Associate PD Discusses Supplemental ERAS Gamification & Strategy

hello everybody and welcome to today's discussion where i have the pleasure of speaking with dr brian carmody a pediatric nephrologist as well as associate professor at the eastern virginia medical school thank you so much for being here um he's also known as the sheriff of sodium who is salty about medical education so again thank you and welcome you know happy to be here can you tell us a little bit more about why you are the sheriff of sodium and what exactly it is you're a little bit salty about in terms of medical education yeah so uh so you're right i have a website that's called the sheriff of sodium i uh i started that website a couple of years ago um mainly as a way to um to sort of make permanence and discussions that i was a part of on um on social media because otherwise those things you know they sort of just get swept up and disappear you know a few days later and i needed a domain name that wasn't taken and believe it or not i was the first first comer for sheriff of sodium which um was a nickname that i earned back in my residency um but but like you said it sort of fits because a lot of the things that i talk about in medical education are things that uh you know to be honest are things that need to be improved at least from my standpoint perfect and you know that leads us to the main thrust of our conversation today which is going to be about the supplemental heiress application so you know we're going to dive into a little bit more of the details of some of the sections and maybe some advice but overall you know i've heard a you present a fairly strong con argument in the nrmp's discussion on the road to residency i believe but where do you fall you know right now what's your opinion about the supplemental errors application and program signaling as a whole yeah so i guess there's two things there um and i'll be honest neither the preference signaling or the supplemental application i don't think either one is necessarily a bad thing from my standpoint they're both sort of half measures um you know the the if you want to make an argument against this uh you know preference signaling or against this supplemental application it really is a way of enabling um continued over application and allowing applicants to um you know to to [Music] behave in a way that's rational but doesn't ultimately work in the the benefits of the group by applying to many many many many programs burdening programs with that many applications necessitating the reliance on convenience metrics for screening making the system more chaotic and congested for everybody neither of these really gets at the root of that problem but what they do is they give program directors a tool that they can use to um to work through the pile you know so that these these supplemental applications allow programs to um to rather than having to plow through a 20-page you know printed eris application you can see at a glance some of the things that might be most important about that applicant and it enables more rapid applicant evaluation to be frank and the same thing for preference signaling um you know preference signaling um you know when viewed in its most favorable light allows programs to not miss applicants that are honest to god truly interested in going there and uh and and from a program standpoint that's that's wonderful because um you know as people apply to more and more programs and as uh programs get more and more applications and interview more and more applicants um they don't want to go through all that effort and use all their faculty's time to to be interviewing people that are interviewing at 20 places and really are not going to end up matching with them you know and so it's it's it helps them be more efficient and so when you look at these interventions from the standpoint of the programs they're logical and i think i don't think they're bad things but they don't exactly get at the root of the problem either so do you feel that programs are going to be most likely you know on september 29th they get let's say 1200 applications are they going to start out by looking at those that have signaled them first or how do you think that's going to play out in the actual review process yeah i think it's going to be it'll be program specific because i mean of course this is going to be new for for everybody you can imagine different strategies that programs may use some programs even now actually look at all the applicants applications they receive you know for instance the program where i work we read everybody's application it takes a while but we do um most programs don't and um and they employ some screening strategy or another to um to look at applications more closely so they may look at they may apply a usmle score filter for instance that's a common way of taking your 1200 applications and narrowing it down to uh you know to 600 or 400 or whatever you want to look at you could and some programs do look at all the applications that they received from usmd graduates before they look at do graduates or before they look at international medical graduates or you could as you suggest as an initial screen you could say let's look at the preference signal let's let's first look at every single person who says they really want to be here for whatever reason and that could become an initial screen for some programs or it may enter into play some point later down the line i think that the preference signaling will almost certainly be part of the initial decision to offer an interview or not um i think from that point forward your expressed interest with that signal is is not that important and it's not going to play into you know ranking decisions so much but if you if you use your preference signals wisely it may open the doors and programs to get your foot in and get an interview and be considered yeah and so in terms of preference signaling there's a few schools of thoughts regarding you know where you should be signaling programs to and you know what the qualifications you have are compared to the expectations or averages for those programs and you know we would definitely encourage people to hesitate before applying to a program or signaling a program that they don't qualify for the minimum requirements you know the stated minimum requirements you know the us emily cutoffs the time since graduation do you feel like that will change you know if somebody is 20 points below the minimum or maybe just five points below the minimum score or two extra years outside of the graduation cut off that they have said is a strict cutoff but they signal that program what's your interpretation or your prediction about what might happen in those cases yeah that's a good question i i think your strategy is the correct one i think that um so so again i think to answer this question you have to imagine that you're in the position of a program and how you might use these signals and if a program chooses you know to use the signals as the first screen you know let's let's take our signals as our first screen well then you're right you may have someone who might not meet the stated minimums but if that's your first screen you might you might get your application looked at but the trouble with with that strategy is if you think about it most programs will not receive so many signals that they can use that as an initial screen um if if you are the the sort of most elite programs i think that is likely that you could get you know let's say you want to interview i don't know let's spit out a number 500 applicants or 400 applicants or 200 applicants yeah you might get if you want to interview 200 people you might get 300 signals and you could use that as an initial screen but most programs because applicants have a limited number of signals probably will not receive that many and so the the presence of signaling will not be an initial screening it may be used later on or it may be used as sort of a mop up strategy to say i mean especially if a program receives very few signals it may be used as all right well here's people we want to interview but here's a couple other people who signaled us maybe we'll give them a look but i think in general um you know to answer the question sort of broadly i think you're exactly right your signal is probably if you were going to make a strategy if you give a signal to a place that's going to interview it you anyhow you just wasted a signal you know the signal did not improve your number of interviews or your chance of matching you've really really sort of wasted it by getting into a program that you knew with certainty was going to interview and that's why i think standard advice is that you would not send a signal to a program at which you did an away elective or a program um you know like at your home institution sending a program a signal to those programs is really sort of wasteful at the same time i wanted to address that and kind of talk a little bit more about that exact point which um you know i i completely agree with that in the context of u.s medical graduates and you know i would like to get your input you know for imgs you know they might do an away rotation or just an elective you know a four month or four week rotation somewhere but they haven't been promised you know that interview or it's just you know they said oh yeah you should apply we'll look at your application um for an img for example would it be potentially more beneficial to apply or you know signal those programs that you have some exposure to but you haven't been promised that interview yet yeah you're right in that case you would because um because again if you if your probability is a hundred percent or if it's 95 that you're going to be offered an interview then i would not send a signal but if it's something less than that yeah i think i think you're exactly right i mean that's the sweet spot is if your signal programs at which you have a you know if you've got five signals and you use them all at programs where you have let's say less than a 20 chance of getting an interview you may have sort of used up a valuable resource that you had to get yourself more interviews and you may come out with with no more than you would have had otherwise um but in the situation that you described yeah if if that program doesn't have a history of um you know drawing on people who do away electives with them um you know to fill their applicant class or to get interviews then yeah you probably need to use that to um to increase your probability perfect and so you were i didn't mean to cut you off but you were talking about you know the difference between you know applying to those programs that you don't qualify for versus maybe having like reach programs you know is that something that you would recommend as you know incorporating you know maybe one or two that's more of a reach and then maybe two that are you know you very solid you have connections with and then maybe one that's almost like a safety where it's like you're over qualified but you know if you have red flags in your application and you're kind of worried about the fact that you might not get any interviews just any sort of you know advice for using those five program signals or even three for uh dermatology you know it's not very many right right yeah this will this will depend on the applicant because um you can imagine on one extreme um you know a very qualified uh applicant with a strong application from a well-known school that applicant probably doesn't need to fear that they're going to go unmatched when they're applying to general surgery or you know internal medicine and so an applicant like that probably more of their five signals maybe even all of their five signals could justifiably be sent to reach programs because that applicant knows that they're you know they're they're gonna match on the other hand if you're someone who's um success in the match is less assured which is a situation that applies to most international medical graduates um then i think it's unwise to spend too many on on reach because um if you if you end up going unmatched i think that's a much worse outcome than um you know sort of under matching and you want to ensure that you that you first and foremost match because then you can you know then you can be a physician and you can you can do what you set out to do and as your career goes by it's of less and less importance where you did your residency uh you know as you get your practice established and so um i think probably answering the question depends on an honest assessment from the applicant's standpoint about what your realistic outcomes in the match are likely to be perfect yeah i completely agree that for each individual it's going to look different for us grads versus imgs strong applicants versus people with you know multiple obstacles in their application in the beginning you were talking about the fact that it's going to be possible potentially to use this supplemental application to get a snapshot of the applicant without having to go through 20 cv experiences that are all you know up to 1020 characters and you know all these things where it's like a very brief overview so um there are five of the most meaningful experiences that they can fill out but it's only about you know 300 characters to actually describe that experience right so it's i mean surprisingly short in terms of the amount of content you know that's like two or three sentences it's basically like three lines uh yeah so you have you know suggestions about you know what you would want to see if you're reviewing you know that meaningful experience would you want to just focus mostly on why it's meaningful and forego some of the details about the or the resume type of information that's like this is what i was actually doing and learning or focus specifically on the act yeah you're right so so once again i think this is sort of the theme of every every question that relates to these supplemental applications is put yourself in the program director's shoes what is it that um you know what is it that you care about and what is it that a particular activity shows you about a given applicant um so you know for instance i mean in our program i mean we might review an application from um oh i don't know maybe somebody who played college sports some applicants choose to highlight that and i think justifiably justifiably so it shows you something about that person it's not that we give a rip about playing sports that has nothing to do with being a resident physician exactly but it shows you a certain capacity for hard work and um dedication and you know being part of a team and so on and so um when you look at it from that standpoint that's how you want to describe it you know it's not just that you were on a sports team or something i mean and i'm using that as a trivial example but um it's it's what that tells you about the person's character and that's the same thing for most uh you know most of these activities i mean someone who has um someone who has served in the military i mean you you know for sure that's someone who knows how to be a part of the team who's not gonna uh you know be a complainer who knows how to get the job done i mean that's a valuable thing even though it has nothing to do with medicine you know you can have someone who has let's say you had a research project that you completed and you know it's not something that's published in new england journal medicine but um but it's something that you got off the ground and you led through to completion that's a very valuable thing to list in your experiences especially in this format because instead of just looking at the article title and the journal name you have more of an opportunity to say this is something that i took from nothing and turned it into a real work product because that's actually what you're communicating to the program it's not anything exactly about the research project itself but it's that i'm someone that given resources i can get something done and so everything that you list on these supplemental applications the way i would kind of frame it in your own mind is when someone reads this when a program director reads this what is it that i want them to take away from this you know and that that will that will inform the way that you describe it yeah and it seems like what you're saying is that the more you can give a glimpse into who you are as a person beyond just you know a medical graduates you know seeking to be a physician you know what qualifications but more so what qualities and characteristics you know what is unique about you you know it's not it shouldn't maybe maybe you're saying don't just list your top five clinical experiences exclusively but consider maybe diversifying those meaningful experiences to show a more full and like true well-rounded perspective of diablo yes yeah this is true so um there aren't many residency applicants who who struggle in residency because of inadequate knowledge there are some you know but there's there's not many most of the residents who are the best residents that a program has or the worst residents their program has it's because of uh skills and attributes um and personality traits that are not related to medical knowledge and so um your your academic record um you know speaks for itself your standardized test scores speak for themselves but here you have an opportunity to communicate something i think about your character about those sort of non-tangible aspects that program directors honestly are searching for because like i said any program director you asked who are the very best residents that you've trained in your career you know and who are the who are the problem residents and you can imagine sort of the um the likely answers that you're going to get to that question are there signals that a reviewer can pick up on in an application to realize that this person might have some inherently problematic traits or qualities you know when you're looking at an application are there beyond just you know maybe a gap in education or a lower score but in the way they express themselves or the content of their application are there red flags that a reviewer can pick up on to say we might not want to work with this type of person they might be qualified and knowledgeable but i'm not getting a good feeling from the application yeah i i i think you do get some of that it's um i mean i can think of a few things um there are some um you know there are some residency applicants that what they say is not so much important but the way that they say it sort of shows um a struggle with um you know with english proficiency and um and that's okay i mean not every you know there are many many many good physicians who english is not their first language at the same time if you don't have a certain standard of english proficiency you're likely to struggle when the majority of your patients are english speaking and you're likely to struggle extracting medica you know information from the medical record and uh and so that's i think that's an important thing um it's this is not related to the supplemental application but um i think when when letter writers don't say something excessively positive i think that's a red flag to be honest i mean we all we all choose our letter writers and so if you um and sometimes people through no fault of their own i mean you you pick a letter writer who's not that good at expressing things to be to be honest um but if you get a group of them that don't seem to come up with anything unique or extremely positive to say i think that's a subtle red flag too i think one thing i guess sort of bring it back to the supplemental applications you know there is an opportunity with these supplemental applications to talk about challenges that an applicant has faced and i think that that's a very good vehicle to um to introduce some of the personal challenges that um some applicants have faced i would i would give it a caveat though right if you're going to describe a challenge um it needs to be something that can be unambiguously interpreted as a challenge in that limited space so for instance i mean if you say you know i'm a first first-generation college student or i um you know um grew up in an impoverished area or i was diagnosed with leukemia when i was in medical school or you know my mom uh passed away when i was in medical school those things are all sort of clear-cut any person who reads it will interpret that sympathetically there are other challenges that may be very real um challenges and very legitimate challenges but they are less unambiguously interpreted so for instance if you if you use that space to say you know i i had a mental health diagnosis when i was in medical school and i had to take time off um for for you know we live in a world where some people will um will take that in a in a very negative way now you can say as an applicant well look you know i don't want to be at a program where uh you know people are not going to be supportive of that and i think that's very legitimate if you're if your goal is to maximize the quality of the match that you get i think that's a very reasonable strategy if your goal is simply to ensure that you match that's probably not a good strategy because many programs like i say will will interpret that in a way that's unfavorable similarly if you said something like if you use that space to say you know i um oh i don't know i failed step one and i had to retake it and it was hard i think that's probably not the place to put that programs are are going to notice it programs are going to ask you about it but when that comes up at an interview or when that's fleshed out somewhere else there can be more context applied than in a section where like you said i mean you have about as much space as a tweet you know to uh to describe it yeah so uh the impactful experiences like the personal challenges should really be focused on something that is clearly a you know life obstacle that you have overcome and helps put into context your again yourself as an applicant you know a bigger picture yes for who's actually behind the paper um and to not just put something there simply to put something there because that can actually backfire or if it's you know not something that's clear-cut as being a you know personal challenge and the aamc guide you know they list a very specific examples of what they might expect to see in that section so i definitely recommend that everybody reads the aamc guide for the supplemental application because it details every section and i think that advice is you know very helpful as well so one thing that we haven't touched on and you know we can maybe talk about it briefly is the geographic preference signaling and do you have any thoughts about you know whether somebody should or shouldn't you know use the preference signaling and how it's going to really affect programs determining who they want to invite for interviews again right yeah i think this is a controversial area i i think most applicants are going to be better off by listing something there um so you know this section like you you know um and like viewers will probably know you have the opportunity to identify a certain geographic area or a preference for urban versus rural or something the programs we'll see you know internal medicine and dermatology programs we'll see the concern is that when you say something that people who don't fit that category will hold it as a negative you know that if i say oh i want to be on the west coast then east coast programs might look at that and say well you know you want to be on the west coast i mean why would i waste time interviewing you and i think that that's true and i think that will occur but i think that the average applicant is going to open more doors than they close especially if you if you have a um a little bit of of strategy about how you deploy your geographic preferences so um you know for instance when i applied uh you know i i i'm born and raised in virginia i lived in virginia my whole life in one place or another i went to college in virginia i went to medical school in virginia and when i graduated from medical school you can imagine that if i sent my application to some west coast program they might justifiably look at it and say well you know why would you ever come here when your whole life's been in virginia um but if i signaled and i said hey you know i'm interested in west coast programs that's probably likely to open some doors and it's probably going to open more doors for me than it would close for programs in virginia or washington dc or north carolina when they see that my whole life has been in virginia so i think the average applicant if you are um if you're smart about how you how you signal that preference um i think it will end up with more doors opened um now compare that to a situation like i said with me where i said oh i'm interested in east coast programs that's probably not going to open any more doors than it would have you know if i chose to do nothing you know so so there is an element of strategy if your goal is like i said if your goal is to maximize the chance of matching then i think there's an element of strategy here if your goal is is to maximize the quality of matching then maybe you know maybe more honesty is better so i think most people should express a preference i think that preference again it's going to open the door to an interview so signaling that preference for an area where you're already likely to get interviews is less valuable than signaling that preference to an area where you're not as likely to get as many interviews and all things being held equal i mean if you're someone who has no geographic ties to anywhere that has no um you know preference honestly to be anywhere in the country you should appreciate that um you know programs on the coasts tend to get more applications than programs in the midwest for instance programs that are in urban areas tend to get more applications than those in rural and so expressing a preference to less preferred areas is probably going to get you farther than expressing a preference to be you know in a major east coast city for instance right yeah i think that's very good advice and it will be very interesting hopefully after the match to be able to dissect some of the data and to see how some of these things actually affected interview rates or match rates and you'll see if there's actually a positive outcome and hear from pro program directors and review committees to figure out if you know this is a step in the right direction um so you know do you have any final thoughts about what you would like to see you know how you would like to see the supplemental ares application evolve or just other aspects of the residency process you know step one going to pass fail and we're implementing now program signaling you know would you prefer to see it across more specialties or what do you want to see in terms of the application process for residency yeah there's a lot there i could talk uh in detail about any of those things for a while yeah definitely so uh so i i think um my last piece of advice for applicants with all this would be um that i mean like i said several times put yourself in the position of the program that's number one um number two though is that if you're stuck i would default to you know being honest about your true preferences because um you know as as this discussion has illustrated there is an element of strategy to how you frame all of these things and what signals you choose to send for specific programs or for geographic areas there is an element of strategy there but um you know using strategy to get something that you don't really want to get i mean you're just gaming yourself and so i think um you've got to frame everything sort of honestly i mean if you honest to god want to be in a certain area then i mean go for it i mean it's your life it's your it's your training i'd go for it so i would default to honesty um when you're stuck but recognize that this you know does add a certain layer of strategy and game theory um as far as what i'd like to see done or how i'd like to see this evolve i mean i think like i said i think the supplemental application is fine i mean eris is um has been stagnant for about 20 years i mean in terms of what information is in there and how it's presented it's not the way that anybody would um choose to design it if it were being designed today it's not particularly streamlined or sexy or you know especially useful to programs and so i think it should evolve i think this supplemental application should be moved into the main application and um and you know along with sort of a thoughtful evaluation about everything that's in eris and whether it's really honestly necessary and whether it needs to be in there whether it's useful and if it is useful if it's presented in the most useful way i think those are all things that you know are fair game and should be considered um i think um you know if you follow me on social media if you read the stuff that i say i um i personally have come to believe after after a lot of thought uh you know about all this that we need to limit the number of applications and that's often an unpopular thing because it's counterintuitive many people say well you know i need to apply to this many programs or i i need to do you know this or this or i won't succeed and the thing is um we have only a limited number of of residency positions we have more applicants than that number of positions so any system that we create is going to leave some people out in the cold that's the reality if we had a giant lottery we would have the residence positions would fill they'd fill with different people then fill them now some people would would find that advantageous some people wouldn't we could you could imagine we could have an auction for residency positions that would also efficiently allocate positions we just say hey raise your hand tell me what you're going to pay for this position that would also fill every position and again it would fill with different people than now and some people would find that useful and some wouldn't and obviously we don't have any of those either of those systems and it's hard to imagine that we ever would instead we have a system that tries to reward merit and um and the reality is that all things being equal if you have two applicants that are exactly the same exactly as qualified as one another but one applies to more programs than the other the person who applies to more programs all things being equal is going to have a better odd a better chance of matching and i don't think that's a system that rewards merit of any kind i think that's a system that rewards financial advantage or greater willingness to take on debt and it doesn't it doesn't lead to overall benefit in the system in fact it leads to a system that as i said before is increasingly chaotic and congested and unpredictable it leads to interview hoarding it leads to reliance on convenience metrics um you know it leads to many things that are pernicious and harmful to our system and ultimately um i think we'd be better off if we um collectively if we chose to curtail that and um you know like i said i it's a it's something that takes a little bit of um thinking to get to that conclusion and it's not something that when you first hear it i think sounds very good to many people um and if you if any of your viewers are interested in learning more about that i've i've got some youtube videos of my own or some stuff that i've written about it because it's something i have thoughtfully considered and it's something that i should i think should be done at some point perfect well you've been sharing so much incredible insight and perspective and advice how can people keep in contact with you through your website social media what what are the best ways to reach you yeah so i'm i'm pretty active on twitter i tweet from uh jb carmody jvcar mody um i have a youtube channel uh the sheriff of sodium i don't put much on there but i put more thoughtful substantive lectures and content in there my own website the sheriff of sodium.com i have now many essays on many different subjects going back a ways that all that also has a form to um to contact me directly and i actually hear from uh you know students and applicants about various things fairly frequently and i try to answer some of those questions periodically in a mailbag feature on my website wonderful well i hope everybody stays tuned for part two hope to have you back and it's been a pleasure and we definitely appreciate the time and we'll hopefully talk to you again soon oh thanks for having me yeah it was fun you

Channel: Match A Resident ®

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Keywords: Match A Resident, Match Residency, IMG Friendly Residency Programs, Residency Programs for IMGs, IMG Friendly Specialties, Customized Residency Programs List, Residency Program Requirements, International Medical Graduates, IMGs, Foreign Medical Graduates, US Medical Residency Programs, Residency Experts, Residency Statement, Electronic Residency

Id: YYaztHem6k4

Length: 34min 15sec (2055 seconds)

Published: Mon Sep 13 2021