Dr. Daniel Knoepflmacher (Guest): Welcome to On The Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. In each episode, we speak with experts in various aspects of psychiatry, psychotherapy, research, and other important topics on the mind.

I'm Daniel Knoepflmacher. I'm normally the host of this podcast, but today we're going to do things a little differently. I'll explain why. A year ago, we put out a special episode of On The Mind geared towards medical students interested in psychiatry. In it, I interviewed two of our wonderful second-year residents, Maya Graves and Nathen Spitz, about their experience applying to residency.

I heard firsthand from many medical students and residency applicants who told me that they really enjoyed it and wish that there was more content like this out there. It's not surprising actually that it ended up being one of our most listened to episodes. Then, earlier this summer, two of our amazing first-year residents this year approached me about wanting to find ways to help medical students who are applying to psychiatry residency. As we met and talked about different ideas, we all agreed that while it was really helpful to hear from residents, it would also be valuable for potential applicants to hear directly from a residency training director who oversees the interview and selection process.

So today, I'm going to flip the script and give the podcast hosting reigns to Phil Martinez and Jaime Peter. I'll be in the position of being a guest for the first time on this podcast as they grill me about the ins and outs of a applying and matching into a psychiatry residency program. So, Phil and Jaime, the mic is all yours.

Dr. Phil Martinez (Host 1): Hi, Dr. K. Thanks for giving us the opportunity to interview you. I think it's a real treat to be able to hear directly from a program director. And since Jaime and I are new to the podcast, we can both briefly introduce ourselves. So Jaime, how about we start with you?

Dr. Jaime Peter (Host 2): Yeah. Sounds good. I'm excited to be here. Thanks, Phil, and thanks, Dr. K, for giving us this opportunity. A little bit about me, my name is Jaime. I grew up in Yonkers in Westchester County, which is just north of New York City. I went to a combined seven-year BS/MD program. I did my undergrad at Sophie Davis in the City College of New York, and then matriculated into their CUNY School of Medicine, which is also located in Harlem, New York. So, I continued my journey in New York as I am now here as a Psychiatry intern at Weill Cornell. So excited to be here.

Host 1: Amazing. And I'm Phil Martinez. I grew up in a town called Westfield in New Jersey. It's a short train ride from Manhattan. I went to college at Cornell University, went straight through into medical school where I attended NYU Grossman School of Medicine. And I'm also now a Psychiatry intern PGY-1.

So today, on the podcast, we'll be covering a variety of topics for any listener interested in hearing about the residency application process. Some of these topics include how program directors eval applicants and how they talk about them and discuss them once they're interviewed.

The first question we have, we spend so much time trying to understand what program directors are looking for, but we rarely get to hear about their journeys. And it's always fun to hear how someone ends up in such a pivotal role. And so, our first question for you, Dr. K, is how did you become a program director? And was it something you always saw yourself doing?

Dr. Daniel Knoepflmacher (Guest): First of all, I want to say, I think, you guys are going to put me out of a podcasting job, and thank you for sharing your stories. . So, I was the son of-- I still am-- the son of a family therapist social worker, and an English professor. And in our house, human psychology and the psyche was always a topic of discussion at the dinner table, whether it was my mom's work or my dad's work and what he was doing. And I think it was natural that by the time I got to high school, I kind of fancied myself to be like the high school shrink. I was the person that would always be there talking to my friends about all the high school problems that we had, and I loved listening. I don't know how much help I actually was giving at the time, but I thought I was helping.

And so again, from there, it kind of was a straight line to college. And I thought of becoming a psychiatrist, specifically a psychiatrist. My brother was already going to medical school at that point. And I thought that that path was the one that made the most sense for me. So, this would be a very short story, except things got pretty zigzaggy, when I took General Chemistry in my first semester of college and didn't make it past the drop add period. We're talking like a month, I was like, "I'm outta here." It was not the subject I wanted to be studying. I really found that the whole gunner environment there was not for my liking, and I was really interested in the humanities. I always had been in, in addition to this, that I saw the psyche and that kind of thing about people's stories being related to the humanities. And I just couldn't find a class I didn't like when it was looking at the humanities and flirted with a bunch of different majors.

I ended up becoming a religion major, which I really, really enjoyed learning about-- especially focused on Islam and Christianity which were my two areas. I wrote my thesis on mystical Islamic tradition. And I just found that the kind of universal human aspects that are explored in religion and spirituality and the narratives, which are so important, very much again tied to kind of human psychology and are something that I really resonated with. And then, at the same time, this was the era of like Quentin Tarantino and other kind of independent filmmakers coming out at that time, I really got into movies. I was taking film theory classes. I even worked on some film productions and decided at the point at which I finished college that I was going to go into film.

And I ended up then going to USC Film School for Graduate School, got a Master's of Fine Arts and Film Production there and really enjoyed film, was found that where I was naturally, I guess, gifted was in, again, kind of the storytelling and the editing, whether it was the writing of scripts or the editing, which was by far the best way to easily kind of make a living right out of film school, because there are lots of jobs in editing. And I ended up doing that on different independent films, on television shows, and fell into through some random turns of events into being a movie trailer editor.

So, I was the guy who , at least in the company I worked for, often did like the stupid Hollywood comedies. That was my specialty. The record scratches, I worked on both Big Momma's House 1 and Big Momma's House 2, lots of different movies and television spots, movie trailers. It was a job I loved the people I worked with. There were lots of aspects I loved about it. But it was punishing, and actually had a worse schedule than I ever had when I went into medicine in medical school or residency actually. It was ultimately kind of physically unhealthy for me being chained to my desk all day.

And as time went on, it was the birth of my first child, Lucy, my older daughter, and I was talking to my wife, Amy, and just was like, "This is not what I came here to do." It was not in line with kind of the things that drove me to want to go into film. And that thing from high school about Psychiatry was still in the back of my head. And I had this crazy idea, like, "What if I threw this all away and went back, got my post-bac?" Because I didn't have any of those classes, and I went to medical school and became a psychiatrist? And shockingly, Amy said, "Yeah, okay."

And so, I tested the waters, I took a few classes and even something like General Chemistry, which I hated in that first semester, I loved when I was in my 30s. And I had this focus and interest in it that I wasn't able to have as an 18, 19-year-old. And that continued through all of my post-bac classes that I had to take. And I went to medical school. I ended up still liking Psychiatry, although I flirted with Palliative Care and Medicine a bit as other specialties. And then, finally got the chance to come back to New York to do residency training. And that was here at Weill Cornell. And I was particularly attracted to this program because they had really strong psychotherapy training. And that was a piece of Psychiatry that was really interesting to me. I really think, again, about the human narrative as such an important part of mental health and the understanding of someone's story as incredibly therapeutic. And that was something that I really saw here at Weill Cornell.

I was fortunate enough to match here, stayed here, was chief resident here, and then worked in a lot of different jobs in the outpatient department, ultimately ending up in the partial hospital program, which is an intensive outpatient program. And then, the pandemic hit and everything got turned upside down in all of our worlds, especially here in New York City. And my friend, who was the program director at the time, for family reasons, had to leave New York. We had somebody who did a great job kind of stepping in temporarily, but it was always known he was going to be temporary. And that's when they opened up the idea of, like, who wants to be program director. And again, that kind of voice in the back of my head, I was like, "Well, there's so much about this that I would love." And really, I love this program. I love this process of thinking about what it takes to become a psychiatrist. I have a lot of ideas of things that we could work on in the program, and get us through this really tough time, which was brutal during the pandemic. And so, I jumped in at that crazy time, and I've been in the job ever since.

Host 2: Wow. Thank you for sharing that. That's actually so fascinating how you've had all these different interests and have been able to combine your interests in Psychiatry and Humanities, film and editing, and maybe that contributed to the development of this podcast as well.

Dr. Daniel Knoepflmacher (Guest): Yeah, it did. And the one thing I always tell people because I see people making pivots in their life, is none of the stuff you did before is a waste. It all is grist for the mill. It's all helpful as you go through life, and that's certainly how I felt in my own life.

Host 2: Yeah, that's great advice. And we're glad that this podcast exists. And now, it's a platform for us to ask our burning questions.

Dr. Daniel Knoepflmacher (Guest): All right.

Host 2: And so, to start off, I think many applicants wonder what happens behind the scenes after they submit their ERAS applications, understanding how these decisions are actually made and by whom can really help demystify the process a bit. And so, I was wondering if you could describe the structure and process of the residency admissions committee, who's typically involved and what kind of factors go into making those decisions.

Dr. Daniel Knoepflmacher (Guest): Sure. So, thinking about the process-- I can talk about the committee too-- is everybody submits their applications on this electronic system. What's the way you pronounce it? "E-rass", "A-ris", I always worry.

Host 2: I don't even know. Is it "e-rass", Phil?

Host 1: I say e-rass.

Dr. Daniel Knoepflmacher (Guest): All right. "E-rass". So, we'll call it "e-rass". So, everyone submits that. And then, we get this other thing that is like the mirror image of that is for program directors. And that's where all of the applications come to us electronically. And I am sure that this is true for most Psychiatry programs. We're talking about hundreds and hundreds of applications. And in our case, that's for 10 spots. So when I think about this process, I think it's important that everybody knows that there's really-- I mean, there's multiple parts to the process. But if it was to divide up into two main parts, there's the screening process and then there's the interview and evaluation process.

So, the screening process is its own evaluation process. But we're talking about hundreds and hundreds of applications that we have to decide who is going to get an interview or not. So, that's the first round of kind of screening through all of the applications. And I think we can talk about this more later, but we really use a holistic process for that. We don't screen by saying, "'Op, if you have this grade or you're from this part of the country, or you have this, then you're not going to be included." We actually look at all of the pieces together. And the way we do that, you asked about a committee, is it's actually not a committee at that point. I get as many people to help me as possible. I do-- gosh, I wish I could tell you-- like somewhere close to half of them myself, or many hundreds myself. But then, we divide up the rest with the other program directors, and we have a few program directors including me. Then, some faculty who have been involved in our selection committee, which I'll talk about in a second, but basically faculty who have been involved in the residency selection process before and/or work very closely with residents know this program very well.

And then, the last group is actually the fourth-year residents. This is something we started a few years ago. And we get all of these people to go through the applications and then basically sort them as to definitely interview this person, maybe interview this person, or don't interview this person. And that's that first round of screening. I look at all of the results. I don't just automatically take what everyone does because there's factors that sometimes I want to explore. So, I end up looking at all of them, but I'm not going to go as deeply into myself, the ones that I have deep trust for those who did go through it and take that into consideration as then we're selecting the number of people that we interview.

So, we are selecting for 10 spots, 10 residency spots, and we're getting over a thousand applications. So, we are getting it down to maybe about somewhere over a hundred, people that will be interviewed for those 10 spots. It's still quite a big number that is getting interviews versus the number that ultimately match. And then, that's when we send out all of those interviews. We try to match those people as much as we can with people who share their interests in Psychiatry. And then, at that point, we have a committee that starts meeting after the interviews are done. So every day, let's say there's eight to 10 interviews, then there are going to be people on that committee, whether it's me or one of the program directors or the faculty who are on that committee, again, who really know the residency. Many of them actually were residents here and also are faculty here. They really care about the residency. They're all people who are on that committee.

And when we've done interviews, they will go through the interviews for that day. And someone will present the person that they met, just kind of summarize their application, we'll talk about them, we'll make an assessment. And then, we don't actually in that committee do a ranking in the sense that we don't say, "Okay, this person's number one, this person's number two." We just, sort by quartiles. And then, at the end of that process, me and the rest of the residency leadership team, we kind of finalize our list, which we submit. And then, Match day comes.

Host 1: Yeah, I think it's really interesting hearing you break down the process of the screening and the committee. I remember when I was a medical student, I did not even know what a program director was. And I think to almost every medical student, the residency application process is such a black box. It's really great to hear it broken down. And something that you alluded to a few times as well when you were talking was this idea of the holistic review process. And I think that's something that is spoken about a lot in this vague, ambiguous way. And I think I'd be particularly interested to hear if you can walk us through what a holistic review process looks like from your perspective and how exactly you apply it when you review the applications.

Dr. Daniel Knoepflmacher (Guest): Sure. Yeah. And I mean, I think you're talking about it all being a black box, and I think that I can't say that-- in fact, I know having talked to other program directors that I'm friendly with-- that their processes are exactly what I described to you in terms of who's on their committees and how they do break different pieces of the labor up. I can tell you that every program director I know of and every program uses holistic review. And even, I'm sure both of you in applying to medical school probably went to medical schools where they used holistic review.

So, holistic review is something that is endorsed by the AAMC that provides like a unified approach to reviewing individually each applicant. And the idea is that it balances various aspects of their application and who they are in a balanced way and really tries to ground that in the mission of their residency program in this case. So that in our case, our goal is to build a vibrant, multifaceted community of residents who are going to be the psychiatrist of the future. And we want to weigh all of these aspects in context equally as we're figuring out our selection process. So, I'll break it down more specifically. The key is considering four main areas with each applicant, and that's their life experiences, their attributes, their competencies, and their metrics, which in this case is like their academic or scholarly metrics. So, I'll say what each one is.

The first I mentioned was the personal experiences. So, that's their life story, the journey they went on to get to this point where they're graduating from medical school and they're choosing the field of Psychiatry. The second I mentioned was the attributes. So, these are the skills, the talents, the abilities, and the personal qualities that shape their identity. That's something which I think really comes through in multiple aspects of the application really also comes through in the interview. The third is their competencies. And this is the way that they've applied their knowledge, their skills, and their abilities as medical students. So, that's going to be in their performance as described in the letter that we get from the medical school, the MSPE, it's going to come through in their letters of recommendation in the way that they've excelled in different activities that they're listing. It might also come through even in the experience of the interview as well. And then, the last one is the most kind of simple, which is the metrics. And that's the scores, right? The academic metrics and then the scholarly metrics. So, the scores on step two, let's say, or scores-- some medical schools have grades, some medical schools don't. Some medical schools seem to give 99% of the students the same grade. Some split it up a lot more. Some have rankings of quartiles, quintiles, whatever. Some don't. So, that's a tough one because we can't compare necessarily from school to school, but it is a factor that is a metric.

And then, the other thing would be awards in that area. And also, like I mentioned scholarly output, if somebody has 50 publications and what's the quality of those publications or one publication, what's the quality of those publications or talks that they've given, things like that. So, the idea is you weigh all of this together and you use all the different aspects of the application to pull this information out and to contextualize it. And again, the key is that we're not considering one area at any point. We're not saying, "Oh, it's just scores. We only care about step two." I mean, that has no bearing frankly, on how well someone does as a resident in my program. I won't say it has no bearing, but it's not an indication of being a successful resident in terms of their performance.

So, what we're trying to think about is weighing all of these things. Do we see someone who we believe will be a person who will excel as a resident in our program? And I mentioned our mission in the beginning, that's really important to ground all of this, this is to provide the best possible training for residents who are humanistic, compassionate, collaborative team players, psychologically minded. They are excellent clinically. They're committed to lifelong learning. They're community-minded and, of course, passionate about the field of Psychiatry.

This, I think-- and I mean you guys are biased, so I'll have to ask other people-- but I think this mirrors the type of residents that we have in our program and that means we've successfully used this process if we can keep all of these aspects in mind and keep getting the amazing residents that we are, and really using the process, I'll say, to kind of reduce the impact of implicit bias, which all of us have as human beings, and make this process as fair as possible for those who took the time to apply to our program.

Host 1: I think it's really clear how much nuance there is from the perspective of a program director. And I know for medical students, oftentimes they're a type A personality and they spend a lot of time thinking about these things. Jaime and I, I know, talk a lot about the process kind of as this game and you need to play the game. And now, that ERAS is being filled out by medical students across the country, we were wondering what the value of signals for the process is, as well as geographic preferences. And so, what role do they both play?

Dr. Daniel Knoepflmacher (Guest): Sure. I'm happy to talk about that. I mean, all of life has certain game-like elements. And of course, this does as well. But let's talk about the signals and we can talk about the other preferences. So, the signal, which I'm sure any medical student who's applying is listening to this, knows what a signal is, but it's really an applicant's opportunity to express their interest in a residency program. And the signal-- it's important for program directors to remember this-- only indicates that applicant's interest at the time that they're submitting that application when ERAS is open. We have to remember that when we've interviewed them, that they may have-- like, let's say they then signal us that they may then have learned about our program and be like, "Oh my God, I really want to come there." So, that signal should not, in my opinion, be part of the final decision-making when it's coming to rankings later on. It should be something which we take into account, as I was saying earlier, during that screening process. So, people who want to come to your program are usually people that you are enthusiastic about being in your program, and it's nice for program directors to have people who want to be there. So, it is a good indicator.

But as they've done more, like with the first-year they did in Psychiatry, there were only five signals. Now, there are 10, that there's been a better distribution across programs when they had more signals. When it was five, it was more the most prestigious or competitive programs that got more signals than the one across the board.

So, I think, the other reason behind this is that the goal is to lower the number of total applications. And it's worked in a lot of specialties where each applicant to-- let's say, I think surgery might have submitted 50 applications before, I'm making up that number-- but after they did signals, that had dropped by like 15%, the total number that they've done. Unfortunately, over the past two years, that has not happened in Psychiatry. I'll tell you guys that Psychiatry, it's scary enough I think in terms of the competitiveness that people are still applying to a lot of places. So, it hasn't really worked.

But basically, it's important, I guess, to really get to your question, Phil, that applicants know that when we see that signal, it makes us feel good. Like we're saying, "Okay, they had only 10 of these and they gave us one of those." And it does call attention to that applicant. We interview people who didn't signal us. And an important thing to know, we can't interview everybody who signals us because we get way more signals than we have spots. So, that's important to know too. Just because you signal doesn't mean that you're automatically getting an interview.

So, I think those are some of the things to know about. I'm trying to think if there's anything else signal-related. I think that's it. Do you want me to talk about preferences? So, there's two preferences. There's geographic preference. And then, there's setting preference. So, let me explain what each is. Geographic preference is the geographic part of the country: the East, South, Midwest, et cetera. And I actually looked at the data because I knew you guys were going to ask about this.

So, it shows that in psychiatry last year, not surprisingly, 69% of applicants selected three different geographic regions, when they applied to psychiatry. So, that meant that they were maybe applying to programs in the South, the Midwest, and the West coast. So, they selected all three of those. So, any of those programs, when they looked up, it said, "Oh yeah, I want to be in your region." On the flip side, let me see, there was only 2% who didn't answer the question at all or 7% who's selected two or one region. And I'll say it's a tough sell and we don't get too many of this, but it's a tough sell. If I look at an application and someone doesn't want to be in on the East Coast, then it's like, "Okay, well, maybe I should give more time to somebody who does want to be on the East Coast." And then similarly, with setting, that is urban, suburban, rural, again, you probably want to select the setting of the program that you're applying to. And if you're not sure, whether it counts as suburban or rural, suburban or urban, then check all three. Because I think that, again, if I see somebody who's not really interested in living in a big city, they shouldn't come to New York City to do their residency.

Host 2: Yeah, that makes a lot of sense. And it sounds like signals, geographic and setting preferences all play a role in demonstrating an interest in that specific program and if all of those factors align. And I'm curious to know, we know that programs are looking for candidates that are not just qualified, but interested specifically in their program. And I know, I remember as a med student, I was always worried and wondered how do I demonstrate interest without sounding or seeming like I'm overstepping or seem disingenuous and signaling geographic preferences and setting preferences are a direct way to do that on an application on ERAS. When it comes to things like letters of interest or tailoring essays, I'm curious to know what your thoughts are on that and whether there's value in doing that.

Dr. Daniel Knoepflmacher (Guest): So, I'll make a disclaimer that these are just my own opinions. I can't say that I'm speaking for every program director out there. I am open to all of those things. Let's explain what each of those are. So, specifically, you mentioned tailoring your essays. You can actually put in something in your essay that is tailored to one of the programs you're applying to. So when it comes to, let's say, Weill Cornell, our program, it says, "Oh, I met Jaime when I did a sub-I there, and she was just such an amazing resident. And I want to be just like her because I love the way that she talks to patients and I want to do that. And I love the fact that there's this program there." And it's like, "Oh, okay. Wow. That's like a specific thing. It's our program. It's genuine." And I almost look at that as like a soft signal because somebody technically could do that without even signaling us and it's going to make me take notice when they know something about our program that seems genuine and specific and shows that they want to come here. So, that is definitely something that people can do. I don't know how much time people have or how labor-intensive that is for every program or et cetera, but I'll just say that's what it feels like on the other side.

You mentioned also the letters of interest. It's complicated because people call those LOIs. But then, there's also letters of intent, which we might talk about at another point. But letters of interest are things that people send in the beginning. And let me tell you, you can imagine if I'm getting over a thousand applications and we're only going to be able to interview a hundred people, that I'm getting many, many of those letters. So, I'm getting tons of emails during that season. Depending on how busy I am, I don't know how much time I can have to read them. But I do try to, and that's me. I think there's some program directors who have harder lines about not reading them or whatever. And I will say that there are times, again, when there was a compelling letter for specific reason that made me go back to an application that maybe was on the fence. And then, I reevaluate, I maybe ask somebody else to think about. Then, we say, "Oh, let's give that person an interview."

So, that said, they're not going to be magic. There's many, many people who send me letters of interest who do not get interviews. It's, again, not a guarantee to get an interview. Could it help? Potentially. Is it the most important thing? Definitely not. So, that's what I would say about those two things.

Host 1: And taking a step back, you also mentioned evaluating applications and how a thousand people typically apply to our program. I remember--

Dr. Daniel Knoepflmacher (Guest): It's closer at 1200 actually, to be honest, the last time.

Host 1: Twelve hundred?

Dr. Daniel Knoepflmacher (Guest): Yeah.

Host 1: That is a lot.

Dr. Daniel Knoepflmacher (Guest): Sorry to interrupt.

Host 1: No, that is totally okay. So, that's clearly a lot. I remember when I filled out ERAS, I thought to myself, there are just so many words in this application. And I was wondering how do you actually evaluate the applications in terms of the order? Do you look at the personal statement first? Do you look at the MSPE? What do you spend the most time reading?

Dr. Daniel Knoepflmacher (Guest): Well, I can tell you the more I've done it, the faster I get. And I know how to kind of laser in on all the parts of the application. But personally, and I tell this to the fourth-year residents, each year I teach them about how to do their screening, I like to begin with the personal statement. And if you go back to that holistic review, you think about somebody's story, their identity, that aspect of them comes through most in the personal statement. And it gives me like window in on what I'm going to be. This is what this person cares to point out about themselves as I'm looking at the rest of the application,.

Then, I typically look at the letters of recommendation, go to often the different activities. And there's opportunities for people to add, like, kind of almost more about themselves and how they write about those activities, like why those activities were important to them. And you can highlight that in the application. They have areas for that. Some people can talk about important experiences they've had where they maybe overcome hardship or things that are extra that they can put in there. So, all of that I look at. And then, I end up usually with the MSPE, which is the overall kind of performance thing. It might have grades, it might not, depending on the school.

I tend to look at Psychiatry very closely among the clerkships, obviously. And I look at the comments and you get good at reading comments that really stand out over time from different schools and different rotations. And I just really look for that both in the MSPE and in the letters of recommendation. I mean, I just give this advice to all the people screening. But the screening, it by nature has to be a faster process, because we just have to get through so many. And I mean it's deciding something final, but it's just deciding the interview or not interview question. But then, when I interview somebody, then I really want to take another deeper look at the application too.

Host 1: I see. And you also mentioned how you've gotten faster at reading the applications since there's 1200 applications, is AI used at all? I feel like that's something that's been very new recently and has a lot of application to medical education.

Dr. Daniel Knoepflmacher (Guest): So, AI is definitely being used. I mean, we used AI this year to help with our residency schedule, and it was phenomenal, thanks to a resident who figured out how to do that. We do not use AI in our process for reviewing applications. There's a lot. I get ads in email from companies that are doing this for residency application. I'm not responding to them yet, because I'm not ready to try to take AI on. I've talked to some people at other programs who are maybe piloting it this year.

So, I wouldn't say that there won't be any AI this round. But I think depending on how AI goes in general, I think this may become part of the process. It could save us a ton of time. What I just don't know yet though is how I can trust AI, in the sense that I just described to you as somewhat complicated human process of how to evaluate these applications. There's some subjectivity, but that's the point that you have to take all these different subjectivities and put them together and try to balance them out. How do I do that with AI? I just don't know. So, I don't see it in our program, certainly not in the next year. But maybe in the future, it could help with parts of certain things to make it faster or more efficient.

Host 2: Yeah. I mean, I would agree, especially after hearing how detailed the holistic review process is. Not sure how AI could really get to that. But I did want to shift gears a little bit. You mentioned earlier a little bit about sub-internships. And I remember as a medical student, there was a lot of mixed advice on whether or not to accept a sub-I or an away rotation, because we all know it's high stakes and it can be a make or break in terms of how the program sees you. And I was wondering if these sub-Is or away rotators are evaluated differently from other applicants. And if so, in what ways?

Dr. Daniel Knoepflmacher (Guest): Yeah. So, the answer is yes. The different ways are complicated. So, the fact is if somebody does a sub-I, and they work with one of our faculty members who I know all, if not all of them and most of them, and I'll tell you, when there's a good sub-I, I get an email often from somebody say, "Hey, I just want you to be aware of this person and I think they may be interested in coming here. And they did such a great job on this rotation." And then, they write them a letter of recommendation. So even if I don't get that email, I see a letter of recommendation from somebody that is down the hall from me or an email away. And, you know, if I'm really on the fence about that applicant or, you know, if I really love the applicant, I might not even write them, and they're going to get to interview anyway.

But if it's like, where there's some questions about it, like I can be like, "Hey, what did you think? I saw your letter of recommendation." And so, it gives you some extra support or, in the cases where maybe something didn't go well, it could hurt you. So, I think that sub-Is are Important for medical students, because they allow you to evaluate the place and see if that's a place that you feel comfortable in imagining yourself as a resident. And then, they can help you, they could hurt you, or they could not really hurt you or help you. And I think when it comes to that risk benefit analysis, you could just get really unlucky, like you got somebody during a really bad time in their life and some bad combination of things happen that you didn't make a good impression, probably unlikely. If you go there and you are yourself and you're a good medical student and you're going to be a great resident, that's probably going to come through. So, I think I wouldn't dissuade people from doing them. But they come with risk. I guess that's how I would describe it.

Host 2: Right. I appreciate the transparency. I mean, I had done a sub-I here at Cornell. And I think as applicants, we forget that, yeah, sub-Is and these away rotations are an opportunity for us to evaluate the program. And that month that I spent there was a chance for me to meet the faculty, work with the residents, and that definitely played a role for me wanting to come here.

Dr. Daniel Knoepflmacher (Guest): Well, without saying too much, Jaime, I heard some things, some great impressions were made in that experience, but I won't say anything more.

Host 1: And I have a kind of interesting hypothetical. So, let's say I am a sub-I, and I got an interview here and I'm very excited. I look at the interview schedule and I see some new faculty members are interviewing me, whereas I know my friend got interviewed by an assistant program director or a chair. How much should I read into that as a probable type A medical student?

Dr. Daniel Knoepflmacher (Guest): I, mean, I think it's always good to think about the psychology of us all as we go through this process. I wouldn't read too much into it. I just, again, can only talk in detail about our process. We do our best. What we do when we invite people for interviews is we ask them about their interest in Psychiatry. They don't have to have any specific interest in Psychiatry. They can be pluripotent. They can want to do everything in Psychiatry and not know yet, and that's fine. But if they have a specific area, they're interested in Child and Adolescent Psychiatry, Geriatric Psychiatry, Addiction, Reproductive, so whatever, we will try to the best that we can and we can't always do it with the schedule, match them with somebody who has that interest.

Then, what we do is we usually have somebody on our kind of chief residents program directors level interview the applicant. We have a faculty member interview that applicant hopefully in that area of specialty. And we have a resident interview the applicant. And then, the fourth person is me. So, we never get into that problem that we may at some point when I get a little more worn out, but I interview everybody. But I can tell you if I did interview everybody, if it was me and Alyson Gorun, let's say, who's our associate program director splitting up the entire list, we would probably do it randomly. So, it should not be read into. So, I don't know if that helps. Does that answer the question, Phil?

Host 1: Yeah, I think that clarifies a lot.

Host 2: Yeah. And it must be a lot of time to interview all the applicants.

Dr. Daniel Knoepflmacher (Guest): It's one of the most fun parts of being a program director. It's very time-consuming. It can be stressful at times. A lot can go wrong. And I'd say in the first two years I was like losing sleep over it because anxious. But I really love it. I love meeting many people who obviously don't become residents here, but who are awesome, amazing future psychiatrists. And it gives me excitement about our field and about the field of mental health in general. So, I enjoy it.

Host 2: Oh, I love to hear that. And so, after these interviews wrap up, programs go off to make their rank list. And us applicants, we are left wondering what actually happens during this time. We know every program probably does things a little differently. But from your perspective, we'd love to hear what typically happens next.

Dr. Daniel Knoepflmacher (Guest): Yeah. So, I mean, I guess at that point, once you've done your interview, we're in that committee discussing all of the people who interviewed and trying to stratify them into these quartiles, which is hard because, again, there's so many great, talented people that we meet. And then, that's actually going on pretty much almost even-- because we get behind, we can't stay up with the number of people that interviewed each day with each meeting we have. So, we're usually a week or two behind in reviewing people at least. And then, that's still going on into January. And then, we tried to finish that process and lock our list by ideally the middle of January to late January.

Host 1: And kind of speaking about the list and locking it in, how far or how many ranks do programs typically have to go through to fill their class?

Dr. Daniel Knoepflmacher (Guest): I don't know the answer to that question, and I should have researched it because I think if you look at the NRMP, which is the national ranking group, their data, I think they may say that. Although they tend to look more at the applicants, like how many programs you have to apply to match. And I think it's different for different programs. And I don't want to say too much about ours, but we're very, very happy every year. And we're looking at a list where we're like, "Gosh, we could go way down this list and be extremely happy."

Host 2: Yeah. And something I, and I know a lot of medical students, have been wondering about is how much networking needs to be done during this residency application process. Many med students will reach out to mentors to sort of vouch for them, reaching out to program directors or interviewers. And I'm curious to know from your perspective, like when you receive an email or a phone call from maybe someone that you know, or someone in the field of Psychiatry, saying positive things about a student, how much does that take into the actual ranking process or even in this time of interviewing them?

Dr. Daniel Knoepflmacher (Guest): Yes. That happens I think sometimes when people are trying to get interviews and then sometimes it will happen after the interview. I think it's media has a slightly different impact depending on what that context is. I think the impact is also dependent on who that person is that's reaching out. So if it's somebody I know, then that's quite valuable, because I know them, I trust them and think about what their opinion is and what they say. And that kind of connects with me. If it's someone who has a really prominent position somewhere, it might sway me, but probably not. Just because I don't know what the story is, how close that person is to the person they're vouching for, how much work they've done for them. I don't know what the circumstances are. They'll usually will catch my eye and I don't think it's going to be a major factor. That's all I would say more in that early phase when it's interview or not interview.

I think later, once I've already met that person, I've interviewed them, I have met that person and I really have probably some opinion, and I'm taking the opinion of all the others who have met them and have their application in mind. And then, it will influence maybe if there's like questions about ranking, but probably not going to be. If I really wanted that person, I was like, "Oh my God, I really hope they match here," I'm just going to be thrilled that somebody else sent an email and, you know, be like, great, that shows that maybe they really want to come here too. But I don't know that there might little hair's-breadth kind of moving of the list, as we're still figuring that out. But I don't think it's usually a major factor at that point. It's nice, but I don't think it's make it or break it.

Host 1: Yeah. Jaime and I were actually talking to some fourth-year medical students recently about this, and it's nice to hear that your perspective on this mimics ours as well. Another thing is-- so, Jaime and I have what one might describe as a competitive friendship or something that we both did, was looked at who sent our letter of intent first to you. And so, I am curious just about letter of intents and when to send them out, how much do they matter. And when you get emails back, how much should applicants interpret that?

Dr. Daniel Knoepflmacher (Guest): Well, I mean, I guess it depends what's winning. Like, is it like holding out to the last minute or it's kind of, "Okay." So, that letter, I told you that in mid to late January, a lot of programs, not all, but lots, will be wrapping things up. So if you send a letter of intent three days before everything has to be locked, but everything goes into the match, it's probably too late. And I've gotten them in December, I think, all through maybe even to February. And I would say that ones that come sometime too early in December, we're still interviewing. So, it's kind of like, I mean, this is really nice and that's exciting, but I'm still figuring it all out. That doesn't mean that it's not very helpful. But it just might not have as much of an immediate impact as if it was a week or two later when the interviews are done.

And we should talk about letters of intent too, I guess, right? I mean, first of all, they're very controversial. There are program directors who refuse to accept letters of intent. I don't know whether people still send them or not, but we are of the mind that we're not really telling people what they can't send us or, you know, that will-- but I want everyone to know that when they interview here, that people match here without sending us letters of intent, that we don't need a letter of intent to match somebody, and that they're only going to help a little bit, if at all. For some people, they're not going to help at all. Some people, they might help a little bit. But mostly, they're just like, "Oh, nice. That's really nice to hear." Like, it feels wonderful to receive them, but I don't know that it makes a huge difference for a lot of people in terms of whether they match or not. And again, for applicants, it's important to know, talk to the program directors that you're interviewing with, and some of them may not want them.

Host 1: I see. That's good to hear. Okay. So, maybe mine and Jaime's competition was a little bit more murky of who actually won then, based off of you saying that. I'm not going to put a horse in that race. I think you guys are both awesome. So, you're not going to get me to pick one or the other.

And can you also talk about rank to match emails and what those mean when applicants get them? Because I think for a lot of people it feels as though it has a lot of sway, but it might not.

Dr. Daniel Knoepflmacher (Guest): Really important question. So, rank to match email is exactly what it sounds like. It's an email from a program director saying you are ranked to match, which means that, like in our case, if someone received that email, that they're one through 10 on our rank list. Now, we do not send rank to match emails. That's something that I just don't feel comfortable doing. So, no one ever gets a rank to match email from me. They will get an email, like I'll respond. Sometimes I think I should stop responding. I should tell everybody in the beginning, I'm not going to respond to letters of intent because it might just make my life easier. But I usually respond to letters of intent and I tell people honestly how wonderful I think they are. And that they would be using those holistic principles, be amazing residents in our program. It does not mean they're rank to match. And I don't say they're rank to match. And I think it's important for applicants to know that a very positive email response, you could be number, let's say we only go to 10 on our rank list, you could be number 11, which means we would be thrilled to have you and you don't match here. But none of what I said was untrue when I say nice things. So, it's something which I think understandably, psychologically, I understand why everyone's on pins and needles and they see something that's positive, like, does this mean? And they can depend on it, and it can be a letdown sometimes.

So, there are programs I believe that send rank to match. Can I just ask you guys, did either of you get rank to match emails? Okay. I see some nods here for those who are listening. So though, they're getting sent out there, you're not getting them from me, and yet you guys matched here. So yeah, it's something that's out there and I'm not here to say whether or not they should be sent. But I think if it doesn't have those exact words, it's not a rank to match email.

Host 2: Right. Yeah. And I'm so glad you were able to talk about this. I mean, like, after all the interviews are done, applicants don't have anything left in a way to do or there's no more input left for them in terms of this process. And so when they get these emails, they're nitpicking, they're figuring out are they really trying to say? So, I'm glad you were able to touch on it.

Dr. Daniel Knoepflmacher (Guest): I thank you for saying that. because I think it's nice for me to hear that, because I can be so in my own head in the process to really empathize with what it's like on the other side. And it does make me think, though, I still think people might not like this, that maybe I should make a policy of not responding at all because maybe then it takes that out, I don't know. But you and I, three of us can talk about that later. But yeah, that's important.

Host 2: Dr. K, you've shared so much important insight and tips about the residency application process, and all of this has been very helpful. But at the same time, I remember how overwhelming fourth year can be, especially during this stage and process. Overthinking, overplanning, looking at the Reddit spreadsheets. Applicants who are listening, you guys know what I'm talking about, and feeling like you have to do all the right things.

And so, as we start to wrap up, I was hoping you can give us and the applicant's listening one piece of advice that you would give to help them sort of step back and see the bigger picture amidst all of this stress.

Dr. Daniel Knoepflmacher (Guest): Yeah, I mean, I think there may be a few things embedded in this rather than one thing, but I guess what I would say is to try, if possible, as much as you can, to enjoy the process. Did you guys enjoy the process of interviewing at all?

Host 1: Yeah, I think Jaime and I talk about this a lot where I personally loved it. I think it was just great to get to chat with everyone. Because you might be interviewing with these people and it might seem really stressful, and I think ultimately though, you're just having a conversation with someone and getting to kind of learn about their career a bit and then them learning about you. So, I thought it was great. Jaime, what do you think?

Host 2: Yeah, I would agree. The only thing I would add is that I think the preparation prior to the actual interview was stressful, because you didn't know what to expect, especially early on in your first couple of interviews. And then, as I started to do a couple of interviews, I noticed it was a lot more conversational than what I had thought. And maybe this is psychiatry-specific and not generalizable in terms of other specialties. But I enjoyed talking to all of my interviewers. It was a lot more casual than what I had expected. So in that part, I enjoyed the process, but maybe the nitty-gritty details of the actual ERAS application wasn't as enjoyable.

Dr. Daniel Knoepflmacher (Guest): That makes complete sense, right? The actual, like, writing of all that stuff and trying to perfect it. So, maybe it's going to be hard to enjoy that part of the process. But once you've completed the application, I'd say try to enjoy it as much as possible. And what I'm getting at here, and I hear this in both of you as you speak about it, is that you guys enjoy it because you're talking to psychiatrists, you're interested in Psychiatry, you're managing what it's like to be a resident. And then, that comes through in your interview and you can feel the passion that the person on the other side of the Zoom screen has for the field and that you can imagine them being a resident in your program.

So, I think some grounding in trying to take a look at yourself and think of what's most important to me, what do I want out of a program, what do I want out of Psychiatry, that's something that maybe is in that harder part of what you were talking about, Jaime, of preparing the application. But once you've really figured out what that is and you're telling a story of who you are and what you want, then live that. Go and meet with these programs and try to convey that, try to understand who they are. And that's just going to come through in the process in terms of you feeling genuine and interested and passionate and hopefully having fun.

And I think one other idea I had, that's an extra tidbit too, which I'm sure some of the listeners have heard about is you mentioned, Jaime, the first interview. It might be good, because obviously the first interview is going to be the scarier; one, because you haven't done it before. Maybe do that at a program, if you can engineer this, that's not the one that's your be-all and end-all. Like, I really want to go and match at this program. Maybe one that you're like, "Yeah, it's a little bit more of a safety." That might be the good one to do first, because then you can kind of get your sea legs in that first experience.

But at the end of the day, be present, be interested, try to have fun. And remember that you're choosing an awesome career path, that there's a lot of great residencies out there. Many, many dozens of them. And I meet all the program directors or many of the program directors at the annual convention of program directors, and they're wonderful people.

So, you're going into the right place. You're going to end up somewhere where you're going to learn how to be a psychiatrist. And it should turn out great even if you don't match at the first choice that you have. So, try to keep that in the back of your mind too, as you go through the process.

Host 2: That was so well said. Thank you for letting us turn the tables today. It's not every day that we get to put our program director in the hot seat.

Dr. Daniel Knoepflmacher (Guest): Oh, you guys can ask me questions anytime. But seriously, I feel like I might want to just have you guys take over a few times because you did a phenomenal job. Thank you.

Host 2: Yeah, I mean, we really appreciate how open and transparent and, thoughtfully, you shared your perspective today. I know applicants listening will not just take the practical advice, but also this encouragement and excitement that you have for Psychiatry. So, thank you so much.

Dr. Daniel Knoepflmacher (Guest): Thank you both of you, and I really appreciate you guys taking all the time to do this. Thank you very much.

Host 1: Yeah. Thank you, Dr. K. And we would also like to thank all of those who'd listened to this episode of On the Mind, the official podcast of Weill Cornell Medicine Department of Psychiatry. The podcast is available on many streaming platforms, including Spotify, Apple Podcasts, YouTube, iHeartRadio, and others. And of course, be sure to subscribe to be up to date with the latest episodes. We'll be back next month. But don't worry, Dr. K will be back to his hosting duties.