Do you have any questions for me?

Recently, Asim A, MD had a thoughtful post on X about a question he thinks that applicants should ask interviewers in the 2024 Match.

This is a very insightful question because of how much the answer reveals about the program. First, the answer will tell you about the practical support systems that exist. Second, how open the interviewer is with the answer tells you a lot about how transparent the program is. The truth is - burnout is so ubiquitous in our field that every program has examples of hard-working, excellent residents who struggle. And it is an absolutely fair question that applicants should know before ranking programs. In fact, if a program does this well, it could even be something that a program would voluntarily highlight in its applicant materials.

Seeing this post caused me to reflect on what questions I would advise applicants to ask as they embark on the interview trail this winter. Thinking back to my own experience, I received the following advice about handling "do you have any questions for me"

1. Always have enough questions to ask to run out the clock. You don't want the interview to end early because you don't have enough to say

2. Don't ask any questions that are negative or critical of the program, as you don't want to end the interview on a sour note.

I largely followed the advice, asking very generic questions or lobbing softballs that would allow a program to highlight what I already knew was a strength. In retrospect, I am not sure whether that was the right approach, although I acknowledge it is very convenient for me to say that having gone through the process and not in the interview seat currently. Ultimately, this approach does a disservice to the applicant because it prevents them from understanding the true nuances and challenges that exist at each program. No program is perfect, but applicants should know whether an individual program's imperfections are compatible with their desired personality and learning style.

In the following paragraphs, I propose a few questions that I think will allow prospective applicants to truly understand what is going on at a program. Of course, this assumes that the interviewer knows the answer and is willing to answer honestly. I also understand that all applicants may not feel comfortable asking these questions, and I cannot speak to whether asking them will be frowned upon. I only hope to make the claim that they would be informative if answered. Finally, I am writing these questions geared towards academic programs. Since the three tenets of academic surgery are patient care (clinical excellence), education, and research, I will group my questions into those three categories. Every program will tell you it does all of them well. Hopefully these questions will help you figure it out for yourself.

Clinical Excellence

We all agree that caring for the whole patient is a critical part of medicine, and learning how to perform patient care is an important component in every residency. Yet, what is unique to surgical training is the need to understand how to perform operations. According to the literature, this is also the area of training in which residents struggle most. Every program will tell you that the residents can operate and that residents get into the operating room early. Naturally, operative complexity and autonomy increases with PGY level and the first year of two of residency will be more focused on learning how to manage the floor, work up surgical patients, and see consults. PGY3 is a nice mid-way point where residents should be getting meaningful operating exposure and this question should give you a realistic sense of how much operative experience and graduated autonomy is available, and how frontloaded or backloaded the operative training is.

As an aside, what operations a PGY3 SHOULD be able is not something that can be answered easily at this point. To figure this out, I believe we need to first map what residents at all PGY levels feel comfortable doing, then use that data to inform national and transparent standards. All learners will progress differently, but having a general guide can help residents tailor their education and understand how "on track" they are to achieve autonomous competency in all required General Surgery operations. We previously published a single-institutional study on perceived operative readiness to lay the groundwork for development of such standards.

Research

Research is an important component of academic surgery and increasingly relevant in fellowship applications. If you are interested in academics, you are going to want to ensure your training program offers adequate research infrastructure. The majority of your research will be done during academic development time if you choose to take it. While you should always have the option to apply elsewhere (and some may have special reasons to), it is laborious to do this - and it is always preferred to have staying at your home institution and doing research as an available option. Having protected funding for all residents is an indication that an institution takes research seriously.

In addition, if you want to do research, one of the most annoying administrative roadblocks will be submitting an IRB. Some institutions have dedicated research staff who can do this for you or at least help. Some have IRBs that can give you quick turnarounds. This is more important than some may initially appreciate. If you want to do research - especially as a clinical resident - you will need to be able to get your study started quickly when you have some free time and momentum. An effective IRB will make that possible; a non-effective IRB will make it impossibly painful.

Speaking of doing research during clinical years, the third question gets at whether your institution has a culture of research and also reveals how much staff redundancy exists. Some programs will try to get all of their residents to go to conferences, others will discourage attending them.

Education

This category was the hardest for me to think about because all of the questions that first come to mind are objective and would likely be addressed either in the interview presentation or can be looked up online. Examples of this include pass rates on the American Board of Surgery Qualifying Examination and Certifying Examination.

For the first question, I ended up modifying Asim A's question to the context of ABSITE remediation. This will tell you whether remediation is just a box a program checks or a personalized plan to help a resident get back on track.

The second question also allows you to indirectly assess a program's staffing redundancy - and it is an area where you will find real differences between programs. While it does not seem like much, one hour vs a half day without having to hold a pager and see consults can be a lot.

Concluding Thoughts

These questions aim to understand the realities of clinical, research, and educational offerings of a program in a practical way based on pain points that residents observe. I did not know to ask these questions as a student, but hopefully these insights can help the next generation of applicants.

I also think that we are witnessing a transformation in the application process. Social media tools like X (formerly Twitter) allow for unprecedented communication about the intricacies of the application process. Even applicant communication about the process that has evolved from a Google sheet which allowed asynchronous communication to a Discord where applicants are discussing their interview experienes in real time. In this environment, I think programs need to increase their transparency, and that doing so will be looked upon favorably by applicants.

I would be curious what others think of these questions and any others that they may find helpful.