Ranking your residency for the Match: Red flags to watch out for

Physician burnout has been previously described as heartbreaking, and this may be an understatement.  The growing complexities of health care delivery, intricacies of documentation practices as required by Meaningful Use, and difficulties inherent to billing and reimbursement are only a few of the issues faced by residents and attending clinicians these days.

Unfortunately, these topics are still not formally taught in American medical schools.

As students, we really do not know what we are committing ourselves to by the time we’ve matched.  The careful selection of a residency program may do well to attenuate these and other reasons for physician burnout.  What I want to address here are several red flags of a malignant program, in no particular order.  Hopefully, these insights might help prevent your match lists from fluctuating “like the weather.”

Few residents attend institution-driven teaching conferences. Either due to the dullness of lecture content or unavailability of the residents to attend conferences, this is a bad sign.  These teaching conferences serve as the primary rendezvous for trainees to gather — sometimes over breakfast or lunch — and engage in academic discussions, didactic teaching sessions, and institutional programming.  But it can be as much of a social gathering as an educational one.  If residents are not showing up to these institutional events, explore the reason(s) why.  One resident I know recently told me she received questions and even complaints from applicants regarding the low number of residents who attended noon conferences.  Yes!  Be suspicious when you see this!

Resident dissatisfaction if and when non-adherent to duty-hour regulations. It is practically inevitable that duty-hour regulations will be broken at some point in your residency career.  Often, this is volitional on the part of the resident, and you won’t hear him or her complain.  Whether due to research interests or project deadlines, or simply the eager participation in patient care.  As an example, I know a number of residents who will intentionally violate duty hours in order to attend invaluable educational conferences offered by their institution.  These behaviors neither put patient care at risk, nor do they adversely interfere with the lifestyle of the residents who make such sacrifices for their education.  What you should be on the lookout for are the residents who are visibly frustrated with duty hour violations, either due to frequency of such violations or the reasons they require violating in the first place.  If attendings are neglectful of ensuring the post-call resident leaves before the 29th hour during rounds, this is a bad sign.  If residents violate duty hours because they have to show up early on call days in order to prepare notes and see patients, and this has not been addressed by graduate medical education, this is a bad sign.

Low board exam pass rate. There is no specific threshold to look for (85 percent, 90 percent, etc.), but you can imagine how disappointed a graduating resident must feel after dedicating 7 to 10 years toward a medical profession and failing their final licensing exam.  Yes, this exam can be retaken.  But is expensive, both financially and emotionally — costing about half one-month’s worth of your resident salary and countless hours in preparation.  If a significant number of graduating residents are not passing their licensing exams, ask why.  Do they lack the available time to prepare for this examination due to work requirements?  Are there not enough teaching/mentoring opportunities?

Nobody is laughing. Perhaps not the best direct measure of happiness in the workplace, but I would say that many people see laughter as a good sign.  If nobody’s laughing, you’re not likely to laugh either.  Sure, we surround ourselves in illness, suffering, and death.  But we deserve to smile just like the next guy.  Enough said here.

Not your cup of tea. This is probably the most obvious red flag, and the one point I make to all applicants on the interview trail.  Think of the less tangible or quantifiable things like resident personality, program location, resident opportunities, and the like.  If you are a spelunking, backpacking, white-water rafting outdoorsman, you probably won’t enjoy a program in New York City.  If you are passionate about movement disorders, don’t choose a program with only one or two specialists in the field.  Even if it is a highly ranked program on U.S. News and World Report, but you were miserable during your interview day, it’s probably not advisable to rank that program highly.

This list of red flags is not comprehensive.  Neither does it reflect only the benefits of my institution — you will not hear me admit that each of these fully apply to my program, but it comes close.  I am not a residency program director, nor do I claim to have their insight into the match process.  That being said, I was always reticent to accept the advice of a faculty member involved in the graduating medical student selection process.  They are salesman, captains of the flagship of their institution.  And like any good salesman, their comments are probably biased in their favor.  “Our board exam pass rate has been 100 percent for the past five years …”  “Each of our residents publishes at least one peer-reviewed research manuscript during their residency …”  “The cost of living is extremely affordable here …”  Obviously, not all faculty members exhibit this type of bias.  But you can imagine their conflicts of interest would narrow any discussion to the benefits of their respective program.

Although I am not a faculty member involved in medical student ranking, I do actively participate in the medical student interview process, and I enjoy it.  As one of the many residents at my institution who were fortunate enough to matriculate at the program of their choice, I could not agree more that the name given to the selection process is exactly what it claims to be, a match.  Students: When you rank those programs, be sure to prioritize your interests in that list so that they match with those of your ranked programs.  Residency is difficult, but it is also exhilarating.  Beware the red flags.  And good luck!

James E. Siegler is a neurologist.

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