First you must disregard the advice that the OSA provides about making your schedule, outside electives, advisors, studying for the boards, ERAS, etc. You may feel compelled to attend the class meetings out of a misguided sense of responsibility or out of guilt, but you can either figure it out yourself or hear it from your friends. The only useful information that they disseminate is the relevant deadlines for the entire residency application process.

Making the choice to pursue Internal Medicine as a career is the first and sometimes most difficult step toward reaching your goal. The way that people come to this realization varies. Even though I was determined to do Pediatrics, at the end of my first week of my Medicine clerkship, I knew that Medicine was for me. Other people go through the whole gamut of clerkships before weighing their choices and coming to a decision. Some people choose Medicine by default, not being able to choose among the widely dissimilar disciplines of medicine. And lastly, some people applying for high-profile, competitive residencies also apply to Medicine as a "backup." In my opinion, Medicine is too demanding of a field (emotionally and physically) to pursue it with anything but whole-hearted enthusiasm.

This step is trickier than it seems. Let me tell you flat out that having the Program Director as an advisor is not a way to secure a spot anywhere, including at BMC. Your advisor does not have to be a high-profile person. As you travel and talk to other students, you find that many people who are considered giants at this institution or in this city are just that, and their names do not carry weight anywhere else. Also, if you are determined to do your residency in a particular region (e.g. the West Coast, the South), find an advisor who is familiar with that area. Although it seems obvious that people can’t advise you on places they know nothing about, many people don’t realize it until too late in the game. If location is not an issue, your advisor should be someone you have worked with. Decide on whom you want to designate as your advisor, and meet with him or her at the end of your third year, before you make your fourth year schedule (remember, your advisor has to sign off on it).

Also, don’t forget the resources around you in the form of interns, residents, and chief residents. Find residents or interns whose backgrounds, board scores (if you can talk about those things), styles, and personalities are similar to yours, and use them as sounding boards when you decide where to apply. Chief residents are generally knowledgeable about all kinds of things, from the application process to making the rank list.

The important fact that you need to remember is that the Dean’s Letter goes out on November 1, and that every bit of information that you want on it MUST be in by the beginning or middle of October. This is absolutely inflexible. The OSA tells you that Block 10 is the last block that will appear on your Dean’s Letter. While theoretically (i.e. in the OSA world) this is possible, by this time you know that it takes forever for most attendings to return evaluations. So the "take-home message" is this: do your Sub-I as early as possible to ensure that the evaluation is in before the deadline–this means Blocks 7, 8, or 9. When it comes to deciding between the Sub-I and the "Super Sub-I," most People In The Know recommend the Super Sub-I. Not only do you get a true appreciation of the life of an intern, but it also shows your evaluators that you can handle the demands of internship. One thing to remember is that when you interview, many programs don’t really know how an "Advanced Acting Internship in Medicine" is different from a Sub-I, so you might have to do some explaining.

You have probably toyed with the idea of outside electives. The post-match feeling, for the most part, is that they really don’t help. If you want to experience a particular program first-hand, or to experience something that BU does not offer, go for it. Otherwise, the other reasons that people do outside electives (to gain exposure, to make new connections) are for the most part myths. The people who ended up with this year’s "hot matches" would have ended up there anyway. Four weeks of hard labor does not guarantee you an interview or airbrush a spotty performance record, so don’t be foolish and sign up for something like Q2 call in the unit.

The rest of the schedule is up to you. Do whatever strikes your fancy. Since the 4^th year rotations each allow you to miss 5 days during the interview season (November to January), you can manage to fit all of your interviews into your schedule without taking a vacation block. Radiology is a nice rotation to have around December…avoid doing Geriatrics.

My personal advice: scrimp on vacation during third and fourth year (you’ll live, trust me) and take it ALL as one giant vacation at the end of your fourth year. Also, travel. Let me say it again in case you didn’t get it the first time: TRAVEL.

The question of USMLE also comes up. I recommend taking it early (i.e. as soon after your third year as possible), others recommend taking it late. I don’t think there is a "right" answer in terms of getting the residency of your choice. Rather, the decision about when to take the boards lies on your motivation. I took them early (August), and looking back on it, I wouldn’t have done it any other way. You will be surprised at how dramatically your motivation plummets as soon as you turn in your ERAS disk. Opening any sort of book becomes exponentially more painful as the Match draws near, and I think that people who had to take them post-Match would rather have died. One tip: choose a date, and STICK TO IT!! You’re never going to feel ready, and you’re never going to memorize all the facts in medicine. Don’t torture yourself by postponing the inevitable. This test is not worth the agony.

During August or September of your fourth year, think of three or four attendings with whom you worked that would be able to write a good letter of recommendation. One letter will be from Dr. Levin/Hershman/Caslowitz (depending on where you did your Medicine clerkship), and another will be from the attending from your Sub-I. If you worked with your advisor, he or she may be able to write one. Many people obtain a letter from Dr. Brown (so what if he’s OB/GYN). Remember that you want someone who has a good command of the English language and can speak highly of you.

If you have a particular program in mind already, find an alumnus of that residency program or an attending who worked there, and arrange to work with that person and get a letter of recommendation from him or her. An endorsement from someone that a program trained and/or trusts goes a long way.

You will get the opportunity to review your Dean’s Letter before it is submitted. This is one of things that the OSA offers that you must take advantage of. People get all bent out of shape about what the Dean’s Letter contains. My bet is that you already know, especially if you are on top of the information that your File contains. Remember the one-paragraph summaries that are on each of your third-year clerkship evaluations? String them together and add a few generic adjectives…and voila! that’s your Dean’s Letter. Nothing special, nothing to stress over. Make the appointment to preview your letter and scour it for misspellings of your name (known to happen), bad grammar, incorrect information, and negative facts (you can have them removed).

Let me first say that ERAS is very self-explanatory. You can disregard most of the ERAS "tips" that the OSA emails you.

Decide on what is important to you in a residency program: location, program size, primary care vs. hospital-based medicine, salary, vacation time, etc. Be honest, or you may get stuck with a lifetime of misery. Use this information to make a preliminary list of residency programs. The FRIEDA site (http://www.ama-assn.org/cgi-bin/freida/freida.cgi) and the Internet in general are very useful.

Make an appointment to see your advisor around late September. Don’t see him without having at least a preliminary copy of your personal statement and your list of residency programs.

When you and your advisor sit down, he should be able to take the information he knows about you (board scores, grades) and what kind of program you want and pare your list down to about 15-20 programs. A good advisor will be able to prevent you from applying to programs that are unrealistically above or insultingly below your level.

Lastly, the whole interview/application process is not a time to be bashful or ethical. Be shameless in trying to obtain connections (not by doing an away rotation, mind you) and exploiting them (old friends, roommates, parents, parents’ friends, etc.) to get interviews at places that you want and to get these people to put in a good word for you whenever and wherever they can.

There will be about a month between turning in your ERAS application and receiving your first interview offer. If you have already taken your boards, then this is one of your least stressful months of the year.

Schedule your interviews in a way that is convenient to you. For Medicine, 9-12 interviews are adequate. You may find yourself canceling interviews as your interview tour draws to an end. One important thing to remember is that when you decide not to attend an interview, let the program know by telephone or by email. It reflects badly on the school and on your classmates who apply there, so don’t spoil it for everyone else. Also, if there is a program that you are interested in that you haven’t heard from, don’t be shy about calling. They may have lost or overlooked your application (it’s been known to happen).

When you are given the opportunity to ask questions, ASK. This is not the time to keep your mouth shut. However, it is not the time to pimp your interviewer on the amount of sick time that interns receive. If you can find it on FREIDA or in the program’s literature, don’t ask about it. The applicants who ask the best questions are the people that programs remember. Examples of questions that made lasting impressions in programs (i.e. garnered the coveted "We want you" phone call) are, "What is the most interesting question that you’ve been asked?" and "What are the questions that applicants should be asking?"

You’ll hear this again and again, but take copious notes on everything. Another hot interview phrase is your "gut feeling." Trust it. Also, take down phone numbers and email addresses of other residents and students you meet for future reference.

Write thank-you notes to ALL of your programs within a week of your interview there. First Aid for the Match has nice examples of letters. Customize and personalize it, and don’t tell everyone you are ranking his or her program first.

After you are finished with all of your interviews, you probably have a general sense of your rank list. Put it down on paper, and then go back and think about the pros and cons of each. Be honest with yourself when you make your rank list. By this I mean: don’t think you are better than you really are, or you may be in for a nasty surprise on Un-Match Day.

Make an appointment to see your advisor in early February, and discuss your rank list. Sometimes, your advisor has insights into the programs that you, as a student, do not. Between the two of you, you can make the finishing touches to your list. The question of the "phone call" inevitably comes up as well. I am not a proponent of the calls advertised by the OSA (think about your options for callers). If he is willing, you may have your advisor make a call on your behalf.

At this time, you should send another follow-up/thank you letter to your number one program and tell them you are ranking them as such. This is another time to use any connection you have (including residents you met while interviewing) to your advantage—remember that the whole match process defies logic and reason, so you have nothing to lose from shameless exploitation and self-promotion.

Enter your program into the NRMP WebROLIC a few days before it is due. This way, you have a couple of nights to live with it and to see how comfortable you feel. This is another time to pay attention to your gut feeling.

The month between submitting your rank list and opening your envelope can be nerve-wracking. Don’t let it be. It’s out of your hands at this point. Just relax and enjoy your fourth year. You probably have a great rank list, and theoretically you should be happy (to varying degrees) with any of the programs on it.

So take a deep breath, open your envelope, and celebrate!

Congratulations!