Improving the Residency Application Process – Dr. Jason Reminick, Founder and CEO of Thalamus

Dr. Rishi Desai: Hi, I'm Rishi Desai. About 50,000 medical students apply for residency programs each year, and each student applies to dozens of schools and gets scheduled for multiple interviews. In other words, this is a big, complicated process. That's where Thalamus enters the picture—a leading platform that applicants and programs use to manage their interview process. Dr. Jason Reminick, its founder and CEO, is with us today to talk about how all this works, how the recruitment process has been impacted by Covid, and what the future holds. Thank you so much for being with us today.

Dr. Jason Reminick: Thank you for having me.

Dr. Rishi Desai: I'd love to start out by learning a little bit more about you and what got you interested in medicine, and in particular, pediatric anesthesiology.

Dr. Jason Reminick: That's a great question. I wanted to be a doctor since I was 12. Fortunately, or unfortunately, I had some relatives who had some health issues when I was younger, but I just really found myself drawn to medicine. I had my own interesting health issues along the way, and really just started to love pediatrics. 

I found my way into medical school and there, my two key advisors in medical school… One of which is my co-founder for Thalamus, her name is Dr. Suzy Karen, she's an anesthesiologist. Her husband happens to be a pediatrician, and they always joke that they both guided me into pediatric anesthesiology. 

But no, I really found my way through med school, trying out all the various specialties. I thought I wanted to be an internal medicine cardiologist to start and that kind of went out first day of third year very quickly. And then I really loved my peds clerkship, and loved anesthesia. Then I found out I could put it together, and then really started developing a clinical interest in pediatric chronic pain, given how underserved the community is, and just how many interesting medical conditions come out: Chronic regional pain syndrome, etc. I really found my niche there. That's where my clinical interests have always lied.

Dr. Rishi Desai: You obviously went through this process that we just talked through about applying and finding your right program. What was it about that process that made you decide to start Thalamus? What problem were you trying to solve?

Dr. Jason Reminick: I lived the problem firsthand, as did my co-founder on the program side. When I was applying a residency in 2012, I got stuck in New York City during Hurricane Sandy and several of my interviews were cancelled, many of which required a lot of rescheduling and some were never rescheduled. I just still remember that next week, being out at a program on Long Island, and one of the candidates paid $600 for a cab before the days of Uber to this program because they couldn't reschedule them. He paid $600 because his car had literally floated away in the storm. I just remember the anxiety and everyone going through this process and the challenges and scheduling. And similarly on the program side, it's a big headache, it's anxiety-ridden, it's costly, and so we wanted to make it easier for all stakeholders, both applicants and programs.

Dr. Rishi Desai: Walk us through it. How does it work exactly, and if you come into Thalamus, like, what is that experience like for applicants? And also from the program side: What is that that they see now which didn't really exist before?

Dr. Jason Reminick: In terms of the way the product’s used, it's probably easiest to start on the program side. It integrates with the common application systems that everyone's using, and other application systems for fellowships as well. The programs can pull the applicant data over in various ways and invite the candidates to interview. They can also use various algorithms we have to invite certain candidates to certain days given the complexities of scheduling.

The applicants, then once they're invited get a link to create a profile that takes less than 10 seconds. And once they do that, that's their Thalamus account. And then they have a calendar link to that account that shows them any program that invites them in Thalamus in real time. For the applicants, they can see any program that invites them through Thalamus, just on one centralized calendar, so they can compare when they're going to different interview days, across the country, focus on particular regions, etc. And then they can sign up in real-time, kind of like Open Table, but instead of booking a restaurant, they're booking your residency interview.

Back on the program side, it allows them to score candidates, write notes, and eventually build their rank lists for the match. Then with Covid, we added several virtual interview capabilities. We integrate with Zoom Teams and WebEx. We also have our own homegrown video interviewing solution. We have an itinerary builder that builds schedules and itineraries for applicants and programs and saves a ton of time there. And we have various tools to help with holistic review for programs as well. That's Thalamus as it exists today.

Dr. Rishi Desai: It's interesting you liken it to Open Table. And that often happens when people say, There's this complex process. We've created a solution. And you can either talk through it or you say, hey there's this analog that will help you quickly get it, right?

Dr. Jason Reminick: Yeah.

Dr. Rishi Desai: What is your sense of expectations now? People, when booking a restaurant, expect that process to be easy. When people go in to do residency match, they expect it to be hard and now you're telling them, "No, it doesn't have to be that hard." How people responded to that change in expectations?

Dr. Jason Reminick: I think overall they've responded very well, but expectations definitely have changed. When I interviewed and scheduled interviews, you had to do everything by phone, and you had to race to your email to write a very professional email back quickly, trying to secure your top three choices for dates. And then two weeks later, you would get an email back saying, "Sorry, those dates were filled. Please pick three more." 

There was less transparency then. Now with the interview scheduling, when someone jumps on that software and they see spots are available or spots aren't available, that just leads to more anxiety and frustration. And I think over time, with medical students being as Type-A as we all are in medical school, and certainly understandably, there's been a race to acquire and secure more spots. And this race has existed even prior to this, but I think it just become more transparent, and I think it's fueled this continued race to these spots. We are consistently trying to figure out ways to slow that down. 

We have met with many specialty organizations and think that a tiered approach to invites— based on the data we've looked at—actually slows down the invites, and results in applicants getting better spots that they more strongly prefer. But really yes, how do you design that experience for the applicants, now being more reliant on their phones and mobile and just being busy on clinical rotations and otherwise, and really design that nice user experience so that we can make it as pleasant as possible for a process that overall has not been... No one would rank it on ‘the most pleasant things they do’ list for sure.

Dr. Rishi Desai: Also on that list is Covid, and you know with Covid, you had a lot less in person interviewing. And now things are winding down in many parts of the country. How has that affected the interview process? Like what are you noticing about how people are conducting interviews at this point?

Dr. Jason Reminick: Yeah. It's a great question and really as GME did with the rest of the healthcare system, adapted very, very quickly to the new normal, and everyone shifted from a historically, very sacred in-person interview to virtual very quickly. Programs were finding out new ways to do this. How do they run their recruitment season? How they get their faculty bought into this new virtual recruitment? And course everyone had to do it because there was no way to travel around the country. 

Programs had done a lot to take their online day and make it virtual. Meet and greets, open houses, even with tours. I know several programs were sticking GoPros on their resident's heads, and having them walk around the hospital—a-day-in-the-life kind of videos, working with their marketing departments. And I think the key for the programs was trying to figure out, how do we recruit applicants to our hospital without them ever stepping foot in the building? And then similar for the applicants: How do I learn where I'm going to spend—depending on what specialty you go into—the next three to seven years of my life in a place that I haven't stepped foot in?

I think, on the whole, everyone adapted quite well. The match outcomes really didn't change. We saw on the whole more applicants interviewing at more programs and more programs completing more interviews than they had in years past. But I think the big key piece that everyone saw was that it really helps in terms of diversity, equity and inclusivity in this process, just from the cost savings alone to both applicants and programs. 

I think where we head in the future is still up for discussion, but at least from a cost perspective, it was much better. Really, the only thing you can't replicate right now online is being in the hospital. But the question is, how much does that necessarily affect people's decisions? And I think that's what we figure out going forward.

Dr. Rishi Desai: Do you have any personal experience that stands out for you? When you think about your own journey through all of this? Maybe a moment where you're like, "Oh gosh, I can't believe that this is the way it is."

Dr. Jason Reminick: Yeah. I think it's every step of the process, really. I just remember going into medicine. My parents who were not in medicine, kept asking like, "This is the process? Who would want to do this?" Really that first moment of just, someone's car had floated away and couldn't get their interview rescheduled, really stood with me. I know there's been a lot of applicants who have had family members involved to help them manage this process, or surrogates watching their calendars and I think those create other challenges also. And then similarly, in some of the ways a lot of programs interview, they're interviewing a lot of candidates very, very quickly, and you just take a step back and you go, how does one truly assess a medical student if an interview is, in some cases only 10 or 15 minutes long? I think those are some of the challenges that still persist.

Dr. Rishi Desai: And you've called on programs implement more holistic reviews of applications. Do you mind walking us through what that means and what response you've gotten?

Dr. Jason Reminick: Yeah, I think overall it's a bigger push throughout all of GME which I'm excited about. But historically, a lot of decisions were made via filtering mostly on Step 1 scores, sometimes Step 2, or strength of medical school and such. And a lot of programs, in a way to try and manage the hundreds to thousands of applications they receive, get them down to a more reviewable group. And all of the data has shown that Step 1 is not a great predictor of who's going to succeed in residency or succeed in medicine. And Step 1 just went pass-fail. Now the question is, what happens with Step 2 and beyond.

But really, I think holistic review is looking at every part of an applicant. We had a forum recently looking at recruitment in GME. And one of the really interesting topics that came up was this idea of distance travelled and resiliency. And that means different things for different programs and different applicants of course. But kind of, look at the information in the application, figure out what you need. Find that data quickly. Some of the tools we have built-in in our software help with that. But that allows and frees up the program directors and the program leadership to really look between the lines of the application. Who is this person? What are they going to be like on call at 2 o'clock in the morning or when a resident calls out sick or something else, or Covid hits? What is that going to look like for our program? 

I think more and more programs and specialties are making a commitment to that as well. And in the long run that definitely helps medicine, not only in helping place people in the right residency programs, but even further down the line to affecting patient care and ensuring that the right doctors are in the right places within this country.

Dr. Rishi Desai: That makes sense. And it brings up a question I'm always curious about: How does this translate to other countries? Like what do you have in terms of footprint in other places and is this process very different or similar around the world?

Dr. Jason Reminick: Yeah. We definitely have a unique process in the United States. Canada, for instance, is not as competitive. They tend to get more together in regional places. It just doesn't have the same challenges that exist here. We have actually found similar processes outside of medicine within the United States—law being one of them. And we have worked with some law firms to recruit students out of law school. It's a nearly identical process. There is no match and the firms usually pay for all of the costs versus the applicants in medicine. And similarly, dentistry, pharmacy, other health professions too, and we work with some customers on that side as well.

Dr. Rishi Desai: I guess, one thing that, of course, comes up a lot is students, they go through this process are always wondering: That's an interesting thing that you've done as an entrepreneur. Starting a business is very different from the normal pathway. What advice do you have for folks that may be interested in starting a company or a business? And how did you get started? What mentors did you have along the way?

Dr. Jason Reminick: It's a topic I am really passionate about. I think physicians should really be involved in innovation. Obviously I'm preaching a little to the choir here as well given who I'm talking to. But I do think there's a real benefit. Physicians starting from the time you're in medical school, or even before that, and going forward into residency and fellowship and beyond: We have such a unique perspective and skillset that can be transferable to so many different and unique ideas that really we only see, right? 

Like, I don't start Thalamus if I don't apply to residency and get stuck in New York City during Hurricane Sandy. And no one else is coming in who's not a physician probably to fix this process in one way or another, or one of the organizations that's part of this process. It's really about finding your passion and then finding those mentors. I have been lucky in that my mentor in medical school co-founded this organization with me. But along the way we found other positions who are entrepreneurially-minded to provide guidance and feedback and I took a more unique path in that I'm not practicing clinically right now. I made the decision to step away from clinical practice. It's something I'm really passionate about and a problem that I think really affects health care. Figuring out what is that transition look like? And what does that future look like? It's a decision that I weighed very heavily, but one I have really never looked back on. And I know I made the right choice.

Dr. Rishi Desai: When you get that question from students, do you feel like a lot of them have mentors in place, or do you think that mentorship in general is still lacking in 2022? That entrepreneurial mentorship?

Dr. Jason Reminick: I do think it's still lacking to an extent. There's a long-established belief in medicine that to be a great doctor, you have to be 100% committed clinically, and I think that is the right mindset for some people. And for others, there's more of a balance and I think there's a lot that can be implemented in terms of medicine and how you lead your career that may not be 100% clinical. 

Medicine had gotten to a point where it's at least accepted that if you're developing a pharmaceutical, or a medical device, or doing bench research, that's an alternative path that one can take. And still a little bit more to the one extreme of the bell curve is this idea of starting a company or starting a product or building an idea and innovation. And I think it's supported in certain areas and certain geographies and certain groups. But on the whole, I'd love to see it become more mainstream because, yeah, I talked to a lot of medical schools and a lot of medical students. I just talked to a group of medical students in a curriculum they have for innovation and gave a lecture there, and a lot of them just really wanted advice as to how they could find resources to grow ideas or who do they turn to or who can they discuss it with as they continue their medical career, whether or not they want to be fully devoted to being a clinical physician. Or because they want to devote their life to clinical medicine, how do they create something then pass it off to someone? 

I think there are a lot of different permutations depending on the individual. But yeah, the more help we can provide medical students and others, residents, fellows, in learning how to do this, I think the better off health care in the country and in the world will be.

Dr. Rishi Desai: We are a teaching company. We love to fill knowledge gaps. Is there any topic that you'd like to educate us on, you think everyone ought to know at this point?

Dr. Jason Reminick: Yeah, I think there's a really big topic going on in this GME recruitment process right now that a lot of people are mentioning called interview hoarding. The concern is that the majority of the interviews are going to candidates who have sort of the top recruitment statistics, considered the most sought-after applicants via whatever metric you want to measure that. It has caused a lot of anxiety throughout the process, and for applicants in general, and concerns people matching, and not matching. 
 

We've looked into this really heavily. We don't love interview hoarding as a term in the sense that it does create this idea of people gathering all of these interviews and keeping them away from others. We've taken a lot of steps on the data side to dive into the data of the interview process. We looked across every single specialty. We've looked across various recruitment seasons, pre-Covid, post-Covid, in-person virtual etc. And we have never been able to find any evidence, at least in the way that it seems to be generally defined, that a small percentage of applicants—say the top 5, top 10% of applicants—have the majority of interviews. I know there's been some research done looking at sort of a top percentage of candidates having a certain percentage of interviews, but that's more just the way the math works out in terms of the distribution.

Every curve we've ever looked at is, as the numbers get very high, the proportion of any applicant pool that has that mix of interviews is very low. Of course, we only have a certain percentage of the overall recruitment market at this time, but it's a large enough percentage that we feel our sample is very representative. And what it shows is that now, the small minority of candidates do not have the majority of interviews. There are candidates of course who are interviewing at 30, 40, 50 places, but that is a very small percentage. 

For the applicants, I know that you see on social media or otherwise that certain candidates have a large number of interviews. I would encourage everyone to try and know that, yes, there are people who interview at many, many places, but at the same time, the majority of the market is not that way. And taking it a step further, we have actually done some research looking at the amount of over interviewing that actually happens, and we know that in primary care and other specialties, you can cut out 15, 20, up to about 35% of interviews, and final match lists would still say exactly as they are. 

I know this process is very high stakes. I know everyone is looking to optimize the amount of interviews that they have. There is a lot of interviews right now, and they aren't being hoarded. Rather, I think the bigger problem is that there's a transparency issue for the programs, given the amount of applications that are out there, trying to figure out who's coming to their program. We’re working on tools to help with that too. But it's definitely not an interview hoarding problem. There's a lot of applications, which are kind of watering down who's going to end up where, and making it difficult for both programs and applicants to signal as to where they want to be, and who they want.

Dr. Rishi Desai: That's remarkable. I think that that makes a lot of sense and especially messaging about that, because I've heard that phrase and misinterpret that phrase myself, so that's great that you share that. Well maybe that's a good place to kind of catch your last bit of advice. We have a lot of folks that are listening, interested in your journey. What advice do you have for healthcare practitioners that are going through this process or maybe have just signed up and may be going through this process down the road?

Dr. Jason Reminick: Yeah. I think it was good advice that I got very early on in medical school. It was take everything one day at a time and then try not to buy into others anxiety. Find your own path. Curriculums are very structured, residency programs and accreditation processes are very structured. You're going to get a good clinical education wherever you want to go. 

It's just a matter of: Who do you want to be as a clinician? Who do you want to be as a person? and finding that path that's right for you. I found that that advice has worked every step of the way throughout medicine for me. And now, even in running Thalamus, and I would pass that off to really any learner looking to get into this space at whatever level they're at.

Dr. Rishi Desai: Awesome, that makes a lot of sense. I think that's a great spot to end this interview. I appreciate you taking the time to join us today. Dr. Reminick.

Dr. Jason Reminick: Thank you for having me.

Dr. Rishi Desai: I'm Rishi Desai. Thanks for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together.