How to soften red flags on your ERAS application

Applying for residency can be a daunting prospect, especially because much of the process involves playing “the waiting game.” For those medical students who are concerned about aspects of their application that might make them appear “less competitive” on paper, such as low or failed licensing exams, remediations or gaps/extended time in education, the process of applying is that much more stressful.

Here to share insights into the application process and how applicants can address red flags are Beth Vitucci, DO, and Emily Schnurr, DO. Dr. Vitucci is an assistant program director (APD) for a family medicine residency program at St. Mary Medical Center in Langhorne, Pennsylvania, which is part of Trinity Health Mid-Atlantic, while Dr. Schnurr is a program director (PD) for a psychiatry residency program and the child and adolescent psychiatry (CAP) fellowship at Michigan State University.

Previously in graduate medical education for over 10 years as a faculty member at another institution, Dr. Vitucci has also served as an APD and director of medical education. In the course of her work, she has advised many medical students. Dr. Schnurr graduated from Michigan State University College of Osteopathic Medicine (MSUCOM) in 2005, then pursued residency and fellowship at her alma mater. She became a faculty member in 2016 and a PD in 2022.

What are some red flags you see when reviewing applications?

Some red flags prominent to residency applications are failed licensing exams, course failure, legal or criminal charges or gaps in education. Dr. Vitucci notes that some programs “may place higher emphasis on boards.” Programs may examine gaps in education to assess if a candidate is ready to handle the load in residency. “If they take time off to develop appropriate study habits and techniques to handle course load, then they’ll be prepared for residency. If they take a lot of time off, then knowing why that happened is especially important,” says Dr. Vitucci.

Dr. Vitucci also emphasizes that “students should research their programs ahead of the application season.” In working with GME for so long and talking to many PDs, she notes that there are different things programs will prioritize: “For example, some programs may be more interested in research than community outreach and vice versa. Certain red flags may be more concerning for one program than another.” She also advises seeking out programs that have interests aligning with your own.

Dr. Schnurr adds: “Convictions and current incarcerations are severe factors that would cause the committee not to look further into an application. Another red flag is if an evaluator states that the candidate was rude or unprofessional. After thorough review of board scores, the MSPE and personal statements, we can get a fairly good picture of the person, so even if there is a red flag, there is context to it.”

What are some things that look like red flags but aren’t?

Dr. Schnurr shares that there was an applicant who had a child during her last semester of medical school, which led her to take time off. She adds that the applicant’s medical training before this happened was fine. She states that “it is just as important to respond to life events in an appropriate way, such as the birth of child, medical illness, death in the family or significant events such as tornadoes … I want to support folks who have had obstacles that made their path to residency less than smooth.”

What piece of advice would you give candidates who have a red flag on their application?

Dr. Schnurr encourages applicants to look for programs that are interested in supporting future doctors who have had to respond to unexpected or unplanned events. Programs such as the FREIDA™ residency and fellowship database or the Doximity residency navigator are excellent tools for this. Secondly, she encourages candidates to “not hide red flags on the application [and to] be upfront and honest and have a clear explanation of what happened and why.”

Even if it’s something like “I thought I understood cardiology, but I realized halfway through the course that my base knowledge was not where it needed to be and had to take a semester leave. However, with remediation, I passed the course.”

Programs want to know that residents have the capacity to continue to learn what they need to learn to become great physicians.

Thirdly, she recommends doing a sub-internship (sub-I) with the program the candidate is interested in. “We’ve had wonderful residents and candidates who did not have the highest board scores or grades, but other aspects of their application stood out to us, especially if they rotated at our program and we saw them clinically and as a person,” says Dr. Schnurr.

For applicants who could not get a rotation through Visiting Student Learning Opportunities™ (VSLO®), she recommends “reaching out to the PD or coordinator to explain their interest and ask if they can shadow faculty or residents. Not all programs accommodate this, however.”

Lastly, Dr. Vitucci and Dr. Schnurr both recommend explaining red flags in the personal statement or the section provided for further explanation on the ERAS application. Dr Schnurr states, “You don’t want the PD or screening faculty to wonder what the explanation is. We had an applicant who started at one school, then transferred to another school. There was no explanation, so we did not grant an interview because we couldn’t understand the progress of their education. Residency is the next step, and we want to know that residents will be able to continue that progress.”

What makes a good personal statement to you?

Dr. Schnurr shares, “I am looking for a personal statement that seems authentic and true for this person. It lets me know the reasons why you chose to become a physician and why you’re choosing to apply to this specialty.”

She states that it’s not necessary to have a theme in the personal statement, such as an essay that ties back to your hobbies and how they relate to medicine. Adding to this, she shares, “my pet peeves are punctuation and grammar mistakes that make me pause. I sort of wonder if they read over this.”

Do scores and grades correlate to clinical practice?

Dr. Vitucci says, “There is some correlation between knowledge and practice, but it’s not the whole picture. Some people have challenges with test-taking due to anxiety and learning disabilities. We see people who have strong clinical skills, yet do not score well on tests due to different challenges. When they have a patient in front of them, they are making good clinical decisions.”

She also adds, “Soft skills are very important in practicing medicine because patients will feel more comfortable sharing history and trusting you. You cannot diagnose someone as easily if they don’t trust you or you don’t understand them.”

When screening applications, what are some explanations you’ve seen students give that help soften the impact of a red flag?

Dr. Vitucci likes to see accountability and recognition that “the student did not meet this standard, reflected on what caused this, and made specific changes to achieve their goal. This shows adaptability. Sharing how they improved on something speaks volumes to how they will do in residency.” Students and residents aren’t expected to know everything, but they are expected to want to learn and grow, she notes.

Applicants who have struggled with board exams and now tutor other students is another instance Dr. Vitucci sees. She says, “It’s impressive to take something that was a challenge and turn it into a strength.” Obstacles can also teach resilience and students can demonstrate that it has helped make them who they are as future physicians.

If A/PDs see red flags, what is the next step in the application review process?

This is program dependent. AACOM, ACGME and AAMC are trying to promote a holistic review of residency applications that considers all factors. Dr. Vitucci shares that some programs create a rubric that scores for personal statement, board failures, letters of recommendation, etc. Some may move applications with red flags into the “second-review process,” which is done after the committee selects interviews from their first pile of applicants without red flags.

Dr. Schnurr shares her review process: “The first screen divides the applicants. For applicants where their Educational Commission for Foreign Medical Graduates (ECFMG) status is unclear (for MD students), we place it in a ‘not review again’ pile. We have a bucket for ‘haven’t taken step/level 2 yet or board failures.’ The second screen is all of those applications, but looking for more subjective, more intangible things. It may be that someone has stellar board scores, but their personal statements and letter of recommendations aren’t great. They’ll go into a different category. And someone with board failures but a fabulous PS and they share why they’re dedicated to patient care and our specialty will be offered an interview.”

If a student gets a sub-I late, is it still possible to get an interview?

Dr. Vitucci advises sending an email ahead of match season or throughout the interview season. She understands that students have a lot of rotations they have to get through. However, it is helpful to reach out to programs and let them know you are scheduled for a rotation with them, even if it is in December.

As an A/PD, what are some of the things you are most impressed by from these applicants?

Dr. Vitucci fondly shares, “I’m always impressed by the breadth of experience some students have had—some of the hardships they have faced, such as living through a natural disaster or experiencing significant medical issues or personal loss. I love learning about students’ experiences in life. I was always involved in med school; I participated in a lot of clubs, sports, community outreach and medical mission trips. That was always a passion of mine.

“Sometimes, students can get so focused on their grades and boards that they forget to participate in things enjoyable to them. I always love it when I hear students do things that bring them joy. Examples could be traveling, new experiences, charity experiences or working with patient populations they are passionate about. When I see passion or hear about passion that’s just not medical, that’s always really special to me.”

Dr. Schnurr says she is impressed by: “Authenticity and enthusiasm for the program that shines through in an application. Folks who show passion even after experiencing barriers and hardships, for example, if a candidate could not get sub-Is but was on an ER rotation and did extra days to get more exposure in the specialty. Things like that get me excited.”

Related reading:

Being a DO in a heavily MD residency program: What surprised me

Strategies for planning audition rotations