Pursuing a residency in general surgery is perhaps one of the wisest choices one can make in the current medical arena. Proficiency in general surgery demands dedication, responsibility, and a strong commitment to the field. Without hesitation, one can say that no residency is as mentally challenging and physically demanding as general surgery. Having said that, general surgery provides one with endless opportunities to pursue individual interests. The field is constantly changing and is currently experiencing radical developments. Of course, as a general surgeon you will have the opportunity to dedicate yourself to either academic or clinical medicine, or a combination of the two. Current research and development in surgical laboratories are rapidly changing the way different disease manifestations are treated and prevented. Clinical trials are in progress investigating new diagnostic and treatment modalities such as robotics, laparoscopy and other minimally invasive techniques, lasers, chemotherapeutics, organ transplants, cell cultures and lines, endovascular stents, and artificial organ replacements (i.e. LVADs) are being investigated. As a surgeon, the research and specialization opportunities are limitless. Indeed, the field of surgery is one that offers a variety of ways in which to practice medicine. Surgery allows one to incorporate both basic science knowledge and a strong understanding of pathophysiology into deriving treatment possibilities for patients. Practicing as a surgeon demands more than just exceptional technical experience in and out of the operating room, but also refined medical management skills in the pre- and post-operative situation. This is perhaps the hardest aspect of a surgical career, as surgical patients are usually the sickest patients in the hospital and require the most intensive care. Most of all, any student should realize that "nothing cures likes stainless steel." As a former SICU nurse told me: "a chance to cut is a chance to cure!"

Like most competitive residencies, applying to a general surgery program is a particularly rigorous experience. Traditionally the number of spots available in general surgery programs averages between two and five per program, with several hundred applicants and between 120-150 interviews granted for those spots. Some programs only interview candidates that are AOA, some only those that were Junior AOA. Some programs only offer interviews to students with board scores in the top quartile or ten percent. However, there are programs that do not require AOA, top board scores, and honors in all rotations to get in. In the past, there have been more than a couple of students from BUSM who did not honor their core surgery clerkship and matched into competitive categorical positions (just not MGH, though). While these numbers may seem a little daunting at first, they should not deter anyone with the proper credentials and motivation from applying. What follows below is some advice in the process for applying – remember though, the number one rule: start early!

This is a question that people invariably worry too much about. The important bit of advice that I can give is this: do the sub-I early, and do it with a faculty member with whom you did not do your 3^rd year clerkship. The reason for this is that you will need at least two surgical letters of recommendation. Now, to dispel some myths: you do not have to do the Chief’s Service Sub-I (with Dr. Becker), you do not have to do more than one sub-I, you do not have to do your sub-I at Newton Pavilion (or whatever University Hospital is called now), and it is not the end of the world if you do not do your sub-I before the deadline for Dean’s letter submissions. This can actually work to your advantage. You can "pad" your Dean’s letter with other interesting electives (see the rest of the Redbook) and then also include a letter of recommendation from your Sub-I faculty. However, do your sub-I early enough so that a letter can be sent with your residency application (which means October-ish). Also, make sure you do exceptionally well in the first part of fourth year. Rack up those honors!

This is probably one of the most important decisions you will make in the residency process. With the help of a faculty member, you will be able to ask general questions about the field, and as time evolves, to make more specific inquiries into particular programs. You should pick an advisor that you feel comfortable speaking to, and one that you trust, not just someone with a big name. Your advisor will become critical in the application, interview, and match process. Prior to fourth year, the advisor can assist you in selecting a fourth year schedule that will maximize your learning and your remaining time at medical school. In fact, you will see that most, if not all surgical advisors will suggest not overloading on surgical electives, but rather taking medical electives in fields that complement surgery, and that you have interests in or are curious about that you may never have a chance to pursue in the future. These include cardiology, pulmonology, family medicine (yes, doing family medicine in a rural area can provide a lot of experience and fun at the same time!), emergency medicine, or international electives (what could be better than traveling abroad, visiting foreign sites, free airfare, cheap housing and food, and getting credit for it at the same time?). On the other hand, don’t fill your schedule with traditionally lightweight or "blow-off" electives, because program directors and advisors can see right through your motives. Early in the fourth year, your advisor will also help you decide to which programs to apply. It is best to be honest here and to tell your advisor all your grades, board scores, your strengths, weaknesses, interests, goals, and importantly, geographic considerations. Doing so will only save you lots of time and money later on. As advisors, BUSM students have traditionally have chosen Drs. Becker, Menzoian, or Beazley. Others have chosen Dr. Millham, Kavanaugh, Hirsch, and Woodson. Recently, new faculty has been introduced to the department from BI-Deaconess. Having worked with most of them, I believe that any of them (Forse and Burke in particular) would also be excellent choices. Also, there are excellent choices for advisors at the VA that should not be overlooked – Dr. Watkins is a surgeon with national renown and his letter would carry great weight. Again, the most important consideration in choosing an advisor is personal preference and compatibility. You can also have more than one advisor. Looking back at it know, I can remember exact meetings where their information and insight was right on the letter.

Another issue that comes up frequently is that of away rotations. Again, here your advisor will be able to provide valuable insight. He will tell you why, when, where, and if you should do away rotations. My recommendation is to listen to your advisor. While some students believe that an away rotation almost guarantees an interview at an institution, experience among current fourth year students at this and other schools will certainly prove that notion wrong. No amount of hard work in 20-28 days can replace a lackluster performance record over the past 3-½ years. Residency committees know that this is what people try to do and usually do not give serious consideration to these applicants unless their transcripts corroborate their performance at the hospital. Otherwise, as one advisor said, doing an away elective is basically submitting to "slave labor and volunteering for scut for one month." Many fourth year students will easily attest to the truth of this statement. On top of that, away rotations are expensive in terms of transportation, rent, food, and other costs. Mt. Sinai Hospital for example is very well known for having hundreds of students per month do away rotations at its hospital and charging them for the opportunity. In the past 5 years, no student doing an away rotation at Mt. Sinai has received a spot in the surgical program (I only found this out too late). Luckily, I was also doing the rotation for another reason (see below). Mt. Sinai apparently interviews three categories of students: 1) AOA, 2) Mt. Sinai Medical School students, and 3) all students who did a rotation at the hospital. Again, the last group was more out of courtesy than anything else. Many programs, particularly those in New York City, are well known to be "in-bred" programs (i.e. Columbia, Cornell, and NYU – taking more than ½ of their residents from their medical school). You will find that many attendings at these institutions did their fellowships, residencies, and medical school education there.

Having said all that, now some good news about away rotations. There are really only three reason to do away electives: 1) to gain experience in a surgical subspecialty that you may not otherwise at BMC (i.e. cardiothoracic, solid organ transplant other than kidney, endovascular), 2) to travel, and 3) to appreciate how things are done in different areas of the country or different types of hospitals (i.e. community vs. university, rural vs. urban). In my own experience, I have noticed a dramatic difference in the way surgical services are run in Boston compared to New York. Generally, the services are significantly busier in New York with scheduled OR cases routinely starting as late as 8 PM and on weekends. It is not uncommon to have a couple of OR suites running 24 hours a day in NYC hospitals. Another difference that I noticed was that Boston hospitals are traditionally more "conservative" in the management and treatment of patients. Boston hospitals have traditionally been behind in pursuing newer surgical techniques and modalities. While on away rotations, I was able to see early uses of TMR (transmyocardial revascularization), complicated cardiac revascularizations and valve replacements, aortic coarctation repairs, treatment of congenital cardiac abnormailities, advanced use of endovascular stents for the treatment of AAAs (being able to treat a patient with only local anesthesia in the groin and then later have the patient ambulate to the bathroom two hours later is truly a sight you never forget!), and advanced laparoscopic techniques and procedures. Many NYC hospital programs are also less "academic" than those in Boston. However, there are an overwhelming amount of "community-type" programs in NYC that place residents in competitive fellowships (and academic placements) comparable or equal to "university-type" program graduates throughout the country.

Most general surgical residency programs require at least two letters of recommendation from surgical faculty, with one of those usually being the chairman or clerkship director. (A couple of programs ask for a letter from three surgical faculty – so be prepared.) The other letter should be from your core medical rotation (if you did well in it), or from another particularly strong clerkship. You could also use a letter from someone whom you did significant research with – and preferably with a published paper or more… One strong suggestion: ask for letters of recommendation early. Personally, I would recommend telling the attending about a week into the rotation that you are planning to ask for a letter so he can pay attention to your performance. Certainly leave at least 2 to 3 months of time. Be forewarned that most faculty want to see a copy of your C.V., publications, and personal statement before they write their letter, so have those prepared. That is why you should start your application now! This means the beginning of fourth year.

Deciding where to apply is perhaps the most difficult part of the entire process. Again, be honest with yourself and set your parameters such as geographic limitations, academic vs. community programs, size, etc. You should look on the FRIEDA site for more information about particular programs. Once you have a general list of programs, you should then talk to your advisor since he will often be able to provide you with the "inside scoop" on programs which is otherwise hard to get. Residency programs and departments are under constant flux and faculty appointments are sadly under great political stress. Two chairmen with whom I interviewed told me that I shouldn’t expect to be entering and leaving a surgical residency program with the same chairman, stating that the average tenure is less than 5 years. There has been an incredible amount of open chairmanships available in surgical departments this past year – which made deciding between programs quite difficult. Not having a chairman is also an interesting situation. They usually lead the department in terms of direction, academics, and future goals of the program. They usually bring new faculty with them to strengthen the department, and consequently improve your experience. Importantly, as the time comes, they are also the ones to help obtain the fellowship of your choice. As one misguided interim chairman told me, "the only reason for residents to be concerned about who their chairman is, is to know who will fire them." If you hear this, run.

There is no clear rank list of programs, though there is some general idea that exists in certain regions of the country. The only way to know is to ask your advisor about how sound a program is, its particular strengths and weaknesses, and how well fitted they think you are to the program. By doing so, your advisor can tailor the list to your future career objectives.

The actual application process is easy. Luckily most programs (practically 99%) are ERAS. For the others, you should write away to them (see FRIEDA for address info) and get their separate applications. Most applications ask for the same information as ERAS does, but just in a different format. If you know how to use a computer, you know how to use ERAS – it’s basically one giant long form. The most important part is probably your personal statement. Basically, write down why you want to do surgery and what you want to do for the rest of your life with your surgical experience. Definitely keep it to one page. If you are applying for surgery, you know how short surgical H&Ps are – and then you know how short a surgeon’s span of attention is – keep your rich, expansive, vast, profuse depth of adjectives and eloquent circumloquacious portrayal of dramatic literature to a minimum – this is not an English class. Also, try not being to "cutesy." Ask your advisor or one of the OSA deans to review/check over your personal statement.

Lastly, submit your completed application ASAP to the OSA. Definitely make a backup.

If you applied to a good, appropriate mix of programs commensurate with your record and experience, you should be able to get a fair share of interviews (at least half). Most applicants interview at approximately ten to fifteen programs (and are invited to more). Doing so will give you a strong basis for comparing different programs and will allow you to interview at programs that you consider "reaches." Most programs interview in December and January (with some in late November and early February). They tend to interview on Saturdays and holidays, although there has been a trend to move interview dates into the middle of the week. Also, many programs only interview on 1-3 specific dates, so when you get an offer to interview, respond IMMEDIATELY – dates fill up fast. Check your email, snail mail, and voicemail often. Be prepared to pick and choose between programs as their dates often conflict. If you must cancel an interview, call ahead of time (at least 5 days ahead, preferably) so somebody else can have your interview spot. Besides, it looks rude, reflects poorly on BUSM and their students, and program directors and chairman talk to each other… Interviews at general surgery programs are more than formalities. While it may be true that some programs have already created a "short list of desired applicants," your interview can have a significant impact on your application and your position on this "list." Be prepared to answer any and all questions about anything. Also be prepared with intelligent questions that are general in nature and some that are specific to the institution. Have questions for both the faculty and residents. Some should be different, but it is interesting to ask the same question to faculty and residents and compare answers…Be forewarned: residents can sometimes report back to the program director with their impressions of applicants. However, if they state that they have no input, believe them. Don’t forget, residents have it in their best interests to also get the best applicants. You will be their co-residents next year and in the future and they need to know if they can depend on you to do the job right – the first time.

The interview day typically involves 2-4 interviews with between one to nine members of the faculty at each interview. Usually, you will have occasion to meet with the chairman for five minutes. Occasionally, chief residents also interview applicants. Be prepared to answer difficult questions. These interviews are not like the social happy hours of other residency programs. For the most part, you will not be pimped at your interviews, although expect at least 2-3 interviews to have a little pimping. Do not be afraid though – this pimping is easy and is usually either extremely basic (i.e. first week of surgery) or on a case that they ask you to talk about – so you already have a deep fund of knowledge about it. (You should have one interesting case prepared from your sub-I for such an occasion.)

All interviewers will ask about future goals and sub-specialty interests. Be honest. These interviewers are experienced and realize that more than 75% of general surgery residents pursue a sub-specialty. If you truly are undecided due to lack of exposure, admit it – it’s a perfectly reasonable answer. If you are interested in academic surgery, be ready to provide a good reason for doing so and be prepared to show that you know what it entails. Other questions have involved ethical dilemmas, outside interests, sports, hobbies, last non-medical book you read, and (though supposedly not legal) plans for a family – they ask this of both women and men. Finally, at the end of the interview comes your time to ask questions. Do not ask questions which place the program in a poor light, and do not ask questions that are easily answered through program literature or that were answered early during a group presentation (this shows that you were either not listening, late, or poorly prepared). Instead, ask questions that allow the interviewer to stress strong points about the program and other questions that you believe to be important (except how well, er, rather poorly, compensated you will be and how often you will be on call – assume q2-q3!). Ask the harder questions about real life and the program’s workings to residents outside of the interview during Q&A sessions or impromptu on the tours. Residents are also an invaluable resource regarding the camaraderie and overall happiness and strengths and weaknesses about the program.

Be very wary when you can only see one or two residents the entire interview day. Why is the administration keeping them hidden? At the end of this residency section, I have included a set of questions that you may be asked or could ask. Also, I have included a little "spreadsheet/database" that I used to keep track of all the programs I have visited and different aspects of each of them. This came in particularly handy when ranking them in February. Otherwise, you will forget the differences between programs. Feel free to copy the page and fill it in as soon as you are done with the interview day (fill it in that day). It will provide you with important areas to consider… Lastly, dress conservatively – this is surgery after all. Most men wore dark suits (blue/black) with dark ties, and most women also wore dark suits (skirt suits more than pant suits).

A few days after interview day, try to send out thank you letters to the program. Some programs assume that you are no longer interested unless you write! Do not tell every program that you plan to rank them #1 unless you do – again, the program directors at different institutions talk to each other. If you are particularly interested in a program, you may be able to make a second visit to look around and round with a surgical team.

There is only one thing that is important here. If you have not been truthful to yourself before, here is the one time that you should. Be 100% honest with yourself about your record, what you want out of a program, where you want to live for the next 5-7 years, how hard you want to work, etc. Remember, this is your life, so do not depend on anyone else to make this list and unless you are married or have a significant other. It will be you who has to live with your decision, not your parents, girlfriend, boyfriend, friends, relatives, or even faculty. There is no strategy to the list – rank the programs in the order that you would want to go. Over the past several years, general surgery applicants from BUSM matched within their top 5, and most within their top 3!

Good luck in the coming year. BU has traditionally done very well in placing students in categorical general surgery positions over the last couple of years, so the prospects and tradition are in your favor. If you have any questions, track down other members of your senior class or the class above you. Also, do not forget to talk to other students on the interview trail – not only are they going through the same thing you are, but they may have insight into programs you do not, especially if they went to school there… Other valuable insight can be gained from the current interns at BMC – remember, they just went through the process exactly one year ago! Good Luck on Match Day and next year!

Special thanks to Drs. Becker and Millham for their advice and support over the years.

Overview of Some Surgery Programs