“He was number one in his class, won several awards, and seemed hardworking. So why is he the resident who keeps me up at night?”
There are tangible ways to assess prospective residents such as board scores, awards, and letters of recommendation. And then there is something markedly less scientific, but equally as important that must be taken into consideration as well…one’s gut or intuition about the candidate. The reality in resident selection is that with no definitive formula, residency directors are left with the option of crafting their own system of selecting—and eliminating—residents.
Dr. John Cardea, Chair Emeritus at Virginia Commonwealth University (VCU), selected residents long enough to have honed his own method. And, says Dr. Cardea, it has proven to be consistently reliable…in 27 years there were only two residents who didn’t complete the VCU program. He states, “First of all, there are few subspecialties that are in as much demand as orthopedics; our program receives as many as 400 applications each year for five positions. This naturally means that we can be very selective.”
If a residency candidate waltzes into Dr. Cardea’s office with a board score of 230 and is in the top 10% or AOA, he is still not impressed. As for what else he looks for, Dr. Cardea says, “If someone tells me that they were a member of Phi Beta Kappa then that lets me know that they had consistently high grades in their undergraduate years.”
Someone could have all A’s in his fourth year, but may have played around prior to that…but not if they are Phi Beta Kappa. This tells me that they are capable of consistent self study. Additionally, I want to know if they can take tests well. Approximately 5 or 6% of those taking the boards fail them…so often because they get flustered.
When it comes to a traditionally important way of assessing residents, i.e., letters of recommendation, Dr. Cardea says one must see what is—and is not—being said. “In time you learn to read between the lines, and can tell if someone was not especially enthusiastic about a candidate. In essence, the referring letter would be generic and not overly complimentary. If, on the other hand, the letter says something like, ‘Dr. X is a stellar physician and I will try to keep him at our institution, ’ then that tells me that I really have to sell my program.”
Not wanting to get trapped with someone whose work ethic is less than desired, Dr. Cardea picks up the phone to get the inside information. “I do a thorough due diligence on prospective residents, and will usually call two people I know from their institution. I am particularly apt to do this if the person’s CV looks too good to be true. I also look hard at the personal letter. Red flags there would be dishonest representation…for example, someone says they have run marathons, but when you dig a little you find that they trained for one, but never actually completed one.”
Not a fan of hand holding or hand wringing, Dr. Cardea states, “I look for people who are calm…those who have no highs and lows.”
“Someone who vacillates between being on cloud nine one day and sulking the next is someone who is overly emotional…and overly emotional people are more apt to make poor decisions. Logic should prevail with regard to patient care, especially if you get into a difficult situation in the OR.”
“In the system as a whole, there are talented, but unstable individuals who somehow make it through medical school, but then can’t handle the pressure that comes afterwards—or expect too much assistance. I think that once you are past medical school then you’re in adult learning. If you don’t have the inherent drive to seek knowledge on your own about your specialty then you won’t be a good doctor.”
I recall a situation where a student with an ACL tear came to me after a lecture and said, ‘Can you tell me what I have in store and can you examine my knee?’ I looked at him and said, ‘Son, if I had an ACL tear during medical school I would be the world’s leading authority on that condition.’ He—along with everyone else lined up to see me—made a quick break for the door.
Dr. Cardea says, “If someone looks especially promising, I would bring them in on a Friday and spend several hours with him or her. I talk to them about their upbringing, and am very attuned to the extent that they want to talk about their parents and siblings. It is a red flag if the person shows no interest in family (i.e., regardless of the questions I ask they change the topic).”
And Dr. Cardea is wary of orthopedic Johnny-come-latelies. “I prefer candidates with a longstanding interest in orthopedics. If, for example, a Ph.D. or masters graduate who previously had no interest in medicine all of a sudden decides to pursue a medical career, then that person will rate a bit lower in my estimation. In my experience, those whose passion for orthopedics reaches back many years are the happiest people in their residencies…and happier people work harder and take better care of patients.”
Finally, says Dr. Cardea, there is the issue of program fit. “Some residents don’t like the hustle of a city hospital; it is too much pressure and they end up leaving. Some people are better off in a place where they will only do two femoral fractures a year, but will study them to death—this is a completely different personality type than someone who revels in, say, Maryland’s Shock Trauma Center. In lecturing my applicants about MCV [Medical College of Virginia] tell them, ‘If you don’t want to be an independent thinker and make some decisions by yourself then do not come here. We see 75, 000 patients a year and you need to be able to handle that load.’ Bottom line: you need people who are going to be willing and able to work hard every day for four years—and who will do so without grousing.”
Another veteran of the residency selection process has more advice: “Make sure they are not crazy.”
This orthopedist, who requested that his name be withheld, states, “A certain amount of intelligence is obviously important and can be measured; the things that can’t be measured are probably more important.”
“The difference between an IQ of 150 and 120 is not that great…the key is to make sure they are not mentally unstable. After years of going through this process, I believe that having a psychiatrist on the admissions committee may be of help.”
We have to remember that each person we select is going to be responsible for other human lives. I know a number of people who dropped out of orthopedic residencies because they couldn’t stand the stress and/or the responsibility of surgical decisions. Or, they couldn’t stand the physical work or the hours in the operating room and had to drop out because of a psychiatric breakdown during their training. These people should have been identified in the residency selection process as unsuitable for the specialty and advised to select a field where they could lead happier and more productive lives.”
“It’s difficult because due to privacy regulations, psychiatric problems are not disclosed in someone’s application. I have seen people come through the admission process whose life decisions belie an unsettled thought process. On one occasion I interviewed someone who had taken a year off to study music, then took more time off to pursue something else. This individual was all over the place and I couldn’t trust that he would be an appropriate, healthy choice.”
Our anonymous surgeon adds, “I cannot overemphasize communication skills. Do they look you in the eye? If not, do you think that person is going to look patients in the eye?”
If he or she is staring at his shoes during the interview then there is a problem with a basic human skill that they should have learned as a two year old. It’s too late to teach them how to communicate with patients and team members.
“These people must be able to put patients at ease, something that won’t happen if they just stare at their little computer, read the lab tests and say, ‘Your numbers look OK.’ As a general rule, if someone has participated in team sports then that is a good sign because you can’t do that and have shoddy communication skills. They know how to work hard in order to perform, they know how to lose, and they know what it takes to come back stronger. They know themselves, they are honest with themselves, and have a better understanding of others.”
Not letting those in the other chair off the hook, this orthopedist says,
“Unfortunately, there are times when the people doing the interviewing don’t have communication skills themselves—or, frankly, they just don’t care enough to be thorough. They ask rote questions and get rote answers…they select residents by the numbers and are happy to have checked the questions off on their little list.”
And when this occurs, says Dr. X, one of the things you will likely fail to assess is the person’s honesty. “I have been presented with many padded CVs. On one occasion I was interviewing a candidate who had included several research papers where he was listed as coauthor. When I asked questions about the studies it soon became obvious that he knew nearly nothing about the research. One of the best ways to get the truth about someone’s honesty is to call someone you know who knows them. This is a very serious issue because you will be counting on someone to do his or her job and you need to ensure that they won’t let you—not to mention their patients—down. Personally, I think all of our candidates should have a letter from the chief resident of a busy surgical service who worked with the applicant for three months; that chief resident will really know the person’s work habits, skills, honesty, practical intelligence, common sense, and surgical potential.”
His final recommendation is one that points to a more streamlined process.
We in orthopedic education must try to identify the common traits of successful surgeons and make greater efforts to select successful residents. They are all bright, but fundamentally, it is something else that makes for success. We need to find out—once and for all—what that is.
