The Successful Match: Getting into Radiology

October 10, 2010

Dr. Vicki Marx

By Samir P. Desai, M.D., and Rajani Katta, M.D.
Authors of The Successful Match: 200 Rules to Succeed in the Residency Match and 250
Biggest Mistakes 3rd Year Medical Students Make And How To Avoid Them
Of the 4,455 total residents training in 188 ACGME-accredited radiology residency
programs, 88.3% are graduates of U.S. allopathic medical schools, 7.6% are international
medical graduates, and 3.9% are osteopathic graduates.1 Dr. Vicki Marx is the director of
the radiology program at the University of Southern California Keck School of Medicine,
and we asked for her insights into the radiology residency selection process.
After graduating from the Ohio State University College of Medicine, Dr. Marx remained
there to complete her residency in diagnostic radiology. She then completed fellowships in
abdominal imaging and interventional radiology at the Washington University Mallinckrodt
Institute of Radiology in St. Louis, Missouri. Prior to joining the Department of Radiology at
USC, she held faculty appointments at both Washington University and the University of
Michigan. At USC, she also serves as the Vice Chair for Education.
At many U.S. medical schools, students are unable to take a radiology rotation until
the beginning of their fourth year. How can medical students who have an early
interest in radiology explore the field?
This is a difficult issue. Currently, many medical students become captivated by the
puzzle-solving aspects and clinical importance of medical imaging as they progress
through their core clinical clerkships. Based on this somewhat aesthetic perspective,
some decide to go into Diagnostic Radiology without having a clue about what the
residency training process and work life are like. Two approaches can help provide this
missing information.
First, join a Radiology Student Interest group. This is an excellent way to get information
about the field. Such groups are active in most medical schools. If your school doesnt
have one, start one! This not only will provide useful information for you, it is a citable
activity to add to residency applications. Make sure at least one session addresses what
the professional work life is like after residency; many practice models exist and should be
explored.
Second, shadow a radiologist often. Shadowing practitioners through a clinical day as
often as possible is the best way to investigate the field. An interested student should
observe radiologists in multiple subspecialties to get a well rounded view. Although this
activity might be difficult to schedule while on clerkships that are time-intensive, it is worth
the effort. In addition, radiologists work evenings and weekends, so shadowing can be
done outside the standard work week. Off-hours work in Emergency Radiology is a
particularly effective way to get an overview of the field.
A good way to begin the process of shadowing is to introduce yourself to the Radiology
clerkship director and/or program coordinator. Schedule some days to shadow. Show up
on the scheduled clinical service and explain to the resident/fellow/faculty why you are
there and what you hope to learn. Pay attention. Stay until the work is done. Participate.
When you get home, think about the experience and write down your impressions of the
specialty. Use the reflection as a resource for further career planning.
Securing a position in a radiology residency program requires that an applicant
have the numbers. In 2009, the mean USMLE Step 1 score among matched U.S.
seniors was 238.2 Many programs have established cut-off points for USMLE
scores. According to a recent survey of radiology program directors, 79% of
respondents reported having a target USMLE score.3 What can lower-scoring
applicants do to improve their chances?
Id like to step back a bit first. Current medical school culture is Pass/Fail. Medical
students learn early in their educational process that P = MD. What medical students
may not realize in their pre-clinical years is that P ! Residency. Competition for
residencies is fierce, particularly in some fields, including radiology. Competition is rising
according to NRMP data (NRMP Results & Data, 2010 Main Residency Match, April 2010,
www.nrmp.org). In the foreseeable future, it is possible that there will be qualified
graduates of US medical schools who cant get a residency position at all. So, why
mention this? The time to begin preparing your medical school record for the match is on
the first day of medical school! Sustained effort over time to achieve a consistently
excellent academic record is the best way to keep all career options open.
Back to the USMLE Step 1 score: The reason this score is so important is that Step 1 is
an easily accessible metric of pre-clinical performance and knowledge base. The rest of
the preclinical transcript is typically hard to read and is nearly identical for all students. All
medical students pass everything. With that background, the importance of a low USMLE
Step 1 score is magnified, implying lack of knowledge, lack of intrinsic ability to learn, or
lack of effort. In general, medical students are not poor test takers. This is especially
true now because medical schools teach to the test, and a large industry exists to produce
study aids for USMLE test preparation. An exception to this pattern is the USMLE
performance of the nontraditional student. Students entering medical school after a
previous career, or educational path, may do less well in the preclinical years and on the
USMLE Step 1 than students coming to medical school directly from college. Other
aspects of the application will make apparent the nontraditional students strengths.
The first thing I suggest to a student with a low Step 1 score is a moment of introspection.
Is Radiology in the current competitive climate for you? Remember, all the rest of the
people getting into Radiology residencies have really high Step 1 scores so the learning
environment of all training programs is geared to that group. Next I recommend that a
student for whom a low Step I score is an aberration in performance explain their
academic strengths very clearly up front in their personal statement. I recommend that the
student work hard over a sustained period of time in the third year of medical school to
excel on clinical rotations. Clinical rotations scores of Honors and High Pass carry
significant weight in screening ERAS applications. So does a high Step 2 score. Finally,
students with a low Step 1 score must apply widely to radiology programs all over the
country in order to match in their chosen specialty. Success in the match is correlated
closely with length of the rank list in the first choice specialty (Charting Outcomes in the
Match; Characteristics of applicants who matched to their preferred specialty in the 2009
Main Residency Match; NRMP; 3rd Edition; August 2009).
Dr. Scott Pretorius, former radiology residency program director at the University of
Pennsylvania, wrote that in this competitive market for radiology residency slots,
medical students with research backgroundsallow themselves the opportunity to
stand out in a field of increasingly highly qualified applicants. As an advisor of
medical students, I routinely recommend that students intending to apply for
radiology residency seek out a research mentor and undertake some kind of
research project.4 Not all agree that research involvement is required, however. In
the 2008 NRMP Program Director Survey, only 64% of programs cited involvement in
research as a factor in selecting applicants.5 What are your views on the importance
of research involvement in the residency selection process?
I see two types of research on applications for residency: 1) real research experience
leading to peer reviewed presentations and/or publications, and 2) simulated research
experience that takes place in proximity to the due date for submission of the ERAS
application and does not lead to a peer-reviewed work product. Real research experience
has a very positive influence on candidacy for residency particularly at institutions where
faculty research productivity is high and where ongoing scholarly activity is highly valued,
or even required of residents. Research done to pad an application is easily identified. It
has no negative effect on the application because it is ubiquitous in the applicant pool. It
has little positive effect either.
Absence of simulated research may have a negative effect on the ERAS application for
students with mediocre academic records. My own opinion is that these students should
put their energy into improving their core clinical skills rather than add another activity that
will dilute the focus of their efforts.
Students with excellent academic performance throughout medical school, supported by
documentation in ERAS, do not need to pad their applications to succeed in the match.
Will some programs exclude them from an interview on this basis? Yes, but not many.
In a survey of radiology residency program directors, audition or away electives in
the field was ranked 15th in importance out of a total of 16 residency selection
criteria.6 While audition electives are not necessary for matching into the field, are
there times when you would recommend an audition elective for a student?
The away rotation is a mixed bag because the student is in the position of being
interviewed by the program over a period of weeks instead of minutes. For most people
this is great but for a few it isnt. The investment and anxiety are most likely to be
worthwhile when the student has a well informed opinion that the program is where s/he
wants to do residency. The drive could be geographic or academic. For instance, an
applicant with an interest or background in molecular imaging has an excellent reason to
do an away rotation at an institution with a mature molecular imaging program. More
commonly, a student of a culture where living close to extended family is a priority has a
valid reason to investigate programs close to his/her family. The student should explain
the reasons for doing the away rotation openly and honestly with the clerkship director and
the residency program director early in the rotation. The rest of the clerkship should be
spent in sustained effort to do a good job and to learn more about the program. The
student should meet with the program director a second time near completion of the
rotation as a courtesy and to remind the PD about his/her interest. We are old. If you
dont remind us (politely and without being pushy) we will forget.
Dr. Sandra Oldham, radiology residency program director at the University of Texas
Medical School at Houston, wrote that the personal statement is perhaps one of
the toughest parts of the entire application processBut once you have acceptable
grades and have an USMLE score above our bar, the personal statement is the
next item on the agenda for scrutiny. After reading your statement, I should want to
meet you, and I should feel that I would actually enjoy working side by side with you
at the workstationRemember, I am reading about 200 personal statements. Make
yours stand out.7 Applicants recognize the importance of the personal statement,
but often struggle to find ways to make it stand out. What advice can you offer to
applicants?
The personal statement is hard to write because no one gets taught how to write well
about themselves. How can you write about yourself without seeming narcissistic or
arrogant when your goal is to sell yourself to an audience you dont know? Egads, put that
way, writing a personal statement should be impossible. So you have to view the task
from a different perspective. The perspective that seems most useful to me is that of a
newspaper article. In journalism class, I remember being told that a good article answers
multiple questions about the topic: who, what, where, when, and why. The objective
ERAS application components (transcript, MSPE, etc) do a pretty good job of explaining
each applicants who, what, where, and when. The personal statement gives you the
opportunity to talk about your why, to explain your past, your stumbles, your dreams for
the future, your motivations for living the life you live, and your reasons for working
towards the goals you have set for yourself. A successful personal statement answers
why in a way that is sincere and succinct. You dont need quotes from obscure
literature. You dont need references to Wheres Waldo?. You do need honest reflection,
clear communication, and ruthless editing.
Dr. Gunderman, Vice Chair of the Department of Radiology at the University of
Indiana, wrote that many residency programs tend to interview students located in
geographical proximity, justified in part by a positive correlation between resident
performance and connection to the region. Therefore, if an applicant has a
particular interest in a program where they have been wait-listed, a telephone call or
letter may be helpful to clarify that strong interest.8 When and how should an
applicant with a strong interest in a particular program express their interest?

The applicants primary goal is make sure the program director (or designee) knows that
the student has a sincere and focused interest in this particular program. The secondary
goal is to avoid being annoying during this effort! Two points in the application process
create natural opportunities for such interest to be brought to application screeners
attention. The first is a focused personal statement where the interest in a particular
program is clearly articulated for the reader. This strategy requires careful attention to
detail dont send a tailored personal statement intended for one program to all the
programs! The second is an email to the program director and program coordinator after
being rejected or waitlisted for an interview. The email serves the same purpose as the
focused personal statement: to articulate clearly the reasons the applicant has for being
interested in the program and the willingness to interview on short notice should an
opportunity become available. If no response comes to the email, a phone call to the
program coordinator is a reasonable step to make sure the email was received. Then
you wait. You may get an interview and you may not. There are no guarantees in this
difficult process.
Speaking from my own experience as a program director, I do have a bit of advice about
actions to avoid if you want to increase your interview opportunities. First, do not make
multiple phone calls to the department. Listen carefully to what is said in the first phone
call and live with it. Second, do not trash the program in question on a public internet
forum. Your username may be less anonymous than you think! Finally, do not let one of
your parents, or one of their friends who has connections with the institution, call the
department on your behalf. Those phone calls are uncomfortable for all involved and do
nothing to change the content of your application.
The transition from residency to practice is challenging. Dr. John Cronan, chairman
of the Department of Diagnostic Imaging at Brown University, cites the frenetic
pace of work, high volume, and stress associated with having to render the final
read as particularly difficult for most graduates.9 In evaluating prospective
radiology residency programs, how can applicants assess a programs ability to
prepare graduates for practice?
This can be tough. The most reliable source of this information is a recent graduate of the
residency who currently has a real job. This person is unlikely to be present at the
interview. Interestingly, this information is becoming more available to programs though
the ACGME requirement to assess residency outcomes by using tools such as surveys of
graduates. It is fair to ask about the results of such surveys but not all programs have a
mature survey process in place yet.
Residency training programs that prepare physicians for the frenetic pace, high volume
and stress of real life radiology practice are those that provide these opportunities during
residency. Programs with high case volume and high expectations for resident
performance under appropriate faculty supervision are preparing residents for the real
world. Programs described by current residents as totally chill may be providing less
optimal preparation. Applicants need to ask about case volume, system for providing
residents with feedback on performance, and level of on-call responsibilities to get a sense
of the training opportunities available. On-call experience is particularly valuable. During
the standard work day, residents typically work alongside supervising faculty. At night,
residents have faculty back-up but it may be a phone call away. This is where the resident
learns to become independent in interpreting images. A resident who has never had to
render a preliminary opinion on a CT study at 3am while alone in the Emergency
Department (with a faculty backup a phone call away) is really not ready to do that without
faculty backup.
Especially daunting to applicants is the residency interview. During the interview,
interviewers try to assess an applicants personal attributes. What personal
attributes do you believe are associated with success in radiology residency?
I hesitate to answer this question because I dont want to encourage residency applicants
to pursue acting careers on the interview trail! However, the attributes most program
directors are looking for are hard to fake, even for 30 minutes.
A successful radiology resident first and foremost recognizes the critical role that radiology
plays in patient care and enjoys the responsibility of that role. Successful residents behave
professionally in all work activities and put the needs of patients above their own, within
the constraints imposed by ACGME work hour rules. Successful residents interpret as
many studies as possible and work hard to learn the clinical judgment, decision-making
skills, and communication skills (spoken and written) necessary to ensure that their
interpretations are meaningful in real time. A successful resident is a positive contributor
to a team that includes the residency class, the residency as a whole, the faculty, the non-
physician members of the department, the referring physicians, and the institution. A
successful radiology resident is smart, hard working, honest, and focused. That focus
must be maintained in three spheres: clinical work, home study, and relaxation time with
friends and family away from work. All of these personal attributes require an underlying
positive energy for being a physician and specific enthusiasm for the specialty of
Diagnostic Radiology that is easy to communicate to an interviewer.
Fewer female medical students pursue a career in radiology. Over the years, the
proportion of female residents has remained relatively static at just under 30%.
Recently, Dr. Marilyn Roubidoux, professor of radiology at the University of
Michigan, wrote about the potential negative impact that this has had on the
workforce, particularly in certain areas, such as breast imaging and pediatric
radiology.10 What do you believe are the reasons fewer women enter the specialty?
This demographic reality mystifies me. Half of medical students are women. Therefore
half of radiology residents should be female. Whassup? According to a recent survey of
medical students (Fielding JR et al, Choosing a specialty in medicine: female medical
students and radiology; AJR 2007; 188: 897-900) the two most important factors
determining specialty choice for men and women medical students are 1) direct patient
contact and 2) intellectual stimulation. Men and women each cited lack of direct patient
contact as a negative aspect of radiology. Men viewed the physics requirement as a
deterrent in greater numbers than did women. Neither cited radiation exposure as a
negative influence. So why do women apply to radiology in such relatively small
numbers? The only potential reason teased out in this survey is that more women than
men cited competitiveness of getting a residency position as a deterrent to choosing
radiology as a career path. I accept the information as true but it makes no sense to me.
A large percentage of medical students applying to dermatology residency are women.
Dermatology is extremely competitive. I think we havent asked medical students all the
right questions yet to guide our response to this reality.
In the meantime, I do think that we in the world of Radiology need to critically review how
we project ourselves to the world. Radiologists have a lot of patient contact (particularly in
interventional radiology, mammography and pediatric radiology) and a huge impact on
patient care. Maybe if we did a better job of demonstrating that to students during medical
school, their perception of the specialty would be closer to reality.
References
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1357-1372.
2Charting Outcomes in the Match, 2009. Available at www.nrmp.org. Accessed July 26,
2010.
3APDR Program Director Survey on the Match, 2008. Available at www.apdr.org/
index.cfm. Accessed on July 26, 2010.
4Pretorius E. Medical student research: a residency directors perspective. Acad Radiol
2002; 9(7): 808-809.
5Results of the 2008 NRMP Program Director Survey. Available at http://www.nrmp.org/
data/programresultsbyspecialty.pdf. Accessed July 26, 2010.
6Green M, Jones P, Thomas JX. Selection criteria for residency: results of a national
program directors survey. Acad Med 2009; 84(3): 362-367.
7Oldham S. Guide to the Radiology Match. Available at www.uth.tmc.edu/radiology/
guide_to_radiology_match_2007_2008.htm. Accessed July 26, 2010.
8Ertel N, Gunderman R. Helping medical students to prepare for radiology residency
interviews. Acad Radiol 2006; 13(9): 1168-1171.
9Cronan J. My first job: the transition from residency to employment what the employer
and employee should know. J Am Coll Rad 2008; 5(3): 193-196.
10Roubidoux M, Packer M, Applegate K, Aben G. Female medical students interest in
radiology careers. J Am Coll Rad 2009; 6(4): 246-253.