Daniel Knoepflmacher, MD (Host): Welcome to On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. I'm your host, Dr. Daniel Knoepflmacher. In each episode, I speak with experts in various aspects of psychiatry, psychotherapy, research, and other important topics on the mind. .

Before we get started, I want to say thank you, first, to The New York Times for featuring On the Mind in their Well Newsletter's Roundup of eight podcasts to add to your queue. This article led to many thousands of new people coming to this podcast. If you're a new listener who found us that way, welcome. I have to say it genuinely means a lot to me that these conversations about mental health are reaching people.

Now, for a disclaimer. Today's special episode is a little different from what we normally do on this podcast. My guests and I will be speaking directly to a specific audience, which is the thousands of medical students who will be applying to psychiatry residency programs in the months ahead. If you're not in that audience, the topics we're covering may not be of interest to you. But if you're curious, please listen on. If not, be sure to come back next month for our regularly scheduled programming. We'll be back tackling a hot topic in the news these days, the rising controversy about SSRIs and deprescribing. It should be a lively discussion with two seasoned experts who will have a lot to say about this topic.

Today, we're doing an Ask Me Anything episode about the process of applying and matching into psychiatry residency programs. We collected questions from medical students from around the country. We know this can be a time of tremendous anxiety for applicants, so we hope that directly addressing people's burning questions can help alleviate some of the stress and uncertainty that comes during the interview season. This special episode is the third of what has now become an annual tradition for On the Mind, where I collaborate with current residents to provide useful information for aspiring psychiatrists. If this is a topic you want to know more about, I recommend also checking out the prior two episodes.

I normally save my thanks for the end of the episode, but I want to give early shout-outs to those who provided us with the questions we're answering today. That would be the medical student leaders of our local Weill Cornell chapter of PsychSIGN, which is the psychiatry interest group for medical students, and also the leaders of the national PsychSIGN organization who also participated. And to Thwisha Anantasagar, a medical student at Case Western Reserve and longtime listener of this podcast, who personally collected medical student questions for us. And I'm also grateful to Erin Cornell, who helps me plan and promote On the Mind and was instrumental in coordinating everything for this episode.

Now, I'll turn to the special guests joining me to answer all the pressing questions we received. Both of them are first-year residents in our program here at Weill Cornell and are, of course, fabulous human beings. Welcome to Doctors Johanna Inamagua and Michelle Zhou. Thank you both for joining me today, guys.

Johanna Inamagua, MD: Thanks for having us. We're very excited.

Daniel Knoepflmacher, MD: Me too. So before we dive into the questions, I'm going to ask each of you to tell our audience a bit about who you are. Specifically, what was your path to becoming a psychiatry resident? Why don't you start, Michelle?

Michelle Zhou, MD: My path was pretty convoluted. I didn't have any doctors in my family growing up or people near me. So, I mostly just had exposure to Grey's Anatomy. And separately in high school, I did a lot of speech and debate. And I loved speech and debate. I loved the, like, practice and art of communicating and trying to convey complex messages to different audiences using reasoning and evidence and good logic.

And so, I think that medicine was a distant thing from me that I didn't have a lot of familiarity with, and I was pretty certain I'd go into policy or go to law school. I went to college at Penn, which actually Johanna and I both went there, and we're the same year and never met somehow. But I started and I was going along this path of taking a lot of humanities classes because that's what I had really loved.

I was pretty confident I would end up going to law school or something similar. I never really had considered myself a STEM person, but then I took an intro to psychology class and I just absolutely fell in love. And even when they were talking about like neurotransmitters and a lot of the psychiatric pathologies and their mechanisms, I was like, "This is interesting and feels a little STEM adjacent and feels doable and like something I would love to learn more about." So, I started taking more neuroscience classes and just fell in love with the concepts behind a lot of the psychiatric pathologies.

I think I still was a little hesitant about medicine, but also had realized that I probably wanted to have a career where I could work with kids. It was something that I feel still brings me a lot of joy and is like a highlight of my day and is important to me. And so, I kind of was like, "You know what? Pediatrics sounds fair." And so, I think I decided on pediatrics even before medicine more broadly. I graduated, went and did all the pre-med stuff, did my gap year in New York. And then, I went back home to New Mexico, where I'm from, for medical school, and I was still fully set on pediatrics.

I think that I had kind of considered psychiatry since that was initially what drew me into thinking more about these disease pathologies, and I was still interested in it conceptually. But I think that I had a lot of misconceptions about psychiatry that I kind of ruled it out even before starting medical school. And then, as we progressed through medical school, I was full set on pediatrics. But then, as we got to clerkships and I did both my psychiatry and my pediatrics clerkships, I realized that the idea that I had of medicine and of providing care and helping people feel better was best suited for psychiatry and not pediatrics.

And I also realized that I felt most like myself on the days that I was doing my psychiatry rotations. Even with really challenging encounters or difficult experiences, I felt most like myself. And then, I switched, and now we're here.

Daniel Knoepflmacher, MD: Yes. Yeah. And thinking about child psychiatry, is that in the mix?

Michelle Zhou, MD: Yeah. I think, I found that there's a lot more in adult psychiatry that I actually have really enjoyed, that I wasn't expecting to like. Like, I really enjoy treating psychosis and mania that is less prevalent in children and adolescents. But I do think that kids are just really fun, and teenagers are so smart. And it's a really important part of their life to be a part of. So, I think I'll probably still do child psychiatry.

Daniel Knoepflmacher, MD: You have some time. You don't have to decide right now. So, that's good. Well, thank you. Johanna, let's hear your story.

Johanna Inamagua, MD: Hi, it's so nice to be here. So, Michelle and I do have a lot in common. We did go to the same undergrad and although we didn't meet until we were here in residency, I also actually once I had decided on medicine, thought that I would be a pediatrician and I thought that I would be a pediatric emergency room doctor.

And so, the reasons why I was drawn to this, I was born and raised in New York City. I come from a background where fast-paced, high acuity was something that I was drawn to. And so, I thought that lined up well with emergency medicine. And similar to Michelle, I think that pediatrics is a very unique field where you are able to work with not only the patient but their families, typically their guardians, and there is more of a team-based approach to healing with the patient and their loved ones as well as the medical team and I really liked being a part of that and those discussions. And that was sort of what drew me to initially think that was my path. Where I switched was also in the third year of clerkship. I had psychiatry first as my first rotation ever and I was on a psychiatric inpatient unit and found that I loved it and that similar to pediatrics, you were able to have that same sort of relationship building and conversations in depth with patients and their family members but in this new context.

So after some time, I circled back to psychiatry. And I decided actually this I think is best aligned with what I see for myself in my practice and in the personality and the sorts of things I value learning about people. And that's how I decided to apply to psychiatry. And I think in our generation, in the past few cycles, there's been a growing interest in psychiatry maybe largely to do I think with a broader acceptance of what mental health is and why it's important. But I particularly wanted to focus and still want to focus my career more so on mental illness and treating acute presentations of psychiatric conditions.

So, that's sort of been what motivated me to enter this field and I'm very excited to be here. So, glad to join you today, Dr. K.

Daniel Knoepflmacher, MD: I'm so glad to have both of you here, and I think really telling these stories is actually important for those who might be listening and are considering this career path. I also think you guys gave good examples of the kind of stories to convey in the application process and the interview process, because you told personal, specific-to-you narratives about how you ended up here. And that's what I think we want to hear when we're looking to understand who's applying to different programs.

So, let's turn to the questions because we have a lot of them to get through, and we're grateful to everyone who sent them in. Some of these are, I think, more geared towards wanting to hear an answer from a residency training director, such as myself, and then others are better suited to residents like you two who recently went through the application process. So, we'll alternate back and forth, answering these questions.

Let's start with a question from you guys. You guys can alternate. Just ask me and we'll go back and forth

Johanna Inamagua, MD: All right. I think we can get started with something I remember thinking a lot that I was asked a bunch when I was applying that my friends and I spoke a lot about, which is how do applicants gauge how competitive they are? How do they decide which programs should be reaches, which programs are realistic, and what are some more "attainable" options.

Daniel Knoepflmacher, MD: It's a very good, but hard to answer question. And that's because everybody is unique. And then, to a lesser extent, programs are unique. But I think really this comes down to a two-part process. First, I think, in order to figure out how competitive you are and which programs are the right ones to be applying to, you have to have an honest assessment of yourself.

And then, I think the second part of the process is to have a careful assessment of the programs that are out there. So starting with yourself, look at the objective aspects of your application, things like your grades, you know, what leadership positions you've had. Are you members or were you a member or not of a honor society, certain awards? Does your school have some kind of rankings? If so, where are you on that? And similar to what you guys did when I asked you about your stories, do you have this compelling story you can tell that really demonstrates why you want to be a psychiatrist and hopefully some passion and commitment to the field?

So if you look at all of those things and you find that you're checking all or most of those boxes, I would say you're pretty competitive. And it is more competitive, Johanna, as you mentioned, to apply right now. But you are covering those bases, and I think you can think about applying to competitive programs that are more selective. I still think everybody should cover their bases in terms of having a range of programs. But let's say you feel like you check some of those boxes but not all of them, you're not sure. Then, I still think it's worth considering the right competitive programs that feel like the right match for you given what they offer, where they are, all the different aspects of them. But also, look more in the middle range and then some places that you feel like are safeties. And then, if you're struggling to check those boxes, but you still check some and you have a really compelling story or there's aspects of real strength that you think come through, maybe think of the most competitive programs as reaches, and definitely apply widely, but really focus on how are you going to shape that application and that personal statement and all of that to convey why you're special and despite maybe some drawbacks on your application, why you are going to make a great psychiatrist essentially.

So, that's the self-assessment part. Then, I think there's evaluating the programs that are out there. I'd say any program definitely in the top 20 of the Doximity rankings is very competitive, and I think that extends much further down the list as psychiatry in general has become more competitive than it was certainly 10 years ago. So, don't assume any program is a given. But the good news, and I really want everyone to remember this, is that the vast majority of people match, and typically among those who match, they're getting into one of the programs on the upper end of their list, near the top of their rankings.

So, research those programs, talk to people in your medical school, whether that's faculty members who are psychiatrists that are teaching classes or are on your clerkships, advisors, even your medical school will know where people have been matching over the past several years. Talk to medical students ideally who've matched before you from your medical school or from elsewhere. If you can get in touch with residents within your home program and residents elsewhere, maybe through—we brought up PsychSIGN, which, you know, is a psych interest group. Get people's insights and advice on all of this.

You may hear wildly different opinions on different programs or how strong and competitive you are or not, but try to take the mean of all of that information and find as many programs—this is really important—where you can imagine yourself to be happy as a resident, and collect as many of those as possible, and that's how I think you should shape your list in terms of thinking about how competitive you are and the programs that you think are going to be attainable for you.

That's my answer to that question. I'm going to give you guys a question and let each one of you decide who wants to answer first. So, given that psychiatry generally does not require aways/ and by aways I mean visiting rotations at that program, how did you guys learn more about programs and then get an idea of the training at those programs and the culture before you actually interviewed there?

Michelle Zhou, MD: I think it's a great question and it can definitely be challenging when maybe you're less familiar with certain programs or maybe it's your first time hearing about them when you're researching, which programs you want to apply to. I think the general consensus is that it's a lot of research through using websites and just going through the available information that the program themselves has and shows what they value, what they find to be important about their program and they're sharing it publicly on their website or on social media.

I think trying to get in touch with residents who are at the program if you know anybody who knows somebody or sometimes even just cold reaching out I think has been helpful just to kind of get a vibe of what is this program like, what would it be like to be a resident there. I actually did aways myself, and I know that it's not required. Partially, for me, it was to demonstrate geographic interest because I was coming from outside of the region that I was really set on being in for residency. But I do think that it can offer a lot of information in terms of how psychiatry is practiced in different places, even just, like, the legalities of how we do certain things. The legal systems can be very different between states. I think that for people who do not want to or are unable to do an away, it's a lot of just online research.

Johanna Inamagua, MD: Yeah, I have to agree with that. I think one of the things that I found a little bit overwhelming at the start of when I was applying was considering how many programs there really are. And I think what Michelle is saying about location, it did end up being that first factor of what I thought about most. Where did I want to practice? Whether it's a specific city, whether it's a type of setting, like an urban setting, a rural, suburban, I think it's important to reflect on that in the self-reflection process that you were talking about, and then focus your energy based off of that.

So, looking into the programs that sort of match on paper other things that you already think that you would align with. And I agree, I think the best conversations I had where I got the most information, where I felt like I really developed a good outsider sense of a program was having one-on-one conversations with current residents. And even speaking to people that had interviewed at a program before and liked it, regardless of whether they matched there or not, that was also very helpful to me. So, I agree with using what you were saying, Dr. K, using your network, whether it's within your medical school or through one of these more, like, national organizations to try and know what it was like for someone who was also once in your shoes and also was in the position of interviewing different programs that you are also interested in now.

Michelle Zhou, MD: Yeah, and there's also an abundance of information, I think, on Doximity from residents who evaluate their own program and write, you know, comments on what they liked, what they didn't like. I think that you can find a lot of things online, it's kind of a time-consuming, exhausting process. But it's helpful when maybe this is the first time you're considering a program or the first time you've heard of a program to do some research.

Johanna Inamagua, MD: Someone once gave me advice on the interview trail, and something they had said to me was, "You can always speak to someone and get a one-off opinion that isn't a truth and isn't how you would feel at this program, but you want to look out for the consistency," like you were saying, the mean of responses. There is a lot of information, especially when something is online and it's possibly anonymous or it's easy to be vague with the information that you're reading. It's good to just pick up on patterns over time, and also take that in mind when you're looking at these different resources.

Daniel Knoepflmacher, MD: Really great advice. Thank you both.

Michelle Zhou, MD: Our next question. In applying into psychiatry, what factors like essays, research, extracurriculars, clerkship performance scores, or recommendation letters, which of those factors carries the most weight?

Daniel Knoepflmacher, MD: The answer is they're all important. I would say there's probably some variability on how different programs weigh these different aspects. But maybe I'm going out on a limb a bit here, but I'd say universally clinical performance on clerkships, especially psychiatry, maybe psychiatry sub-Is, and to a certain extent medicine. I'd say your extracurricular activities, your research, the letters of recommendation, and your personal statement are all definitely weighed in the process.

And I think what that means is that Step 2 scores, certainly I'll speak for myself and the process we go through, not a huge factor. If someone has this tremendous Step 2 score, that's not really going to weigh on us very much because that's probably not a good predictor positively or negatively of how they're going to be as a psychiatrist. Similarly, like I think awards and honor societies are really nice, and they might tip the scales when you're comparing two people who are equally matched, but they're not necessarily the best indicator directly as something like really nuanced feedback that you see in a clerkship evaluation or that you read from letters of recommendation.

So, I guess I would say that it's like similar to what we were talking about before actually, that there's all these trees, right? You just mentioned a bunch of trees, and it's how do they come together into a coherent forest that tells the story of that candidate. So, there's no one specific combination of trees that we're looking for. We're just looking for nice forests that have all different kinds of variety. And I think this really gets back to—it's actually another question that we received that I'll answer in this process too, is about holistic review. If you want to get a little more in-depth information on what holistic review is, if you listen to last year's podcast, which had two residents, Phil Martinez and Jamie Peter, we did get into holistic review in a more detailed way.

But the basic principle is that there are various factors that are all weighed together when we're assessing applicants. And this is their experiences life, but also in medical school; their attributes, who are they as individuals; competencies, which really gets down to that medical school performance that I was talking about; and then metrics, which are objective numbers or things like scores, grades, rankings, number of publications. So, all of those things are weighed.

And I think there used to be, and certainly in some specialties, more of an emphasis maybe more towards the metrics. I would say metrics are not unimportant, but they're certainly not the thing that we are focused most on. They're just balanced along with everything else. So really, the question that I want to pull from all of this information is how will this person relate to the diverse populations that we serve in our community here as psychiatrists? How will they function collaboratively with peers and also on an interdisciplinary team that we are often working on in psychiatry? So, those are kind of the things that we want all of this information to bring us to.

So with that, I'll turn to the next question for you guys. What did you spend way too much time worrying about during your fourth year or the whole application process in hindsight? And is there anything you wish you had done differently more or less of, let's say, during your fourth year?

Johanna Inamagua, MD: Yeah, that's a really good question. Honestly, so many ways I could answer this. But I think something that comes to mind, I think, I was worried so much about how a first impression would be made virtually. We've done all this background research. We have all these sources, like we spoke about, that we use to get a sense of a program, and then it starts to kind of make you feel anxious a bit about how am I conveying myself to these programs in the 30-minute slot, 15-minute slot that I get to speak to someone from this program.

I think something specifically that I possibly spent too much time focused on was the background of my virtual Zoom room. spending so much time thinking about what's behind me, what's distracting, what adds a bit of personality, what adds too much that someone is focusing on instead of listening to me.

But I think, overall, these sort of silly little things that I fixated on were unnecessary. Because at the end of the day, sort of what you're telling, a person can get a sense of who you are regardless of what bits you choose to show them, and a lot of that does translate best on an interview day. So, I think, yes, focus on your application and the written parts of that and the first introduction that you make to someone in your application, but they're really also going to get more of what you were speaking about with the sense of who are you on a team, what is it like to work with you from the way others describe you in parts of the application that you can't see, like letters of recommendation, and in meeting you when they hopefully do get the chance to meet you on an interview day.

Michelle Zhou, MD: Yeah. This is funny because I asked my partner, you know, when I was discussing the episode and the different questions that we were going to ask each other, and he was commenting that he thought it was totally bizarre how much time I spent on my background. Like, I rearranged our furniture. I, like, was moving things around. And in hindsight, I'm actually glad for myself because I didn't have a dedicated space that would've been good for interviews before then, but I spent too much time on that.

I think something else I spent too much time on and was so worried about was carefully crafting all the communication with different programs and also reading into the communication I was getting. Like, I think I was really concerned about my grammar to too much of an extent, and then reading into the smallest things from different emails from different people where I think that a lot of the programs themselves are getting such a high volume of communication that they don't have time to read into every single comma or extra word or if you said something a little bit weird.

But I think that just being able to focus on the actual interview and conveying who you are and spending less time focusing on the before and after of the different emails I was worried about sending.

Johanna Inamagua, MD: It's so true. I remember feeling it was like crafting a text message to a first date or something. You feel like you have to have multiple eyes on every sort of interaction that you have written with a program, but it's true. Usually, that's more so a reflection of how you're feeling and not really the reality of how they are looking at these different bits of their communication with you.

Daniel Knoepflmacher, MD: We should go back and look at our emails to each other.

Michelle Zhou, MD: Oh, no.

Johanna Inamagua, MD: Oh, let's not.

Daniel Knoepflmacher, MD: Because you're absolutely right though that, as the programs were getting so many emails, and obviously, I mean, I'll say it here, but you guys were exceptional candidates, so we did care a lot about what was written back and forth, but we just can't spend that much time, you know, because it's just one of many things. But yeah, I can say there's a little bit of that on the other side too.

Johanna Inamagua, MD: It is mutual to some extent. All right. So, our next question is, how important is research, and specifically psychiatry-related research, to matching at an academic program? Could you also talk about a bit of what an MD-PhD student might focus on when they are applying to physician scientist training programs? What could they focus on to boost their application?

Daniel Knoepflmacher, MD: Yes. So, there's a lot in this question. I think, first, I want to focus on the word research because I think research means a little bit there's some variation in what it means to different people. I think to an MD-PhD applicant, research is pretty hardcore. It's like, you know, important publications, maybe doing bench research, translational research. Someone who has a PhD, that's a component of the time they spent coming up to residency. Whereas for others, research could still be that. But also, I think people are using that word sometimes when they mean doing writing that's scholarly that leads to publication. So, that could be being part of a book chapter, which sometimes medical students get to do, or writing a review paper, which is a form of research, but not the same, or having case report, doing a poster. You know, those are things that are scholarly academic work that don't necessarily fall into that hardcore research—I don't know that any hardcore is an official word—I'm making that up for this. But into the more intensive research part of the spectrum.

So, I think it's important to have a scholarly, or you can use the word research component to your portfolio if possible. If you don't, does that mean that you can't match in an academic program? I don't think so. I do think it would be helpful, and I do think it would round out your experiences and show that you're interested and capable of doing academic work, which of course at academic institutions is part of what we do. But I think if it's not there, maybe you created a program or did a lot of leadership in specific areas that show where you're putting your energy beyond being a student in a way that's exceptional if you're not having that research. Maybe it would be somebody who had a deep interest in a certain area, and that's why they weren't doing research.

To specifically talk about the MD-PhD piece, so there are programs, often at academic institutions or chiefly at academic institutions that are MD-PhD-oriented, like research track programs for physician scientists. And I think the question was what can those applicants who have MD-PhDs do to boost their application?

I think for those programs, you really want to think about the research being done in that department and where would you see yourself fitting in with some of the big PIs, the principal investigators, in that department that are doing interesting, important work, where would your interests lie with them? Does that mean that you yourself had to have done the same exact type of research? No. It just means that you can tell a story of, given your experience as an MD-PhD, why you're interested in that and why you could be an asset to working in that research and bring to that.

So, I think that's an important piece for MD-PhDs, is to really understand what's in the department and tell a story of why you would be a good match for the research that's going on there. If you're not necessarily going to do an MD-PhD track, but you have an MD-PhD, but you still might be interested in doing some research but not want to take that formal path where it goes towards specific grants that you would be getting and maybe extra post-doc work, et cetera, then you're telling a slightly different story. But I would still say think about the department where you're going and where your specific interest in research might fit in

All right. So now, I'm going to turn back to you guys with a question. What are some—oh, this is a good one. This is kind of a juicy question—what are some subtle green or red flags applicants should pay attention to when figuring out whether a program is a good fit?

Michelle Zhou, MD: So, I think that it is kind of a common thing for applicants to read a lot into how the residents look. Like if they seem tired or if they seem like they have a lot of energy and are very happy during interview socials or throughout the interview day, which I think maybe that resident is just having a bad day. Maybe the program is great and they do love it. And so, I think that you can take that with a grain of salt. But what I actually would recommend paying attention to most is when they talk about their program, does it feel like there are fair and valid criticisms that they have and things that they recognize are not perfect, that they're willing and comfortable to share with you? And if so, if they've been able to bring that up to leadership in the past and how they've been able to implement changes in response.

I think it is a subtle red flag if on interview day everybody, including leadership, your interviewers, the residents, just says that everything is perfect and they have no concerns because I think that's never true. There's always something to improve on. And if people are feeling comfortable enough to candidly share that with applicants in a, like, substantive way that feels that they are working on things but recognize that things are not currently perfect, I think that is a subtle green flag.

Johanna Inamagua, MD: Yeah. I have to agree with that. I think, like we're saying, you can only expect so much from an institution, from one program, and it's nice to know that the residents feel comfortable speaking about that with you and that I specifically loved—I saw it as a green flag—when residents not only could say what it is they would change about their program or what they would want to work on if they were in leadership, but also that they've voiced these concerns and that some change has happened or that there are conversations going on to make these changes happen. I always thought that was a great green flag.

And one thing I can think of actually that's a red flag, I would say when I think you meet a lot of faculty and they don't make themselves accessible to you as applicants. So, I found it a little suspicious when you would meet these wonderful people in their department, and they would say they're so excited to welcome you and to speak about the program, but then the communication would end after the 10 minutes that you've met them. Whereas at other programs where they actually seem genuinely interested in fostering a relationship with you and answering questions or in redirecting you to someone that might, convince you—not convince you, but might help you make an informed decision about your ranking, I always thought that was a green flag. So, I thought it was a red flag when someone would say they were open to speaking one-on-one, open to having more one-on-one conversations, but then wouldn't be able to follow up on that.

So speaking of green or red flags, I think a lot of applicants want to know, as a program director, when you are reviewing the ERAS activities, what do you look for? And is it a red flag if someone has not done a lot of activities beyond med school?

Daniel Knoepflmacher, MD: I think I got it. I'm going to sound like a broken record, but I think the same thing about activities is whether there's a story and a person that kind of emerges from the activities. Now, having said that, I understand, having gone through medical school myself, that you're going to do different activities and something might seem cool, and you don't have to be reverse engineering every choice you make about what activity you do to tell this perfect story.

I think it's fine for it to be organic and varied, but it's maybe how you piece it together in your essay, and tell the story of like, "Yeah, I really wanted to be an orthopedist, but then I had this experience, and that's why I had these interests, and then I switched." Which gets back to the red flag question here is, is it red flag if you switch into psychiatry? Which both of you told stories of switching from pediatrics into psychiatry in terms of your main interest.

So obviously, that's natural and we love anyone who finds psychiatry the natural way. When it comes to whether you have activities beyond med school, I think it depends on the applicant. Like, I was a non-traditional applicant. I had a whole career before I went to medical school. So obviously, I had life experiences outside of medical school. Some people are going straight through. I think they may have some experiences outside, but they're going to have less of that because medical school's going to be a really important transitional period for them from college to residency. So, I think it depends on the person. And so, the answer is no, it's not a red flag. But again, tell the story. Who are you? Why did those choices emerge the way they do? And how do they tell the story of why you're now becoming a psychiatrist?

Michelle Zhou, MD: That makes a lot of sense. Could I also add onto that from, like, the applicant perspective? I think that, at a certain point, I was trying to sort out, like, which of my activities did I really want to focus on and write more about, or which activities to even include at all, because I know there's a limit that I can't remember the number of.

So, I think just sitting down and thinking about, like, which activities matter most to you and that you'd be able to really discuss in depth in interviews and convey your interest. I think that there were some things that an interviewer would read, like, one sentence that I wrote about an activity and I was kind of like, "Oh, I kind of forgot that I wrote that."

But because they were actually things that mattered to me and that I could discuss them in depth, it was always, like, helpful as a conversation starting point. Because you never know what will resonate with different interviewers or the people who are screening your applications. Like, sometimes people share the same very niche interest or have a lot of questions about something specific.

Johanna Inamagua, MD: And I think in that it's also important to not understate a bit of just the challenges of medical school itself. It is hard to be a medical student. There is a lot of responsibility and a lot of learning that happens in that context alone. And going back to some of what we were talking about with this more, I guess, numerical ranking sort of performance-based metrics, I would imagine if someone, let's say, is performing incredibly well in one of those and maybe their extracurriculars are a bit more decreased in number but are very valuable and they've shown a lot of leadership and a lot of commitment to them, I'm sure, I would imagine, right, that you would weigh that differently. And that, like you're saying, it is sort of on a case-by-case basis.

Daniel Knoepflmacher, MD: Definitely. And I think it's what it means to you. What was meaningful about that activity? And as you guys have mentioned, maybe in the interview, if it has meaning for you, you don't know what in there might be meaningful for somebody who's reading your application or interviewing you, and then it is a place for potential connection, which is very valuable during interviews.

So, I realize an example of a program director admitting that things are not perfect and that we make mistakes. I asked you guys the wrong question, so I'm going to go back now to the question I should have asked you before, and I hope that wasn't throwing you too much of a curve ball. But how many programs should students apply to, and how do they figure out which programs to choose?

Michelle Zhou, MD: That's a great question that I remember I was very stressed about, if I was applying to enough programs or too many. So, I asked some of our other interns in our class to see the range of programs that everybody had applied to. It seems like mostly everybody applied to 40 to 50 programs. And I applied to more. I applied to 60, because I think the average or, like, the number that MD students who match the number that I was told was 58 programs. And so, I was pretty cautious, and I think I have a lower risk tolerance and so applied to maybe more than I necessarily needed. But it seems like depending on your own skills and where you rate your own competitiveness like we talked about before, 40 to 60 is about where our class was.

Johanna Inamagua, MD: Yeah. Shout out to our co-interns for participating in our small study that we did. I applied to 40 programs. And I think, in the end, I personally might have done a little bit less, and I was trying to rethink about why I felt that way. And I think, not to again sound like a broken record, it does go back to authenticity. I, like I said, am born and raised in New York. I really knew I wanted to stay here. And so in the end, I was applying to cities and places that geographically didn't make a lot of sense for me, I didn't have a convincing connection to, and I wasn't able to signal as well.

And so, I think for me personally, the lack of ability to really spread out did mean that I was applying to programs where likely it wasn't a convincing story that I wanted to move to this location, that I wanted to start new. So, I would also reflect on that. Granted other people might come from different backgrounds where you don't have a hometown that you consider to be obvious, that you've moved around a lot, or you are someone who loves to try new things and is always bopping around to different places. In that case, it might make more sense to do upward of 70. So, I think it is case by case.

Usually, we would recommend looking at the NRMP data too about what they would recommend for a solid, feasible amount of applications to thoughtfully turn in on time as well.

Michelle Zhou, MD: Yeah. And one of the other interns had mentioned that I think they were really concerned about the number of interviews that they had received, and I think that it's really easy when you're an applicant to be fixated on the numbers that you are getting from NRMP or that you're hearing from other people of, like, how many interviews should I be getting? How many programs is the exact right number? But I think that when we talked about it, our consensus was that, oftentimes, like the numbers are not going to be as useful as considering what is actually a good fit for you, like Johanna said. Like, there are programs that I applied to that I knew I would not be a good fit, I would not want to go, but I was just trying to reach that 60 number that I had seen and that I was so worried about.

And so then, obviously, I didn't get an interview because it was clear that it wouldn't have been a good fit, and then I could have just saved some money. But I think it can be really stressful when you're hearing a lot of conflicting information, but thinking about the fit is really important.

Daniel Knoepflmacher, MD: I hope those numbers go down because, I mean, I look at the two of you and you guys are so competitive, and the idea that you had to—not that you had to—but that you applied to 60. Not to be the old guy, but when I applied, it was like 12 or 13 programs, you know? And it becomes this like arms race and everyone's anxious. But at the end of the day, I mean, you guys can answer this question way, way better than I can, and I hope that those listening take your advice on this.

Michelle Zhou, MD: So, it's general advice to keep your personal statement to be roughly one page. Do you have any thoughts on this advice?

Daniel Knoepflmacher, MD: It is good general advice to keep it one page. I think it's good to exercise concision, you know, to be concise when writing. I think that there are so many essays being read by these programs that there's a little bit of like an "ugh" you know, when you see something that's a page and a half, as you're reading, you know, hundreds of applications. That's a minor thing. have I read essays that were longer than a page that blew me away? Yes. But I would say if you're going over a page, definitely you should feel very strongly about the fact that it's going over a page. I hate to be this, like, strict, but because, I mean, obviously it's not a rule. It can be over a page, but I think it's good to be mindful of that if you can.

Michelle Zhou, MD: I think that makes a lot of sense. And I started I think with two pages, and I really was like, "There's no way. There's absolutely no way I can cut anything out." Like, this is all so important. I love it at two pages. And then, you know, over a period of time as I did edits and had new drafts and I got it down to one page, I realized, "Oh, it's much better this way." Like, you're able to distill things into a more compelling, concise, just one page kind of situation.

Johanna Inamagua, MD: Yeah. Yeah, I agree. Yeah. I also was given good advice to read my personal statement out loud, which was a cringey experience in the early drafts of it. But it does help you focus on what sounds like, "Oh, now we're getting into a side tangent that is meaningful to me but doesn't need to be said here." And again, the anxiety of the first impression, and sometimes a little bit less is more, and you want to say what's valuable to you. You want to explain your interest in psychiatry. If there's anything particularly unique about you or your path to medicine, definitely want to have that in there. But at some point, let something be discovered along the way.

Daniel Knoepflmacher, MD: I love that advice about reading it out loud. Did you do that with an audience?

Johanna Inamagua, MD: Oh, absolutely not. Absolutely not. I was by myself. I was by myself.

Michelle Zhou, MD: Yeah. And something else that I think does come up that was maybe also talked about in one of the previous episodes you did, Dr. K, was tailoring, like, the end of your personal statement for certain programs or just some part of it to convey that, you've really looked into this program, you're very interested, and putting that in your personal statement. And I did find that to be really valuable and helpful for me, not just in conveying to the programs my interest, but also just actually thinking about if a program is a good fit for me. And I think it's pretty exhausting to do that for a lot of programs, but just thinking about the ones that you are really interested in and want them to know that too.

Johanna Inamagua, MD: Following up on the personal statements, as a program director, we're curious, when you are reading a personal statement, what are you actually looking for? Are there certain why psychiatry stories or themes that have become so common that they don't really stand out anymore?

Daniel Knoepflmacher, MD: Why psychiatry stories? I mean, that is the point of the personal statement is to explain why psychiatry is being chosen by you as an applicant. That said, going back to red flags, like there's ones that they make me cringe when I read them, because I've read them so many times, because I believe that a lot of people might have had similar reasons for choosing to go into psychiatry.

So, yes, they're more common. And yeah, it might not really break through as being like, "Oh my gosh, that's the first time I ever read this." But as I said, I think when I did this last year, really the personal statement for the majority of people, in my opinion, receiving them, reading them, is something which is a way for you to tell the program who you are, and it rounds out what you've been presenting in your application, and is a good kind of glue to put all of that together.

Does it boost you and be like, "Oh my gosh, that was a great personal statement, and I really, like, want to interview this person," or, "This is a person I want to put at the top of the match list based off the personal statement"? It's usually not something that's going to boost you so much. It's going to maybe boost you in a indirect way by us being able to understand your story, but not based on the fact that essay blew us away.

I think the essay, for the vast people, is in the middle, something which doesn't hurt and it doesn't, as you're reading it, help because it, again, blows you away. It's more that it supports what's already there. For a few rare situations, it might hurt you if it's somehow conveys something that's not great or it has a lot of carelessness in it, let's say.

Or on the flip side, there are a few I can think of where it was like, "Wow, that really blew me away, and I really want to meet this person and talk to them more about it," or they told something that really was exceptional. But those two parts of the bell curve are definitely exceptions. Most of it is in the middle. So, yes, try to make it unique. Try to make it authentic. Authentic is something you guys have brought up. But don't worry if you're worried that somebody else might have told some version of that story so much.

Michelle Zhou, MD: Do you feel like when you're reading a lot of these personal statements that you can feel like it, maybe not in a, like, you know, identifiable way, but when something does feel more authentic, does that come across?

Daniel Knoepflmacher, MD: It might be the language. It might be the specificity of the details of what somebody's describing. Is it more generic in their language, or can you feel and get a sense of what's unique? So, I think some authenticity comes through.

That said, some people are more vivid writers than others, and that shouldn't be the thing that makes or breaks their application. I keep that in mind, that then, like, I might read an essay that, "Meh, it's fine," but there's a lot of other things in the application that are really great. But then, I meet that person, I'm like, "Oh my gosh, what a really amazing person who's so alive, so impassioned," you know? And that, for whatever reason, didn't come through in the essay.

Johanna Inamagua, MD: How do you feel about when an applicant might use a story and they might be telling the story in a very descriptive way to get their point across? Is there a point at which the focus on the type of language that's being used or the writing style overpowers the greater message of what you are interested in as a program director?

Daniel Knoepflmacher, MD: If it's really like it's a one-page poem that's all, you know, done with tremendous metaphor, you know, and then doesn't actually get a ton of information across, then maybe that would be too much erring on that side. I'd say that's rare. It's rare that the language overpowers the information. I think that sometimes people may be a little flowery in the way they describe things or overly dramatic. And it'd be something that if you're writing an essay to ask people, if you're just conveying something that's dramatic or important, like is this language hitting the right note, going too far or is it too bland? But again, that's not typical that I experience that.

Michelle Zhou, MD: I did not want to do it. I remember, like, when, you know, application season started, I was dreading it, but I really just forced myself to get a first draft down. And I'm so glad, every single time I went back and edited it, like pretty filled with a lot of dread and just didn't want to do it, but every single time it really did get better until it became something that I was actually really proud of.

And through different iterations, I would ask like every attending that I trusted, everybody in psychiatry that I really valued their opinion and people outside of psychiatry to just give feedback on. And I think that was really crucial, was the multiple drafts, multiple stages of revision and getting feedback from a lot of different eyes.

Johanna Inamagua, MD: Something I can remember being told was that not only is it your personal statement, it's also your professional statement. I think that's where we get into a bit more of where you want the message to still be something that you're proud to speak about on interviews, that you're comfortable delving into with people that you're meeting for the first time. And in telling stories of perhaps clinical experiences or people in your life that were part of your desire to join psychiatry, to make sure that you're always pulling the focus back to you as the applicant, that we're not spending so much time as the reader, as the person getting to know you through this personal statement. We're not spending so much time learning about the wonderful other people in your life, but that we see you for who you are and what you've gained from the different experiences that you've had in clinical settings and outside as a person.

And I found that to be very helpful to focus on, okay, how many sentences have I spent introducing XYZ character or XYZ external thing about my motivation for psychiatry, and how do I make sure that that's not the main focus, and that the focus is who am I as an applicant, what am I going to bring to a program, what do I see for myself in my career, and how do I want people professionally, how would I want them to walk away from this one-page essay to how would I want them to think about me.

Daniel Knoepflmacher, MD: Really great advice from both of you. Those listening, take note of what Michelle and Johanna are saying. So, I want to turn to ask you guys a few questions about the interview process. You talked a little bit about red flags, potentially green flags. I want to ask you specifically a question that someone sent in about the interview itself. You know, now these are all virtual. So, how much information can applicants actually learn from doing the interview virtually?

Johanna Inamagua, MD: I don't know if this is a hot take. I ended up really loving interviews. I think, in hindsight now that we know where we ended up and that we had, it's all over and the anxiety has melted away, it can be really fun, I think, to meet so many different people. And regardless of where you end up, they're all excited to get to know you as a future colleague, to hear about you.

And I thought it was ultimately pretty fun. I think from the interview day itself, things that I looked out for for a program was the structure. That told me a lot. I really liked when we had some time at the beginning of the day to hear from the program directors, not only from their professional role, but when they also gave us a bit of background about themselves. It kind of felt to me like a very human, leveling the playing field sort of thing to think about. And I thought it was a good green flag when programs took the time to do that or when my interviewers also gave me a bit of something about them at the start of our meeting so that it could make it easier to connect virtually and to find things in common. So, that's just something that initially comes to mind. Michelle, what do you think?

Michelle Zhou, MD: I agree. I really loved doing interviews. I think that, I mean, that's part of like why I think a lot of people who enter psychiatry enjoy the human conversation and getting to know other people. That's just all the interview is really, is people wanting to know who you are and you getting to know them and ask questions about them and the program.

So, I actually had a lot of fun. I think that the exhausting parts of like scheduling and a lot of like back-to-back or just rigorous stuff can be tiring, the actual conversations I really enjoyed, and I think gave a lot of information. And I would often walk away from the interview day with a pretty different perspective than I had started with about a program with all the things that Johanna talked about in terms of structure and, you know, what these programs are choosing to share about themselves.

But also, I think just in how I felt after, like I think that you just kind of walk away with a sense of, like, was that a good time or was that kind of stressful and it felt like it wasn't necessarily productive or that people were just going through the motions versus actually trying to get to know you.

So, I think that there's a lot of information both consciously and also unconsciously of, you know, is this place a good fit for me? Do they seem like they really care about their residents? And, yeah, that kind of stuff.

Johanna Inamagua, MD: Michelle and I spoke about something that is sort of related to the interview day that we really appreciated, that I will say Cornell did, which is giving you an information packet, something that laid out the logistics of the boring stuff that we care about but it's not so interesting to review on an interview day when you're very nervous about the interviews that are coming up.

And I remember we both were speaking about receiving these materials. And it feels like a nice, again, thoughtful thing where all of the basic information that an applicant would want to know is laid out for you to have and there's less pressure for you to pay attention during like a PowerPoint presentation or to be taking notes at the same time. So, I like that, the part of the programs where they were thinking about the logistics for us and making things easier.

Michelle Zhou, MD: I also think it's important to be really discerning and when people ask what questions do you have, to have real good questions that you have thought about and that really matter to you in choosing a program. So, I think not just coming up with questions for the sake of having something to say in response to that, but like what things actually are concerning to you about the program that maybe you were worried about before interview day, addressing it during and saying like, "Maybe this is something I would like to know more about and know what you guys think about that."

And I think asking real questions is important to make sure that you're getting the most information you can from what is a pretty limited process, because it is hard when you're not there in person and doing everything there.

Daniel Knoepflmacher, MD: We've have so much that we've talked about and we have limited time, so I'm going to follow up a few times to hear more about the rest of the process.

So, you've gotten through the interviews and you have to make a rank list. Is there anything you wished you had asked programs before you were submitting yours?

Johanna Inamagua, MD: That's a good question. I'm curious, Michelle, were you one of the people that had like a spreadsheet or something to keep track? How did you do it?

Michelle Zhou, MD: I did. I had multiple.

Johanna Inamagua, MD: That's what I thought.

Michelle Zhou, MD: Johanna knows me too well. I had a spreadsheet. I had a separate list of just keeping track for everything else in a different kind of database. And the spreadsheet, I considered all the things that mattered to me for residency, so like location, work-life balance, the different training opportunities. I really was worried about like the balance between having autonomy versus enough supervision. And so, I made a weighted spreadsheet where after each interview, I would put in values and then kind of just let it happen formulaically. And I also just did one vibes-based first, and it was interesting because my vibes rank list actually matched up with the spreadsheet pretty much exactly.

Yeah, and I think that's something that I heard that I thought was really good advice was before you sit down to actually make your rank list is to think of two or three just core values, like what is absolutely most important to you, and let that guide your decision-making, and I think that that was really helpful.

There's so much information. I had so many conflicting opinions, and there were a lot of programs that I really loved. And so, thinking about those values and making my rank list in relation to that was really helpful.

Johanna Inamagua, MD: Yeah. I agree. There is a lot to think about, to weigh, and the question of what would I have asked or was there anything I wish I asked programs before submitting? Honestly, no. I think at the point where you are coming up with a match list, I personally felt there was so much information. I had everything I needed to.

And going to what Michelle is saying about the vibes, it really is, it's annoying to hear when you haven't done any interviews yet, but you do get a gut sense of how you felt walking away from an interview and how you felt meeting the specific people that they thought matched up with your interests or that they thought you would have a good connection with.

And I ultimately ended up going and making my ranking mostly off of that feeling, the feeling of when I walk away from a second look or when I walk away from a social event that the program has planned, how did I feel and where was I excited to go? Where was I really hopeful and imagining myself, and sort of daydreaming about what it would be like to be there? That was what I helped guide me to make my rank list.

Michelle Zhou, MD: And I think that for a question that maybe you should ask, but probably before you submit your rank list, like probably during the interview day, I think something that has come up with conversations with our other interns is that it can be hard to conceptualize call when you've never had to do that in medical school. And people will give you the call schedules for a program, but like what does that actually look like in practice? And then also, the time that different people in the program spend with you, like how much time are you with an attending just one-on-one or are you with different residents, like maybe seniors? Because especially in psychiatry where I think you often don't have a senior, it's often just you and the attending, it's a helpful benchmark. But that is kind of digressing because I think that should be asked during the interview.

But also additional advice for rank list is something else that came up that a lot of people in our cohort did was writing or somehow recording your reaction and your impressions immediately after the interview because so much of it fades away. And so, writing down your thoughts and then just having that as a record. I recorded myself and watching it back, like there was so much that I could tell on how I felt about the program and the interview day that wasn't necessarily what I was saying, but in how I looked and how excited I was to talk about the program. And I think that is helpful when making a rank list.

Daniel Knoepflmacher, MD: So, you actually had videos, like, of yourself talking about the—

Michelle Zhou, MD: I did.

Daniel Knoepflmacher, MD: Wow. Cool. You'll be able to look at those years from now and that's pretty cool. One more question. So, we went through the interviews, went through the match list. Now, the question is, what's the biggest difference between what you thought residency would be like versus what it's actually like day to day now that you guys are in your third month of residency?

Johanna Inamagua, MD: I think the biggest thing that I just really underestimated was how quickly you join and get into this role of being a doctor. And someone said it to us during orientation, and I was shocked by it at first, and then it really kept happening day to day, which is that you do have to introduce yourself every single time with every patient, with every new team. And a lot of the times you are introducing yourself with this new title, and it can feel a bit jarring at first. I felt that it felt a little unnatural, but you start to get more comfortable, and that was something that I wasn't expecting I would find not difficult, but that I would be surprised by and that I would feel like, "Oh, this is a big role to step into."

So, I was in the application process, so fixated on what it would be like to be a resident, I kind of forgot what it's like to then turn and you have patients and you have people who look at you as much as you are, yes, in training, also in a position where there's a lot of trust that they're putting in you. And as much as you are learning on the job, that you also want to convey the same competencies and leadership qualities that got you to the residency that you're at.

Michelle Zhou, MD: Yeah. I agree. I think that, for the first couple probably weeks, I would have to correct myself and be like, "Sorry, sorry, I'm actually a doctor." Because I would just introduce myself to patients as Michelle and they'd be like, "Aren't you one of my doctors?" But I think also when you're on call or just in different scenarios, like sometimes often you are the first person that people come to when there's something that is concerning or new or important that needs to be addressed.

And I think that like triaging that you're doing now is there's more responsibility, more weight with it, and that was definitely like, "Whoa, a little shocking for me." But I think it's like the natural progression of this is what we've trained for, this is, you know, the four years of medical school was for, and this is my job now. And I think it was just a fun odd transition.

Daniel Knoepflmacher, MD: It's such an important rite of passage. I mean, I've met you guys in person for the first time during orientation, and I always think about that experience. I remember it, that new identity and, really, you kind of stepping to the edge of where you are the person that the buck stops with, even though obviously there's somebody to turn to and you should never feel alone in making any decision ever.

But still, you need to feel that because eventually you are going to be that person that happens very early on in training. So, you guys really described it beautifully. So, Doctors Zhou and Inamagua, we're going to finish by each of the three of us providing one tip to applicants who are applying to psychiatry residency. So, you guys start and I'll finish.

Michelle Zhou, MD: My practical tip is that I made a separate email and just did all of my residency application stuff through that email. So when I would get interview notifications or just communicating with programs, and I think it was helpful for me to organize myself, but also just to keep track of things and not lose things in my regular email that is filled with spam.

And then, my other, like, bigger tip is that people, you know, say try to have fun on the interviews, try to stay true to yourself, but it really is, I think, so important, especially in psychiatry more than any other specialty, that they get a good sense of who you are, that you are not conveying yourself to be somebody that you're not, and really just trying to enjoy the conversations that you're having and getting to know people and letting them get to know you.

Johanna Inamagua, MD: I agree with the logistical tip. That is so true. It's so much easier to keep track of all the information that you get when you have a designated space for it. I think the tip I would give is that to let yourself entertain as an applicant the possibility that you could end up at many numerous programs and have equally great outcomes, do just as well, learn just as much, get along with your co-interns just as well.

I think it's hard when you're ranking these programs and you're putting it on such a numerical hierarchical way, it's hard not to get caught up and fixated on only so many possibilities. But the reality is that a lot of the programs in some way will train you similarly. In terms of location, your life may look very similar. And so, let yourself entertain the possibility of you could be very happy at multiple programs and it just might look different, but that you are only working with so much information. And, in the best ways, you can also be wrong and you could also end up somewhere that you are just as happy and you wouldn't know anything different.

Daniel Knoepflmacher, MD: Well, we didn't coordinate this, or at least I didn't know what your guys' answers was going to be, so this is going to be a little repetitive. But my big hot tip is be yourself. And that I think was a bit of what Michelle was saying too. But really, a lot of what we talked about today, I think, is in this, that you want to take this opportunity to be a learning process for you. Ask yourself questions about what you want, who you are, those core values that Michelle had brought up earlier. And use that as you're thinking about your application and you're shaping your essay and you're going into the interviews.

But really, that's important for you as a psychiatrist because there are many different ways to go even within the field, and you don't have to decide this before you're a resident. But just to start to ask yourself questions and to have that questioning, curious mind about yourself and others, if you're already there with that and you make that part of this process, which will make you, I think, enjoy the interviews because you're curious and you're interested in the people and they're interested in you. If you just turn that part of the process into what drives you as you're choosing programs and you're presenting yourself, I really think it will help you, it'll help the programs understand who you are, and it'll make it more enjoyable.

So, I really want to thank the two of you. I mean, Johanna, Michelle, I know you took time out of your busy schedules as residents to provide insights and experiences that are just going to be so helpful to those who are hoping to follow a similar path as the two of you. So, really grateful not only for your participation in this episode, but for all the work that you guys do here in our community and really for being a part of this residency family. Thank you. Thank you very much.

Johanna Inamagua, MD: Thanks so much for having us. This was so fun.

Daniel Knoepflmacher, MD: It really was fun. So, I'm grateful to both of you. And I also want to thank everyone who listened to this episode of On the Mind. As you probably know, we're the official podcast of the Weill Cornell Medicine Department of Psychiatry. Our podcast is available on many major audio streaming platforms, including Spotify, Apple Podcasts, YouTube, you name them.

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