my hands bloody a few times by "running the intestines." Whatever you do, don't waste time during the summer. If you need to make money by getting a job, that's understandable. See if there's a paid internship or lab job out there first. If you have to deliver pizza or whatever, try to find time to shadow or do some small project. Another reason to start it now is because this is the last vacation you'll take until the end of your 4th year, and in some respects, that will be the last real vacation you take until you've finished residency/fellowship and take that job you've always wanted (and fully noting that your college buddies have been working for 10 years and have 401ks that are larger than your medical student loans.
Get involved in your ENT interest group. Often there will be upper level medical students who will have met a handful of the otolaryngology attendings or pass along pearls that will help you navigate your system and how to maximize your chances. This is part of the process of networking that you will need to be prepared to do for the next several years. You're not too young to start it.
The main thing is to buckle down.
MS2
Time is short. USMLEs are right around the corner. Your classes have that hint of something that smells like medicine or surgery, and things are starting to make a lot more sense as time goes on.
From an academic standpoint, treat this year as even more important than your MS1 year. You need to remember everything you learn this year, because it could very well be on the USMLE. You may be subjected to lectures from the administration about the impending USMLEs. At my school, in order to assuage some anxiety of the collective student body, the dean and vice dean would frequently remind us of what the passing score was for the USMLE and that we should concentrate on "concepts" during our second year.
Nonsense.
Concepts and barely passing won't get you into much at all when you finish medical school, and it certainly won't get you into otolaryngology. In my opinion, those lectures did a huge disservice to many students who felt their options would be open if they continued their journeys under those provisions. It may have been that way in the 70s and 80s, but it isn't that way now.
As I said before, I really don't pay attention specifically to MS2 grades. Most ENT applicants have MS2 grades that parallel their MS1 grades – the average person does very well (As/Bs or H/HPs). I can't say I've ever encountered a situation in which we have candidates so similar that we've gone back to compare their MS1 and MS2 grades, so we never look at them with that much scrutiny. However, if grades are an early indicator of USMLE performance, then you better do well your MS2 year as well.
Continue your work with the ENT interest group.
Continue to look for those volunteer or shadow positions through the year.
Continue to look for research projects such as case reports, simple data analysis/collection, chart reviews or journal queries. Remember, the average ENT applicant has some sort of research experience under his belt. You should too.
USMLE Step I
I cannot overstate how critical this is. This test does only one thing for you: It closes doors. You can keep those doors open by doing well – very well.
First, a word about scores and what they mean. No one in my program looks at the 2 digit score. We look at the three digit score. It's more meaningful. When I was applying to residency, the national average was 215 (232 for ENT) and the standard deviation was 20 points. Last year, the average USMLE score of a medical student getting into ENT was 240. It has risen predictably over the last ten years.
If you score a 240 on the USMLE Step I examination, you have achieved the mean score of medical students matching into an ACGME accredited program. I don't know what the standard deviation is for ENT matches, but logically thinking, some applicants score above this and some score below this. May programs have a cutoff of 220 to interviews, so for all intents and purposes, it would seem POSSIBLE that the standard deviation is 10. If you are within 2 standard deviations of this, you have a USMLE score that could conceivably make you competitive for the match.
This is thinking liberally.
If you are more conservative, I would put the standard deviation around 5 points. Most applicants that hit my desk have scores between 230 and 250. Some crazies have 260+ and some poor souls are in the 220s. So, I would shoot for 240. But know that a score between 230 and 250 is likely to make you competitive for most programs.
I can't tell you how to get a 240 on the USMLE Step I exam. I did it by busting my ass my first two years and doing Kaplan Q bank. (I think that came out my year and it was very helpful.) I got all the review books. I dictated myself reading these review books and played them back while jogging every morning (nothing is more hideous than listening to yourself talk while exercising). I probably went overboard, but I did match. So, it's just my perspective.
I don't think there's a single attending on this forum who will disagree that Step I is critical. You should treat it that way.
So, no more posts about USMLE scores and whether it's competitive. The answer is in this post.
I don't recommend cramming the night before the test. You're not likely to learn (or relearn) anything new. Don't underestimate the epic fail you can achieve by not getting enough quality sleep. If you're too jazzed up to sleep, then watch a couple of movies or work-out.
After the exam, I wouldn't concern myself with going back to rehash questions with your buddy or look up the answers. There's nothing you can do about it. Celebration is in order; you've earned it – even if you tanked Step I.
After you've recovered from your hangover, many students typically have some time before they start their third year. If you have a relationship with an otolaryngologist, use your time wisely to build up that resume. If you are really sure you want to go into otolaryngology, meet up with the program director and find a mentor. Getting guidance is critical for young careers. I still seek it from my older colleagues. The knowledge you gain from those with more experience is priceless. Note: this knowledge can tell you as much of what to do as it does what not to do. It goes both ways.
MS3
Now you feel like a doctor, only it's clear to everyone around you that you don't know ****.
You have a single job your third year: honor your core rotations. If your school only has PASS or FAIL (weak), you need to do something that stands out and helps beef up your dean's letter, which is basically a summation of the comments you got on your evaluations for your third year rotations.
Again, I am going to say something the others may disagree with, you but you should try to honor all your core rotations. Why? Doors are open. Yes, we see plenty of applicants with HIGH PASS scores in rotations, and that's OK. But, the majority of applicants honor most of their core rotations. That should start molding your perceptions of your competitiveness. If you are all HIGH PASS, you're coming into the game with weaknesses and are below average.
We look primarily at the third year core rotation grades: surgery, medicine, OB/GYN, pediatrics, family medicine and psychiatry. In some cases it is neurology. The more you honor, the better. But, we look more positively on those who honor surgery and medicine and HP everything else than we do the person who honors psych and FM and only HP'es medicine and surgery. Clearly the latter are much more robust and difficult rotations.
If you honor a surgery rotation, stay in touch with the surgeons you work with. We value good letters of recommendation from all faculty, but we value recommendations from surgeons more than others because most surgeons understand what it takes to make a good surgical resident. Although we value ENT letters more, a letter from a surgeon (IMHO) carries some weight.
It's nice to get letters from your rheumatologist who thought you were God's gift to arthritis or the pediatrician who thought your 10 page progress note for the "little guy" with Kawasaki disease was the bomb. But don't package those letters at the expense of more meaningful letters.
EXCEPTION: letters from lab MDs or PhDs. If you spend time in a lab, particularly at some Howard Hughes fellowship or the NIH or whatever, I would (and many others) would expect a letter from one of those mentors. This is going to give us insight into how you manage time, assimilate date, write, think critically and work in a group. Highly valuable.
Away Rotations Part 1
For those of you who have known me a long time, I have never advocated that you do away rotations. I'll speak more about that later. I do understand, contrary to many opinions, the value of doing these rotations, however.
If you are going to do away rotations, start thinking about them – the sooner the better. Many programs have limited spots, and many programs are so popular that they fill up quickly.
I recommend selecting a program that seems like a fit for you. How do you know? You ask your matched buddies and your ENT attendings at your home institutions. Sit down with them and brainstorm your goals and where you want to be. Does your husband/wife want to be in the big city or are they married to a career where you are now? Don't rotate at Hopkins because you want a letter from Cummings because you think that'd be awesome and would get you in anywhere. I see so many letters from so many chairs and famous people that are absolutely meaningless – they either are form/stock letters or clearly show that they don't know you apart from their own grandchildren or wouldn't recognize you if you passed them in the hallway 5 minutes after you're off their service. Sorry to burst your bubble, but that's the way it is most of the time. Go to programs that will give you a good taste of a well rounded program, and get letters from people you spend an appreciable amount of time with.
MS4
Repeat MS3.
Honor your ENT rotations. Anything less is a red flag.
Since you have more time, you better produce some research.
USMLE Step II
You have to do well on this test. Although it is commonly seen as the lesser important exam, it is quickly becoming more important than it was in the past.
You cannot score significantly less on this exam than you did on the USMLE Step I. If you feel you are at risk for this, delay your Step II as long as you can. If you scored 230 or more on Step II CK, you are probably in good shape; however, I've seen a shift if mentality over the past few years. In the past, we never really paid attention to Step II, mostly because of the early match. When ENT became a regular match, Step II all of a sudden became a factor. So, it reflects poorly on you if you score lower on Step II than you did on Step I. That obviously creates a challenge for those of you who scored 2SD or greater on Step I. As long as Step II is close to Step I, we see it as performing consistently.
For those of you who scored "poorly" on Step I, Step II provides you with an opportunity to show us that you can redirect yourself and achieve to what we consider to be the highest standards of those who match into otolaryngology. So, for every 10 points below the mean on your Step I exam, I would shoot for 10 points higher on Step II (e.g., if you scored 230 on Step I, shoot for 250 on Step II).
The Step II CS exam is important. It may seem like the collective joke, but if you fail that exam, it looks really bad.
The majority of people applying to our program pass the CS exam and score >230 on Step II CK.
Away Rotations Part II
I firmly believe that Away Rotations (Sub-Is, AI's, whatever) are the best forum for showing programs how terrible you are. You're supposed to keep this a secret, but these rotations much more often than not reveal all the reasons why programs shouldn't take you.
It continues to surprise me that students so frequently shoot themselves in the foot during these rotations. Here's a list of why students perform terribly on rotations:
- Not prepared for the OR. You need to know the basic anatomy for whatever case or cases you are seeing. You should expect to be "pimped" about the anatomy. If the questions get harder and harder, it's possible the attendings are trying to see how far you can go, but generally speaking, you'll be asked about basic things. It is unacceptable to not know basic anatomy on a surgical rotation. This applies to just about any surgical specialty.
- Disappears from the OR. Unless you have to catch a flight home or are going to an interview, there's no reason to leave the OR. I don't leave the OR. I schedule everything around my OR time.
- Operative skills are subpar. You don't need to know how to drill a mastoid, hold scopes, or be able to suture vessels. However, I do expect you to be able to tie knots and I would hope you know how to close the skin. If you don't know these basic things by your 4th year, you're in trouble.
- Clinical skills are subpar. I'm not expecting you to workup a completely new patient in 10 minutes or less, but you do need to know how to take an accurate history. Please don't spend 30 minutes talking to the patient about every single episode of dizziness or how the dizziness has created all these social problems. Please don't tell me that the ear looks "OK" and the rest of the exam is normal. This is a statement I would accept from my senior partner when he tells me about a patient. You give me a complete exam when you present to an attending. When I know that you know that everything else is "normal" and I say you can say everything else is normal, then you can say everything else is "normal." Get in, introduce yourself and get the focused history. I would be more impressed with you if you got an accurate history than an accurate exam at this stage.
- Hinder the residents. Don't be the unhelpful student. The unhelpful student doesn't "fetch" a report or film, doesn't volunteer to write (or type, I guess) the op note or progress notes; does stuff the residents don't want you doing; says something to the patient that a resident has to correct; tries to outshine resident; shows up late to rounds or leaves before asking the residents.
- Gun the other students on the rotation. Don't do this; it only makes you look bad.
- Trys to correct the attending or give advice to the attending. 99.9% of the time, you're wrong. I remember a student this year telling me that if I turned down the irrigation flow while drilling, the lens wouldn't get splattered by wet bone dust so frequently.
- Make inappropriate comments about women, gays, ethnic groups, etc. Yes, it happens.
- Revealing too much about yourself (drinking, drugs, run-ins with the law)
- Thinking everyone loves you.
Here's a short list of medical student habits that have impressed me over the years
- The pre-rounding student. Has everything ready for the team when it rounds
- Asks if s/he can write the notes
- Fetches the radiology films (remember, this is a sub-internship; you do intern things)
- Knows how to tie knots. Practice your skills. If there are cadaver labs during your rotation, ask if you can go to them.
- Is prepared for all cases. You do this by looking at the schedule, talking to the residents and reading about the anatomy and cases the night before the case.
- Is prepared for clinic. If you know you're going to be in my otology clinic tomorrow, I'm probably going to see someone with ear pain, someone with otitis, someone with a perforation, someone with hearing loss, and possibly someone with a tumor. Read up.
- Helps the other medical students and gets along.
- Does what the OR nurses tell them to do, even if they are being snarky. Your character is under scrutiny. Frankly, the nurse I work with in the OR who knows all my instruments, preps my cases, makes sure my instruments are clean, makes sure all my disposables are ordered is more important to me than you. Do what she (in this case) says.
- First in, last out. If you're on a collective rotation (meaning there are no services), check in with all the chiefs before you leave. If the chiefs say you can go, check with the junior residents to see if there is anything else that needs to be done (notice I said needs to be done and not "what you can do more before you go"). If the junior resident says you can go, then go.
- Takes call. Unless this is prohibited, take call with the junior. Be helpful.
- Being a normal person. This is the hardest part about being on a rotation. You really want to impress, and that is understandable. When people attempt to impress, they often reveal themselves in such a light that it makes them undesirable to work with.
Letters of Recommendation
In a nutshell, shoot for the associate professors and the professors. They are more likely to be known nationally. Try to get letters from people you have interacted with during the course of your rotation. You want a positive, in depth letter that is meaningful to the reader. I want to know as much about you as I can if I'm going to offer you an interview. If the super duper chair at XYZ university writes you a letter and it's a paragraph long and tells me what your grades were and your usmle scores were, that letter is completely wasted. Your home institution chair is likely to write you a decent letter. The chair from an away rotation is not likely to do so. Too little time to get to know you.
Applying to Residency Programs
Apply broadly. Eat the cost. You'll regret it later if you don't get any interviews and you could have applied to more programs. This is where you need to drop your arrogance at the door. We've turned away people with >260 on their USMLEs because of bad letters or shot them down on site because they were bad fits. If your scores are low, you definitely need to apply broadly. If you have great scores, you still should apply broadly. Remember: you may be number 3 out of 50, but if the program takes only 2, you ain't getting in.
Don't pester the residency program coordinator. Our coordinator is so busy managing our own residents and visiting medical students that she doesn't have time to field your 100th phone call about whether the application was received or how you want to switch interview dates with this person or that.
I am in a osteopathic program. Can I match in an allopathic program?
This section of information shouldn't serve as a forum for comparing the two types of medical education. If you are in a DO program and want to apply for the match in an allopathic otolaryngology program, I will say that chances of matching are not impossible, but extremely improbable.
Having said that, if you are going to apply despite the overwhelming odds, I would charge you with the task of building up your resume in such a manner that any one of the programs out there must unequivocally match you and you alone. This means that you cannot simply be the "average" applicant (honors/HP, 240 Step I, great LORs, some research, interviews well). You have to be better than the average allopathic applicant in order to overcome the biases many programs will have simply because of those two letters that will follow your name. I cannot say what expectations will be required of you since there are so few data on DO matches into MD programs. Remember that the matching process is a game, and you win the game by playing it to your advantage.
If you are an osteopathic medical student and wish to match into an osteopathic otolaryngology residency program, then I suggest you read this very excellent thread on osteopathic residency programs and experiences. There seem to be a number of very dedicated DO students/residents who have researched this topic very well and can say more about DO programs & requirements than I could ever speak to. However, I'm sure these DO Otos would pretty much say the same thing about what you must do to get into a DO residency. Given the number of programs and spots, I'd venture a guess that it would be more competitive than getting into an allopathic program.
Interviews
This is the last of the line for you, and in many ways it is the most important. Get advice. Talk to your program directors and the residents. They have been through this before. They may have really good advice about programs and what really goes on there.
Be patient with those that interview you. Every year I screen many applications. Before each interview period, I read up on about 20 residents (and I do this three times during the season). I do this in addition to everything I have to do for my own practice and my family. So, if I don't remember the details about you, it's generally not because I (or we) are disinterested in you. We may simply have forgotten. So, don't sigh and say things like "As I said earlier. . .." We're just trying to get to know you. (At least most of us are; true, there are some jerks during the interview who are trying to stress you out.)
Expect me to ask you about anything. I'm sure many of you will perk your heads up and say: "you can't ask me about x, y, and z – those are match violations." I personally don't know what all the "match violations" are. If I did, I wouldn't ask them. If I ask you a question, it's because I'm genuinely interested in the answer. I'm interviewing you to work with me for 5 years; I don't want any surprises.
Expect me to ask you about your background: where you grew up, what mom and dad were like, how you passed your time in childhood, high school, college, jobs, friends, likes, sports, travels and the future.
Expect me to ask about that PASS you got in surgery when all the other core rotations were HP and H.
Expect me to ask about your research. There are many cases over the years during which students have been completely unable to talk to me about what they did for their research, what the goals were, what the implications were or what further involvement they will have in their projects. Frankly, if you can't talk about it, you did nothing for the project.
Expect me to ask you about some hypothetical ethical dilemma you will experience during residency. It's a test of character.
Expect me to ask you why you want to come to my program. The answer is not "I want a medium-sized residency program that is well-rounded and will get me into a great fellowship" or "I love NYC!" You need to say something about my program that is compelling to you. This tells me that you really are interested in this program and that it isn't just another stop on the trail.
Make eye contact. Wear bland clothing. Nothing flashy, trendy or provocative. Sell your mind, not your fashion.
Shake firmly.
Thank everyone.
If you have a social event with the residents, this is not the time to let it all out and treat the residents like you've known them for a long time (unless you have, of course). They are evaluating you during this time for compatibility. I've been a part of a dysfunctional residency program before, and it is a disaster. You simply can't work effectively with someone who is not a fit for the program. We take our residents' comments and experiences very seriously.
Thank you letters
If you were raised to send thank you letters, then send thank you letters. If you are writing letters to thank people because deep down you know this is going to earn you extra points, don't waste your time and money. 9/10, we've ranked you before you've finished your lunch on the day of the interview.
That's what I think will make you competitive.
Good luck.
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