The Ultimate Guide for Matching into Competitive Specialties

Breaking Down ERAS Residency Application Components and Best Practices

Oct 26, 2020 · Doximity Insider

The “Road to Residency” series is developed by Residency Navigator, the most comprehensive online directory of U.S. residency programs. The program is used by 90% of 4th-year medical students to view program stats, read hand-written reviews from current and former residents, and view ratings on 4,000+ residency programs.

Getting matched into a competitive specialty has never been harder. In the 2019 Main Residency Match, a record high 38,376 applicants submitted program choices for 35,185 positions. In a recent NRMP Program Director Survey, Program Directors reported that the average residency program received 904 applications, and immediately rejected 48% of those applications based on a “standardized screening process.” Of the applications reviewed in-depth, programs only sent out 121 interview requests, of which only 82 were actually ranked. A fraction of those ranked actually matched at a given program.

Given the increasing competition for top residency programs, we wanted to break down the various components of the ERAS application you should pay extra attention to, and the best practices to present your candidacy in a unique, compelling manner.

Step 1 Score

Step 1 is probably the most important test you'll take in your medical education, more important than your board exam I argue. It's similar to the MCAT for getting into medical school. A low score on this test could be the one thing that prevents you from matching a competitive specialty. Charting the outcomes in the match lists the average step 1 scores for each matched and unmatched candidate. Dermatology, orthopedic surgery, otolaryngology, and plastic surgery are specialties that typically have the highest average of all specialties.

Step 1 isn't everything (my step 1 score was significantly lower than the mean), but it is really important. Doing well on this exam will make your life so much easier. Joyce from Tea with MD wrote a post on step 1 studying and so did Laura from A little Bit of Lacquer. My biggest advice to you is to keep your study method simple, and ask previous people from your institution for advice.

Medical schools all teach the same information, but each curriculum has its strengths and weaknesses. For instance, Emory has a very strong clinical and ethical curriculum but it's pretty poor when it comes to the basic sciences. Therefore, students naturally do better on step 2 than step 1, and students have to spend a lot of time learning pharmacology and biochemistry for step 1. As with any advice, talk to a few people (who are willing to tell you their score! Never take advice from someone just because they offer it.) to see what they did and then pick something that works for you. Do not make it too complicated. Don't use too many books. Focus on learning 1-2 resources frontwards and backwards.

Oh - word to the wise - DO NOT USE UWORLD STEP 1 QUESTIONS BEFORE YOU SIT DOWN TO STUDY FOR STEP 1. Some people use them to study for the preclinical exams, and I think that's a horrible idea. That is by far the best study resource, so you should save it for your concentrated studying. Kaplan and usmlerx are other study bank options if you want to study from questions during the preclinical years.

Step 2 Score

Your step 2 score matters less, but it appears to be becoming more important each year. Traditionally, if you do well on step 1 you are advised to push step 2 until after ERAS is submitted, just in case you don't do as well (at least that was the advice given to me in dermatology). There are some programs that require step 2 for an interview (I think UCSF dermatology is one of them). I didn't do that great on step 1, so I took step 2 and really knocked it out of the park. I think that partially made up for my lower step 1 score. To study, I did the entire step 2 uworld qbank in a 3 week period (I'd already done it once to study for shelf exams. It was really depressing how much I forgot).


If you're applying to an academic program (which almost all competitive specialties are), you'll be interviewed by academic clinicians who want to produce more academic clinicians - for the most part. I did interview at some programs, like UMichigan, who really don't care if you want to become an academic clinician, but that's definitely the exception. **Research is basically necessary to match a competitive specialty. I was lucky enough to join, and later take ownership of, a few research projects I really, really cared about.

The two biggest questions for research are when and how. More detail on the how coming soon, but basically you've got to work, work, work, work, work. I was told before the start of my research period by a dermatology resident, "if you're not overwhelmed, you're not working hard enough," which I very much took to heart. Not to say, your personal life has to fall to shambles (in fact, I met my perfect boyfriend during my research period), but you should be balancing multiple projects because the reality of research is everything takes 5 times as long as you think it will. Typically, clinical research can be published sooner than basic science research because you can publish preliminary data more easily with clinical research.

By far, my research was the strongest aspect of my application because I'd not only shown I was proficient at designing, executing, publishing, and presenting, but I got to know my home program faculty very well through clinic recruitment. This resulted in very strong letters of recommendation.

Clinical Grades

The biggest mistake you could make is to neglect your clinical rotations for research. You guys know this, but it's not okay to slack off on rotations just because you don't want to go into a particular field.

Doing well on clinicals requires balancing time on the wards/in clinic with time in the books. It took me awhile to master this balance. It sucks coming home from clinic and studying late at night. It also sucks getting off early, only to have to go study. or spending your 1 day off studying. It really, really sucks, but you have to do well on the shelf exams to do well overall. Up until the middle of 3rd year rotations, I was always trying to be a stellar wards candidate to boost my shelf exam scores, but I realized that wasn't the best plan. Book knowledge helps to be more impressive on the wards and the shelf exams grade a lot harder than your clinical grader, usually. Keep a book, your ipad, or your smartphone on you at all times and study whenever there's down time. Some of my classmates would get uworld questions done throughout the day like that and then go home and enjoy themselves. That looks good too!

Overall, work hard. It will ultimately be up to you where you let the balance of clinical time and book learning fall. I do encourage you to soak up all the clinical time you can while balancing your book studying because you'll never get to experience 3rd year again.


Related to clinical grades is AOA. Different schools have different selection criteria -some being very open about their selection process while others are a little more secretive. AOA is like the golden stamp of approval on your application. It doesn't guarantee that you'll match - I know people who were AOA who didn't match - but again, it's another hurdle that you can cross off the list.

Letters of Recommendation

These are very important in small fields. Every applicant is going to look great on paper, so having someone highly respected in the field vouch for you goes a long way. In general, you want all of your letters to come from that specialty. Also, your chair should write you a letter. My four dermatology letters all came from my research mentors - the chair of the department, the vice-chair of the department, and two junior faculty. I know they were all strong letters, but it was obvious during interview season that the letters from the chairs held much more weight. I was explicitly told in an interview that I was invited for an interview because "someone I think very highly of thinks very highly of you."

An aside on dermatology interviews. Every program chooses interview applicants differently. For some programs, the program director reviews all of the applicants. For others, the applications are divided among faculty and each faculty member picks a certain number of applicants to invite for an interview, which means it's kind of luck of the draw if the faculty member that gets your application finds you and your CV interesting. That's why the bigger the name and the more diverse your application, the better your chances.


There is a section on ERAS for you to put your hobbies. Don't overlook this. This area could get you an interview. Say you and another person have the exact same application, but you and the person reading your application and marathon runners - unlike the other applicant. Who do you think will get chosen for an interview, all other factors being equal? Also, it's really good for easy conversation during interviews.

I put "Reading (Recent Reads: The Power of Habit, The Casual Vacancy, The Goldfinch, The Emperor of All Maladies) - Running (ran the silver comet half-marathon in 2011 and the rock 'n' roll marathon in 2012) - Yoga - TRX - Cooking" - yep, I just pulled out my ERAS for that one. Literally, at every interview someone asked me about TRX! It was so unexpected and a really fun and light conversation. Other people commented on books that we'd both read. We discussed how "The Goldlfinch" was overrated and really unenjoyable. Others gave me book recommendations based off of my recent reads. I gave others tips on how to go from being a non-runner to training for a half-marathon.

Who You Know/Who Knows You

Let's keep it real here. This may go on your application in the form of a letter of recommendation or it may come in the form of a phone call, but let's be real - who you know matters within small communities. There are only a certain number of spots and some of them will be filled by sons, daughters, wives, and husbands of important people.

Personal Statement

In the words of my mentor, "I guess it kind of matters. Occasionally we look at it." People make the mistake of making their personal statement a love story to their chosen specialty. News flash, the person interviewing you knows how awesome the specialty is, way more than you actually. Tell them about you and why you would make an excellent radiologist!

I LOVED my personal statement. Alex thought it was really trite (so much so that he still teases me about it). Whatever. Do you boo. In general though, it's probably better to have a really boring personal statement than one that could possibly offend people or be taken the wrong way because it's the least important part of the picture.

Extracurricular Activities/Volunteer Experience

I have no idea how much this matters at all, but be a good person and spread goodness anyway. Volunteer work is helpful to remind yourself of what's really important in life - outside of your medical school bubble.

Setting Yourself Up for Success

The “road to residency” typically starts far earlier than the actual ERAS application. Understanding what it takes to achieve admission into the most competitive specialties is critical, and getting into a top program requires foresight, planning, and excellence in academics and research. I wish you the best of luck in your application strategy and residency decision-making process!

Elyse M. Love, MD is a board-certified dermatologist trained in the wide spectrum of medical and cosmetic dermatology. Originally from Alabama, Dr. Love completed her undergraduate education at the University of Alabama, where she graduated summa cum laude. She received her Doctor of Medicine from Emory University School of Medicine, after which she moved to New York to complete residency training at The Ronald O. Perelman Department of Dermatology. She currently practices at GlamDerm, a cosmetic and medical dermatology practice. Read more of her writing on her personal blog Love and The Sky.

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