Information for the Pathology Residency Candidate
by Benjamin R. Coleman, M.D.


Friday, February 14, 2003

Information for the Pathology Residency Candidate
By Benjamin R. Coleman, M.D.
Original: 2.17.02 Updated:2.16.03

Introduction

Congratulations on choosing pathology! It is an exciting and challenging field offering a rewarding career, reasonable work hours, excellent salary and an essential role in patient care. In writing this, I hope to provide you with information and personal experiences in order to assist you in the process of choosing a residency program. Going through the process myself, I felt that there were very few resources for the pathology residency candidate. Thus, I wanted to share my experiences in hopes that they would serve as a guide for future applicants in pathology. Despite my good intentions, you may disagree with some of the information here. Great! The most important thing in choosing a residency is to trust yourself and your own judgment. Do this and you will find the program that best suits you.

I have divided the information into three sections: pre-interview, interview and post interview. Best of luck!

Pre-Interview

Choosing pathology as a career can be a difficult decision. In many circles, pathology is considered the black sheep of the medical world and being a pathologist is not what most medical students envision doing when they start their first year. Many attendings will give you a hard time about choosing path. Moreover, a pathologist is not the kind of doctor that the layperson thinks of when they think of the word “doctor”. So be prepared to endure questions about your chosen field. Most commonly, I heard “why pathology?” , “don’t you like to see live patients?” or “what in the world is pathology?”. Do not be discouraged. Pathology is a great field.
To begin with, a great resource that will help your throughout every step of the residency application process is Kenneth Iserson’s book Getting Into a Residency: A Guide for Medical Students. This book has a wealth of information from determining what field of medicine you would like to go into to what to wear to your interviews. I used it often and advise picking it up. Also, there is an excellent article in The Archives of Pathology and Laboratory Medicine called Informed Evaluation of Pathology Residency Programs. This article is a great guide explaining what sort of things the pathology residency candidate should be evaluating during the application and interview processes.

The first thing you will start with is the personal statement and CV. In my personal statement, I chose to write about my struggle in deciding between pathology and primary care. I read another personal statement in which the writer discussed a pediatric case that she was involved in and how the role of the pathologist in that case made her develop a strong interest in pathology. Choose a topic that means something to you. Often, writing about how you came about deciding on pathology makes for a great personal statement. As pathology is such a different field from the rest of medicine, many of the pathologists that read your statement will identify with the issues involved in choosing path.

You will get plenty of help with writing your CV and personal statement from your student affairs programs. Thus, I will not go into any more detail on that topic.
The first question that should be addressed is: do you need to do an away rotation in pathology? Well, in short, no. You don’t need to. If you’ve already made your decision to go into pathology (I had to do my path rotation before I decided for sure), doing an away path rotation is not necessary. Doing the one at your medical school will usually get you a good letter and a good grade. However, an away rotation can be very helpful. It can help you rule in or rule out a program in which you are interested. It can help you get an inside track on a program you like. I did not do an away rotation. What I did was schedule an away radiology rotation at the same place that there was a pathology program I was interested in. Then, while I was there, I looked at the path program, got a tour, met residents, etc. My thinking was that I had already done a month of general path, I was scheduled for a month of forensics, so why do a third month of path? I’m going to do that the rest of my life; these are the last chances I’ll get to do rotations in other cool areas of medicine.

So you’ve decided on pathology, you’ve done the personal statement and the CV. Now you’re ready to start sending out the ERAS application. A common question is how many programs to apply to. I applied to 16 programs. I based my choices on geography. I am somewhat of a homebody and so I did not want to be more than 7 hours away from my parents, who live in southern Illinois. Thus, I picked Midwestern programs to apply to. Many of you will have a variety of reasons to narrow down your choices of programs. My thinking is, any program that you think you might be interested in, apply to. It does not hurt to over-apply. You can always refuse an interview if you decide you don’t really want to look at a particular program. And you’ll regret not applying to a program that you later hear is outstanding. So apply away.

Besides geography, there are many other factors to consider in choosing which programs to apply to. First, I would advise assessing what you want your future career to be. This will be helpful in narrowing down which programs to apply to and it will also prepare you for the inevitable interview question “Where do you see yourself in 10 years?” Some things to consider are: 1) Do you want to do mostly research or hospital based pathology? 2) Do you want to practice in an academic setting or a private one? 3) Where in the country do you want to practice? 4) Are you going to do a fellowship? All of these considerations can help you narrow down the field. Some programs are excellent at training academic pathologists, so if you see yourself doing that, apply to those sorts of programs. Others train mostly private practice pathologists. In reality, you can do either academic or private practice after training at any residency; some just have a good reputation in one or the other. Also, going to a residency that has many fellowships can give you the inside track to a fellowship there (most programs give preference to well-qualified residents from their own programs over those from other programs). However, during residency, you can do away rotations at places that have the fellowships you are interested in if you are at a program that does not offer many fellowships. In addition, many times it will be easier to get a job in the state you do your residency in because you will develop connections there. However, don’t rule out a program that you like simply because you wouldn’t want to end up practicing in that state.

A good resource for information about pathology programs is The Directory of Pathology Training Programs, which is published by the Intersociety Committee on Pathology Information. This is available to medical students for $5 if you have a pathologist countersign the order form, which can be printed off the Intersociety Committee’s website. The book has listings for every pathology program and fellowship in the US. It’s a great place to find contact information, specimen numbers and other information about pathology programs.

Now you’ve applied to several programs and you are waiting interview offers. How many can you expect? That depends on the programs you applied to and on how good of a candidate you are. In general, pathology is not a competitive field. If you are an American medical graduate, you should have no trouble getting interviews and ultimately matching. I got interview offers from all 16 programs to which I applied. You should probably expect to get interviews from most of your programs unless your grades and letters of recommendation really stink.

That brings up another topic: letters of recommendation. First, you DO NOT need a letter from a well-known pathologist or program to match. The only situation that you might need one in is if you are applying to a top program (Wash U in STL, Memorial Sloan Kettering, UCSF); however, I got interviews at Vanderbilt and Wash U in STL with letters from my local medical school pathologists. In fact, my letters were from our local path guys, a pediatrician and a family practitioner. I think 3 is a good number for letters but if you have 4 folks who’ll write really good ones, go for it.

Okay, so now you’ve got several interview offers. How many places to interview? I interviewed at 9 of the 16 programs that I applied to. Many of the residents who interviewed me thought that was too many. I disagree. I think you need to be as thorough as possible in choosing your residency. This choice is one of the most important choices you’ll make in your lifetime. It doesn’t hurt to overkill a little. My rule of thumb was, if I thought I’d regret not interviewing somewhere, I interviewed there. And out of 9 programs, I only found 3 that were a good fit for me. So, I’m glad I “overdid” it.

One caveat. Be wary of community based path programs. You really need to train at a university-based program in order to get the variety and depth of training you need. Another thing to consider is how many surgical specimens the program gets in a year. Too low of an amount and you won’t get the variety of cases necessary for good training. Too many cases and the attendings will be too busy signing out cases to teach you much. A good number is probably between 20 and 50 thousand a year. One program at which I interviewed had a service which saw 80,000 cases a year. The attendings were signing out 70 cases a day. It is physically impossible to do all that work and still teach something to the resident with each case.

Another bit of advice. Finish your ERAS application early. The sooner you get it in, the sooner you will start getting interviews. This will allow you to set up interviews at a schedule that is convenient for you. That’s right, you set up your schedule. The nice thing about pathology is that at most programs, you can pick the day you interview. It’s not like other specialties where they have only 3 interview days and you have to fit one of those 3 days into your schedule. You pick the day within the timeframe they give you (most programs interview from late November thru January, some into February, some end in late December). Thus, you can make sure that you interview schedule works for you.

You should also decide when you want to interview. The statistics show that if you interview late, you have a slightly better chance of getting in a program than if you interview early. While the difference is probably not much, why not have that difference work for you instead of against you? Of course, the problem you could run into is bad weather in December and January.

How much time should you take off to interview? I took 6 weeks of vacation (all of December and the first 2 weeks in January). I wanted time to get all my interviews done without missing rotations and have time for the holidays as well. I scheduled my interviews in geographic clusters so that I could do 3 or 4 interviews a week. Thankfully, I only had one week of 4 interviews. The interview trail is tiring so give yourself ample time to rest and travel. I think taking adequate time off to interview is important. It lets you focus on learning about each program and making a good impression there, rather than worrying about missing time on a rotation.

The Interview

Now comes the most important part of the process of selecting a residency program: the interview. You will most likely worry a bunch about interviews, as I did. In actuality, pathology interviews are very laid back, low stress affairs. Most pathologists are easy going folks and so you won’t have to endure thousands of questions and large panels of interviewers. The usual interview process is as follows. Often, the night before the interview, the program will schedule dinner with some of the residents. This is an informal dinner and a good way to meet some of the residents and ask questions of them. I would take advantage of this if it’s offered and if you can make it. You want to meet as many of the residents as possible and dinner the night before is a good way to do that. Again, these dinners are not formal, so wear something nice but casual, relax and be yourself. One issue that you might be concerned about at these dinners is alcohol. My general rule was that if it were offered, I would accept a drink or two. If not, I didn’t go ahead an order alcohol. Use your own judgment on this but remember, you don’t want a hangover the next day. When you go to bed that night, set at least 2 alarms (or one alarm and a wakeup call). You absolutely do not want over sleep so be cautious.

The day of the interview, give yourself plenty of time to find your way to the program. Often, the university or the hotel will have a shuttle service that will take you to the building where you start the day. Utilizing this will decrease the headache of trying to find out where the heck you are going. When this was not available, I drove myself. Again, the golden rule here is do not be late. While pathologists are usually laid back, they will not like it if you start the day off arriving late. This makes a bad first impression and honestly, is quite rude to your interviewer who must make time in his or her busy schedule to talk to you. BE ON TIME.

The typical pathology interview will go something like this: First, you will meet with either the program secretary or the residency director who will give you a general introduction to the program and information on how the day will run. You should receive a schedule at this initial meeting. If you do not, ask for one. You will want know where you are going and whom you are interviewing with. Also, this list will be invaluable when you write your thank you letters (you want to remember who to write them to). After this initial meeting, you will interview with several members of the pathology staff in 30 or 45-minute blocks. The interviews are one on one and often, you are the only resident interviewing that day. This will differ markedly from the interview experiences of your colleagues in other fields, who will often be interviewing in large groups and/or with panels of several interviewers at once. After morning interviews, you will have lunch with the residents. This is the most important part of the interview. The residents will give you the low down on how the program runs, what the faculty are like, and everything else you want to know. Ask plenty of questions of the residents. See how you get along with them. Remember, you want to find a program where you think you will fit in well. If the residents seem very happy with the program, this is generally a good sign. If the residents seem to be hiding something, seem worn down or seem less than happy with the program, these a red flags. A very good question to ask the residents is “what are some things you would like to improve about the program?”. Not only is the answer itself important, but how the question is answered is important as well. Hiding something in response to this question is a red flag. On the flipside, if the residents say that they would not improve anything, this is another red flag. Medical students and residents are notorious for being critical of things and every program needs some improvements so saying that a program needs no improvement should make you cautious.

Another point about meeting residents: make sure you meet some first year residents. They are in the position you are going to be in next year and you will be working with them the longest (besides your own classmates of course). A program that doesn’t let you meet first year residents may be trying to hide something.

After lunch, you will again be interviewing with several faculty members, one at a time in 30 or 45-minute blocks. At some point (either at lunch or later in the afternoon) you will meet with the chief resident. You should also get a tour at some point during the interview. If it is not scheduled, make sure you get a tour. You want to see the facilities, especially the gross room to make sure it is adequately spacious and modern.

Interviews usually end somewhere between 3 and 5 pm. Often they will run behind as you will get to talking with one faculty member and then use up more time that you were allotted. Don’t worry about this; it’s the standard way things go. Always stay around if the program offers to have you meet more residents or faculty members (unless you really know you don’t like the program; then just leave and don’t torture yourself anymore).

How do the interviews themselves go? Generally, you will not be asked very many questions about yourself. In fact, in interviewing at 9 programs with somewhere between 6 and 8 faculty at each program, I was never asked more than 4 or 5 questions about myself. Remember, path applications are down and programs really want to sell themselves to good candidates. The most common questions I heard were the following: 1) Why did you choose pathology? (you will hear this one more than any other question), 2) What do you look for in a path program? 3) Why did you choose to apply to our program? 4) What type of practice do you see yourself in? (or where do you see yourself in ten years?) 5) What other programs have you interviewed at? 6) Do you plan on doing a fellowship? Honestly, these cover most of the questions I was asked. One good question I was asked was “Will you regret not being able to see patients?” Fortunately, I answered yes because the interviewer said that anyone who answered no to that question should not be a physician.

So what ends up happening after they ask you the 4 or 5 questions about yourself? They will ask you if you have any questions about the program. You should always say yes and begin asking questions. You will find that towards the end of the interview day, you will be asking the same questions over and over again. That is okay. It’s good to hear different people answer the same question. Also, you will find that you may not be able to remember all the questions you want to ask. That is why I suggest making a sheet of questions that you will use at each interview. Carry it with you in your satchel and do not be afraid to consult it during the interview. I think most people will admire your preparedness and organization if you pull out a nice, typed sheet of questions to consult. I used my question sheet during the interviews as a reference and then, at the end of the interview, I filled it all in. Here is a vital point: take notes. Whether you use a question sheet like I did or some other method, make extensive notes on each program and do it immediately after the interview. You will inevitably forget many details by the next day or confuse one program with another, especially if you do two or three interviews in a week. Also, make sure you get contact information (email, phone numbers, etc.) of some of the residents and faculty you met. I’d make sure that you at least have the email and phone number of the chief resident and the program director. It is nice to have this information; as you do more and more interviews, you will think of more questions to ask the earlier programs you interviewed at.

Post Interview

Alright! Interviews are finished! Now comes a fun but stressful part of the entire process: choosing your rank list. Before I talk about that, however, let’s talk a little bit about interview follow up and feedback from programs. It is usually customary to write thank you letters to the programs you interviewed at. The way I handled this was I wrote up a standard thank you letter thanking the interviewer for his or her time and stating that I was impressed by their program and I was considering it strongly. I sent this letter to each person I interviewed with during the day (this is why it is important to have a schedule of events indicating who you interviewed with and what their titles are) but I only sent thank you letters to the programs I was interested in. Now, I probably should have sent letters to at least the program directors of the other programs I interviewed at but I did not have the motivation to do so. Do what you want with this, but at the very least, send letters to those programs who you liked and are considering ranking.

What sort of feedback can you expect from programs? This is quite variable. Some programs will tell you that they were very impressed by you and they would like to have you in their program. Others will simply thank you for interviewing at their program and wish you good luck in the match. Still others will not give you any feedback at all. And some might even write to tell you that they ranked you in one of their top spots and thus if you rank them high, you will match with them. I wouldn’t expect too many programs to spell out exactly where they ranked you but usually you will get positive feedback from several of the programs that you interviewed at.

So the real question is, how much do you read into this feedback? Honestly, unless they explicitly tell you where they ranked you, take all feedback with a grain of salt. Some programs will tell every resident that they were very impressed with them and that they hope they end up at their program. Others will tell every resident something noncommittal. While it’s nice to have positive feedback, don’t make too much of it and definitely don’t let it influence your rank list to a great degree.

Another issue to consider is second looks. I personally did not return for a second look at any program, but I think it would be valuable in some instances, especially if you are on the bubble as to whether or not to rank a program or if you would like to have your spouse look at the program with you. Don’t be afraid to call up the chief resident and ask if you can come back on a weekend and meet some more of the residents and faculty. Or ask if you can come during the week (if this is possible for you) and maybe spend some of the day with the residents signing out or grossing. Programs should not balk at this and if they do, be suspicious that they are hiding something.

How much feedback should you give programs? This is very much up to your own personal tastes. In my thank you letters, I wrote that I was considering the program to which I was writing strongly. At my top choice, I told them that they were my top choice at the time of the writing of the letter. I don’t think it hurts to be straightforward with a program. If you like them, let them know because that could influence their rank list (if someone they like shows a strong interest in them, they might rank that person higher on the list because they know there is a greater chance of them coming to their program). Then again, be professional. Don’t tell 5 programs that you are going to rank them number one when you are not. In general, I wouldn’t give specifics as to where you are going to rank a program. Just indicate to them that you are very interested in them or say that they are one of your top choices. Don’t over-commit yourself.

The toughest part of this whole process is deciding your rank list. You have to consider many, many factors in this decision. The most important things you can do are to be honest with yourself and go with where your heart tells you to go. I know that it is difficult to know what your heart is telling you sometimes, so figuring this out can be a challenge. I struggled a lot determining which program to rank first. In the end, I ranked a program first that at the time I thought might not be quite as strong as my number two, but I knew I would be very happy there and would get good, general pathology training. A very important rule to follow, one which you will hear numerous times fourth year, is do not rank a program at which you would not be happy. It doesn’t matter if one of the top path programs in the nation is telling you that you are number one on their list. If you don’t think you would like being at that program, don’t rank it. Similarly, don’t rank a program high just because you think you might have a better chance of getting in. Base your list on where you would want to go the most without regards to the program’s national reputation or to what feedback you’ve gotten from the program.

A problem I ran into in making my decision was determining if a program was a “good” program. What I mean by good is a program that has a strong reputation in the pathology community. The problem is that everything you hear about programs in this regard is simply hearsay. No definitive source exists that ranks path programs. All you have to go on are what pathologists say about a program. I found it difficult because I heard that the program I wanted to rank second had a great reputation while the program I wanted to rank number one, no one had heard a whit about it, good or bad. Did that mean I was ranking a bad program at number one? No. The message here is make your own determination. If you get a good general impression of a program and think you will get good training there, rank it high. Do not listen to all the talk. While it is nice to hear your number 1 ranked program has a good reputation, by no means base your rank list entirely on such things.

Something that helped me in determining my rank list was talking to my classmates about it, especially my closer friends in the class. They are likely having similar issues and may have interviewed in another field at the same location so talking about it together can give you new perspectives on things. Don’t be afraid to discuss your decision with your family, spouse and whoever else will listen. Also, take advantage of the pathologists on staff. You will likely find some that are very good to discuss these issues with. While hearing all sorts of opinions is a good way of helping you make your decisions, in the end, as I’ve said a few times in this document, trust yourself. You’ve made tough decisions before and you will choose well with your rank list as well. And remember, don’t be afraid to contact programs with your questions. This is a huge decision and you want to know as much about the programs that you are ranking as you can.

Conclusion

I sincerely hope that this document will help you in finding a pathology program that is right for you. I have tried to give you general guidelines, not strict laws on how to be successful at matching at a program you are happy with. Again, please do not hesitate to contact me with questions. Also, please give me feedback on this document. I will continue to revise it as my experiences grow (the latest revision has occured during my first year of residency). Let me know if there are areas you would like covered more or less in this writing. Best of luck!

posted by BC | 5:33 PM
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