DIP Episode 534 - Addressing ERAS Application Red Flags

Welcome. This is episode 534 of the Divine Intervention Podcast. Into this podcast I'm going to be addressing a topic I title. Addressing Eras application, red flags. Addressing Eras application, red flags. Red flag is basically something on your application. They are worried about, they'll potentially make it harder for you to match into residency. So my goal in this podcast is to address some general principles and then after that I'll go into some specific common situations I've collected over the years from my experience working with lots of people that are applying for residencies in the US. I believe I will cover pretty wide swath of situations. So chances are you would find this podcast to be helpful for your situation. So let's jump right into it and discuss some general principles. So what are some general principles to keep in mind with addressing red flags on your application? Number one is don't lie. Don't lie. Don't try to forge the numbers when you're discussing your red flag. Again, some people that are very experienced in the process can see right through a person trying to be deceitful. So don't lie. Second thing I will see to keep in mind as a general principle is to be concise in your descriptions. You see people, they write a whole essay relating to their red flag and then their personal statement essentially goes from because like a three page tomb. That's not the kind of thing you're trying to achieve with these things.

The third general principle to keep in mind is that this should be made in a separate paragraph. Most times if something is a significant enough red flag, you should address it in your personal statement. You should give it a separate paragraph, but again, let's not be like a half-page paragraph. No. Let it be something that is concisely written. So make it a separate paragraph in your personal statement. Now general principle number four is again, let it be well edited. Let it be well edited. Let it be well edited. So obviously a red flag is something that is ten us. So it's not something you just want to describe in a very flip-and-� manner. No. It's something you want to make sure that is well edited and is constructively written. General principle number five is don't hide. So you see some people, they have ginormous red flags and then they just choose to not mention it at all. Like it's something that's very significant that you know that it will very likely come out either during your application or something a program director can look up and figure out pretty quickly or something that ECFMG will relate to the program or whatever. You don't want to hide those kinds of things because when it comes out, it can end up causing you bigger harm in the future. Now the next general principle is when your addressing red flags don't show a pattern.

So like for example, if a person fails one US Emily exam, it's not wise to then in your personal statement used terminology like oh, I have always struggled with x, y, z exam or I have always struggled with standardized tests. By using such pattern B statements, you're showing them a pattern that oh wait, oh this failure you have is a symptom of you just being bad at standardized testing. When you pinch those kinds of patterns, then people look at it as your story. And if you look at it as your permanent story, then they would probably extrapolate to you having those same kinds of issues in a residency. Because in a residency, you're still going to take standardized exams like your training exams post residency, you're going to take standardized exams like your board on your license or exams. As a program director, you would no one to get a kind of person like that into your residency program. And then another general principle, I decided to stop numbering them because it's kind of like it's hard to keep track of the numbers and still focus as I teach the spot cast. But another thing to also mention is avoid excuses. Whenever you're addressing a red flag, avoid excuses. Obviously this does not like this partially applies. To truly bad situations, so say for example, you lost a loved one while we were studying for a US Emily exam. And because of that, you know you failed or you didn't do as well as you wanted to do. That's obviously something that that's a decent excuse.

But the thing is, even with mentioning that you still have to take some degree of responsibility. That's a smart so balance it out that way. Balance it out that way. But you see some people, they just give excuses for everything. Even if those excuses are tenable, it may not be acceptable to a residency review committee. Next general principle to keep in mind is clean your social media or delete your social media. Clean it up. Because again, an increasing part of the screening process these days is to look at people's social media. What was your, what Reddit comments have you made in the past? What Facebook posts have you made? What have you put on Instagram? What have you put on X? All these things, some people check those things. And if they find anything that is lube, they find anything that may be construed as offensive, they find anything that may be construed as controversial. That may very rapidly torpedo your application. So just keep that in mind. And then another thing, another general principle for red flags is whenever you are addressing an experience, make sure it's a substantive experience. It kind of comes across as a red flag where people are just basically box checkers with the applications. People, the bunch of experiences where it was like two hours on a Saturday, something they almost didn't invest anything in, just as a means of padding one's application.

It's better to have fewer experiences that are substantive than to put a bunch of non-substantive experiences that just dilute the quality of your application. So now that we have talked about these general principles, let's then start going to specific situations. So the first situation I'm going to start off with is what a very common one I've dealt with this for years with many people. So common situation is who I feel the USMD exam, or I got a very low score, or I've had multiple failures. So the thing is whenever you have something like this, you have to address it in your personal statement. So how do you address it again? Like I said, you're going to give it a paragraph. And the first thing you're going to do is you're going to state the problem. Okay, I feel the USMD exam, or I passed this example with an crazy, crazy low score, like one point of both passing or something like that. Honestly, if you're 10 points of both passing or thereabouts, I don't really see why I should start explaining as a red flag. But you know, although that may be according to question, if you're applying to a discipline that is very competitive, then in that case, maybe you want to offer an explanation. But most times I'll see that this should be reserved for people that feel an exam or have multiple failures. So whenever you have this thing, the first thing you do, you're going to state the problem, right? Hey, I feel this exam.

And then you're going to try to give your reason for feeling it. But again, there is a difference between giving a reason and giving an excuse. Some people, they literally just blame the problem on everybody else. They never take any kind of responsibility. That is not the kind of person you want to be. That does not come across well. So it's very helpful. Take responsibility. That hey, I didn't have the right study habits. So that's like a reason. I didn't have the right study habits. So notice that's not an excuse. That's a reason. But again, it's a taking responsibility kind of reason. It's a taking responsibility kind of reason. You know, I had poor study habits. But after you didn't take responsibility, you didn't need to talk about the corrective action you took. What corrective action did you take? Oh, I changed my study approach or I consult it with a mentor to give me guidance. And then after you talk about your corrective action, talk about the results of that corrective action, talk about your comeback story. So after changing my study habits, I retook the exam and I passed and I got 30 points above passing or whatever. On my scores improved by 40 points. You want that comeback story. That's very helpful. Now, I'm not going to try to mean words here. What if you're a person that has filled USMLE's multiple times? To be honest with you, you either have to consider applying to a notice competitive specialty or consider something different as a line of work.

You see some people, I feel like sometimes and again, I want to be truthful here and be as blunt as possible while being respectful and cognizant of the struggles that people are going through. But if you feel the USMLE, again, I cannot give a specific number, but let me give something egregious. Let's say you filled USMLE exams like four times. To be honest with you, the only thing that would get you into a residency program is if you have some very strong connections. If not, it is highly unlikely that you'd be able to match into a residency program. I'm just being honest with you because in that situation, it may just make sense for you to consider another healthcare career that you may still feel pretty fulfilled and still earn pretty good pay from. So just something to keep in mind. You know, like being a physician's assistant or a nurse practitioner or respiratory therapist or an anesthesia assistant, there are many things you can do because many people you see them, people online, you know, because everyone online wants to be. I don't know. I just feel like it's not kindness. It may seem like tough love with what I'm saying, but sometimes you got to be, it's not sometimes you got to be honest with people. So I didn't keep wasting their money applying when the probabilities of getting anything done or getting any successful outcome is almost zero. So it's something to keep in mind.

Now what is the next situation I'm going to talk about the next reply I'm going to talk about is being an order graduate, being an order graduate. Oh, I graduated from school 10 years ago or something crazy. Well, here's the thing. If you're an order graduate, you should take step three. That's that is one of the best ways to address your reflex. Take step three. And also you need to be able to discuss what you've been doing since you graduated. So for example, if since you've graduated, because maybe let me address it from this perspective, I've noticed this problem with I.n.g. a lot international. So the word I in G means international medical graduate because I work with tons of I.n.g. I in Gs, whatever reason they'll have clinical experience in their home country, whatever bizarre reason they're just very shy to talk about it in an application. No, that is precisely the wrong thing to do. So if you're an international medical graduate, unless you graduated like 10 years ago, what man in that 10 year period, you were resident in your country, you work as an attending at a clinic or a hospital, you worked with ICU patients and all those things, you should absolutely mention that. That very quickly in a sense brings down the hit. It doesn't completely take care of it, but it significantly helps you deal with the hit of having graduated from med school a long time ago.

In that by explaining your experiences, what you've been doing since then, especially when it's clinically related, you're showing people that, oh, wait, yes, I know it was a long time since I graduated from med school, but see, I have all these skills. In fact, make them see that, oh, wait, you're almost like a resident, or you're almost better than a resident. Now, wait, I'm applying into internal medicine, but I graduated from medical 10 years ago, I did residency for three years, where I had to in my home country, where I had to work with patients that had malaria, typhoid fever, my cardio infarctions and all those things. Oh, and since then, I've been working in this government hospital, where I work 24 hour call every three days or whatever by using those specific terms, again, make sure you're telling the truth by discussing your specifics, you're making them see that weight. The only thing is, is this person graduated a long time ago, but the 10 year period between when this person graduated and the present time, this person has not just been burning it sitting at home, playing video games, hanging out on social media, doing nothing. You're literally showing them that, oh, this person actually has pretty strong clinical experience. So maybe they may struggle a bit with getting in tune with the US healthcare system, but that medical knowledge that working with patients that clinical experience, the half. Okay, now what is the next red flag that I'm going to address?

I feel so horrible saying that this is a red flag, but again, it's just the reality of the world we live in. What's this next red flag is having a mental health issue? Please, again, don't believe on me for seeing this. Literally look at what I said. I feel sad saying that this is a red flag, but again, believe it or not, I'm just trying to be realistic and trying to be truthful. Now, here's the thing, if you have a mental health issue or a health issue that does not affect your performance, where you can take your patients very well and no problems, then I don't necessarily see the need for you to disclose. Again, please, you'll mileage me very well with this advice I'm giving. I'm just trying to give honest advice here. So you don't have to disclose. You don't. You don't. It's sad, but it's true. Because again, believe it or not, there's stigma out there for people that have mental health problems or people that have certain health issues. But if it's something that you know that way, this thing truly is affecting my performance is something that's going to impact my ability to care for patients. It is probably something you should mention. It's probably something should be truthful about. It's probably something you should mention. Okay, again, I'm just basically here saying share information that is necessary. Share information that is absolutely necessary.

If you have a mental health disorder that is well managed, you've been stable for years, you've had no issues with help caring for patients and everything, I just don't see the great need for you to mention it. Maybe again, if you feel like you want to mention it, that's fine. But I don't necessarily see the great need for that. I'm trying to be careful here with what I say. Okay, now what's the next thing I want to discuss? The next thing I want to discuss is kind of similar to what I've discussed already. But again, it's a gap in your education. That's another reply. That's pretty common. Gapping your education like, oh, you were in med school, instead of graduating in four years, it took you five years or six years or seven years. Now, those, if it's a small gap like two months or three months, it's not a big deal. Let it go. But if it's a substantive gap, wow, like a year, two years, three years, you need to describe what you were doing during that period. And again, make sure you're describing the productive thing you did during that period. I would hope that that year of you took it off for research or let's see, maybe you had a medical issue that needed attention during that period. So let's say, oh, you had a unfortunately, you know, so many so many questions get cancer that you have cancer or you have cancer. Hopefully you're in remission now and you have to under rookie therapy or you therapy and whatnot. All those things take time, right?

So you need to describe what you did during that period. Well, I took a year off to do a full bright. So I took a year off to get my MBA or whatever you need to explain what you did during that period. A gap over a year or whatever you need to explain, right? Because you don't want people getting the impression that, oh, wow, there's this gap. You didn't explain anything about it. What did you do during that period? You want to make them know what you literally did during that period. That has to be explained in your application. This is one of those things you may not necessarily need to explain in a personal statement. But if I'm not mistaken, I'm pretty sure he has a section where you can elaborate on these ideas. Okay, now what is the next red flag? The next red flag, this probably applies pretty much to international medical graduates. Having no UX clinical experiences, no USC's, no US clinical experiences. So again, I've kind of answered this already. You think it's a kind of similar, but this may be avoided if you have strong international experience. So let's say you've, you've pretty much been doing a lot of healthcare in your home country. That may actually deal with that issue for you. Another thing I'm going to say is again, going to detail, going to detail your level of care, right? Don't just say I worked in a hospital. Hey, did you work with ICU patients? Did you work with patients that have to be an event later?

These are things that will be valuable for like an internal medicine program director to know because you'll be like, oh, wow, this person pretty much was an ICU worker. While they're in their home country, that gives more credibility to your application. That gives more credibility to your application. Although not having US clinical experiences to be honest with you, it probably will not fly for the competitive specialties. Just something to keep in mind for competitive specialties, you probably need to go ahead and get some US clinical experiences. And then what is the next red flag? The next red flag is you've applied on errors before. You've applied multiple times. You've literally applied multiple times, multiple times. So whenever you, if you've had prior applications, you know, the way you address this red flag is this. Number one, this cost of mistakes of the past that you have made. What mistakes did you make? Like what do you feel? Because it demonstrates insight. You want to show them that, okay, my previous application was on successful. You know, I reached out to program directors that I interviewed with and whatnot to ask for some feedback. I reached out to mentors, trust for some feedback. They told me, you know, that my application could use some work in this area and that area in this area and that area. So you want to first highlight, okay, this is why I don't think I this is why I didn't much last year.

And then you need to discuss when you're addressing the red flag. These are the tangible steps I took to fix that problem. These are the tangible steps I took to fix that problem. So I'll just tell you this right now. If between applications between years, you didn't do anything to before your application. You didn't do anything to address some of the concerns on your application. You probably will not match. And you want to be realistic because some people, the reason they didn't match is not like they need to change many things about the application. They just maybe need to change what they're applying into. So be realistic. You have like very poor scores. You have almost no research. And you're still trying to apply to orthopedic surgery. That doesn't make much of any sense. But let's say for example, oh, okay, you applied to ortho last year. What man, you had only like one publication. Okay, let's say you spoke to program directors. They said that man, you're kind of lacking in the research angle. You're kind of lacking here. You're kind of lacking here. And let's see if graduate from med school. And then you're like, oh, okay, I took step three. So you have for a good of 250. And hey, I have these four new publications. I have one in JAMA. I'm just giving examples. You don't have to publish in JAMA to get into residency. But I'm just kind of giving an example.

So in those circumstances, when you do that, you're essentially showing them that, okay, you, you deep tangible things to fix whatever. But if your scores are really low, you applied ortho last year. You were not successful. You had, you have like horrible scores, no research. You know that your application is not competitive for that discipline. It's probably realistic for you to apply to something completely different. It's just a smart way to go about life instead of you going because the more times you go through the errors application process, the lower and lower your, your probabilities of my life. Your probabilities of matching successfully. And another thing I'm going to say is if you're reapplying, make sure that you get like new letters. What least update the letter? You see some people have seen this. I believe I've seen this a great just thing before. You see people they're applying again for another year. And you're using a letter that they use last year. Same date, same everything, no updates. Those letters have lost a lot of their power. So try to update things literally try to update things. Try to update things. Try to update things. So if you use the exact same stuff, it's, it's a very bad look if I'm being completely honest with you. Now, what is the next red flag I'm going to address? The next red flag I'm going to address is having failed coursework. Failed coursework failed coursework. Honestly, if it's like something super minor, let it go.

Oh, I feel this one week class on some like name less subject that no one really cares about. Big deal. Let it go. Let it go. Even if they see it, they probably ask you during your interview, mention it, move along. But if it's something very major like, oh, wow, I had to repeat a rotation. I had multiple course failures. Then you absolutely need to explain. And again, basically follow the mantra I used for, oh, you failed a USML exam. Describe the situation, take responsibility, state, you know, the causes, the reasons. Again, remember, a reason is not necessarily an excuse. Stay your, your, your, your reasons. What did you do to fix it? And then stay your comeback story. Hey, I realized that, well, this is why I failed this rotation. This was my, this is the reason I consulted with a mentor. I got some guidance from a coach. I changed this thing and oh, my goodness. I took this rotation again. And it was a much better experience than the first time. I did much better, got much better evaluations. All my shelf exams course improved dramatically. And these principles have been using them in future rotations. And boom, I have been very successful in that regard. That's a great thing to do. Right. That's a nice comeback story. Now, what is the next thing I want to address the next red flag, the next red flag. This one is a little rare, but it's certainly those come up every now and then. Again, I've done this for many, many years, right?

But it kind of comes up every now and then. And the big thing here is disciplinary actions or issues with a law, disciplinary actions or issues with a law. So if you've had disciplinary actions against you or you know issues with a law, here's what you need to do. You need to come clean. You need to come clean. You need to come clean. You need to come clean. But don't overgrute us. This is not a real term. Something I kind of just made up. But I think it expresses the idea I'm trying to get across here very nicely. Come clean, but don't overgrute us. So you see some people depaint every single gory detail of what they did. No, come on. That's no wise. I'm not seeing you should entertain falsehood. But again, give the information that is necessary to explain what happened and leave it at that. Well, you see some people start opening up this web and this kind of warms that may not necessarily need to be opened up. You can state what you did be completely truthful and not overfinalize yourself. Make yourself look like this person has no hope. This person is a person I should be legit scared about. No, don't present yourself in that light. Don't present yourself in that light. So again, what are you supposed to do here? Explain the situation. Take responsibility. This should be in a separate paragraph. Talk about what you've done since that time. Talk about the lessons from the experience. This goes how you applying those lessons in your current life.

This goes how as you applying those lessons in your current life. It's paying off. In fact, a very high level thing to do here is really to these lessons have learned to you being a resident to be you being a physician like, Oh, wow, I got in this trouble with the law. You know, I've learned the value of patients and you know, I feel like I've been practicing patients. I've been very intention about practicing patients and it's something that's really going to help me as a resident to spend time with patients. Make sure that I get all the information from them. Be very humanistic with them and you know, being patients to also think through things so I don't miss out on things. So I'm a person that is very good from a patient safety perspective. Again, I'm just coming off with off the cuff examples, right? But you're showing them that wow, the lessons I picked up, it just demonstrates insight. When people demonstrate insight, it makes them get looked upon very favorably by a genuine person that is reading through that application. So should I have grown, should I move past that issue? All right. Now what is that next red flag? We're going to wrap this up pretty pretty quickly. So pretty soon. So what is the next red flag? No research. The next red flag is she you have no research, although to be honest with you, this is something that is very preventable, very preventable. Try to not be in this situation if you can. Let me give you a bunch of case reports you have.

That's better than having that section of the application being completely follow, right? So you have no research. So here's the thing. If you have no research, the way you can sort of kind of deal with this problem is one generator, ton of case reports. If you can, case reports are things you can bang out pretty quickly to try to really emphasize your other tangible sides, you know, let's say for example, there is a big initiative that you have championed talk about it, talk about it. That's a smart thing to do. Like for example, say you didn't have research, but man, you were like a big time tutor at your medical school and you held review sessions at your medical school or whatever. Talk about it. That may not be a research, but it shows you that you're a value art person to a program. Or that this is a person that me, you know, teach other residents as they go higher down the line, there'll be a kind of person that will love to do money report, you'll like to teach medical students that may rotate with this program. XYZ, right? So emphasize your other tangible sides, you know, initiatives you've championed and things like that. All right. Now what's the next red flag?

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ouple of examples of

Address it in a separate paragraph within your personal statement; keep it concise and well-edited.

State the problem $\rightarrow$ Take responsibility (reason, not excuse) $\rightarrow$ Detail corrective action taken $\rightarrow$ Show results/comeback story.

It suggests that the issue is systemic or inherent to your ability (e.g., poor standardized test skills), which program directors may extrapolate to residency performance.

Substantive clinical details—don't just say "worked in a hospital"; specify the level of care (e.g., ICU, attending duties).

Clean it up or delete anything that could be construed as offensive or controversial, as this is a major part of the screening process.

They must be updated and reflect current work/achievements; using old, unupdated letters diminishes their power.

Come clean (be truthful), take responsibility, explain the lessons learned, and demonstrate how those lessons are applied in your current life/practice.

Lying, making excuses, or showing a pattern of failure/struggle.

Focus on case reports or championing other tangible initiatives (e.g., tutoring, leading review sessions) to demonstrate intellectual engagement.

A reason involves taking responsibility for your part in the situation (e.g., "I had poor study habits"); an excuse blames external factors or others.

Describe productive, clinically related activities undertaken during that period (e.g., research, full-time work, specialized training).

If the condition does not affect your performance or ability to care for patients, disclosure is generally unnecessary due to stigma.

Come clean (be truthful), take responsibility, explain the lessons learned, and demonstrate how those lessons are applied in your current life/practice.

Lying, making excuses, or showing a pattern of failure/struggle.

Focus on case reports or championing other tangible initiatives (e.g., tutoring, leading review sessions) to demonstrate intellectual engagement.

A reason involves taking responsibility for your part in the situation (e.g., "I had poor study habits"); an excuse blames external factors or others.

Describe productive, clinically related activities undertaken during that period (e.g., research, full-time work, specialized training).

If the condition does not affect your performance or ability to care for patients, disclosure is generally unnecessary due to stigma.