Dr. Daniel Saddawi-Knefka, Program Director of the MGH Anesthesiology Program, has seen residency applications evolve dramatically. With rising application numbers, the introduction of program signals, and USMLE Step 1 shifting to pass/fail, today’s applicants face a more complex and strategic process than ever.
In this article, Dr. Saddawi-Knefka shares expert insights on how programs like MGH evaluate candidates. Whether you’re a top-tier applicant or concerned about red flags, this guide offers practical advice to help you navigate the process and improve your chances of matching.
The Changing Landscape of Residency Applications
Q: How has the residency application process changed in recent years?
Over the past decade, the number of applications per applicant has increased dramatically. “When I applied in 2006, submitting eight or nine applications was typical. By the 2020s, anesthesiology applicants were applying to more than 60 programs on average,” Dr. Saddawi-Knefka explains.
This surge created challenges on both sides. Applicants struggled to meaningfully research so many programs, while programs faced the challenging task of reviewing thousands of applications—many from candidates who had little actual interest in attending. As a result, highly qualified applicants sometimes lost interview spots to those who applied indiscriminately.
To address this, many specialties have introduced a signaling system. “Programs needed a way to identify serious applicants. Signals provide an opportunity for applicants to say, ‘I am genuinely interested in your program,’ which helps us prioritize who to invite for interviews,” he says.
Q: What is the signaling process, and how does it work?
The signaling process is a strategic tool designed to help applicants express genuine interest and help programs identify candidates who are truly invested in their program. Dr. Saddawi-Knefka explains, “Applicants receive 15 program signals—five gold and ten silver—which they use to indicate genuine interest in programs.” Gold signals carry the most weight, signaling a top-tier preference, while silver signals indicate strong but secondary interest.
For programs, signals are a way to filter out low-intent applications and prioritize candidates who are serious about joining their ranks. As Dr. Saddawi-Knefka notes, “Over 95% of interview invitations go to applicants who sent a signal. So while it is possible to get an interview without signaling, it’s extremely rare.” This system not only streamlines the process for programs but also empowers applicants to be strategic about where they express interest, ensuring their signals align with their true preferences and realistic goals.
Q: Has the number of applications to MGH changed with the signaling system?
Yes. “Before signaling, we were receiving close to 2,000 applications per cycle. Since implementing the system, applications have decreased by about 30%,” he notes.
This reduction helps programs focus on applicants with genuine interest, but it also raises concerns that some strong candidates might hesitate to signal top-tier programs, fearing they won’t be competitive.
Despite this concern, he remains optimistic, “If we’re not in an applicant’s top 15 choices even as a reach program, then the number of truly missed opportunities should be relatively small.” This highlights the importance of applicants being bold yet strategic in their signaling decisions.
How Residency Programs Evaluate Applications
Q: How do programs prioritize applicants for interviews?
Signals heavily influence interview invitations, but the process is more than just ranking them. Dr. Saddawi-Knefka explains that over 95% of invitations go to applicants who send a signal, with gold signals being the most likely to lead to an interview, followed by silver. Those who don’t signal have a very low chance.
At MGH, gold signals aren’t an automatic ticket. Applicants are sorted into three groups: clear fits, unlikely fits, and those in between. Then, silver signals are reviewed, and top silver applicants may be chosen over weaker gold ones. This shows that while signals matter, a strong overall application is just as crucial.
Q: What factors matter most in selecting candidates for an interview?
A: Beyond signals, programs evaluate applicants based on a combination of clinical performance, test scores, letters of recommendation, and personal statements.
“Clinical performance—especially in sub-internships and core clerkships—carries a lot of weight,” he emphasizes. Strong letters of recommendation can also make a significant impact. Personal statements, while not a make-or-break factor, can help clarify an applicant’s motivations and address potential concerns in their application.
Q: Does Step 1 becoming pass/fail change how applicants are assessed?
Yes, but academic performance still matters. “With Step 1 now pass/fail, there’s greater emphasis on clinical grades, letters of recommendation, and Step 2 CK scores,” Dr. Saddawi-Knefka explains.
While test scores remain important, residency programs now rely more heavily on evaluations of an applicant’s clinical skills, professionalism, and ability to work in a team.
Maximizing Your Chances of Matching
Q: What advice do you have for applicants when deciding where to send their signals?
Choosing where to send your signals is a key strategy in the application process. Dr. Saddawi-Knefka advises applicants to be honest and thorough. “For geographic signals, just be honest—if you prefer a certain region, say so. If not, consider selecting ‘no preference,’” he says.
For program signals, research is essential. “It’s not just about where you want to go, but whether the program is within reach. Many programs share what they look for on their website or in open houses,” he explains. At MGH, for example, clinical performance matters more than test scores. His advice? Be strategic but bold—don’t hesitate to signal a reach program if it’s truly a top choice.
Q: How can applicants with weaker applications improve their chances?
Letters of recommendation, away rotations, and personal statements can help mitigate weaknesses. “If an applicant has a lower Step 2 score or weaker clinical grades, strong letters from well-known faculty can be a game-changer,” he says.
Similarly, performing well on an away rotation at a desired program can increase an applicant’s visibility and improve their chances of securing an interview.
Q: What are common red flags that might hurt an application?
Red flags can hurt even the strongest application, and Dr. Saddawi-Knefka highlights key ones to avoid. “Failing a rotation is a major red flag,” he warns, emphasizing the need for consistent clinical performance. Weak letters of recommendation are another concern. “If a letter focuses on an applicant’s personality but says little about their clinical skills or decision-making, that’s a problem,” he explains.
For IMGs, language skills and cultural fit can also raise doubts. Dr. Saddawi-Knefka suggests a simple fix: “A strong letter stating, ‘Their English is excellent, and they perform well in a U.S. clinical setting,’ can make a big difference.” Addressing concerns head-on is key to overcoming red flags.
Long-Term Strategies for Success
Q: How can medical students prepare early to improve their residency prospects?
Success in the residency match begins long before applications, and Dr. Saddawi-Knefka urges students to focus on meaningful, sustainable preparation. “Prioritize doing good over just looking good,” he advises, stressing intrinsic motivation over superficial achievements.
Strong study habits and a solid work ethic are also key. “If your goal is a place like MGH, remember there are many paths to get there. Even if you don’t match at a top-tier program right away, hard work and strong performance can open future opportunities,” he explains. This long-term mindset encourages consistency and clinical excellence over short-term gains.
Q: What is the difference between ‘doing good’ and ‘looking good’ in a medical career?
Dr. Saddawi-Knefka draws a clear line between “doing good” and “looking good,” urging students to focus on meaningful actions rather than simply checking off boxes. “Some students focus too much on getting publications, joining clubs, and padding their CV. But what really matters is engaging meaningfully in whatever you do,” he explains. Residency programs can easily distinguish genuine passion from superficial involvement.
He offers an example: “If you stay after your shift to sit with a dying patient who has no family, knowing no one will see or reward you—that’s doing good.” This philosophy extends to studying as well. “Some things you study just to pass an exam, while others truly make you a better doctor. This mindset not only strengthens residency applications but also shapes a more patient-centered career.
Q: How do IMGs and non-traditional applicants improve their standing?
IMGs and non-traditional applicants often face extra hurdles, but Dr. Saddawi-Knefka offers clear strategies to overcome them. For IMGs, addressing concerns about language skills and cultural fit is crucial. “A strong letter of recommendation explicitly stating, ‘Their English proficiency is excellent, and they perform well in a U.S. clinical environment,’ can make a big difference,” he advises.
Beyond strong letters, gaining U.S. clinical experience, such as through away rotations, helps demonstrate competence and fit. Mentorship is also key, offering guidance on navigating the residency system and strengthening applications. Non-traditional applicants should take a similar approach, focusing on clinical excellence, addressing any gaps, and using strong letters and experiences to craft a compelling narrative.
Conclusion
Navigating the residency application process can feel daunting, but Dr. Daniel Saddawi-Knefka’s insights offer a clear roadmap for success. From understanding the strategic use of signals to prioritizing clinical performance and addressing red flags, his advice emphasizes the importance of authenticity, preparation, and strategic decision-making.
Whether you’re a top-tier applicant or someone overcoming challenges, the key is to focus on what truly matters—doing good, not just looking good—and to approach the process with resilience and intention.
As medical training evolves, the path to a top residency isn’t a single road but a network of opportunities. With careful planning, honest self-assessment, and a commitment to excellence, you can turn challenges into success.
