I arrived at medical school with what I would call a "liberal arts bias." I believed that students should survey as many fields as possible before deciding on a specialty. I was a bit jarred, then, when I was introduced to another first-year student who told me within minutes of my meeting him that in three years, he would be applying in cardiothoracic surgery, one of the most competitive specialties of that time. (The field has experienced ups and downs in its popularity.) I wondered how someone could have made such a monumental life decision with so little exposure to the practice of medicine.
And yet, this student had strategy on his side. Getting into residency is laborious for any field, but doing so for competitive specialties is that much more arduous.
While my heart still says that being a generalist is the best intellectual and character-building path, the system doesn't conform to my personal conviction. If you are aiming for a position in very competitive specialties like plastic surgery, otolaryngology, neurosurgery, interventional radiology, dermatology or orthopedics, among others, there are several hoops you'll need to jump through. Here's how you can prepare.
Start early
The statistics demonstrate that my medical school colleague was strategic in having an early plan for a competitive field. The most recent (2018) National Resident Matching Program® (NRMP) Program Director Survey shows that "perceived commitment to specialty" is a characteristic residency directors value when deciding whom to interview, especially in competitive fields.
When all specialties were combined, 69% of surveyed program directors responded that "perceived commitment to specialty" was an influential factor in offering interview invites; on a scale from 1 to 5, the mean importance was 4.3. On the other hand, for the very competitive field of interventional radiology, the numbers were 87% and 4.9. (Having said that, there are outlier competitive specialties like orthopedics, where "perceived commitment to specialty" only came in at 49% and an average of 4.2.)
Demonstrating commitment to a field is not easy. Presentations, posters and peer-reviewed publications require months of investment, as do participation in specialty-specific local and national organizations. The sooner you start, the more you can do, and, of course, one opportunity in a field often leads to another. Commit early, and demonstrate that dedication often.
Conduct research
Research is necessary for getting into most competitive specialties. According to the NRMP Charting Outcomes in the Match 2018, successfully matched dermatology applicants had an average of 5.2 research experiences and 14.7 abstracts, presentations and publications. Successful neurosurgery candidates bested even those impressive numbers with 18.3 mean abstracts, presentations and publications. As a comparison, successful applicants to family practice, a less competitive specialty, had an average of 2.1 research experiences and 3 abstracts, presentations and publications.
I've seen brilliant medical students with stellar numbers from top schools bomb when applying to competitive fields for lack of multiple research experiences. Again, starting early and conducting research during school and breaks is key for highly desirable fields.
Find a good adviser
Not only should you find an adviser in your field, but the sooner you can find someone who will advocate for you, the better. A mentor can help you find research, introduce you to grant opportunities, facilitate the publication of your work, acquaint you with other physicians in the field and familiarize you with local and national specialty-specific organizations.
A good adviser can write you a strong letter of recommendation as well, and that endorsement will be even better if the faculty member has known you longer. If your adviser does not have a lot of residency admissions or writing experience, it is worth getting help from someone who does.
Ace step 2
The United States Medical Licensing Board® recently announced that the USMLE Step 1 will be moving to a pass/fail grading system in 2022. That change will take some pressure off of those applying to competitive specialties — that is, until they take Step 2. Those seeking desirable fields need to excel on Step 2. According to Charting Outcomes in the Match, mean scores for neurosurgery, orthopedics and dermatology were, respectively, a whopping 249, 255 and 256. There is little room for error for those applicants.
My colleague did in fact pursue a career in cardiovascular surgery, whereas I struggled to choose between multiple fields, eventually settling on emergency medicine. While my "liberal arts" path was advantageous for me — it stimulated me intellectually, allowed me to travel internationally and made it possible for me to accept a science writing grant — it would not have worked if I had sought to enter a more competitive field. If you are aiming for a desirable specialty, making an early decision will help ensure you hit the ground running.