Robert T. Hasty, DO, FACOI, FACP

Top 10 Pieces of Advice for Getting into Residency or Advising Students on Residency Placement

by Robert T. Hasty, DO, FACOI, FACP
ACOI President

April 29, 2024

Considering that thousands of our members are medical students and that so many of our members advise medical students, I decided to share my top 10 pieces of advice for getting into residency programs. Advising medical students on residency placement has been a keen academic interest of mine over the last 20 years. Having served as a residency program director for years in the past, I feel that it helps me share that perspective with future residents. I have had the honor of being an ACOI Visiting Professor at nearly every college of osteopathic medicine (COM) in the nation and advising thousands of medical students and I have been incredibly rewarded by hearing of the success stories of so many medical students.  

As far as I can tell, the DO degree is the most valuable degree in America in terms of job placement with 99.50% of graduates placed into residency programs in the summer after graduation. Many people do not realize we have more GME positions than US medical school graduates. In fact, we are reliant on international medical school graduates to fill over 20% of our current residency programs.  

Getting into residency is probably the most complicated job interview and hiring process there is. I am sharing my top 10 pieces of getting into residency with the hope and desire that it helps future medical students reach the residency position of their dreams.

Do Well on the Boards

Board scores have historically been the number one factor for selecting applicants for interviews. In fact, the Electronic Residency Application Service (ERAS), which is used by virtually every residency applicant, has a useful filtering tool that can be used to select applicants based upon their board scores. A few years ago, COMLEX-USA Level 1 and USMLE Step 1 converted to a pass/fail system. This has changed the review for many program directors to focus on screening out failures and for some program directors to look closer at COMLEX-USA Level 2 and USMLE Step 2 scores. While many hoped the implementation of a pass/fail system for the initial licensure exams would switch the residency admissions decisions to more of a holistic process, the board scores are still very important.

Make Your Specialty Choice by January 1 of Your Third Year

There are several things a medical student needs to do in the spring of their third year, including researching residency programs, scheduling fourth-year rotations, and working on their residency application. To stay on track, medical students need to decide on their specialty/specialties by January 1 of their third year.  

Perform a Reality Check on Your Desired Specialty

Medical students should have a reality check on their desired specialty. For example, students sometimes have unrealistic expectations, such as a student with multiple failures wanting to go into orthopedic surgery (one of the most competitive specialties). I never want to hold anyone back from going for their dreams, but sometimes it is prudent for a student to look at a less competitive specialty as a safety specialty when their reach exceeds their grasp.  

Get Excellent Letters of Recommendation

Letters of recommendation have historically been very important for considerations for getting into residency. Programs typically do read the letters of recommendation and I have seen many students get or lose interviews based on their letters of recommendation. Students should be careful who they request letters from and focus on getting excellent letters, particularly in their selected specialty. Also, it is ideal for the letters of recommendation to be relevant to their top-choice programs in terms of relationships.  

Apply to Plenty of Programs (and Include Safety Programs)

Applicants should apply to a reasonable number of programs for their specialty. In general, folks applying to surgical residency programs will need to apply for more programs. It is also important to apply to stretch programs and safety programs to ensure a reasonable number of interview invitations (usually around a dozen or more for successfully placed students).  

Plan for Interview Season

Successful applicants typically have a dozen or more interviews. Historically, these were in-person, but are now done mostly virtually. This can be a significant amount of coordination. Also, most applicants will do visiting rotations at highly desired programs and there is a significant expense as well as planning needed for these.  

Use “Golden Months” Wisely

Most applicants will rotate at their desired programs during the late summer and fall of their fourth year using elective rotations. These rotations are commonly called “golden months” due to the value of getting to know programs and for programs getting to know them. It is important to use the golden months on the programs that they are most interested in, and they have a reasonable likelihood of being accepted into. It is also important for students to pay close attention to the residency program and see if it is a place where they will be comfortable spending years of their life.

Prepare for Interviews

The interview for a residency program is especially important. Residency interviews are usually predictable in terms of common questions (e.g., why do you want this specialty/program, tell me about yourself, etc.) and preparation is important. Many medical schools offer practice interviews and these or other types of practice can be quite helpful.  

Maximize Interview Offers

It is important to stay connected to the program after the interview and for the programs that you want to know how much you are interested in them. Recently, ERAS began implementing “signaling” for applicants to allow applicants to send a finite number of signals (numbers are specialty specific) to their most desired programs. Kindness to the program coordinators and professional follow-up communications are usually welcome.  

Strategically Rank Programs

It is important to understand that when there is a match between an applicant and a residency program, there is a binding commitment required. Therefore, it is important for applicants to only rank programs that they feel that they will be reasonably happy with, if matched. Successfully matched applicants often have a dozen or more programs that they rank.  

I am always happy to talk with anyone who would like my advice. My email is

Here are some important references for additional reading:

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