How to For the Red Flags

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					How to       For the Red Flags
   in Resident Applications

         Gretchen Schulz
  University of Missouri-Columbia
        ARCS March 2005
Unraveling the Mysteries in
 the Resident Applications
    Where do you begin?

So MANY Applications and
    so LITTLE Time!
            UMC Applicant
   Pass USMLE Step 1 & 2 on First Attempt
   Class Rank in the Upper 1/3
   Undergraduate GPA of 3.5
   Three Letters of Recommendation from
   No Felony Convictions.
   Must have graduated from Medical School
    within the last three years.
           Reviewing the
   Usually easy to eliminate the poor candidates.
   Usually easy to identify the great candidates.
   What do you do with the applications that fall
    in the middle?
   What are the red flags that you need to look
Where do you look for these
        red flags?
              RED FLAGS
           Reference Letters
   1st Place to find clues.
   No letter from the Chairman or PD.
   Letters from physicians in other specialties.
   Less than three letters of reference.
   Very short reference letter – no real
   Chairman‟s letter states you should call for
    additional information.
               RED FLAGS
              Dean’s Letter
 Review comments from other rotations to
  be sure evaluations of the applicant are
 No explanation of gaps in medical school.

 Failed clerkship‟s or lots of B‟s and C‟s.

 Failed NBME Shelf Exams.

 Review last paragraph for final Dean‟s
        RED FLAGS
    Personal Statement
   Strange personal statement.
   The word “I” is used on almost every
   If the applicant had a leave of absence
    from medical school and does not
    address it in any way.
               RED FLAGS
             Basic Application
   Large list of volunteer activities, of which all or
    most are self serving.
   Multiple research projects and no publications.
   Disconnect between USMLE Scores and Clerkship
   Consistent spelling errors in their application.
   A parent calls regarding their child‟s application.
Let‟s see what we can uncover
      in these applications
     Applicant A
Will graduate from LCME Accredited School

Undergraduate GPA – 3.8

USMLE Step 1 Score - 184
USMLE Step 2 Score – 183

Class Standing – 100 out of 126

Publications – 0
Honors - 0
Dear Program Director:

It is my pleasure to provide this letter of recommendation for Applicant A. She is
currently a senior medical student at the University of ____________ and is
expected to receive her MD degree in June 2005. I worked with Applicant A while
she was serving as an acting intern n my VA surgical service.
Applicant A entered medical school with a background in research and the
pharmaceutical industry. Her added maturity has served her well in developing the
skills necessary to become a physician. As such her academic performance is not
reflective of her clinical abilities. Her attention to detail and concern for her patients‟
well being is notable. She is a true team player who is well liked by peers, faculty,
and patients.
As a senior, she successfully completed the Departmental honors program in
surgery. This program is an intensive eight week experience in the fundamentals of
surgical science designed specifically for students who will be competing for surgical
residencies. She functioned as an acting intern in the surgical ICU and consistently
provided compassionate and thorough patient care. Her patient presentations were
well-organized and concise. She was a model of professionalism.

I believe that Applicant A is dedicated to a career in surgery, and will work diligently
toward this goal. I sincerely recommend her to you for consideration. Please feel
free to contact me should you need further information.

Associate Professor of Surgery
Chief, General Surgery
Associate Program Director
Dear Program Director:

It is my pleasure to provide this letter of recommendation for Applicant A. This letter is
     written in support of her application to your surgical residency program. Applicant A is
     a senior medical student at the University of ______________ . I know Applicant A
     well having worked directly with her during her 3rd year surgery clerkship and also
     while she completed our Departmental Honors Program in Surgery as a senior
     medical student.
Applicant A is an enthusiastic and energetic young woman who did her surgery clerkship
     late in her junior year and fell in love with surgery during her clerkship. Applicant A
     may be the most pleasant and outgoing medical student I have worked with in recent
     memory. She is a role model of professionalism and is an absolute favorite of our
Applicant A‟s academic record is solid. During her surgery clerkship, her clinical
     performance was excellent. Unfortunately, she had a substantial amount of difficulty
     with the NBME surgery shelf examination which was probably related to a family crisis
     which occurred at approximately that time. Currently, she has an incomplete grad in
     surgery and will be retaking the NBME surgery shelf examination. Despite her
     difficulties with the shelf exam, we accepted Applicant A into our Departmental
     Honors program in Surgery, on the strength of her performance as a 3rd year clinical
     clerk. To absolutely no one‟s surprise, she excelled in all requirements of our
     Departmental Honors program.
I have no doubt that within a few years this applicant will be an outstanding young
     surgeon of whom I am very proud. Her academic record could certainly be better, but
     I am convinced that she has what it takes to be an outstanding surgical resident and
     to develop into an outstanding surgeon. We will rank her at _________ and I am
     willing to do whatever is possible to support her as she pursues her dream. I am
     pleased to strongly suggest that you carefully look at this candidate. I recommend
     her to you without any reservations.

Associate Professor of Surgery
Director of Surgical Education
To whom it may concern:

It is with pleasure that I write in support of the application of Applicant A for a internship
     in general surgery. Applicant A did an absolutely wonderful job with regard to her
     clinical rotation. She interacted well with her peers, was a clearly competent medical
     student functioning at an intern level, and was diligent in her work.
However, she had a horrible experience in that she made an incredibly poor grade on the
     NBME shelf examination. Her score was at such a level that she received an
     incomplete for the surgery rotation. She will be retaking that examination in order to
     qualify for a passing grade.
The above having been referenced, I have committed to her that I will help her realize
     and fulfill her lifelong dream toward becoming a general surgeon. I am confident that
     she will do well. She is working diligently to rectify her test taking problem, and in
     fact, is engaged in a remedial course with me personally at the current time. Part of
     that course will result in her taking the in-training examination in January with our
     residents. I told her that she simply needs to get about and get on with acquiring the
     fund of knowledge necessary for a career in general surgery and I am pleased to say
     that she is showing evidence of that commitment on a daily basis.
Unlike many fourth medical students she is working as hard in the fourth year as she did
     in the third. It looks to me as if she will turn out to be one of the medical students of
     whom I am most proud. Gathering ones boot straps and pulling them up to the point
     that you rectify something so significant is a commitment which is truly exceptional.
     The easy thing for her to do would have been to pick a less strenuous or demanding
     personal career. The fact that she is working about solving this problem so
     systematically and so faithfully with our instruction indicates to me that she is going
     to be a successful surgeon for the long term.
I hope this letter convinces you not to underestimate the potential of this talented young

Professor and Chairman
Department of Surgery
    Applicant B
Will graduate from LCME Accredited School

Undergraduate GPA – 3.5

USMLE Step 1 Score - 206
USMLE Step 2 Score – 172

Class Standing – Unknown

Publications – 0
Honors – None given by this school.
Dear Program Director:

I have been asked to write a letter in support for Applicant B. I met
   Applicant B this year when he rotated on our surgical service at
   _________ as a subintern.

Applicant B is a kind and caring student. While on the service he
  followed several patients and participated in surgery. I would
  categorize him as a good student and given the right
  environment he will really shine.

As you can see from his personal statement, he is passionate about
   surgery. He has had some unique experiences and his family is
   proud of his accomplishments. I have had time to discuss his
   plans and he is committed to a career in General Surgery.

In summary, I recommend Applicant B for your training program.

Associate Professor
General Surgery
Dear Program Director:

I am writing in sincere support of Applicant B‟s application for a residency position in your
    program. I have had the opportunity to work closely with the applicant, both during
    his third-year clerkship and during his four-week sub internship on the GI Surgery
    Service here at _______. From this experience, I can speak to his qualifications with
    personal knowledge.
When I initially met Applicant B, it was at one of our affiliates during a very busy clinic. I
    think that this was one of his early clinical rotations, and Applicant B and I spent the
    afternoon together. His quiet demeanor initially led me to believe that he was
    overwhelmed and unprepared, but my later experiences with him proved this early
    assumption wrong. In working with him during that earlier rotation, and then later,
    much more closely during his sub internship, I found him to be extremely enthusiastic
    about general surgery. I believe he does have the “fire in his belly”. Particularly in
    the OR and in the clinic, he consistently exhibited a very extensive fund of
    knowledge, and very thoughtful evaluative and analysis skills. He could easily
    formulate management plans for even moderately complex patients and situations.
    Even more importantly, he was always thorough, responsible and very caring of his
Applicant B has not participated in much research or teaching to date, though he has not
    ruled out an academic career. My impression is that his primary love is clinical
    surgery, and for this reason, I have encouraged him to look at programs that will
    provide him with the best possible training.
In summary, I enthusiastically recommend Applicant B to you. I think he will become a
    very dedicated, compassionate and clinically excellent surgeon. I sincerely believe
    that he will prove himself in any training program fortunate enough to recruit him as
    a welcome and respected addition. I would be most happy to speak on his behalf.

Professor of Surgery
Director, General Surgery Residency Program
Dean‟s Letter

Surgery Comments:
“Histories and physicals are considered average. Fund of knowledge is
   considered below average. Clinical judgment is considered average.
   Case presentations are considered below average. Personal interactions
   and communication skills are considered below average. Professional
   attitudes and behavior are considered average. Over he is an average
   to slightly below average student. Faculty comments include:
   „Adequate performance. He was reliable and typically competent. Hard
   to assess knowledge as his responses seem below the 3rd year. He
   appears to be okay regarding clinical judgment. His case presentations
   were a little too concise. His histories and physicals are typically
   complete and accurate.‟ „He needs improvement in knowledge,
   presentation, communication skills. Good attitude and tried hard but
   has many deficiencies.‟ „Would be better if shows more initiative and
   interest in learning about surgical patient‟. „He was punctual. Apathetic;
   did not show interest. His history taking was too succinct, not well-

Final Dean‟s Letter Recommendation:
   Based on Applicant B‟s achievements as a medical student, he is a very
   good to excellent candidate for a residency training program in general
     Applicant C

Will graduate from LCME Accredited School

Undergraduate GPA – 3.68

USMLE Step 1 Score - 182
USMLE Step 2 Score – 193

Class Standing – 134 out of 190

Publications – 3
Honors – None given by this school.
Dear Program Director:

I have known Applicant C since his fourth year rotation on my
   General Surgery Service. During his rotation I found him to be
   an outstanding student. He was always well read regarding the
   patients who were under his care. He treated all individuals,
   both hospital personnel and patients with the utmost respect.
   His work was always top notch because of his rapport with the
   patients and his meticulous and thorough examinations and
   notes. Applicant C‟s previous experience in the _________
   University Student Senate has prepared him with maturity and a
   solid foundation of teamwork.

It is without hesitation that I highly recommend Applicant C for a
    position in your residence program. He is a solid candidate in all
    frontiers. He is personable, intelligent, hardworking, conscience
    and dependable.

Associate Professor of Surgery
Director, General Surgery Residency
Dear Program Director:

This is a letter in written in support of Application C in his application to
    general surgery residency programs. Applicant C is a senior student in
    good standing at the University of ___________. As an attending
    physician on the Trauma and Emergency Surgical Service, I was
    initially approached by Applicant C towards the end of his first year of
    medical school, at which point he desired an opportunity to gain some
    research experience in the field of Trauma and Emergency Surgery. At
    my suggestion, he got involved in an injury prevention research project
    under the direction of our trauma director. Through his efforts that
    summer and during his 4th year he has become coauthor on two
    manuscripts that have been submitted to major peer-reviewed
    journals. I can honestly say that without Applicant Cs efforts the survey
    regarding their thoughts on gun ownership would not have made it to
    manuscript submission.
In addition to his research efforts, he has shown that he is a very
    dedicated clinician. He is drawn to the care of the surgical patients in
    the ER and shows a good acumen for understanding surgical problems
    – to the point that he is a good resource for the 3rd year students.
As such, I recommend him without reservation for any residency program
    in general surgery and I have no qualms about taking him in our
    program here.
Associate Professor
Division of Trauma & Emergency Surgery
Dear Program Director:

I am pleased to recommend Applicant C for your surgical residency. I have
    known Applicant C since his second year of medical school. He also
    performed a rotation on the trauma service as a third year medical
    student, and has continued to work with faculty from our service on an
    independent research project. These interactions form the basis for my
Applicant C was excellent on his trauma rotation. His fund of knowledge is
    good. He is extremely focused and dedicated to becoming an excellent
    surgeon. He performs well under stressful circumstances. He was
    diligent, reliable and perseverant. He was very good in the operating
    room. He seems more mature and reliable than his peers.
He has worked on a research project since he was a second year medical
    student. Applicant C has completed the research and has completed a
    manuscript that has been submitted to JAMA. He took a lead on this
    project and has been instrumental in seeing it through to manuscript
In summary Applicant C is a very strong medical student and I have no
    doubt that he will develop into an outstanding surgeon. Please call me
    with any further questions.

Associate Professor of Surgery
Division of Trauma & Emergency Medicine
Dean‟s Letter

General Surgery Comments:
Average fund of basic surgical knowledge. Good
  performance of basic surgical skills. Good
  ability to care for patients in inpatient and
  outpatient setting. Good interpersonal
  relations with surgical team, professional
  behavior, and personal qualities. Average
  understanding of utilization of health care
  resources and delivery of surgical care to
  patients. Continued to improve his knowledge
  of basic surgical health care concepts. Nice
Overall grade: C
NBME Shelf Exam: 65 (Class Mean 72.7)
            Key to Success

Unfortunately there is no 100% fail proof method
 to identifying the potentially problem residents.
   Review your “middle of the road” applications
    carefully. If it sounds too good to be true, it
    probably is.
   If something doesn‟t sound quite right, then it
    probably isn‟t.
   Trust your instincts, your opinion counts so be
    sure to speak up and let your PD know when you
    have concerns.
   The interview day is an excellent opportunity to
    spend time with your questionable applicants to
    see if you can identify any further red flags.