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So you want to do a surgical subspecialty? Good decision. Really, really good decision. There are many reasons that surgical subspecialties appeal to medical students. The first and probably most incorrect reason is that acceptance into a surgical subspecialty justifies your academic worth, as only the most competitive candidates are able to make the cut. I would have to say that if this is the reason you're choosing a surgical subspecialty you should really reconsider. The most successful residents in my experience are those who have a passion for the field, who are engrossed in the subject material such that reading a relevant research paper or scrubbing into a surgery is more of a way of life than a forced maneuver. The hours are long, the competition is tight, and you submit yourself to being a student for the rest of your life. That being said, most people pursue surgical subspecialty for the right reasons.

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Surgeons generally appreciate the immediacy of intervention and the hands-on approach to treating patients. General surgery offers much of this, and indeed, it has become more competitive, but I opted to pursue a subspecialty because it enables me to be an expert on a focused group of organs (in my case, organs related to urology) that function in aggregate to serve a common purpose (to comfortably make urine). With general surgery, the subject material is much more broad and you often have to be a medical internist as well as a surgeon, and may see more patients who don't actually need surgery. I wanted to feel confident that patients were in need of urological surgery before they were sent my way. 

So, how exactly do you match into a surgical subspecialty? I'm going to share with you FIVE Pearls of Wisdom that will enhance your chances. I myself am a urologist, but what I'm going to be telling you is fairly applicable to any of the surgical subspecialties.

PEARL 1: You Have to Crush Step 1

Do well on your USMLE Step 1. This is kind of a no-brainer. There's no one actively out there who's trying to do poorly on their Step 1, but I have to mention it first since it cannot be overemphasized. Step 1 is hands-down the most important exam you will take in your life. People can argue otherwise, but there is no other exam that will determine exactly what you will be doing in your future career path. Many programs have filters set in place to wean out applicants who score below a certain threshold. Based on my experience with Urology, that cutoff tends to be a 230 for mid-tier programs. In discussing with my colleagues who are neurosurgeons, ENTs, orthopods, there is some variability. For orthopedic surgery the cutoff for mid-tier programs is generally between 230 and 240. For neurosurgery, surprisingly it can be a bit lower. I've seen it as low as 220 some mid-tier programs. But if you have to guess a universal cut-off for middle tier programs, it would be 230.

The better you do, the more bonus points you get. In this respect, your Step 1 score will not only get you into the door, but it will also help you stand out. Surgeons are very busy people. Between operating and seeing a full day of patients, the last thing they want to be doing is scrutinize a medical student’s application to see if their hobbies serve as a perfect fit for the program. We’re very cut-and-dry when it comes to application screening. Most surgeons have a standard algorithm for review and they spend on average about 5 minutes per application (I know – those hours of work you put in boil down to 5 minutes - and that's even pushing it). The first thing most surgical staff look at, especially the program director and chairman, is your step 1 score. From my experience, I can tell you 250+ is probably the golden number.

How you do on Step 1 is beyond the scope of this discussion, but my advice to you is start early. From the time you're a first-year medical student. However, it's possible that people reading this blog are already third-year or fourth your student, so this advice doesn't really hold true for them. In that case, here's more:

PEARL 2: Who Said Greek Life is Bad? Alpha-Omega-Alpha (Medical Honor Society)

Achieve AOA (Medical Honor Society) status. There's two types of AOAs. There's Junior AOA, which is based on your academic performance during the first two years of medical school. This is highly selective and often times only two-to-three students in a class achieve this. The easier one to get into is the AOA that 3rd and 4th year medical students are inducted into. Honestly, most surgeons don't realize the difference. To get into AOA (from this point forward, I’ll be referring the AOA you are inducted into as a 3rd/4th year medical student), you essentially have to do well on your rotation shelf exams because doing well on your shelf exam usually translates to doing well on your rotation. Passing will not suffice. You have to honor your rotations. Which ones specifically? You need to ace your Internal Medicine and Surgery rotations. Those are the core rotations that prove to the decision committee you've got the right stuff. In addition to these, sprinkle in an Honors for one more rotation and you’re golden. When I was doing away elective Sub-I rotations in urology (which will get to Pearl 4), among the most common question I was asked by staff while scrubbed in the operating room was whether I was AOA. It really is your sign of legitimacy. Not to mention, it's something less awkward to ask then your Step 1 score. And don’t forget, a LOT of sub-specialty surgeons are AOA themselves (they were able to match into the subspecialty after all!). It’s almost as if being AOA gives you membership to their exclusive club.

PEARL 3: And you are... 


Get to know the department. Subspecialties generally consist of a small community of providers and residents. In stark contrast to other specialties, they're more like a family. You'll encounter a higher degree of collegiality between the staff members and residents. There are more group outings, dinners, conferences, holiday get-togethers. Everyone gets to know each other really well. With the strong sense of camaraderie within the department, everyone will want to make sure whoever they select is not a misfit to their program or the surgical sub-specialty in general. In this context, it becomes critical you get to know everyone from early on to show them you're not a weirdo, but have a personality; that you're not some awkward kid who's really good on paper and inept in person.

So again, it's key get to meet the members of your department early so they have ample time to formulate a favorable opinion of you (given that you earn it, of course). Meet with the chairman during your third-year and express your interest in pursuing the specialty. Attend departmental conferences (morning reports, visiting professor lectures, journal clubs), because this will show them you’re truly serious about your decision and are dedicated to the academic aspect of it.

After establishing yourself on the Chairman’s radar, get to know the residents. You can do this many ways, but the best initial approach is to meet them on an elective rotation in that subspecialty. You’ll have the opportunity to work with them closely and show them you have a strong worth ethic. That’s what stands out to surgical residents most – a hard-working, proactive medical student who makes their lives easier. Don't be alarmed if you initially get a cold shoulder. Surgical residents are overworked, sleep-deprived, and always hungry – a combination of factors that doesn’t contribute to making acquaintances easily, particularly in a non-work setting. If you can show them on an rotation that you are dedicated and not lazy, you’ll make a lasting favorable impression.

A bonus would be to help them finish a research project they are actively working on. If you can take the burden of chart review and even writing off their backs, they will be extremely grateful, and it will score you a publication – something great to talk about during your interview. 

I have to caution you about something really important: Be understanding of a surgical residents’ personal space. You want to convey a sense of diligence, but the LAST thing you want to do is be known as the annoying medical student. So, interact with the residents, but keep it primarily business. Don’t try to become buddy-buddy with them, because in the end, you’re not. You don’t want to blur that line between the personal and workplace setting because that’s when things get complicated. I’ll leave it to your discretion how to manage this, but my suggestion is to introduce yourself, ask how you can help, get tasks done without continuously asking the resident how to go about doing so (because then the resident might as well have done it him/herself), check-in with the resident two-to-three times per workday regarding status of assigned tasks and asking how you can be of further help, and be proactive about doing the monotous and menial tasks (so the junior resident doesn’t have to – e.g. getting morning vitals, collecting daily lab results, stacking the charts, getting evening vitals). Most importantly, NEVER over-step your bounds. Know your limits as a medical student. 

An inescapable truth about residency is EVERYONE TALKS. Surgical residents are not immune to human instinct. If you show the residents that you have a strong work ethic and are good natured, then that’s the picture they will paint for the attendings when they talk. The last component is to meet the remaining faculty. This will happen over the course of your elective rotation, through conferences or when scrubbed on a procedure. It's important if you scrub on any of their cases that you introduce yourself and ask their permission. By doing so, you portray yourself as being respectful.

To sum it all up: by your third year, if not earlier, get to know your department. Meet the chairman first then gradually meet the residents, and then meet a few of the other faculty members. 

PEARL 4: Into the Wild (The Away Rotation)

The away rotation. This is such an important opportunity for anyone pursuing a surgical subspecialty. While it can tremendously enhance your chances of matching, it can equally break you if you make any false moves. Away rotations involve going to an outside institution for one-month to showcase your work ethic and knowledge base. This means that you will be judged carefully for one entire month by an entirely foreign group of residents and faculty. Ideally, an away rotation should be done after an elective rotation in the surgical subspecialty at your home. The subject content is often foreign in the beginning. We’re not accustomed to the various pathologies, surgical procedures, postoperative management algorithms etc. You don’t learn much of this during the first two years of medical school, nor does it come up much during Step 1 studying. As third years, med students are essentially underdeveloped internists. Therefore, there's a major learning curve to climb. Fortunately, a motivated student will climb this curve quickly while on a subspecialty rotation. You want to be climbing the curve at your home institution because there's an understanding that you don't really know much, and a greater willingness to teach the basics. The expectation when you go to an away rotation is that you have some degree of proficiency in the way a subspecialty service functions.

The key to success during an away rotation involves demonstrating two attributes about yourself: humility and hunger.

You could be as smart as you think you are and have excelled on standardized tests, but as a medical student, you are on the bottom of the totem pole. No wait – you're not even on the totem pole. It's crucial when interacting with the residents on an away rotation that you keep this in mind. No task is below you. Assume responsibility for the basic intern-level jobs such as getting labs, recording vitals, and grooming the inpatient list. It's really not about scrubbing into as many surgeries as you can to maximize face time with the attending physicians. Although this is important, of greater significance is how the residents perceive you because this will dictate what the surgical staff hears. And so, you want to respect the surgical hierarchy and convey (through your actions) that you understand where you stand within it. No one wants a cocky medical student.

The second attribute is hunger. This can be manifested in many ways:

1. Be over-prepared rather than underprepared.

2. Be the first to arrive in the morning and the last to leave at night. Surgery hours are very long. By doing this you show that you have what it takes to be a surgical resident. 

3. Know the surgical indications for a patient's management as thoroughly as possible. So you’re asked a vague question about the patient's prior pathology or some esoteric fact about the mechanisms of disease, you’re able to string together a answer. This shows more than just that you're well read, but that you're interested in building yourself up to be a knowledgeable resident. 

4. Have the dressing bucket fully stocked every morning so that you are ready for dressing changes on morning rounds. This shows you've anticipated and are interested in being a part of the team.

5. Give a killer end of rotation presentation. The rotating medical student will give a grand rounds presentation at the end of their rotation. This usually involves a specific case they we're involved with while on service. In addition to the patient history and hospital course, there's usually a brief didactic portion at the end. Among all the things you need to do right while on an away rotation, this is probably the most important in terms of making sure it's perfect. The student presentation is what really defines your legacy to the chairman to the program director once you leave. It showcases your knowledge but more importantly your public speaking ability and composure in front of a crowd. The primary tip for doing a good presentation is to get started early. Within your first week of rotating, ask the residents for a case that you should present. Make sure that you are succinct. Don't drag your case beyond 20 minutes because everyone will lose attention – I guarantee it. Keep your didactics very focused. Try to speak about something that's on the research frontier rather than giving a lecture on established facts that anyone can read in a textbook. Topics discussing controversial issues being actively researched are always more interesting for the faculty.

I've given you some advice on what you should be doing during your way rotation. What about what you should not be doing?

1. Don't try to show off your knowledge. Only answer when asked. No one likes the "pick me, pick me, pick me" kid who raises his hand in a frenzy trying to show the teacher and everyone else around that he knows the answer. More likely than not, you will be with other medical students on your away rotation. Never make them look bad. If they don't know the answer, don't chime in with the answer. It makes it clear that you are not a team player.

2. Know your limits as a medical student. Don't go and proactively take out staples or remove a drain on a patient without being told. I've seen it happen, and it doesn't bode well for the student.

3. Never lie or make up things. Surgical residents can see right through it. And it chips away at your character assessment. If you don't know the answer, respectfully reply that you’re not sure, followed by the assurance that you will look it up.

4. Never sell yourself. You are likely extremely accomplished, but do not advertise is. Let your work ethic be what garners interest.

In summary, the away rotation is super critical. You should be doing two-to-three away rotations in your surgical subspecialty. This will maximize your chance of getting letters from multiple high-profile surgeons in the subspecialty (Pearl 5), but it also increases your chances of matching at these institutions. So my advice is to select institutions where you feel you have a shot of matching based on your Step 1 score and third-year performance. If you have an average Step 1 score, don't rotate through Harvard. Go to a mid to your program or even potentially a lower tier program.

PEARL 5: Stamp of Approval

Remember how I said surgical faculty look at your application for at most 5 minutes? After looking at your Step 1 score, the second most important element of your application are the letters of recommendation. They serve as an external source of validity of your worth. As I mentioned before, surgical subspecialties encompass a very small community. Most providers in academics know each other. And so, having faculty from another institution vouch for you is critical. You will need three letters of recommendation. But have four just in case. Always have a letter of recommendation (LoR) from the departmental chair of your home Institution. The best way to score a good LoR from the chairman is to have done an excellent job on your home institution elective rotation as the chairman usually asks the residents their opinion of you. The other two letters have to be from faculty also within the subspecialty. If you're planning to apply to ENT, do not get an LoR from an attending in Internal Medicine. No one will care because no one will know them.

The second letter should be from the chairman of the institution at which you did an away rotation from. The way to secure a good letter here is to have done a good job on the service obviously, but more importantly a good job on your end of rotation presentation. That's what they'll remember and that's what they're going to mention in the letter. 

And lastly, the third letter should be from a faculty in your home department. It's important you choose a faculty member who is more heavily involved with the academic process – is actively involved research, is known to give talks at conferences. People will likely know this faculty member and therefore their stamp of approval will matter more than new faculty members who have just joined the department and are still trying to establish themselves. 

So there you have it — 5 Pearls to help you achieve your dream of become a surgical subspecialist.

Best of luck!

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Dr. Paras Shah

Dr. Paras Shah

Paras was inducted into the Alpha Omega Alpha Medical Honor Society for his academic prowess and dedication to his community. He has been a tutor and teacher of advanced sciences, medical subjects and USMLE for the last 6 years, and his commitment to his students’ success is without compare.
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