In the last 10 years, dermatology has become one of the most, if not the most competitive specialty in medicine. Hundreds of extremely qualified applicants are disappointed each year. Therefore, not matching is not a reflection of one’s qualifications as a future doctor. It just means there aren’t enough spots. This year 700+ applicants competed for roughly ~450 spots. 250 applicants didn’t match. (120 of whom are U.S. medical students.)
I didn’t match dermatology the first time.
It was a harrowing experience and I had a chip on my shoulder for a very long time. The embarrassment and heartbreak ebbed and flowed, but the anxiety and self-doubt stayed with me until the day I opened my match envelope.
If you’re applying into dermatology, you’re competing against the top medical students in the country. Last year’s mean USMLE Step 1 score for matched candidates was 249 — the highest for any given specialty. But even the unmatched applicants were equally as competitive, averaging a 241 on Step 1. That’s still 10+ points higher than all test takers. 49% of matched candidates are members of AOA (Alpha Omega Alpha), a selective honor society reserved for students with high academic achievement. The reason I mention these stats is because they are both important and trivial at the same time.
Why are stats
Having good stats is not enough. That was the hardest lesson I came to terms with on my journey. Throughout my medical career, I allowed myself to be defined by my academic merits and achievements. In medical school, you’re placed into a pressure cooker where the only distinguishing factor separating you from your peers are your grades. But when everyone looks the same on paper, what separates you and the applicant next to you is your advocate.
Let me repeat this: you match by having an advocate. And not just any advocate will do. You need an advocate who sits on the admissions committee.
Why do you need an advocate?
Let’s break down why it’s so important to have advocates on the admissions committee. First, each program receives 500-600 applications. Some programs may have an automatic Step 1 cut-off to make the process more efficient. After that, faculty members on the committee are assigned a stack of applications (probably 20-60 applications each) to screen for interviews. Programs have on average four spots open each year. If a program interviews 1:10 applicants per residency spot, that means each faculty member can only flag a few applications out of their stack for interviews.
Having been a premed advisor, let me tell you that screening applications is not easy. Yes. If you scored 280 on your Step 1, you’ll get flagged for an interview. But more likely than not, your application looks just like everyone else’s: competitive scores, good grades, tons of derm-related publications. But remember: what you look like on paper is important, but also trivial at the same time. So rest assured if you don’t feel like you’re the perfect candidate. You can still match! Because your advocate is going to get you an interview at this point.
Who is an advocate?
An advocate is your recommendation letter-writer. She is your mentor. Your cheerleader. The one making calls for you to other program directors. If your advocate is well-known (because dermatology is a small field), her letter will bear much more weight and your application will get flagged. If the faculty member reading your application is somehow friends with or trained with one of your letter-writers, you will get flagged. Accidents do not happen in competitive specialties. I was able to trace a link to all of the programs I interviewed at. Someone felt compelled to flag your application and it probably wasn’t your personal statement.
How do I find one?
Home institution and/or research fellowships
Cultivating a strong relationship with an advocate takes time. Establishing yourself at your home department early on is the most accessible way. But if you don’t have a home program (or even if you do), research fellowships can be just as rewarding. More and more applicants each year enter year-long research fellowships. Publishing research articles is important (many applicants have 10+ publications accepted or submitted by the time they apply), but your ultimate goal should be to get to know the department. Research fellowships are essentially a year-long audition process for the department. If you show you can work hard and are well-liked by everyone, you are automatically in a more favorable position to match there. Stellar scores or 10+ publications are not going to impress anyone if you don’t have advocates. The more advocates in your corner, the higher your chances of matching become.
However, a research fellowship is a huge investment and not a viable option for everyone. If that’s the case and you don’t have a home program, away rotations are additional opportunities to find advocates. But away rotations can be a double-edged sword. They are costly and picking the right one is so difficult. The best rotators are not only strong clinically, but also well-liked by the department. If you are not both of those things, you’ll kill your chances of matching there. Once again, your goal should be to impress or establish relationships with advocates on the committee. A good place to start is by identifying programs you may already have a connection to. If your letter-writer or research mentor is friends with a committee member at another institution, you now have another advocate by proxy.
Choose away rotations carefully
As an aside — don’t just pick programs that interview all of their away rotators as a courtesy. That’s not going to help you. Courtesy interviews are just that — a courtesy. They DO NOT increase your (actual) chances of matching there (see below). Good programs to rotate at have “real spots.” “Real spots” are residency slots that are available to all applicants. If a program has four residency slots, but two of them are promised to internal candidates, then only two of the remaining spots are “real.”
After you are miraculously plucked from obscurity and placed into the coveted “interview” pile, your chances of matching skyrocket. But it’s still not over. From this point on, you’re interviewing against an even more elite group of individuals who are all somehow personally connected to the institution. I won’t delve too much into interview tips here — I’ll save that for a later post. But the general structure of dermatology interviews is akin to speed dating. Typically, you’ll rotate through ~10 rooms with 1-2 faculty members each. Each room will last ~10 minutes. Immediately post-interview, the committee gathers together to rank the interviewed candidates.
Preparation and luck
The interview is immensely important, because it’s another opportunity to gain advocates. Strong interviewers can win over departments with their charisma or impress them with their passion for research. Luck also plays a role. If you serendipitously sat next to an influential committee member at your pre-interview dinner, or showed up early to the interview and bonded with a faculty member for an hour, you will increase your chances of winning over advocates. The more advocates you have sitting in that committee room, the higher your chances are of matching at that institution.
The opposite is also true. When committee members are trying to rank 40+ extremely qualified applicants in order, every little blunder is microanalyzed. Nowadays, no one is socially awkward or blatantly hostile during interviews, but small details like yawning, appearing disinterested or shy during pre-interview dinners, sounding smug or generic, can all be reasons to tank someone. It’s like walking on egg shells.
The number of interviews DOES NOT matter
My last point about interviews is that your chances of matching DO NOT improve with each additional interview. Yes there’s a correlation, because strong applicants tend to receive more interviews. However, the number of interviews you receive DOES NOT impact your chances of matching at a particular institution. Therefore, do not start flexing on the interview trail if you do have 15+ interviews. But also, don’t feel too bad if you don’t have that many. Having a strong connection to one program is better than weak connections to 15 programs.
Okay, so if it’s just about who you know, why even bother trying to look good on paper?
Because it’s still easier to advocate for someone who checks all of the boxes. If you’re weaker on paper, it will be an uphill battle for your advocate to make a case for why you should be picked over someone else. But having the right advocate trumps (almost) all deficiencies. Obviously, if there are major red flags on your application, it will be that much harder to match.
Take home messages
I sincerely hope my post encourages anyone who didn’t match to not give up. You deserve it just as much as the person next to you. Do some introspection and address any deficiencies (we all have them!) in your application and try to focus on your strengths. Or it might just take more strategizing. Maybe other applicants simply had advocates fighting harder in the committee room. Or maybe you just got unlucky. Getting ranked #6 versus #5 could mean the difference between matching and not matching. If dermatology is truly your calling, you’ll get there.
I also hope to better prepare applicants applying into dermatology (or a competitive specialty) in the future. (Refer to my ultimate medical school survival guide to learn how you can be the best applicant you can be.) But do not rely solely on your merit. Find advocates invested in your journey. I would not be where I was today if it weren’t for my amazing advocates who fought tooth and nail for me every step of the way. I can only hope to pay it forward one day. For a different perspective on matching into derm as a PGY-1 reapplicant, check out my friend’s story here.