Medicine From The Trenches

Experiences from medical school and residency.

Conferences and Practice…


If you practice medicine/surgery, you will undoubtedly attend a conference or two during the year. Some of them are gigantic like the American College of Surgeons which draw thousands of surgeons from around the country and some are a bit smaller but are,nevertheless great opportunities for learning, even perhaps widening one’s frame of reference. It’s always good to attend conferences at every level of your training from medical student to resident to attending physician. A good conference reinforces what you are reading in the literature and allows networking/exchange of ideas. Once in awhile, one can attend a conference (I did just this week) where one hears something that profoundly changes the way that one views aspects of one’s practice.

This Week’s Conference

First of all, the person who gave this amazing lecture is a genuine “rock star” of the highest magnitude in medicine. His talk was placed right before lunch (the conference had started at 7:15AM so you know he had to be good to fill that space) when most of us were contemplating just being able to get up and walk around ( opposite of food coma). The first thing that he asked us to do was drop the “compartmentalization” of our lives and integrate our roles as members of our communities (parent, neighbor, coach etc). Now why would someone of this caliber start right off asking his audience to “feel and not think about too much” “to let our professional guard down for a second” rather than absorb profound knowledge that no doubt, this eminent speaker could easily impart?

The Message

When we do what we do in medicine/surgery, sometimes there are not good outcomes. Sometimes we have to deal with families and by extension, communities that are suffering profound loss (losses). We are all very familiar with the tragedies that seem to be in the news more often these days. Some are so profound that they can be described by one word, such as 9-11 or a location such as Newtown, CT. “To get up and give a lecture on sad topics isn’t so much fun… but it’s such an important part of what we do”.

He encouraged us to think about the effects of the injury of a child on the child’s family and the effects of taking care of injured children (or adults for that matter) on our team. Often we do our jobs and put our feelings somewhere so that we can get those jobs done. Later on, those feelings, especially when little ones are involved, can well up and overwhelm us in ways that we might not be even aware of. He spoke of us being mindful of those in the family that might be left, our colleagues who have shared the job of caring and the community that might be feeling the loss (schoolmates, teachers and others). ” One child is injured, there are a lot of challenges for that child but the ripple of challenges begins to spread to other children who may have been involved in that event or near that event; to the parents and siblings of that injured child; to the community, their friends, their teachers,  their coaches, their clergy.” He also mentioned “ripple of challenges” can extend to the people who rescued and cared for that child. The effects can be profound even for the trauma surgeon.

While we, as surgeons, can move onto the next patient or the next challenge, often these families/communities have deep and long lasting effects. We have to be aware of those effects both in ourselves, in our colleagues and in our communities. He spoke of Post Traumatic Stress Syndrome which even though we might put our brains in a place to deal with the present, the cumulative effects of all things that happen to us can come back if we don’t acknowledge our feelings (ah,that word that we as surgeons don’t like much).

Honestly, I have never head anyone verbalize what this man spoke about. No psychiatrist could have imparted the message that was imparted, yet it came from a surgeon of all professions. I don’t think that many of the psychiatrists actually “get it” but I actually received validation that when I walk over to a younger colleague who has just finished dealing with an emotional outcome that is tragic and ask, “What are you feeling right now?” “Tell me and don’t try to explain it but just tell me your actual thoughts”, that I can no longer say, “Go home and decompress because for human beings, decompression may not be possible. This is a message that anyone who anticipates a career in medicine (or even the allied health care professions) needs to be very aware of. I have always been aware of how deeply my patients can affect my life/thinking but I always put that awareness in a place where I could think about it at some later time- often in my meditations or when I am out running.

Bottom Line for Me

I will now play even closer attention to my feelings and the feelings of my students, co-workers and colleagues in these situations. I will also pay closer attention to the families and to the communities. Events happen in our community and as physicians, we are often thrust into the heart of raw emotion. We have to speak about our feelings and not be ashamed that something touches us so deeply that we are brought to tears. Even better, we have to connect with the folks on our team and with those who surround the patients that we treat. When I walk into a family room, I now see everyone in that room and not try to “get out” as soon as possible. I look at the families, the siblings and friends of my patients, young and old, to try to get a sense of where they are. I will also try to keep a little closer watch on where they might be going. I am a teacher but even greater, I have been given the gift and trust of the ones who love the patients that are placed in my hands. I can’t compartmentalize anymore and somehow, I don’t think I should.

17 October, 2014 Posted by | medical school | , , | 1 Comment

Achieving a balance


As I write this, my career has been shifted into a higher level of comfort. I have spend the years since graduation from medical school and residency honing my surgical skills and the craft of taking care of patients. If anything has suffered in the task to become the best physician that I can possibly be, it has been my personal life. In short, it became easy to head off to the hospital or university rather than deal with things in my life that just were not working. Well, working in medicine has a way of making one reflect on what is truly important and making one move past things that are not a good fit for life.  I had decided after ending a relationship that had somewhat sustained me through medical school and residency, that I would throw myself into my work with vigor and a quest for self-discovery.

Make a definition of your “complete” life

I always knew that I was a person who saw the miraculous in all of medicine and humankind. I am just an instrument for our creator does the actual healing. You can call the creator anything that you like, God, Mohammed, the Great Spirit but positivity and balance have a way of forcing one to move along on a plane that is stable. One gets used to “death” as part of “life” and one can sometimes feel how to be aligned with the universe in one aspect of life but “going through the motions” in another aspect of life. So it was with me and I attempted to fill in my “gaps” and “blanks” with interests, flying, sailing and so forth. Being above the earth or on the ocean/lake can allow one to exhale and just marvel at how wonderful the world is at times.

I also knew that I wanted to share the miracles of my life with another soul; as a human we all reach out for intimacy in some form. We can have a close friend or we can have a significant relationship (marriage) that allows us to find that person who can help us complete our mission in life. At times, I believed that I needed to work on myself and put all parts of my life in compartments so that I could achieve a close bond with another human that doesn’t mind that I sleep on my abdomen hugging a pillow and look like a “street urchin” in the morning after my nightly pillow fight; that my phone frequently rings all night if I am on home call; or that I might be away for 30 hours straight taking in house call. These are the realities of being in a relationship with most physicians and certainly with a surgeon. I can also add the time that I must spend in reading and study to keep up with my craft. In short, any person who is involved with a physician needs to see that they won’t have 100% of our attention all the time but when we are “with” you, we are 100% committed and need you like we need oxygen, food and water to live.

My definition of my complete life was to meet and find a person who could be my friend first and perhaps more later. The inhumanity that is sometimes represented in my trauma bay can color how I look at relationships between humans. Domestic violence is very difficult to deal with but deal with it, I must and I must have a place in my mind that allows me to give my best treatment to the victims and sometimes to the perpetrator too. I am not the judge but only an instrument to an end point – getting that person back to health and solving health problems. My complete life has to allow me to find that person who can allow me to complete my “mission” on Earth and I complete them.

What I tell myself…

I had told myself that my life could be complete and satisfying with a job well-done. I would enjoy “discovering new truths” in my research and writings. I would enjoy hearing the successes of my students and colleagues. I would have a rich and satisfying career giving back with my skills and teaching. Yes, my life was indeed full but not complete. I didn’t have that intimate relationship that adds the depth and richness that just needs to be there. And so I was going through my career, happily enjoying my friends, colleagues and adventures in surgery, medicine, flying and sailing.

No, one can’t plan everything…

I was happily moving along with the things that occupy my time. I decided to do some exploration in trying to reach out and expand my circle of friends. It’s good to be a trailblazer in some aspects of one’s life. I have always challenged myself to take some risk with something at various times. I took a risk and was happily enjoying the experience when a man reached out to me in a most unexpected manner. There was something in the things that he shared so readily with me. He knew that I was a physician/surgeon yet he said that he saw something that drew him to me. At first, my scientific training kicked in and I attempted to define what was going on here; I ran in the opposite direction. Well, there is no definition but only that one has to have the courage and sometimes the faith to know that your instincts are correct (much the same as how I treat a critical patient). In short, life does not always come with clear directions. I have been in uncharted “exploration” the past few weeks and it’s been both exhilarating and unnerving at the same time.  Here I am in a relationship that I can’t plan or define and suddenly my life that I thought was so full, seems empty before I was able to get to this point.

Why this is so vitally important…

In order to give our best to our patients and colleagues, we have to give our best to ourselves. My best now includes a very brilliant environmental engineer (he can’t stand the sight of blood) who inspires me to reach higher and further in all aspects of life. Suddenly the things that gave me immense satisfaction go beyond that and give me immense joy at the same time. I smile and laugh with my patients, my students and my colleagues. In short, he has made me a better and more fulfilled person. The only downside has been that my favorite OR music has moved from my signature “thrash metal” to a bit more “smooth jazz”. For those who work with me, that’s a huge change but they secretly like the music change. I am not playing as much Pantera or Goatwhore in the background.

As you move through your university work and your preparation for medical practice, one has to have the best of humanity brought out from within themselves. To be able to give my heart, a myocyte at a time to this environmental engineer who can’t even see my lectures without getting sick, has made me a better surgeon, physician and human being. One simply has to find balance in all things in life and not shut off any part of life to focus on other parts of life.

10 October, 2014 Posted by | organization, relaxation, stress reduction | , , | 5 Comments

Failure and Work Ethic

At some point in your career, you will “fail” at something. How you recover from that failure speaks volumes about your work ethic. I am going to explore some strategies for preventing and recovering from failures (or just poor performances).
Course Exams

At some point in your education, you will fail (or not perform well) on a course exam. Your first stop is to look at why you failed the exam. Was your preparation not detailed enough for the questions asked? Did you put off studying until the last minute and hope that you did enough to pass the exam? Did you approach the material from a position of “fear” rather than a position of “mastery”? In any of the above instances, you have to go back, correct your study methods and strive to perform better on the next course exam. Correcting your study methods means that you have to shove your ego aside and take an objective look (often best done with a professor), at what you need to add to your study session or how you have to change your approach to the materials. This is not the time to “make excuses” but this is the time to make sure that you hone your approach and add in any strategies that you may have missed the first time around.
If you are having a difficult time understanding your course material, then look at your background (or pre-requisite) preparation for the course. Most undergraduate science courses require a solid grounding in college algebra and trigonometry. If your mathematical preparation is not sound, you are likely going to struggle through much of your physical science courses. Courses such as physical chemistry (if you are a chemistry major) require a solid working and application knowledge of calculus (through multivariate). In short, make sure that you have the math preparation for the coursework that you undertake so that you are struggling to master both the math and the scientific concepts (a task that is formidable for the best students).
You also need to make sure that you reading skills are sound when you begin college-level work. If your reading skills are poor, specifically comprehension, take skills courses and upgrade your reading efficiency (speed and comprehension). If you anticipate the study of medicine, you must be able to read efficiently and understand the concepts as they are presented. Again, struggling with basic skills while attempting to master a large volume of materials is going to cause early burnout and lead to a poor performance in coursework both at the undergraduate and graduate level. Additionally, the Medical College Admissions Test (MCAT) requires strong reading comprehension skills for a solid score. Many medical college admissions committees will focus on the Verbal Reasoning skills portion of the MCAT as a means of deciding whether or not to admit a candidate.
Strong reading comprehension skills can be achieved by taking coursework that forces one to constantly and consistently analyze and critique different types of writing. Good writers without exception are good readers and good readers are usually very strong writers. It is a sound practice at the undergraduate level to challenge yourself with academic, scientific and scholastic writing experiences and courses. It’s also a good idea to read a variety of disciplines as an undergraduate. While it is expected that a physician will be able to read and evaluate medical literature, it is also expected that a physician will be able to incorporate new information and evidence-based medicine into their practice in an efficient and accurate manner.
Standardized Exams
Standardized Exams are well-represented in the career of physicians. Many of these exams have severe consequences when a test takers performance is not strong. Many students will have their first experience with standardized testing with the Scholastic Achieve Test (SAT) or the American College Testing (ACT) Test. Many people were able to take prep courses (expensive) and many people took one or both of these tests more than once. With most standardized tests in medical school, there are no “do-overs” unless you fail one of the steps of USMLE or COMLEX. If you go into one of these licensure board exams with the idea that you are going to fail (or do-over), you have put your career in serious jeopardy.
The key to a strong performance on USMLE (COMLEX) is through mastery of your medical school coursework and a thorough review before taking any of the steps of these exams. A review course does not overcome a poor knowledge base from poor coursework mastery. If you struggled with one or more of your courses (or clinical rotations), then you need to make sure that you review and shore-up that knowledge deficiency. Your test preparation needs to include going to the websites of these standardized tests and learning everything that you can find out about the test. What is the topic base being tested? How are the concepts tested? Are their retired exams available for practice? (Practice questions can be a good addition to your preparation strategy but you can’t memorize these questions because they are “retired” meaning that you won’t see them on the actual test). Don’t get “hung up” on material that is review material if you don’t know the concepts in the first place. This is why a potential test taker need both a knowledge base and a review not one or the other.
Your mindset going into any type of achievement or licensure board exam has to focus on taking the test one time and performing your best. The best way to insure that you have a strong performance is to not have an emotional reaction to the material on the test but to plot a sound review strategy once you have become eligible to take a licensure board exam. Many people focus on what they will do if they fail or what they will do if they don’t get a good score or what how they feel going into the exam (no one ever feels 100% ready but you have to ensure that you have done a thorough and sound prep). If you have been objective about what you need to review and learn and you have not attempted to take “short-cuts”, then you should be able to take your licensure board exams with the confidence that you can handle any concept that is presented on these types of exams. If you have mastered the concept and can recognize how the concept is being tested, then you can answer the question. If you can’t outright answer a question, ruling out possible wrong answers can be in your favor if your knowledge base is sound.
I know I am not ready but I will take the exam for “practice”This manner of thinking is a huge mistake on any standardized achievement exam. These types of exams are not designed to be taken for “practice”, thus consequences come with practicing on actual exam sessions. If you feel that you need practice exams, then spend the money on test prep center practice exams but don’t use an actual MCAT, USMLE or COMLEX exam session as a practice. If you take these exams and score poorly or fail, you have greatly compromised your future career in medicine. A string of mediocre MCAT scores even coupled with a strong undergraduate GPA will not yield success in medical school entry. In terms of USMLE/COMLEX, residency program directors are very wary or people who have multiple attempts at any of the steps in these licensure exams. All specialty residency programs have yearly in-training exam and specialty boards for board certification. If an applicant is struggling with USMLE/COMLEX, they are likely going to struggle with certification exams which will reflect back poorly on the residency program. Don’t take any standardized licensure board exam unless you are ready to pass the exam. There are no exceptions to this rule. In today’s world of residency slots being competitive in specialties that were less competitive even three years ago, you can’t afford to make yourself less-competitive because you took a USMLE/COMLEX step for “practice” and planned on repeating the exam. Get the “repeat” mentality out of your vocabulary and thinking.
Bottom-line Work Ethic
You have to be willing to let go of your ego, change some things that you have become accustomed to and objectively look at yourself if you want to move past an exam failure. If you failed any of the steps of USMLE/COMLEX, you have to let go of your “dream” of a lifestyle or surgical specialty and realistically look at what specialty (likely primary care) for which you are competitive. This means that high-achieving academic university programs in Internal Medicine, Pediatrics or even Family Medicine are going to be out of your reach. This means that community based programs in primary care which often require more self-learning are going to be the basis of your training. If you have a very strong work ethic, a community-based primary care residency program will be a great place to thrive and learn but you have to be willing to put in the work and you may have little choice in the location of your training program. You also have to be prepared for the strong possibility, especially if you have not received invitations for residency interviews which may herald that you may not match into a PGY-1 position, a state that is fraught with stress and pitfalls.
If you find that you have failed a course exam, you have to do the following with speed and purpose:

  • Seek out your exam and your professor so that you can review your exam and correct your preparation mistakes
  • Shore up your deficiencies in your coursework and keep up with your class so that you don’t fail another exam
  • Attend any tutorial sessions and office hours even if you believe you are on track with your exam prep. Checking your learning is a very good idea to make sure you don’t get off track a second time
  • Put any negative thoughts about your previous failures behind you. Every test is an opportunity to change your thinking and upgrade your performance.
  • Remember that you are in competition with yourself to do the best job with your coursework that you can achieve. There are few opportunities for “do-overs” in health care professional learning.
  • Stop comparing yourself to others in your classes or school. You have to do what you need to get the results that you want. What works for others, may not work for you so adapt and apply so that you get what you need for yourself.

By doing the above, this becomes your work ethic and sets the bottom-line for future success. If you can’t adapt and learn for your educational experiences, you will have a tough time moving forward with your training under any circumstances.

29 March, 2014 Posted by | academics, failure, MCAT, medical boards, standardized tests, USMLE | 8 Comments

” Not because they are easy, but because they are hard..”

“We choose to go to the moon. We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win, and the others, too.”  John F. Kennedy at Rice University on Sept 12, 1962.


Why choose medicine (or any profession in health care) if the work and preparation for that work is so hard? I asked myself why I spent hours in chemistry, physics and biology lab when my friends who were business and marketing majors were spending their weekends enjoying the club scene and knew the latest shows on the telly? Why was I putting in the hours making sure that my organic chemistry lab reports were accurate and complete? Why did I choose to study advanced applied differential equations, multivariate calculus and higher algebra (math minor) when I could have stopped with integral calculus? In short, why did I deliberately choose a rigorous college education in math and science where I demanded only the highest performance from myself when I could have taken a far easier route? The answer for me was pretty simple, “I had to know how things worked” and setting a hard goal energizes me and my skills.

Yes, my majors in undergraduate were considered difficult by some people but they were sheer heaven for me. Every minute that I spent in lab and applying math theories was not a chore but a pleasure. I had always loved to “figure things out” and I had parents who challenged me (and my siblings) to always do our best work no matter how many hours the job would take. From undergraduate to graduate school (I was a research scientist before medical school), I could focus in on a problem and see many alternative methods to solve that problem. I wanted to explain mathematically, how energy from a laser was transmitted via a heavy mineral acid matrix to a delicate protein in order for that protein to become ionized. I wanted to understand the mathematical model for that phenomenon and others. Fortunately for me, science allowed me to go where my mind could take me and then some.

So what does that mean in terms of medicine? This means that all of my previous studies from primary school to secondary school to undergraduate university to graduate university and medical school are all aimed at understanding why and figuring out how things work especially the human disease phenomenon. One simply has to have a grasp of the whole picture and the whole person in order to have a strong perspective as to how to best help that patient. Medicine is not like business in that one can take a “shortcut” and still get to goal. Medicine is like preparing for a marathon or to lose 100 pounds in that one has to see the long-term goal, work constantly and consistently at a high level and one has to remain vigilant or the goal slips away. This doesn’t mean that the path toward the goal isn’t pleasant because the journey is great fun but the most enjoyment comes when one sees how building upon a knowledge base and application of that knowledge base actually solves a problem for a patient.

I remember spending hours as a third-year medical student in the anatomy lab as I was perfecting my suture techniques. I sutured the skin of cadavers much to the chagrin of the first-year medical students who had spent hours removing or dissecting that skin. I would come into the lab before my surgical rotation started (I was there at 3AM); practiced my suturing and tying techniques and was off (smelling of formaldehyde) to write my morning notes before rounds. Yes, it was “hard” to get up on a cold and snowy morning when it was dark outside and head to a cold anatomy lab with cold steel tanks all around. No, I didn’t “have to” get up early and practice my suturing and tying but after I knew that I wanted to be a surgeon, I knew that I had to put in the time and hone my skills.

When I was in the hospital on overnight call, I went to the library and read about my patients’ problems. I refreshed my knowledge of pathology, I reviewed every medication that they were on and I made notes of how the disease process should progress. Was this easy? No, it was far easier to grab a nap because the Trauma pager would be going off practically continuously after 9 PM and I would be in the emergency department almost constantly until 5AM when it was time for pre-rounding. I learned to cat nap on call (sleep no more than 20 minutes), read when I was exhausted (putting my feet up was better than sleeping for hours and hone in on a surgical procedure while the rest of the world slept. Was it easy? No but I had set a long-term goal for myself and I was determined to get the job done with the same work ethic that my parents instilled from day one.

Conquering Hard Goals

Excellence becomes a habit if it is practiced on a hourly basis. This was the first thing that my parents instilled in me. When self-doubt creeps in and procrastination begins, remember that you can turn around your thinking in the next instant. Why is it so easy to NOT do something well when it is just as easy to DO that something well? There is always more than one way to do anything and any method that one chooses that brings about excellent results that are safe and ethical  is the method to accomplish something. In one’s academics, there is little time to spend on “thinking” about how inferior/superior you are in relation to one’s peers if one is constantly striving toward a long term goal of consistent excellent performance. This doesn’t mean that one wastes time on being “anal” or a “perfectionist” because these two traits carried to an extreme waste too much energy. Consistent excellence means building upon a foundation and linking prior knowledge to present knowledge to setting the foundation for future knowledge.

Sometimes one needs to get a different perspective. If you are finding that you are “spinning your wheels” on a task that seems insurmountable, break that task into more manageable pieces and tackle each one in turn until the whole task is done. Again, if you have 100 pounds to lose, you have to lose that weight one pound at a time. You can’t spend time hating the process (takes away from time that could be better spent working toward the goal) and you can’t afford to indulge in self-pity “Why is it so hard for me and so easy for everyone else?”. In short, your goals and challenges are unique to you and trust me on this one, everyone has goals and challeges that you may or may not be able to see or appreciate. You are no lesser or no greater than any person around you but you can make better or worse decisions as to how you will handle your challenges and goals.

Look from a different perspective

I have been fortunate enough to have spent some quality time looking at the world from the cockpit of my small plane. When I need to put a problem or goal into perspective, I head “up top” and look at the wonders of the world below. When I fly in a commercial airliner, the world below is much smaller at 37,000 feet (on a clear day), than at 3,000 to 6,000  feet where I can mentally interact with things below. The people below are not insignificant at that altitude and the world below becomes more than just the day in and day out tasks of getting things done. In short, find something (for me, it’s flying) that can take you out of your world for a short period of time and help you refocus. For me, flying takes focus and concentration but the pay off is worth the effort. It’s a challenge for a person who thrives on challenge.


You can see the goal (the runway) down there and you can take the steps to line up and get down there to that runway. Flying for me, is a metaphor for meeting the challenges that I encounter on a daily basis. Again, I learned to fly not because it was easy but because it was a hard challenge” that it “serves to organize and measure the best of (my )energies and skills ” and it allows me to accept, willingly, other challenges (not postpone them) that I meet in life.

14 December, 2013 Posted by | organization, relaxation | 8 Comments

The Post-Match “Supplemental Offer & Acceptance Program (SOAP)


In previous years, a process known as “The Scramble” existed for:

  • People who were unmatched on the Monday of Match Week
  • Unfilled residency programs
  • People who matched to an advanced position but not a first-year residency position.

The Scramble was also utilized as a primary residency application process for people who didn’t want to go though the Electronic Residency Application Service (ERAS) who often submitted their application materials via fax to programs who didn’t fill (from the list provided on the Monday of Match Week) or even contacted those programs via phone or e-mail. The Scramble does not exist any longer and programs who participate in the Match cannot accept applications outside ERAS. In short, the SOAP process is a different entity with hazards and plenty of opportunities for mistakes on the part of applicants.

SOAP is NOT “The Scramble”

Programs that participated in the Match are no longer allowed to interact with applicants outside of ERAS as this would be a violation of the Match participation agreement. This means that all applications to unfilled programs (those programs that are on the unfilled list) have to be submitted via ERAS. For programs, this means that e-mails, fax machines and phone lines are not jammed with people attempting to submit application materials. Frequently in previous years, many applicants (IMGs, FMGs in particular) could pay for a mass fax service to fax applications to every program on the unfilled list as soon as the Scramble opened which often jammed machines. Most residency programs were only interested in filling with desirable applicants who may not have matched (by mistake usually) and were not able to screen for those applicants because their fax machines, e-mails and phone lines were jammed.

SOAP should not be your primary residency application

If you are seeking a residency position in the United States, you need to meet the deadlines for ERAS with your application materials. In short, you need to submit your application materials (to your medical school if you are an American grad or to ERAS if your are an FMG/IMG) and participate in the regular Match.  If you are an applicant with problems such as failures on any of the USMLE Steps or failures in medical school coursework, do not make the mistake of believing that unfilled programs are desperate and will take a chance on you rather than remain unfilled. First, there are far more applicants in the regular match than ever before. Many people who will find themselves unmatched either overestimated their competitiveness for a program or were just below the cutoff for a program to rank. If a program interviewed you but you didn’t make the cutoff for them or you didn’t rank them at all, you have a better shot at securing a position in that program through SOAP than an applicant who didn’t interview at all. Programs would rather take an applicant that they have seen and interviewed rather than just a person on paper (which is why trying to use the SOAP rather than the Match is a poor strategy).

You are limited to an absolute maximum of 45 programs in the SOAP

In the SOAP, your maximum is 45 programs. You can apply to 30 programs during the first cycle (Monday) and 10 programs during the second cycle (Wednesday) and 5 programs on the third cycle (Thursday).  Applications do not roll over so that if you don’t get a match by the third day the start of the second cycle, you are likely not going to find much out there. There are more applicants who will be unmatched (because there are more people participating) thus the positions will go quickly because programs can review applications to chose the most desirable candidates with the SOAP system.

If you have problems that prevented you from getting any interviews in the regular Match season or you didn’t get enough interviews to find a Match, then you are going to be less likely to find a position in the SOAP. This means that you won’t have a position for residency. If this happens (you know if you have academic or USMLE/COMLEX problems), have a contingency plan in place. This means that rather than sitting around wishing, hoping and praying while your classmates and colleagues are going on interviews, you need to be looking at alternatives to residency that will enable you to earn a living and alternatives that will enhance your chances of getting a position in the next Match.

Strategies to enhance your chances of getting a PGY-1 position

If you know that you are a weaker candidate (failure on USMLE/COMLEX Step I, failure in medical school coursework, dismissal from medical school and readmission), then don’t apply to the more competitive specialties. Don’t apply to university-based specialties in the lesser competitive specialties and apply to more rather than less programs. If you have academic problems, you are likely not going to match in Radiology, Opthalmology, Dermatology, Emergency Medicine, Radiation Oncology or Anesthesiology. You are likely not going to match in university-based programs in Surgery or any of the surgical specialties, Psychiatry, Pathology, OB-GYN,Neurology, Physical Medicine and Rehabilitation, Family Medicine or Internal Medicine. In short, community-based programs in Family Medicine and Internal Medicine may be your best options.Do not believe that if there are unfilled positions in programs that are university-based or competitive, that you are going to snag one of those positions in the SOAP. A majority of those programs would rather go unfilled than fill with a less desirable applicant (in spite of what you hear, those programs are not desperate enough to take any applicant just to fill).

If you are an IMG/FMG, you have to meet the requirements for application which means that your USMLE Scores likely will have to be higher than those for American grads and you can’t have any USMLE failures. There are also cutoffs in terms of year of graduation from medical school for many programs. In short, you need to look at the application requirements for any residency program that you apply to and make sure that you are eligible (better yet, that you exceed) those application requirements.

The best resource for estimating your competitiveness for a particular specialty is to look at the previous years  National Residency Matching Program ( NRMP) reports for those specialties. You can look at the characteristics for matched and unmatched individuals to see where you fit. With a greater number of medical school graduates (most American medical schools increased their class sizes) and the number of residency positions staying static, there are fewer positions out there to be filled. There will be fewer position in the SOAP and the competition for those positions will be greater. Since the competition in the SOAP is greater, it is best to avoid having to use that system all together if possible.

If you know that you are a weaker candidate, apply for preliminary (not transitional) positions in either Internal Medicine or Surgery. You will stand a better chance of getting a preliminary position (more available) and you will have a job where you can demonstrate your clinical abilities for one year before you re-enter the Match for the next year. If you do a good job in your preliminary year, score high on the in-training exams and perform at a high level clinically, you may be able to secure a categorical second-year position in the same program where you do your preliminary position or you may position yourself to become more competitive for another specialty at another institution. The upside to this strategy is that you will not be relying on the SOAP as a primary means of residency application but the downside is that you have to be ready to perform extremely well in your preliminary position without exception. In short, getting into a preliminary position can be a huge asset if you are ready to work hard and prove yourself but can be a huge liability if you are not ready for clinical residency and perform poorly.

Things that generally DO NOT enhance your chances of matching

Doing graduate degree work if you do not match will generally not help your chances of matching. If you can complete a graduate degree (such as an MPH), you may enhance your chances but most graduate degree programs close their application submission dates before you know whether or not you have matched. If you anticipate that you are not going to match, then apply for graduate school long before Match Week or you will find that you can’t get into graduate school. Additionally, you need to complete your degree before the clinical year starts after the next Match. This means that you have to be able to ensure on your next ERAS application, that you will complete all of your degree requirements by the start of your PGY-1 year. Again, if you know that you have a high change of not matching, get your graduate school application done ahead of time or better year, delay entering the match and just apply for graduate school outright (can’t do a Ph.D) but plan on spending no more than one year away from clinical medicine.

Hanging out and “schmoozing” with residency attendings if you are not in their residency program is generally a waste of time. Doing additional observerships (IMG/FMG) generally will not help you if you have done enough before you applied. Working in “research” will generally not help you unless you already have an advanced degree (MS or Ph.D)  or you are able to produce a major paper or article for a national or international peer-reviewed journal. When I say produce, I mean first author not just run a few experiments  or enter data. If you can get yourself on a major clinical research project where you are actually gathering some clinical experience, you can use this to enhance yourself for residency but you face stiff competition for these types of projects and you need an unrestricted license to practice medicine (difficult to obtain without a passing score on USMLE Step 3 + 1-2 years of residency training).


Making sure that you match requires a bit of strategy and planning for everyone but for some applicants it will be a difficult process.

  • People who have academic and USMLE/COMLEX problems will have even more problems getting into a residency
  • It is important NOT to rely on the SOAP as a primary means to apply to residency programs because you put yourself at a distinct disadvantage in terms of the number of programs that you can apply
  • You need to make sure that you are even eligible for the SOAP in that you have to have applied to the Main Residency Match (at least one program) and are fully or partially unmatched.

Learn as much about the process as possible as soon as possible. The decisions that you make in the residency application process can profoundly affect your career in medicine. Educate yourself about all aspects of the process as there is little room for error.

29 November, 2013 Posted by | applying for Residency, Match Day, residency, scramble, USMLE | 4 Comments

Everybody is doing better than I am doing…

Well, for most people, it’s nearing the end of the first semester of school for this particular year.  It’s a time to complete the projects, papers and assignments that are needed to complete the year strong and it’s a time to start getting organized for those final exams that are looming in the future. This is not the time for berating yourself for not performing up to the standards that you created when you began the semester. For all students, there is quite a bit of “life” in between the start and end of any semester (or any period of time) in the educational process. Over any period of time, distractions and immediate needs/problems will get in the way of your learning. How you manage those distractions/problems is something that you can change to help you in the next semester. In short, as soon as you are done with your work for this semester, take an honest appraisal of what you would like to change and keep the things that worked for you.

Every person has a tendency to compare their lives with what they perceive as the life of another person. That other person might have been your sibling as you were growing up. ( I thought my sister was smarter, more beautiful and more talented that I could ever imagine).  That other person might be someone in your class (I see that X or Y is at the top of the class and he/she doesn’t even have to study) or that other person might be someone you see on the telly or in the movies that you perceive would have a better life or greater abilities than yourself. This practice of comparison is a huge time waster because the only person that you can compare yourself to (in any way) is your previous self. Only you know how to live your life and only you know what you need to succeed in getting what you need to live your life. It’s always easy to believe that others are somehow innately “better” that you are but in reality, they can’t live your life as well as you can live your life and you can’t know what challenges them.

The stress of school, especially medical school or any professional school, can send many students into behaviors that they would not even consider if academic stressors were not present. Assignments, tests and projects seem to be endless. The time that you thought you would have at the beginning of the semester, at this point, seems to have evaporated faster than dry ice. You find that you feel overwhelmed and rushed to complete things often feeling less satisfied that you have been able to give your work your best efforts. When this happens, stop and take a minute to prioritize the upcoming tasks. This is a good time to make a very simple list of the things that have to been done immediately and the things that can wait until you have a bit more time. This is also a good time to pencil in at least 30 minutes of time daily to just reward yourself for keeping up with your semester/academic tests as best you can. That daily 30-minute reward should be something affirming (not self-destructive) that you can keep coming back to when you need to take a short retreat.

Why is it so easy to believe that everyone else is doing better that you are doing at this minute? This happens because you project your feelings of inadequacy into your thoughts about others as you compare yourself to them. You are no more inadequate than the next person in your class but you may be making decisions that are not productive in terms of getting your academic work under control. Just allowing distractions to eat up your preparation time for study and completion of projects can be counter-productive to doing  your best work. If something is so distracting that you can’t concentrate on things that you need to be working on, then take that daily 30-minute reward time and use it to indulge in your favorite distraction (social media for example) as a reward instead of “beating up” on yourself for procrastinating on Facebook.  This means that you use your Facebook time as a reward for getting your other work accomplished rather than something that takes you away from what you need to do. In short, make a better decision not to deprive yourself of indulgences but to limit the amount of time that you participate in them.

Another thing that you can do in this minute, is to replace your belief that you are somehow inferior to others with the affirmation that they would have no idea of how to live your life. Only you can live the life that you are living. You were born with all of the tools that you need to make a success of what you would like to be successful in. All skills can be mastered if you put yourself in a position to master them and take each step needed toward a goal on a daily basis. Success is more of a habit rather than something that is “conferred” on a few “lucky souls”. Success in little daily tasks always adds up to overall success in the “big” items. If you attempt to “rush” or “short-cut” your way through your academics/projects, then you WILL run out of time to do your best work. Objective and thoughtful planning, with daily adjustments, works better than waiting until the last minute because you have the idea that “working under pressure” will spur you to work better. Adding pressure to an already stressful situation adds more stress and does little to get your tasks accomplished. Remember, people who are stressed tend to exhibit behaviors that add to stress rather than relieve it.

The other problem with constantly comparing yourself to others is that under stress, you always believe the negative thoughts first. In stressful situations, it’s aways easy to believe that you will “never” understand all of this or that you will NEVER get everything done that you need to get completed. In reality, if any student in the past was able to get the work completed, you will be able to get the work completed. You have all of the tools do your best under any circumstances. There is no other human out there that can life your life better than you can live your life.  You make a list of what needs to be done and you plan how you will do it. This doesn’t apply to anyone except you because only you can figure out what you need (and how much time you need) to complete your list. Yes, it’s true that there are only 24 hours in each day (and you have to sleep) but look objectively at your priority items on your list and do the most important items first. This is how we triage patients (we treat the sickest patients first and take care of the less acute patients in turn). If you don’t get everything completed, then you examine how you would change things and take action so that you get the most out of your academics.

Finally, telling yourself that you have “passion” for something is not the same as putting yourself in a position for being successful with something. Passion does not overcome or offset daily work toward a long-term goal. If you seek a long-term goal, realize that these long-term goals are reached by taking regular/daily small steps toward them. There is a path toward a goal and the steps along that path are the challenges that you have to meet. Meet and greet each challenge with the idea that you will figure out what each challenge requires and get the job done in your unique manner.

Put comparison terms out of your mind and replace them with action terms such as ” I can” and ” I will” do what I need to do along with asking for assistance at the first sign of trouble. Asking for guidance or assistance is not a sign of weakness but a sign of logical and careful evaluation of that you need for success. If you needed to lift a car, would you keep struggling alone or would you enlist the assistance of 10 others to help you lift that car? Anyone can lend you a hand along the way because most people are willing to help others if asked. You just need to be able to swallow your ego, ask for assistance if you need it and affirm that you will live your life, taking care of your needs without comparison to others and what they are or are not doing. In reality, those people that you believe are so much better than yourself are more like you than you would believe and have the same challenges that you have. In the end, you are equal to them and better in living your life.

7 November, 2013 Posted by | academics, organization | | 2 Comments

Preparing for Residency Application- You can’t begin this process too early!


If you are a pre-medical student, nothing in this post is directed towards you. If you have not entered medical school, you can’t even think about residency. For you, your task is to get into medical school period. I am always mystified when premed students want to ask questions about residency application when they have no medical school acceptance in hand. A better strategy would be to concentrate your efforts on doing well in undergraduate coursework, on the Medical College Admissions Test and on putting a competitive medical school application together.

First Year Medical Students

If you are at this point, many of you have recently begun your medical studies or are about to begin your medical studies. Your first task is to get the best grades possible in your coursework. You are totally in control of your destiny in terms of your academics, thus you need to put most of your focus in that area. Hone your study skills, master your coursework thoroughly and look at doing a couple of things that may help you in making the residency application process a bit smoother when you get to that point in a couple of years. Trust me on this, the time zips by in medical school, once your classes are underway. You have to keep up and you have to anticipate the major steps so that you are ready for them when they come.

One of those little “extras” that you can do as a first-year medical student, is go to the Electronic Residency Application Service (ERAS) website and download a copy of “My ERAS Residency” User Guide.  The 2014 edition is available as a 34-page pdf which may be downloaded. This booklet will allow you to look at all of the elements that will be needed for a solid ERAS application. You will also get an idea of the time line that you will have to meet when your residency application begins.

Armed with that little book, you will see that academics (coursework and licensure board exams) are the main elements in your application. Also note that the application is going to ask about membership in Alpha Omega Alpha (if your school has a chapter) so you can investigate how you can become a member of this very prestigious organization for allopathic medical students. At this point in your medical school experience, Alpha Omega Alpha (AOA) is a great achievement to aspire to and you have time to investigate/perform what is needed for this honor. I can tell you from experience, every residency director/faculty member that interviewed me, make a comment about my AOA membership. Alpha Omega Alpha opens the door to securing a strong residency program in any specialty. Alpha Omega Alpha induction requirements vary from chapter to chapter thus you need to inquire at your particular school so that you know the requirements and can meet them.

Everyone isn’t going to be inducted into Alpha Omega Alpha but you can still keep your academics high by thorough mastery of your coursework because everything counts in terms of having a strong knowledge base for a strong board exam performance. Do not make the mistake of believing that you can “memorize” a board review book and ace your board exams. You can’t “review” what you haven’t learned in the first place. You also get one shot at not ruining your coursework performance in medical school, thus you need to be striving for solid coursework mastery at this point. Armed with a solid knowledge base, you will be able to review for boards more efficiently and will invariably score strongly if you prepare well.

You can also join some specialty interest groups at this point. Most medical schools have these groups which will give you some idea of what each specialty has to offer. Membership in these groups will help you meet the clinical faculty at your medical school which will be useful when you begin your clinical rotations. Being a member of a particular specialty interest group does not “lock” you into entering that specialty but will allow you to learn more about the practice. For example, I was a member of the pediatric interest group, the internal medicine interest group and the pathology interest group. I didn’t enter any of those specialties but I learned valuable information.

Second-Year Medical Students

At this point, you have one year, and a summer, behind you. You should have some idea of what is left in the pre-clinical curriculum for mastery so that you can plot your strategy for getting your coursework mastered. For most medical students, second year is a time when you begin putting much of your preclinical information together so that you can become a solid clinical practitioner.  You will gain much of the knowledge that you need to become an efficient clinician during second year but you will not gain much experience -wait until third year for that. Most medical students will be taking board exams at the end of second year, thus quizzing your upperclassmen, who just completed boards, should allow you to make some decisions as to what review books might be best for your style of study for your board exams.  Getting yourself in position for a solid review and a strong board exam performance coupled with a strong coursework performance is your main tasks of second year.

Again, have a look at the current MyERAS Residency User Guide and make sure that you are on track with setting a schedule for board review when that time nears. If you are going to be applying for and participating in a summer fellowship (I did a paid pathology fellowship between my second and third year), you will need to begin board review much earlier than your peers. Keep in mind that summer fellowships, especially paid research and specialty participation fellowships are competitive and require early application. They are also a good source of material for presentation at national meetings and publication in peer-reviewed journals, something that is very attractive to residency programs. The beginning of second year is a great time to investigate these opportunities so that you can apply for them in a timely fashion.

Participating in some extra-curricular medical school activities at this point may be a great option for you, but unlike undergraduate school, medical school is not the place to join lots of clubs to the point that your coursework performance begins to suffer. Do some activities, perform some community service but be very mindful of your time and of anything that takes you away from your medical school coursework study and mastery. Spend some quality time with younger(newer) attendings in specialties that are of interest to you. Pick the brains of the folks and allow them to point you in the best direction for you to be as competitive as possible. I always recommend that people seek out the newer attending physicians because they tend to be closer to the residency process and are usually honing their mentor skills thus they will answer questions and will guide you in the specialty selection process.

Some students at this point have some idea of what they might be interested in pursuing and start to angst about third-year clinical rotation order. This practice is useless because order of clinical rotations makes no difference in your grade. When I encounter third year medical students at the beginning of third year, I hold them to a different standard than third year medical students at the end of their third year. As clinical teaching faculty, we know how much clinical experience a student will have at a particular point in time and we judge that student accordingly.

Third Year Medical Students

By this time, you should have your Step I board score in hand. If it is a strong score and your coursework performance is good, you will have more specialty options that someone who is lacking in either of these two aspects. At this point, you either have to do “damage-control” or you keep doing excellent work. A strong third year will not offset a poor performance on boards and in coursework but you can help yourself by doing well clinically. Do be aware that grading in clinical rotations is quite subjective. You need to be sure that you can be a valuable member of the clinical team to which you are assigned regardless of clinical rotation and your interest in that rotations’ subject matter. If you don’t know what you want to enter, don’t lie to the intern, resident or attending of any specialty because you believe you will get a better grade. A strong work ethic coupled with an interest in all things that pertain to the care of your patients will help you in getting the best clinical grade.

Don’t make the mistake of “sucking up” to the attending physician and ignoring the intern or resident because you believe they won’t be grading you. My main resource as to a medical student’s clinical performance is the intern that they have been working under. When a medical student begins on our rotation, we don’t know your preclinical grades and we don’t care about those. Every student is judged according to our standards for solid clinical performance, thus, you have an opportunity to start with a clean slate and do well.

Sometime around the middle of third year, you should have decided what you want to do, within the context of your Step I performance and course academics. This is the time to ask for letters of recommendation from attendings on the services that you have done rotations. When I asked for a letter of recommendation, I included a packet which had the address of my academic deans office, my personal statement and my curriculum vitae/resume. I also included a photo so that the attending could remember me. Don’t wait too late in your third year for these letters because your Deans office will have started a file and will be submitting these to ERAS as you designate them. You also want them to be in your file so that the dean can submit your Medical Student Performance Evaluation (MSPE) in a timely fashion. The MSPE usually is not submitted with the early ERAS documents but if you have strong letters of recommendation in your file, your dean will submit a strong MSPE which can move you to the top of the bunch when you are being evaluated by the residency faculty committee.

If you haven’t had professional wallet-sized (passport) photographs taken, the beginning of third year is a good time to get this done. Please dress professionally and conservatively for these portraits. Get at least a dozen of these photos as you are going to need them for your ERAS, your licensure application and other documents. Just keep them handy so that you can get things out quickly without having to run and have photos taken.

Fourth Year Medical Students

At this point, you should have all of your ERAS documents ready and submitted to your Deans office. If you haven’t do so already, you need to register for the MATCH and get your ERAS submitted. Ideally, you should take Step Ii (both steps) as soon as you have completed third year but no later than September of your fourth year. If you wait to take Step II, it just gets in the way of your fourth year electives and travel for residency interviews. I took Step II the first week of August of my third year, before my fourth year started. That way, I had my Step II score back and ready for my ERAS transcript. It was also nice to have nothing between Match Day and graduation except to show up and get my diploma- I used the time to house hunt at my residency location.


Meet and exceed every deadline when it comes to matters of residency in medical school. Know the process, especially the requirements for entry into various specialties. You may love Dermatology but you are not going to match into Derm without very strong academics. You may love Orthopedic Surgery but you are not going to match into Orthopedic Surgery without very strong academics and so forth. If you have performed well in medical school, you have more options but you need to be realistic about your match chances for any given specialty in addition to making sure that all of your application documents are submitted as early as possible.

You need to know the process so that you can optimize your application. Get good advice from the people who have just completed the process and from medical faculty who can look at your documents and advise you on changes. With the increased numbers of applicants, you can’t afford to be one of those people who are trying to find a residency slot because you didn’t match. Good luck.

30 August, 2013 Posted by | applying for Residency | | Leave a comment

Study Skills (Part VI)


When sitting down for study, one has to have a plan for getting the best results most efficiently. This post is designed to assist any student in getting the best results for their study time in the most efficient manner. In professional school, it is vitally important for a student to obtain a strong knowledge base and continue adding to that knowledge base and refining that knowledge base for the rest of their career. In 2013, when there is so much information practically at one’s fingertips, it is still vital for a modern medical professional to have a strong and refined knowledge base.

Set goals and objectives for your study session

Don’t sit down at that table in the library without having a study plan. It is best to set some goals (and time frames) to accomplish for that particular session. For example, I would plan on studying at least two hours for every hour spent in lecture and 1/2 hour for every hour spent in lab. Depending on the subject matter, I would list the specific items that I planned to study in each session. Next to each of those items, I would place the amount of time, based on my time frame and the amount of time that the lecturer had spent on those items next to each of the times. When I had had completed an item, I would cross it off my list. If I needed more time, I would move that item to the end of the list and add more time before I crossed the item off my list. In short, I always had a study plan. An example: Plan for studying gross anatomy.

  • Review the previous lecture items – 30 minutes
  • Review the present lecture and organize it – 10 minutes
  • Lecture item – 20 minutes
  • Break- 10 minutes
  • Lecture item-20 minutes
  • Lecture item – 30 minutes
  • Break- 10 minutes

On my breaks, I could walk around, get something to drink or go up and down a flight of stairs so that my circulation could get moving. If something crept into my thoughts, I would jot it down in a piece of paper and think about it on my next break while I was moving around.


I always made sure that I covered the assigned reading in my textbook before attending lectures. By doing this, I knew what was important in the next lecture and I had an idea of what might be covered. Sometimes, textbook reading is the only way something would be covered that needed to be in my knowledge base. The textbooks would generally put items into perspective that I needed to learn to become a good physician. This meant that I was adding to my knowledge base as well as organizing the materials to be studied. In general, I used 1/2 of my study time on weekends to get ahead in my reading.

When I became a resident physician, I read at least 30 minutes per day (no matter how tired I was) and a minimum of 3 hours each weekend. I kept a running list of the articles that I read from journals and the subjects that I covered in my surgical textbook. By the end of 6 months, I had completely finished Sabiston Textbook of Surgery and had kept up with my journals. I always had something printed out to read over lunch or while I was waiting to begin a case. I kept notes on cards and summaries of articles that were pertinent to my rotations/practice goals. When I completed my surgical textbook, I re-read the sections that I felt were most important for my practice so that my knowledge gained from the textbook could be incorporated into my long-term memory.  I also covered any topics in the textbook that were covered in conferences and grand rounds.

Journal Reading

It is important as a physician for one to keep up with the literature of one’s practice. This habit started in medical school when a medicine professor challenged us to read the New England Journal of Medicine each week. I started with the case of the week and moved to the review articles and then the original research articles. At first I understood very little of what I was reading but in a few weeks, I was used to most of the language of medicine. I kept a medical dictionary on my desk and looked up words that I didn’t understand. Not only did I start to understand upcoming changes but I started to learn which journals were important to my future medical practice.

I had completed graduate school before medical school and knew the importance of learning the literature of one’s subject area. I soon came to love and appreciate Nature Medicine (lot’s of basic science here) and Physiological Reviews (very dense review articles but great reading).  If you are at the undergraduate level, get used to knowing how to read and understand original research in the journals of medicine and your field. It is vitally important that even before attending medical school, one has to be able to read and critique journal articles. One also has to become comfortable with evidence based practice which should begin long before medical school with reading and critiquing the literature of your particular field of study. If you are a non-science major, you should force yourself to read and assimilate some of the journals of basic science (biology, chemistry or public health).  I am always puzzled with a medical student will be sitting in my office offering being a “non-science major” as an excuse for not knowing how to read and evaluate the literature of medicine. Once you walk through the door of medical school, you have to become familiar with the language, science and art of medicine no matter what you studied as an undergraduate.


The best part of the weekend is that generally you have a bit of extra time to review and refine your daily study habits. In medical school, I used the weekend to plan my next week’s work. I also used some of my weekend time to review the materials from the previous week. This meant that I was on my third pass of materials that I had previously studied in the week before. Yes, my studies might cut into my relaxation time but in medical school (and any school for that matter), one gets one “shot” at not “screwing up”. I still had plenty of time to shop, explore and party  but these things were not the purpose of my weekends. Even today, since quite a bit of my time is spent preparing lectures and curriculum for my students, the weekends are still used to review and refine materials from the week before.

I generally kept the same sleep/wake schedule on the weekend as I utilized during the week. It becomes highly disrupting to keep changing a sleep/wake schedule. This generally means that if I go out for a late night party, I still have to continue with my weekend schedule. On my vacations, I might “sleep in” a couple of hours but I utilize my early morning hours on vacation to read books and enjoy a movie whereas during work time, those early morning hours are used working or keeping up with my professional reading.

Social Media, Television and so forth…

It’s great to have Twitter, Facebook and other social media sites to keep up with friends but these sites can’t become major distractions during your study time. If you have to keep up with Facebook on a regular basis, then utilize one of your study breaks (the10-minute ones) to post and catch up. If social media is more important than your schoolwork, then you might want to consider changing to a vocation that doesn’t require as much reading and study as medicine. There is plenty of time to do things on social media, as I am proving now as I take the time to write this post, if you plan the other things in your day accordingly.

Having a recorder on my telly has been wonderful. I simply look at the log for the upcoming week and decide what I want to watch so that I can set the DVR to record it. If there is a football game that I want to watch, I simply have my I-Pad with me so that I can multi-task. I have always been able to answer correspondence and read while enjoying a sporting event. Needless to say, I don’t get to too many live games (unless I am one of the physicians on the side lines) and instant replay is one of my best friends.  Once I started undergraduate work, my telly watching become a very secondary entertainment event. Even today, I usually end up erasing shows that I just can’t get around to watching but everything comes up on Netflix or Hulu at some time in the future so I don’t think I am missing many things.


Meetings can cut into your study and reading times but I have learned to treat most meetings like conferences. In administrative meetings, I look at the agenda and listen to the things that are of greatest importance to me or my division and let my mind go to my I-Pad (substitute any tablet, smart phone or paper) when things do not concern me directly. When I am conducting a meeting, I set strict time limits and stick with them. I don’t like my time being wasted and I respect the time of others. Sometimes, I have to decline meetings that are just not a useful way to spend my precious time.

If you have to have a meeting, try to schedule them over breakfast or lunch so that one can eat and meet if necessary. Having a meal also helps to keep a meeting from running off the “rails”. I find that administrative academic meetings can quickly affect my clinical time. I have to make sure that my administrative colleagues understand that I have to keep my clinical hours, my office hours and my practice (OR) hours. This means that I am often leaving meeting early and usually can’t go overtime. Learn to conduct a concise and informative meeting and learn to say “no” to things that interfere with your professional/personal life.  In short, one has to learn to set priorities.

When things come undone

When your can’t keep up with your schedule, within reason, it is time to look at your priorities. A schedule can’t be so rigid that adherence starts to cause stress. If things are so stressful, take a look at what you can do to unload some of the demands. You still have to schedule in some reasonable relaxation time. If you are not getting some relaxation/recreation, you become less efficient and more prone to interruptions that take you off course. If you have too much recreation/relaxation, you can’t get things accomplished. In short, refine and revise as you go along.  You have to realize that emergencies will happen and have a means to get back on track once the emergency has passed. Again, weekends are good for “catching-up” if this needs to happen. If something gets you behind during the week, go to where you need to be and catch up on the weekend. If you stay a bit ahead, an emergency need not completely derail you and your schedule.

24 August, 2013 Posted by | academics, study skills | 1 Comment

Before you shadow…

As the new school year begins, I am receiving requests from premedical students about shadowing opportunities. I am happy to honor some of these requests and I am happy to pass some of them along to my colleagues so that as many students as possible get an opportunity for a shadowing experience. What can a pre-medical applicant do to prepare for a shadowing experience? I will offer some suggestions in this post. These suggestions are based on my requirements for shadowing and on some of the requirements of my practice institutions.

Do Your Homework

When you contact a physician (or physician assistant) for a shadowing experience, be sure to ask about dress requirements, paperwork and expected times of arrival. It is a good idea to contact the person (or office of the person) that you wish to shadow a minimum of a week in advance to make sure that all arrangements are in place. You want to have the best experience possible thus you need to ask about the schedule for the day, logistics of when and where you should arrive and what you should bring. Many places like for you to bring a copy of your resume (or CV), your personal statement (write one if you don’t have one ready) and a list of questions or goals for your visit. Remember, you are not going to a party where you are expected to be entertained, you are collecting valuable information as to your future career. Shadowing opportunities are become more difficult to obtain (patient privacy and liability concerns) thus you need to make the most of any opportunities that you can.

Be sure that you know something about the profession of the person that you expect to shadow. If this person is a physician, then you need know about the practice of medicine as it relates to this particular specialty. As a surgeon, I am not interested in hearing how you don’t like surgery but are only with me to get a letter of recommendation. I am likely not to write a letter of recommendation for a person who first, has no experience in surgery, other than perhaps as a patient, and who doesn’t understand that whether or not you become a surgeon, any physician needs to know something about surgery other than just not liking it. I don’t expect everyone to want to become a surgeon but I do expect every pre-medical student to have at least an intellectual interest in the practice of all aspects of medicine.

Do come into a shadowing experience with some knowledge of the process of entering medicine. Again, the time of the person who has generously allowed you to have this experience should be respected. If you have no idea of what you need, go to the AMCAS website and check out their Aspiring Docs pages. This should be the minimum knowledge in your possession before you seek shadowing experiences.  this page also gives you some ideas of what you may want to request from your shadowing physician at the conclusion of your visit.

Arrive Early

Most physicians arrive at their offices early in the morning. It goes without saying that you don’t want to be late. Do a “recon mission” and figure out traffic, driving directions, parking and the like. If something catastrophic happens, you also need to have a number where you can contact the person that you are supposed to meet. You don’t want  to be the reason for an entire day getting off to a late start. If you are unavoidably delayed, the person you are meeting may be able to reschedule or make arrangements for another person to meet you so that both of your days are not ruined. If you know that your experience is going to involve observation in the OR, be sure to arrive early enough to change into scrubs and other operating attire. It’s always better to be early and wait rather than have a busy professional waiting for you.

Proper Attire

Before you select that new outfit, keep in mind that most physicians wear business attire in the office. If you are a female shadower, wear comfortable shoes that you can stand and walk fast in. Ultra high heels with slick soles that clack on floors are not acceptable. You have to be able to keep up with the person that you are shadowing. Keep makeup, jewelry and perfume to a minimum as you may be in contact with patients who are ill. I remember a young lady appearing in platform heels and ultra-short suit with large hoop earrings ready to make rounds with my surgical team. Not only was she not able to keep up with us moving from room to room, her earrings made noise as she walked and she missed a great deal of the morning rounds experience because the rest of us were going to the next room while she was applying Band-Aids to the blisters on her feet. Moral of the story: wear comfortable, well-broken in shoes and clothing that will allow you to move. She was dressed fine for a business or law office but not for medical rounds. Minimally, wear low heeled shoes, comfortable suit (slacks) with shirt and tie (men) , comfortable blouse and jacket.  You may be given a lab coat to wear for the day so pick something that will go under a lab coat.

Follow Directions

One of my hospitals will not allow pre-medical students in the operating room but offers some of the best clinical experiences for shadowing students. If I am doing surgery at that particular hospital on the day that a student is shadowing, I have to abide by the rules of that institution. If you are at an institution that does not allow you in the OR, the you wait in the surgeon’s lounge until the case is over. I do try to avoid having shadowers if I am operating at that particular hospital. If you are allowed in the operating room, make sure you introduce yourself to the circulator, ask if this person is not pointed out. The circulator will tell you where to stand. The operative word here is stand though you may be given a stool to sit as long as you are far out-of-the-way. If you are standing, keep your arms folded in front of you or at your sides and don’t touch anything.  Most of the circulating personnel that work with me will make sure that you can see as much as possible. Eat breakfast, use the rest room and get something to drink before you enter the Operating Room. You can’t afford to be dehydrated or develop a case of low blood sugar just as the incision is underway. Often the anesthesiologist will invite the pre-medical student to sit at the head of the table. If this happens, again, keep your hands close to your sides and follow any directions. Last direction, if you feel faint, notify the circulator so that this person can take care of you quickly.  Fainting happens and most people know when they are going to faint. Just say something.

When I bring a shadower into the operating room, I usually introduce them to the circulator and to the anesthesiologist (anesthetist) so that everyone knows who you are and why you are there.  I usually give the circulator a card with your name and why you are there-for their records. The circulator will help you understand what is going on and will explain things once the case gets underway. Also, be aware that the patient on the operating table is our main concern so that you understand that we are not ignoring you but are performing patient care in a very specialized manner. When the introductory procedures are completed, scrubbing, anesthesia induction and other pre-operative procedures, people are willing to explain things. (Do keep in mind that I will have already informed the patient that you are present and sought their permission for you to be present.). Every patient has the right to refuse having unlicensed personnel in the operating room or clinic when they are being seen. Most patients are happy to be part of your experience but not all patients.

Keep in mind that sometimes things become tense  in any clinical situation. If this happens, move out of the way and allow anyone and everyone to handle the situation. There is nothing personal about this but we always have to be prepared for the unexpected. You may observe some things that are not planned and may be tragic. Under patient confidentiality rules, which many institutions will have you sign, you are not allowed to speak about anything that you observe.  The unexpected and the tragic are part of medicine more often than in other professions but keep in mind that the confidentiality and safety of the patient is our first and foremost job. We will get back to you as soon as the emergency has passed.

Take names!

Bring a card so that you can write down the names of everyone who was part of your experience. It’s a nice gesture to write a short note of thanks to the office managers, operating room personnel and others who have helped to make your day as informative as possible. Most professionals who are in health care are happy to provide information to people who are cordial and interested in joining their ranks. A short note of appreciation is very welcome and let’s them know that you appreciate what they do.

Enjoy yourself!

A shadowing experience is a chance to see health care professionals do their jobs. Enjoy the experience and learn as much as possible. Actual work in medicine is not like what is on the telly or in the movies but is fairly routine for us who are there every day. While things are never routine for the patient, they are our main focus. We are all happy to have you learn and join our ranks but keep in mind that we enjoy our routine days. The best surgical experiences for me are those where everything goes according to procedure and the patient’s outcome is excellent. Take in everything and don’t take any comments personally as that is never the case. Some people are stressed on any given day and may not be a cheerful as you would like but are capable of teaching you something new and exciting. Make sure that you are in a position to learn which is why you are there in the first place.

9 August, 2013 Posted by | application, medical school preparation | | 2 Comments

Applying for Your Residency


Many thanks from the blog wellnessrounds for this post. It is well worth reblogging here because there is something for everyone. This was posted on OnSurg, a notable and necessary site for anyone who is in their surgical rotation in medical school, in any surgical residency specialty and in practice. Enjoy some of the notable and excellent writing out there.

Originally posted on wellnessrounds:

The following guest post waswritten by Daniel Fox, MD with the help of other residents in ENT for medical students applying to otolaryngology.  I thought it was so outstanding that I asked his permission to publish a minimally edited version that would apply to all medical students applying in the NRMP match. 

The application process starts with knowing and understanding the rules.  The following are the websites that will help in this process:

Match Statistics h This will give you an idea about the qualifications of candidates that match into each specialty.

ERAS website is for applying to residency programs.

NRMP website is for submitting your rank list.

FREIDA This website gives some very basic information about individual programs, but overall is not very useful.

Residency Program Director Survey (38% response rate)  This gives you an idea about what program…

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2 August, 2013 Posted by | medical school | Leave a comment


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