Making the Personal Statement “Truly Personal”: Recommendations From a Qualitative Case Study of Internal Medicine Program and Associate Program Directors

The personal statement is an integral component of a residency application and acts as a narrative that highlights the distinctiveness and character of an applicant. The intention of the narrative is to reveal the professional identity and humanity of an applicant, and can be the most unique element of the residency application.^1,2  Given the paucity of guidance on what to include in the personal statement, it is not surprising that the majority of medical students report anxiety surrounding crafting a personal statement.³ 

The Association of American Medical Colleges (AAMC) provides general guidance regarding the content of the personal statement, including that it should communicate fervor for the medical specialty, address setbacks in training, and serve as a basis for interview questions.⁴  A study of pulmonary and critical care fellowship applications suggested that valuable components for the personal statement are career goals, information not found elsewhere in the application, and inspirational experiences.⁵  Additionally, a review article noted that personal statements should include unique characteristics, information regarding future career and program choice as well as an explanation of any gaps or negative events.⁶  Finally, a study of personal statements in anesthesiology residency applications identified that personal statements should include the proper use of English, while other factors, including career goals, originality, and decision for pursuing anesthesiology, are less important.^5,7  Together, this literature provides some guidance for applicants, but is less than ideal in providing prescriptive goals, particularly as they relate to how statements should be tailored based on one's specialty.

Residency programs are increasingly aiming to perform a holistic review of applicants during the selection process.^8-10  The AAMC defines holistic review as “mission-aligned admissions or selection processes that take into consideration applicants' experiences, attributes, and academic metrics as well as the value an applicant would contribute to learning, practice, and teaching.”⁸  Since the personal statement is a component of the residency application that can be truly individual, and also the only part of the application that communicates to the program director (PD) directly, it seems it could be an integral part of holistic review.^11,12  Despite this, the 2021 National Resident Matching Program (NRMP) PD survey shows that internal medicine, as well as other large specialties such as general surgery, anesthesiology, and emergency medicine, rely heavily on United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores as well as the Medical Student Performance Evaluation (MSPE) when selecting applicants to interview and rank.¹³  As USMLE Step 1 moves to pass/fail and several academic institutions transition to a pass/fail grading system, residency programs will need to rely more on other components of the application, including the personal statement.

Isomorphism refers to the process by which organizations, such as residency programs, model themselves after one another.¹⁴  It's a useful framework for understanding how residency programs, which outwardly aim to distinguish themselves from peer institutions, are quite like each other in their aims and selection processes. As DiMaggio and Powell explain, isomorphism occurs through 3 mechanisms: coercive, mimetic, and normative.¹⁴  Coercive isomorphism occurs when external pressures and “cultural expectations” are exerted on organizations to be a certain way or to engage in or adopt certain values.¹⁴  When ambiguity and uncertainty arise, organizations engage in mimetic isomorphism and look to other organizations for direction on how to behave to legitimize their own processes. Finally, normative isomorphism “stem[s] from the conformity resulting from professionalization.”¹⁵  Lipson,¹⁵  Warikoo,¹⁶  and Price-Johnson¹⁷  use isomorphism to explain why universities, particularly elite ones, have converging policies around admissions as it relates to diversity. Isomorphism illuminates why residency PDs have been keen to incorporate holistic review and personal statements into their admissions process: there are external pressures to build racially diverse classes (coercive isomorphism), the ambiguity around how to consider diversity has spurred programs to imitate their peers (mimetic isomorphism), and the field of medicine is highly concerned with training physicians who adhere to certain standards of professionalism (normative isomorphism). Thus, isomorphism helps us understand why personal statements remain an important part of the application process. Isomorphism may also shed light on how statements are used.

This exploratory study aims to clarify the weight that PDs and associate program directors (APDs) give to personal statements when selecting applicants to interview and rank as well as establish the components that PDs and APDs are looking for when reviewing this part of the application. Gaining a better understanding of how internal medicine PDs and APDs use personal statements, and how this is affected by isomorphism, may provide insightful guidance for residency applicants writing personal statements.

We conducted a qualitative case study utilizing semi-structured phone interviews with PDs and APDs from across the United States. Our PD, who works with PDs and APDs across the nation through the Alliance for Academic Internal Medicine network, identified individuals to interview based on their program's location and characteristics. We purposively sampled institutions to include academic residency programs with diverse geographic locations and sizes. An invitation to participate was sent to PDs and APDs in August 2020. Interviews were conducted between August and October 2020 with PDs and APDs from residency programs representing all 4 AAMC regions: Western (n=3), Central (n=2), Northeast (n=3), and Southern (n=5). Participation was voluntary and informed consent was obtained. Participants did not receive any compensation.

All semi-structured phone interviews were conducted by an internal medicine resident investigator (M.M.). Phone interview questions were developed by expert opinion of the PD, 2 APDs, and an education PhD with expertise in qualitative design. Questions focused on what content should be included in a personal statement and how PDs and APDs use personal statements in their selection of applicants to interview and rank. In addition to seeing what PDs and APDs said, we were interested in the extent to which their answers converged, because convergence would indicate isomorphism at work. The complete protocol is available as online supplementary data. The investigator with an education PhD (C.J.C.) trained the resident investigator (M.M.) in how to conduct a semi-structured phone interview.¹⁸ 

After the initial 4 interviews were completed, 3 authors (M.M., C.J.C., K.L.) met to review the interview questions and interview transcripts. It was noted at this time that the PDs and APDs who were initially interviewed made frequent comments about the “fit” of an applicant, however, did not specify what fit meant. Thinking this was an opportunity to further explore the role of isomorphism in the residency selection process, the resident investigator (M.M.) made a point to ask a more probing question regarding fit in the following 9 interviews if the PDs or APDs being interviewed used that term.

We audio-recorded interview data using the Rev Call Recorder phone application (Rev.com Inc, San Francisco, CA), which was then transcribed by the same service. We used Dedoose Version 7.0.23 to engage in content analysis of the data.^19,20  Three authors (M.M., K.L., C.J.C.) independently and inductively coded 4 transcripts, compared results, and came to consensus on initial codes and categories in order to develop a codebook. Two authors (M.M., C.J.C.) then used the codebook to independently code all 13 transcripts so that each transcript was coded twice, with the understanding that new codes could be added to the codebook and that coding would take place until thematic saturation was achieved.¹⁸  Following individual coding, they met to discuss any new codes that they had created, how to further refine codes and categories by collapsing and reorganizing codes, and to resolve any discrepancies in coding. After making additional revisions to the codebook based on these discussions, one author (C.J.C.) reviewed transcripts a final time to ensure that data were thoroughly described by the codes in the final codebook.¹⁸ 

Our researcher positionalities are relevant to the study because they influence the perspectives we bring to our work. Having multiple coders (M.M., an internal medicine resident, and C.J.C., an educational researcher), each of whom has a different relationship with the data and the internal medicine context and culture, was important in exploring multiple interpretations of the data. M.M. and C.J.C. also engaged in peer debriefing with K.L., an APD and clerkship director, to gain an additional perspective. Writing memos also helped us keep an audit trail of our codes and coding process.²¹ 

The Institutional Review Board at the University of Utah School of Medicine deemed this study exempt.

Findings were organized into 4 broad themes: (1) how personal statements are used by PDs and APDs; (2) what personal statements should include; (3) what personal statements should not include; and (4) elements that PDs and APDs disagreed on. In the following paragraphs, we describe each theme and provide exemplary quotes. We use the term participants and PD/APD interchangeably.

Participants reported that personal statements were used during the pre-interview and post-interview processes and to form a gestalt impression of applicants, as shown in Box 1. Participants identified using the personal statement most often in the pre-interview process to prepare for the interview day. In addition, many participants reported using the personal statement in some way to screen and select applicants for interviews. Following the interview, some participants identified using the statement in the ranking process to distinguish between 2 applicants or to move an applicant from one grouping on the rank list to another. Finally, participants identified using the personal statement to form an overall impression of applicants, as it is an opportunity to gather information not available in other areas of the application and to assess an applicant's fit for a program.

Participants reported that statements should be well-written, include information that makes an applicant stand out, and include data that shows how the applicant's interests match those of the program, as shown in Box 2. They noted that statements should be easily readable and interesting. In addition, several participants stressed the importance of the personal statement in highlighting an applicant's unique characteristics and experiences. Finally, many participants commented that applicants should use the personal statement as an opportunity to convey their fit for a program.

According to PDs and APDs, personal statements that are poorly written, indicate a lack of or superficial interest in the program, and demonstrate an applicant's poor character reflect negatively on the applicant, as shown in Box 3. Participants reported many things about the statement that would make for a poor impression, including the length, poor grammar, generic format, and cliché analogies. In addition, participants noted that personal statements that fail to convey interest in the program, such as when statements convey interest in another specialty if an applicant is dual applying or mention a program's name as a way to “name drop,” are viewed poorly. Finally, participants reported that personal statements that revealed an applicant's character flaws gave them “pause in wanting to interview an applicant.” These include statements that demonstrate a lack of professionalism or include elitist statements or overconfidence in one's achievements.

There were 3 topics that participants did not agree on, including future plans, a patient story, and explanation of interest in internal medicine, as shown in Box 4. Some PDs and APDs felt including information about future plans was important while others thought providing career goals was unnecessary. In addition, there were differing opinions about whether or not a patient story should be included, although most identified that if students were going to include a story, it should capture something personal about them (eg, how the interaction affected their decision to pursue internal medicine or made them feel differently about patients). Finally, while some participants wanted to hear about an applicant's interest in internal medicine, others found this to be less useful.

To our knowledge, this is the first study to explore academic internal medicine PDs and APDs recommendations for personal statement content. PDs and APDs used personal statements to distinguish between applicants with otherwise equivalent applications and help form an impression of the applicant. We identified 3 themes that participants thought were important for an effective personal statement—that it be well-written, include personal or unique information to make the applicant stand out, and demonstrate fit with a residency program. Participants also recommended avoiding poorly written or excessively long statements, inappropriately signaling interest in another program, or highlighting negative characteristics. Elements where there was a conflicting opinion—patient stories, future plans, and interest in internal medicine—hint at potential common pitfalls of the personal statement.

In our study, PDs and APDs identified that personal statements should highlight unique personal characteristics of the applicant. While applicants invest significant time and effort into personal statements, prior literature suggests personal statements often lack originality and uniqueness in favor of a more formulaic structure.⁷  Perhaps a lack of originality stems from little guidance from residency programs to date stating what is important to include in the personal statement. It is also possible that applicants are unknowingly influenced by mimetic isomorphism. In wanting to write a statement that will be deemed acceptable, all applicants are using the only available guidelines, which means that statements end up being like each other. With an overall lack of specialty-specific guidance, applicants rely on general guidelines from the AAMC and expert opinion.^4,6  Future work should focus on creating specialty-specific guidelines for the content and structure of the personal statement to improve its utility in the residency application.

Several PDs and APDs reported using the personal statement to gauge applicants' fit for their residency program. We found that most commonly, participants referred to how an applicant's individual attributes, interests, and goals aligned with that of the residency program. This use suggests that the PD and APD definition of fit may be contributing to the holistic review of the applicant and supports the idea that isomorphism plays a role in residency application review. Holistic review relies on assessing an applicant's unique experiences with the intent to recruit a diverse group of residents (coercive isomorphism). For example, the implementation of holistic review in an emergency medicine screening application process, which placed more emphasis on applicants' attributes, resulted in increased recruitment of underrepresented in medicine applicants.²²  In contrast, fit often hinges on recruiting applicants who possess similar characteristics to the program (normative isomorphism). This practice may be helpful in some situations (eg, applicant demonstrates a personality that aligns with the institution's culture), but it also can promote unconscious bias and threaten diversity.²³ 

Humans all possess unconscious biases that may negatively influence our view of interviewees who are dissimilar to us. A gestalt impression may result in only selecting applicants for interviews or ranking who appear similar to the interviewer (eg, race, sexual orientation). Further, at a program level, evaluation of an applicant by gestalt impression with a focus on fit may promote “cultural homogeneity”²³  and normative isomorphism where the eventual matched residents reinforce areas that their institutions have historically valued. To address homogeneity and unconscious bias, residency programs could employ the principles of personnel psychology to align fit with a more holistic review of applicants.²⁴  Within personnel psychology, fit is expanded to include person-job fit (ie, knowledge, skills), person-workgroup fit (ie, interpersonal attributes, group performance), and person-organization fit (ie, values, goals).²⁵  Person-job fit may include an applicant's cognitive ability as measured by standardized examination and clinical performance. Person-workgroup fit may include tests of integrity (eg, personality assessments, situational judgement tests) during the interview process. Finally, person-organization fit may include assessing if a resident's values align with that of the institution. As hinted at by the participants in our study, personal statements may be an important element to assess person-organization fit addressing personal values and goals.

Residency programs may improve assessment of this domain by identifying their core values, placing them within an overall brand, and sharing transparently with applicants so they can be addressed by the applicant. The addition of the supplemental Electronic Residency Application Service (ERAS) application for internal medicine, general surgery, and dermatology could provide a structured way for applicants to reference signal programs that have similar values and to highlight their most meaningful past experiences that demonstrate their values. It is possible that as the supplemental ERAS application is more widely used across specialties, the guidance provided to applicants regarding content to include in the personal statement may evolve. Future work should focus on how residency programs may be able to utilize the personal statement and supplemental ERAS application to assess person-organization fit.

There were conflicting opinions about the inclusion of career goals, use of a patient story, and explanation of the decision to pursue internal medicine. Career goals and patient stories are common themes of internal medicine personal statements.^1,2  Interestingly, the conflict highlighted in our interviews hints at how to personalize content. PDs and APDs seemed to support the inclusion of these topics when they were used to emphasize a personal quality of the applicant (eg, use of a patient story to explain “how it made them think differently about patients, or feel, or learn something”). Comparably, pulmonary and critical care fellowship PDs found that quotes and stories without explanation of impact on the applicant were viewed negatively in review of applications.⁵  While themes of the personal statement may vary, the overarching recommendation for the personal statement is that it is personal and, ideally, sparks the program's interest to meet and learn more about the applicant.

Finally, we found that internal medicine PDs and APDs most often use the personal statement in preparation for the interview, which is similar to findings from other specialties.⁷  In addition, programs identified using the personal statement in the pre-interview and post-interview processes to either extend an interview invite or move an applicant up or down the rank list if the applicant was otherwise equivalent to another applicant on the list. In the 2021 NRMP PD survey, 73% of internal medicine PDs reported using the personal statement in selecting applicants to interview with a mean importance of 3.6, which is well below that of USMLE Step scores, MSPE, clerkship performance, and class ranking.¹²  The survey results are similar for other large specialties including general surgery, anesthesiology, and emergency medicine.¹³  This is likely due to the poor interrater reliability of personal statements,²⁶  which likely precludes their use in the decision to interview and rank applicants the majority of the time.¹²  Yet, the PDs and APDs in our study converged on many criteria—how they used the personal statement to what they wanted to see to what they did not want to see in a personal statement—indicating that residency programs are more similar to each other than they think, which suggests that mimetic and normative isomorphism are at work. Additional research with PDs and APDs in other specialties about the use of personal statements could further shed light on the role of isomorphism in the residency review and selection process.

The main limitation of our exploratory study is the focus on sampling academic PDs and APDs in a single specialty. While participants were questioned about their use and recommendations for personal statements, some internal medicine programs may use personal statements in ways not represented by this data. Given the sample program characteristics, recommendations from this group may be less applicable to applicants applying to community-based programs, to smaller programs (<30 residents per year), and to other specialties. However, the sample covers all geographic regions as defined by the AAMC and represents residency programs with intern class sizes ranging from 33 to 64. Additionally, as with all qualitative work, our identities and experience influence our interpretations of the data. We have done our best to ensure trustworthiness by including multiple coders who bring differing perspectives to ensure multiple interpretations of the data, engagment in peer debriefing, and keeping a written audit trail.

Our study found that the personal statement can be a valuable part of the internal medicine residency application when it includes unique attributes, is well-written, and demonstrates a fit with program values. Additionally, PDs and APDs noted that when applicants highlight their unique characteristics, it can help distinguish themselves from otherwise equal applicants.