Doing Well on Your Cardiothoracic Rotation

Many times, third-year medical students will have to spend a portion of their required surgical clinical clerkship on Cardiothoracic Surgery. This portion of your surgery clerkship can provide a good informational background for anyone going into medicine, pediatrics or surgery. For the medicine, emergency medicine and anesthesia folks, you get first hand experience with the actions of pressors such as dopamine and dobutamine and other cardio pharmaceuticals in the postop management of these patients. You see the real-time effects of agents like nipride and nitroglycerine because most cardiac surgery patient will have pulmonary artery catheters in place in the immediate post-operative period. For those anticipating entering pediatrics, you will get a chance to see some of the effects of the congenital heart disease entities and how repairs are undertaken. For those entering the surgical specialties, you can develop an understanding of some specialized surgical techniques in addition to becoming familiar with the surgical intensive care unit.

Approaching the Rotation

The first step in any clinical rotation is to have good reference materials so that you understand the language that these surgeons will be using. For cardiothoracic surgery, I strongly recommend the following: Essentials of the Surgical Subspecialties by Lawrence, Cardiac Surgery Secrets by Solotoski or Handbook of Patient Care in Cardiac Surgery by Vlahakes. Any of these books will provide a solid background into the types of pathology that you will encounter in your rotation. The Lawrence book includes good sections on the thoracic elements of this rotation which are not included in the other books. In addition, you need the usual pocket books such as the Pocket Pharmacopeia or Epocrates which may be used to look up dosages of medications and the Maxwell Book which outlines SOAP charting, brief operative notes and discharge summary writing.

The players on any cardiothoracic service are the Cardiothoracic attending surgeon, the resident or fellow surgeon, the intern and you the medical student. You need to understand your role as both a member of the team and as a student of medicine/surgery. This means that in many cases, this busy service will require that you become very proactive in terms of getting the information that you need. You should thoroughly understand the following for every case that you encounter on this service (or any service for that matter):

• The relevant pathology of the underlying disease entity
• The relevant anatomy of the underlying disease entity
• The “gold-standard” of diagnosing the disease entity
• The accepted treatment of the disease entity
• For surgery- the surgical approach and performance of the operative procedure
• For surgery – the postoperative disposition and management of the patient

   

In the case of a patient that is undergoing a coronary artery bypass graft procedure, you need to understand the indications for the procedure, how the diagnosis of coronary artery disease was obtained (how to read the cath report), where is the disease (in which arteries), the relevant surgical anatomy, how the case is done including the operative approach, how cardiopulmonary bypass works, the effects of the cardiopulmonary bypass pump on the patient and how these effects are managed in the postoperative period, how to read and interpret data from the pulmonary artery catheter, where the grafts for bypass were obtained and how they were utilized and the care of the patient both in the intensive care unit and on the postop ward before discharge home. You should also know why the patient is discharged on certain medications and what you may expect to see and evaluate in the clinic when the patient returns for postoperative care.

 

Armed with that knowledge, you should make sure that you observe (you probably won’t be actually scrubbing in these cases)the preparation for anesthesia, how the chest is opened and closed, that you see how the grafts are harvested (done by a surgical resident) and how that wound is closed, how the grafts are sewn I place (best to use the camera overhead for this observation rather than try to look over the shoulder of the surgeons, how the pacemaker wires are placed, how the patient is placed on and taken off the cardiopulmonary bypass pump, how the chest tubes are placed in the chest cavity and how blood is evacuated from the chest cavity when the sternal wires are placed. Placement of the sternal wires is also a good opportunity for you to observe an interesting procedure.

 

After the case, you should accompany the patient to the intensive care unit and you should carefully note and observe the data that is obtained from the pulmonary artery catheter, the arterial line and the 12-lead ECG. You should look at the pre-operative ECG and compare the two. Another good exercise is to note where the grafts were placed and the number of minutes of pump time and any circulatory arrest time. You thoroughly familiarize yourself with the preoperative workup and the postoperative course of every patient that is on your service. Look at things like electrolyte replacement, ventilator weaning, urine output and transfer from the intensive care unit. This is also a good time to learn how to remove chest tubes and arterial lines. You should observe the conversion of the pulmonary artery catheter to a central venous line but leave the rewiring duties to a resident. If you anticipate entering a surgical subspecialty, you might observe these procedures but you should never perform these procedures as a medical student.

 

In addition to the routine patients, you may get an opportunity to observe some trauma that involved the cardiothoracic service. You may see the repairs of lung lacerations, penetrating cardiac injuries and the relief of cardiac tamponade from a traumatic injury to the chest. It is always interesting to see a patient who is admitted to the emergency department with a stab wound to the chest, knife in placed, rushed off to the operating room where the object is removed and the repair completed with survival of the patient. These are some of the most interesting cases. You may also see how damaged cardiac valves are replaced and how congenital heart defects are repaired. All of these cases are under the practice of a cardiothoracic surgeon.

 

The thoracic cases may afford you an opportunity to scrub in on the procedures. In the case of the video-assisted thoracic (thorascopic) lung procedures, you will have a good view of lung pathology. You can follow the patient from biopsy (in the case of a tumor) or chest wall abnormalities/problems through the repair. These cases will have interesting anatomy and will have excellent postoperative observations and challenges that will teach you many good skills. You can learn about chest tube management and the physiology of the chest cavity. You will also learn about pain management and the prevention of major postoperative complications as these patients may often be a challenge in terms of pain relief. You may get a chance to observe a thoracentesis or placement of a chest tube.

 

This rotation can teach you many important skills and hone your ability to understand the critical care of patients. It is an excellent learning opportunity for you. You may not get much hands-op operative experience but you can be invaluable in the post-operative care of these patients.

Memorial Day at the Veterans Hospital

Typical Wound Rounds

It was one of those typical wound rounds days at our VA Hospital.  We made our (the complete vascular surgical team) over to the long-term care wing of the hospital to do our weekly check of patients who didn’t have formal vascular clinic appointments or who were bedridden with chronic wounds. The mid-level practitioners would put names of patients on a list at the nurses station for us to check.  The patients who were ambulatory or wheel-chair bound would return to their rooms so that we could  check them as we made our way down a T-shaped hallway with two long wings. The entire process generally took from 2-4 hours depending on how many patients to see and how extensive the wounds were and what care was needed.

The hallways

Most of the rooms down these hallways were semi-private (2 vets to a room) with a ward (4 vets to a room) at the proximal ends. At the end of the hallway were the private rooms for those vets who were in isolation for infections or for those who were too loud or ventilated  and would not be amenable to sharing a room with another vet. The rooms at the far end of the hallway, though private, had views from the window that rivaled any 4-star hotel. They overlooked the front grounds of the hospital and the baseball diamond. Flying in the breeze was the state flag, the POW-MIA flag and the flag of the United States. The entire VA complex sat upon a hill that overlooked the surrounding town and mountains in the distance. No matter what time of year, the views were spectacular and I always paused to admire nature’s show for these men who had given so much.

Chronic Wounds

We made our way from room to room. Many of these patients were post toe amputations and needed wound checks. Others were diabetic with foot ulcers from poorly fitting shoes or injuries that they could not feel and thus the wounds had become infected.  Many of the vets were long-time smokers and diabetics with peripheral vascular disease  from smoking and neurovascular disease from their diabetes.   Some were despirately trying to “keep their feet” while others had both lower extremities amputated starting with the toes, then the feet and finally the leg above the knee. With each room change, there came a new challenge or a new evaluation. We removed dressings, evaluated vascular supply and made recommendations for each patient. With each week, I grew to know these patients and to learn to predict whether the wounds would heal, or an intervention was needed, or progression to limb amputation. Sometimes it wasn’t wonderful to tell a patient that he would lose his foot but a good amputation with a well-healed stump could mean a return to ambulation and increased freedom. It was the progression of things each week.

Moving toward the end of the hall

This week, we decided to divide the duties with the interns doing post op checks and the more senior residents examining those patients who needed evaluation for possible surgical interventions. I elected to see the last two patients who were bedridden and in isolation for MRSA (meth resistant stap aureus). I knew that these guys had extensive wounds that would take some time inspect, debride and re-dress. I loaded my pockets with enough bandages for the dressing change and left my coat on the cart outside of the door as I donned the yellow isolation gown, a mask , gloves and shoe covers. I greeted my first patient and set to work removing the old dressings.  We had ordered that dressings be changed every six hours on this patient but it was clear that his dressings were being changed daily instead of three times daily.  How was this wound going to heal? It’s the wet to dry dressings that debride the wound and help to clear the necrotic tissue that would promote healing.  I chatted with “George” as I completed the inspection and dressing change. I left my initials, the date and time on the outside of the dressing. If this was still here in the AM (I had planned to stop in early and check), I would be writing an incident report. If George was to keep his leg, this dressing needed to be changed. For George, a very pleasant gentleman who was post stroke, this was limb salvage.

The last room

I moved into Fred’s room after I cleaned up and washed my hands from George’s wounds. It was now well past dinner time and the sun was low in the sky. Fred’s bed was facing the beautiful setting sun. Fred had congestive heart failure, diabetes and emphysema. He was a small thing gentleman with bright blue eyes that still held a twinkle when you greeted him with “Semper Fi”. Fred had been a marine and by his looks, a real scrappy guy. I always chatted about baseball with him and he loved the company. Sometimes he sang “Take Me Out to the Ballgame” off key as I worked on his infected decubitus ulcers. Twice we had taken Fred to the OR for surgical debridement where we cleared away foul-smelling dead tissue down to the bone. Fred had little tissue left on any of his pressure points and had been failing rapidly.

Today, Fred appeared to be dozing quietly in the setting sun. I touched his hand which was wrinkled and warm. I noticed that Fred wasn’t breathing and had likely died a few minutes earlier. He looked peaceful and happy as the sun’s last rays of the day were settling on him. On the ball field, one of the local town teams was finishing up a game. Most likely, the last thing that Fred saw was his beloved baseball and a beautiful May sunset. To the man who had given so much so that I could come and dress his wounds, God had given one last baseball game in sunset.

There are thousands of veterans in hospitals around the country presently. They love company and they don’t care if you are not related to them. They are very appreciative of everything that we do for them. Many times, the interns and medical students would complain about wound checks but for me, they are the highlight of my week. I might make a difference that will allow a vet to keep his feet or I might be reminded of how special these guys are and why I love what I do and have the opportunity to do it because of them.

Do I really NEED an MCAT Review Course?

You have completed your pre-med coursework with no grade less than B+ and a majority of A grades. You feel that you have a solid grasp of the material and the concepts presented in your pre-med courses. Do you really “need” to take a review course for the Medical College Admissions Test (MCAT)? The answer to that question depends on whether or not you are good at solving the types of problems that are presented on the MCAT. If your knowledge base is good, then taking a review course that emphasizes knowledge refreshment is largely going to be a waste of money for you. If it’s been a few years since your pre-med coursework, then getting your knowledge base up to speed is your first priority and thus a knowledge upgrade type of review course may be the key to a strong score on this very important admissions test.

How are your problem-solving skills?

You can quickly find out how well you solve MCAT-type problems by downloading one of the retired exams and working the problems under actual testing conditions. If you are finding that you are struggling with these types of problems, then try to find a review course that gives you plenty of strategy and experience with problem-solving. Problem-solving is often the main gap in the education of most pre-med students. With many undergraduate institutions placing more emphasis on “rote memorization” rather than application of knowledge to problem-solving, pre-med students may have earned high grades in science coursework with little training in how to apply those skills to new situations. Even the so-called “ranked” universities can be seriously lacking in terms of making sure that students have problem-solving skills. Many times these skills are utilized most in coursework like Calculus and applied Differential Equations; courses that many students avoid because of rigor or lack of math background.

How are your reading skills?

In this age of electronic media at every corner, many students have lost the ability to produce (and evaluate) good writing. Many students view the analysis of literature, primary resources and scientific papers as the torture of producing research papers and as a “necessary evil” of obtaining an education. Many professors routinely pass out PowerPoint lecture slides that contain the bare minimum of facts/information that students attempt to memorize verbatim without regard to analysis or research beyond what they have been handed. These processes have tended to rob many students of the skills needed to evaluate information sources and information. While Wikipedia may give starting points for a wide variety of subject matter, many students will often use the “cut and paste” function for research paper writing rather than spend some time evaluating a cross section of resources. Reliance on quick media resources is a great starting point but this reliance can’t be the end point of your information evaluation and gathering skills. Learning how to evaluate the primary literature is a valuable skill that you should have acquired in your undergraduate training regardless of major course of study.

The sections of the MCAT – Biological Sciences

This section will test and evaluate your mastery of General Biology with some Organic Chemistry thrown in. While it may seem strange to put these two subjects together, organic chemistry is largely the most concept application course that is taught in chemistry. Organic Chemistry relies on your understanding of the chemical properties of carbon as an element to solving problems across a wide variety of conditions. Many students hit a major roadblock with organic chemistry because there are many problems that can be created to test your knowledge of carbon chemistry. Trying to sit and memorize every problem that you were presented with in organic chemistry is not going to be very helpful but making sure that you know the concepts of carbon and its chemistry will enable you to solve any problem that you are presented with.

In addition, many student mistakenly believe that they must “take a course” in every type of subject matter that is covered on the MCAT. This could not be further from the truth. A good comprehensive General Biology course will give you the knowledge foundation to apply concepts to the problems that the MCAT will present in Biology. You don’t need specific coursework but you DO need to be able to do some creative thinking in the application of your concepts to novel experiences. A good comprehensive General Biology course will cover physiology, botany, zoology and ecology. Thus, you don’t HAVE to be a biology major to have exposure to the subject matter but you do need to have a grasp of the concepts of a good comprehensive General Biology course. Being able to synthesize and build upon a basic knowledge base are the types of skills that you will use in medicine thus your ability to do these types of problems will be measured by the Biological Sciences section of the MCAT.

The sections of the MCAT – Physical Sciences

This section tests your ability to solve quantitative problems using concepts that you learned in General Chemistry and General Physics. These types of problems are often answered by being able to apply order of magnitude type strategies rather than working though an entire problem. Students who thoroughly know quantitative relationships presented in their coursework will tend to do well on this section. Between General Chemistry and General Physics, the quantitative relationships of many concepts can be probed and tested. It is practically impossible to rote memorize every type of problem that can be presented in these courses but having a sound knowledge of quantitative relationships in addition to being able to apply those relationships can bring success in this section.

The sections of the MCAT – Verbal Reasoning

This section of the MCAT can often be very difficult to improve or prepare for. Being able to analyze critically the reading passages from a wide variety of sources and disciplines generally takes years of careful practice and skill building. Preparation for this section should have been occurring over students previous years of study in practically every subject. College coursework in the humanities with strong achievement can also hone these skills. In addition, good readers are always good writers and thus, the writing section of the MCAT is likely going to mirror the Verbal Reasoning section of this exam. Can you consistently read and learn from your text books and journals? This is a very valuable skill to take into medical school with you as medicine will require a lifetime of learning and the acquisition of new knowledge that will be outside of a classroom.

Some final thoughts…

Finally, the review courses are expensive and time-consuming. You have already paid thousands of dollars in tuition and book purchases in order to master your coursework. Do you actually NEED to pay a few thousand more for a review course of that work? If you didn’t master what you needed the first time around or if you find from doing a few practice retired MCAT exams, you are struggling with this test, and then perhaps a review course can make a difference for you. You should thoroughly investigate the materials offered and you should thoroughly understand what the courses are offering for the fees that they charge. You should also be prepared to master some of the material on your own as many of these courses are taught by people who have a variable ability to teach others. Doing well on the Medical College Admissions Test may not translate into being able to teach others to do well on this exam.

The Medical College Admissions Test is one aspect of your application to medical school. This test requires solid and thorough familiarity with the mode of testing and a solid knowledge base that must be applied to the problems asked on this test. Several retakes of this test do not bode well for medical school admissions. You want to be prepared and take this test one time. With this test being administered 22 times annually, you also have more options in terms of being able to time your preparation for this exam. The important thing to realize is that you don’t want to take this test unless you are thoroughly prepared at your own pace. This is not the time to listen to your peers tell you how much or how little time they needed but the time to set the study schedule that works for you.

Burn Surgery

I was the resident in charge of the burn unit and working on my daily notes for the patients that were currently residing there. There was a 19-year-old who had suffered severe inhalational burns and brain damage after the carburetor that he was cleaning with gasoline caught fire from a static electricity spark. There was a 70-year-old who had fallen asleep with a lit cigarette and sustained 25% full thickness burns to his upper torso. There was a mother who had burned her hands and face when she opened the door to her house, smelled gas and pushed her children to safety just before her house exploded. All of these patients require intensive care, intensive wound management and attention to every detail of their progress and condition. Also, some of these patients were in the process of being grafted which required operative timing and preparation.

The call came in just before lunch that a 39-year-old highway construction worker was being flown in with 96% partial and full-thickness burns to his body. This man was working in a manhole when he accidently hit a steam pipe that ruptured. He was wearing steel-toed boots which kept his feet and lower legs from the burns but just about every place else on his body was burned. This would be a major trauma to this young man and this would predict months of recovery if he would be able to recover from such a traumatic blow. In the case of burns, the patient doesn’t stop in the Emergency Department but come immediately to the Burn Unit where the staff can start treatment as soon as possible. At stop in the Emergency Department would delay initiation of the treatment unnecessarily and would expose this patient to infection because the Burn Unit is far cleaner than an open Emergency Room. He would arrive in less than 30 minutes.

The nursing staff set up one of the evaluation rooms: scrubbed stainless steel tables lined with sterile liners and warm water for removal of any clothing that might be adherent to the skin. In the field, most paramedics know that burned clothing will hold heat and continue the burn process unless removed from the skin. They will make sure that any smoldering clothing is removed and will wrap the burns in sterile dressings and drapes. The patient’s airway will be protected and two large bore intravenous lines will be inserted so that fluids can be infused as quickly as possible. The paramedics had indicated that they had inserted three 16-guage lines into this patient and has already infused 1.5 liters of fluid. The patient was intubated, stripped of clothing and wrapped completely to prevent fluid and heat loss because of the burns. They had done an excellent job in the 15 minutes since the patient has been burned. They were 15 minutes out from the hospital.

The man arrived and we quickly set to work debriding any scorched skin and clothing from his wounds. I inserted a cordis intravenous line into his internal jugular vein for even more fluid infusion and extra IV access. We also induced a pharmacological coma for pain relief (about 60% or his burns were painful partial thickness and the other 30% were full-thickness (not painful but devastating). His face was swollen and red; his hair was gone; singed by the steam. It appeared that the pipe exploded, he inhaled the hot gas and turned to his left while covering his face. His left arm and back had the full thickness burns but his eyes were in good condition. I used an ultraviolet light with dye to assess corneal damage and found none. His ears were singed red with large blisters that wept fluid. His chest and legs had partial thickness burns that needed to be debrided too. Three nurses helped me start the initial debridement process while the respiratory therapist made sure that his ventilation was taken care of.

Full-thickness burns cause the skin to take on a leathery appearance. Since all layers of the skin are totally destroyed, this leathery eschar would need to be removed. Just under this layer would be a layer of ischemic damage that would be lost unless proper fluid resuscitation had been undertaken. Our patient had an IV rate of 1,950 ml/hr in the first 8 hours because of massive fluid loss. We didn’t want to get behind and cause further damage. After the first 8 hours, we cut the IV fluid rate back to 980 ml/hr for the next 16 hours. Overall, our estimate was that our patient was 31,000 ml of fluid down because of the extent of his burns. In addition, his body was massively stressed by the injury to his lungs and fluid loss from there. He was fortunate in that he had been in excellent health before this accident. We were able to hold blood pressure and urine output adequate in the first days after his accident.

My attending burn surgeon arrived after the patient had been in the unit for about 20 minutes. He helped with the debridement and wound evaluation. Our patient was fortunate that he didn’t need an escharotomy (incisions made to release burned skin so that the patient would be able to breathe/be ventilated). After 35-minutes, we had infused several liters of IV fluid, placed the patient in a pharmacological coma for pain relief, undertaken mechanical ventilation and cleaned/dressed his wounds. My preceptor surgeon and I sat down with the nurse assigned to the patient to plan for covering this patient beginning the next day. We also had antibiotics started and had placed a feeding tube for liquid nutrition which is so vitally important in burned patients. This young man would be in a hyperdynamic state with the ultimate demands on his body both physically and nutritionally. In addition, we would need to start to cover his burned skin as quickly as possible. Our first cover would be donated cadaver skin.

Cadaver skin would be a good cover to start with but the patient’s own skin would have to be harvested slowly as he healed. As soon as donor sites would become available, we would use them and would harvest. On our first assessment, the backs of both calves were not burned along with his right upper posterior thigh. These would be harvested first. We would start on hospital day 2, harvesting skin from the donor site and covering the full thickness burned areas with cadaver skin. The patient’s own skin would be meshed and would be used to cover the partial thickness areas. We would also perform a tracheostomy as he would require mechanical ventilation at least two week and possibly three or more. He had been fortunate in that he had not inhaled carbon monoxide but he did inhale heated gases which had caused some lung damage. We hoped that this would heal and we would come to see that this damage was minimal in the next week.

At the first surgery, our team consisted of seven people: the attending surgeon, the chief resident, an intern, a nurse practitioner and three medical students. Our attending surgeon set about further debriding the burned areas after anesthesia had been induced. I performed the tracheostomy creation while the intern and nurse practitioner harvested and meshed skin for beginning the coverage. Once the recipient sites had been properly debrided and prepared, the meshed skin was applied with everyone having an opportunity to do some suturing. In the coming weeks, he would undergo more of these coverage procedures as his body rejected the cadaver skin and the donor site would allow more harvest. In all, it took about three weeks to get his would covered with his skin and to keep the donor sites healthy and thriving.

In addition to coverage, keeping infection at bay and nutrition, we had the challenge of pain relief. At first, we kept the patient strongly sedated. As his lungs began to heal, we gradually cut back on the sedation to allow him to breathe on his own. After 2 ½ weeks, he was doing well and we removed mechanical ventilation. At this point, he was able to talk with his family by covering his tracheostomy tube. With is grafts and tubes, we could see that the greatest joy for this young man was having his family gathered round for encouragement. When he was pharmacologically comatose, his wife made tapes of their children singing for their father. The nurses would play these during the daily would care and dressing changes. Any person who entered his warm room (to prevent heat loss) would have to dress in sterile garb and wear a mask. In addition, the massive facial swelling started to resolve after about a week so that his children could see him from the door. His wife had carefully prepared them for the sight of seeing their father in bandages from head to toe.

When I left my burn rotation after two months, I would stop in to see him from time to time. He said some of his first memories had been of my voice and the staff speaking with him and encouraging him. During his dressing changes, we had sung (recommended by our music therapist) along with his children and that this had been of great comfort to him. He also said that he didn’t remember having a huge amount of pain until near the end of his recovery when he started to have difficulty with some mild contractures. He continued physical therapy and when I saw him one year later, he looked fantastic. One could tell that his arms and torso had been burned but the plastic and reconstructive work that had been done on his face and ears was very nice. He was upbeat and looking forward to changing careers. He had decided to go back to school to get a degree in counseling so that he could help other burned patients. The staff in the burn unit said that he would often visit young men who were burned to tell them his story as he was recovering. He said that he thought that recovery for a younger man was especially difficult.

I still remember what this gentleman looked like when he came in and often had to look at the portrait that his wife had supplied so that we knew what he had looked like before his accident. We also saw the incredible love and support that came from his family and parents. He had brothers and sisters who took turns sitting with him and reading to him while he was comatose. This was a very close-knit family who prays for and supports each other. We saw the incredible determination in this patient and in others that have undergone this type of extreme stress and life adjustment. All of these patients taught me the value of appreciating how easy it is for me to do something as simple as walk across a parking lot or sip a cup of coffee in the morning. Often it takes weeks and months for a burned patient to even get out of bed.

And finally, taking care of burned patients is the ultimate team effort. The surgical procedures take multiple hands and personnel who have the goal of getting the burned patients covered as soon as possible. In addition, the nurses, nursing assistants and environmental services personnel in the burn units are invaluable. They have some of the strongest work ethics of any area of the hospital. If the environmental services folks were not dedicated to their jobs and doing a job well, the infection rate in these units starts to climb. Every single person “counts” when it comes to getting this massively injured patients back to health.

Working and college at the same time…

Potential lethal combination?

Many students find themselves in the unenviable position of HAVING to work and attend college at the same time. This a a potentially lethal combination in many ways. First of all, when something starts to suffer, it generally isn’t the job and second, burnout is a strong possibility. Both of these problems can be potentially avoided if you cut back on your coursework if you find that you must work full-time. If you are a full-time employee at most jobs, you have minimal time to study in between and thus, you can’t take on a full-time course load that includes pre-med lab courses. Decide that you are going to take your time and do well in your courses while leaving yourself plenty of time to rest from both coursework and employment.  No medical school admissions committee is going to give you “brownie points” for trying to do a full-time course load along with full-time employment especially if your uGPA (or postbacc) work has suffered.

Recharging your batteries

You need time to digest and assimilate the material that you are learning in your pre-med coursework. Rushing through these classes with last minute “cramming” is not going to leave you with enough time to get the material in your long-term memory so that you can apply it on the Medical College Admissions Test. You need to be able to see the subtleties of what you are studying in addition to having some time to let your brain just rest. Again, rushing through your coursework makes MCAT review on the other end a total chore instead of a progressive process that will lead to success. Take your time, recharge your brain (even take a semester off if necessary) and then come back refreshed and ready to work at very high level.

Damage control

If you are retaking courses or attempting to take additional postbacc work to enhance your application, you need to do well without exception. You can’t keep posting mediocre grades and retaking courses with the expectation that eventually you will get that A and get into medical school. If you have significant prior poor coursework to overcome, take your time and remediate one course at at time. Pair a more demanding course like Physics with something less demanding like English/Psychology. Again, if you have prior poor coursework, you can’t afford to either do poorly in your recent coursework or drop courses because you have overloaded yourself. Slow, steady excellence will bring the success that you seek.

Keeping some perspective

If you have a family to support and take care of, be sure that you allow plenty of time for them. Working, attending class and then diving for a nap on the sofa or heading for bed is not going to do much for your relationship with your loved ones. They need your undivided attention and you need to interact with them for your sanity too. Let your loved ones be your much-needed and much-desired break from your schedule. They generally don’t expect your to be on your best behavior but only want you in your basic form. Allow them to see you, hang out with you and take you away from the grind of work/study on a regular basis. You grades will be better, you will be happier and you can keep yourself reminded of why you seek your goals in the first place.

Setting goals and achieving them

The whole key to finding success in the medical school application process is keeping your eye firmly on your long-term goals. I have stated in other posts that the process is like having 100 pounds of weight to lose. It isn’t going to happen overnight and you must take small steps on a daily basis to stay on track. It’s easy to get off track by the demands of work but you can’t achieve your goals by letting this happen. This means total organization and total commitment to the task at hand, be it work your studies.

If you are at work, you give your work your full attention. When you attend class, you give your classwork the attention that it demands. It’s neat to be able to multi-task but most people are not able to work at a high level and achieve those A grades that you need for medical school admission at the same time. Again, if you work full-time, don’t expect to attend school full-time. If you attend school full-time, don’t expect to work full-time. The end result is that you wind up doing both things at a mediocre level which won’t allow you to achieve your goals.

Finally…

There are no “points” for getting this process “almost” right. The level of academic achievement that is demanded of a potential medical student is getting higher every year. The MCAT is getting more competitive as many students are taking prep courses and spending more time preparing for this exam. You can’t expect to be competitive next year with this year’s work because the bar will move higher. If you are attempting to upgrade your credentials, then you need to do a complete overhaul and put up some good academics (even one course is better than nothing).

Don’t expect to be the exception to any of the rules in this process. You are not generally in a position to be objective about yourself and your abilities. Make sure that you get some honest and objective advice. Trying to self-evaluate is like asking your Mum if you are a great kid. Of course, she’s going to answer in the affirmative but it’s far better to get someone who doesn’t know you, to look over your things (like a good academic adviser who knows the pre-med climate). Allow plenty of time for getting your work done at a high level and you will see movement toward your goals without sacrificing your employment records, your sanity or your soul.

Venting

I remember doing a case with one of my favorite attendings. This person was a colo-rectal surgeon who would talk through out the case. I was an intern at the time but I remember him saying that his talking was just “venting” and that he hoped it wouldn’t bother me.  I looked at him with amazement because his “venting” was putting to word, many of the thoughts that I was having as we went through the case.  I had felt honored to be able to scrub this case with him because usually, one of the chief residents would have taken this case but everyone was tied up and thus I asked if he would mind if I scrubbed with him. He said that he was happy to have me there.

The Teaching

He explained the fine technical points from skin to skin allowing me to mirror many of the things that he was doing. He pointed out anatomy and explained why he loved mobilizing the rectum and why colo-rectal surgery was always a rush for him. I was mesmerized by how fascinating going through this case was.  In short, I was being treated to the first of many one-on-one mentor-trainee sessions with this young colo-rectal surgeon. His enthusiasm for his craft and his ability to teach me what he found amazing was delightful. From that point on, I always held a special reverence for colo-rectal surgery.

He marked out the incision line for me and handed me the scalpel. He showed me how to make sure I had just the proper amount of tension and counter tension as we entered the abdominal cavity. He showed me how to explore the abdominal cavity and how to palpate the liver for cancer mets. He pointed out the fine points of living anatomy as we located the tumor that we knew we would be able to resect.

His next lesson was how to put two ends of bowel together. Today, he said, we would do a hand-sewn anastomosis. Sure the stapler is nice to use but once in a while, a hand sewn anastomosis is a good thing to do. He showed me how to resect the section of colon leaving plenty of margin and the fine technique of location the numerous vessels that fed this wonderful organ. Again, the living anatomy is a wonder to behold and being able to see how this tumor would be removed was great.

We carefully sewed the remaining ends of  the colon together using Lembert stitching. He talked, he vented and I watched and listened. Together we completed the case and at that moment, I understood why operating on the colon is both fun and something of a challenge. I had to always keep the anatomy in mind, the technique perfect and move in an efficient manner. I remember laughing at him describing the “big honking vessels” that we would be ligating and why one doesn’t want to even think about ties not holding. He said that when he started residency, he would lose sleep over thinking that his ties were not secure.

Technique

One of the great things about doing a case with an attending like my colo-rectal professor is that he does vent the things that go over and over in my mind. Are my ties secure with every knot? Are my hands going in the right direction? Have I identified the vessels correctly and ligated them using proper technique? After all, surgery is a practice which has to take place over and over for years. Even now, year’s later, when I don’t have to think about every suture or every tie, I still mentally revisit some of the cases that were turning points in my training for various reasons.

There isn’t anything magical about surgical technique but there is something magical about having the knowledge, background and education to use that technique properly. This is what I learned across the table from my colo-rectal professor. He vented and I listened to all of those pearls that he would verbalize. For me, his venting was golden and some of the best teaching that I ever encountered. He was an extraordinary teacher and he would often tell us that if he was in our position, his venting would drive him crazy. Well, that was never the case for me. His venting made me see the artistry of colo-rectal surgery and why having impeccable technique was paramount for these patients.

The best teaching

It’s no accident that the lessons that I remember best came from my first two years of surgery. By the time one reaches third year, there is a comfort level with being in the operating room. The lessons of my first two years were magical and have not left me. Those late night cases with the chief residents, moving through the abdominal cavity on a laparoscopic case or the first time I was able to close the abdominal cavity and feel confident that I had done this correctly, were memorable for me.

I was fortunate to be exposed to some of the greatest professors of surgery under a variety of circumstances in addition to having some of the best chief residents who were willing to give me their best too. There is much joy in this type of learning and a great amount of joy in venting.

Getting Through The Semesters (or what if I Fail Something?)

“The Thrill of Victory or the Agony of Defeat”

The Drama of Human Competition as the opening lines of ABCs “Wide World of Sports” promised. By now, many students have had their first blocks of exams in medical school. Some people have done very well and some people have “breathed a sigh of relief” that they passed and some people have not passed one or or more of their exams. To fail an exam at this stage can be a huge personal blow but your actions after discovering that you have not passed (I am going to avoid the word “failure” here) are critical to figuring out what you need to do to get “above the yellow line”. Sure you NEED to do a bit or mourning in terms of the loss of those wonderful feelings that infused during orientation week but don’t let the mourning phase go on longer than a couple of minutes. Replace mourning with a very objective strategical look at what might have gone wrong and how you are going to fix the situation.

There is something in medical school that will throw every person. It may be that first round of exams, that USMLE score or a patient contact that just did go well. The important thing is that out of every experience, good or bad, you learn something about yourself and what you are capable of achieving. It is out of experience that you will learn to treat your future patients so let your experience become your teacher and move forward from here. Not passing an exam just doesn’t feel good and can play with your “head” in terms of how your look at your future. My point here is that nothing except that round of exams is over at this point. You mourn a bit and then you push forward because (and I am not wrong on this), the material for the next round of exams is already upon you.

As soon as you know that anything has not gone well for you academically, ask for help. Your first action should be reviewing the test and trying to figure out where you went wrong. Do you need to rely on more detail? Did you move too fast and not answer the question that was asked? Did you neglect to read every answer choice with a more correct answer further down? Did you not fully understand the material? Were you distracted by something outside of school such as a relationship or illness and not put in enough time studying? In short, try to figure out what went wrong and take steps to make sure that you don’t repeat your mistakes.

What if I fail a whole course, like Biochemistry?

The consequences of failing an entire course in medical school are largely school-dependent. Some schools will want you to retake only the material that you did not pass while others will have you go through an entire summer remediation course. In any event, look at your remediation/retesting as an opportunity to hone this material well. You definitely want a strong knowledge base for your upcoming classes and you will have made some steps toward review in terms of preparation for USMLE. In this light, having to retake or remediate is not totally the worst situation that you can find yourself going through.

Plunge into your review with total concentration on the subject at hand. If you have one course or one area of subject matter, this is easier than if you have multiple subjects to remediate. Your only resolve in this situation is to not miss this golden opportunity to thoroughly master this material. You are not a “lesser person” because you need a second review and keep in mind, that you are reviewing at this point. In most cases, you have learned the material on the first shot but this review gives you insight into the material that you likely previously missed.

I am always more concerned about those students who “barely” passed than the students who failed and are re-mediating. In most cases, the student who re-mediates does not carry a knowledge gap forward while the student who barely passed likely has gaps in their knowledge base. It is those who barely pass that will need the most intensive review and preparation for board examinations.  I always encourage students who scored below an 80% to study for and take any optional shelf subject exams if offered by their school. These shelf exams can pinpoint knowledge gaps that can be filled in before taking Step I.

Class Attendance – Is this time well spent for me? 

In some medical schools, class attendance is not mandatory. If this is the case, and you ran out of study time, try figuring out if there is one day a week that you can stay home and study the material using note service/lecture tapes or vids/textbook and syllabus reading. Many students do not attend class and find that home (or away from school study) works best for them. This may work for you but be careful if you have too many distractions at home or find that not attending class puts you behind. (Getting behind in medical school is deadly.)

If your work is not detailed enough, figure out which classes do not require the detail and which ones DO require more detailed study. In short, give each course what it demands. Many schools have integrated courses that definitely demand loads of detailed work coupled with “professional-type” courses like Practice of Medicine that are more performance-based. Try to look at your coursework from this perspective and see if you can give your integrated course a bit more time and your performance course a bit less time.

Another problem is that in many first year courses, the load of information can seem overwhelming. Resist the urge to dwell on what seems overwhelming and nibble away a chunk at a time. I always remember that scene in the movie “Shawshank Redemption” where the protagonist chips away at the prison wall over the course of 17 years with a small rock hammer. Eventually, he gets through the wall and escapes. Extreme but I think you get my drift in terms of divide your work into manageable chunks and stay on course. Keep moving forward because you can only affect what is happening now and use that to impact the future. Weekends are your friend because you can breathe a bit, relax a bit and catch up if you have fallen a bit behind your class. In the middle of the week, go to where the class is and use the weekend to “catch up”.

Wasting time and less efficient practices

I discourage students from recopying notes as a means of study. When you have volumes of material and information, you can become more of an excellent clerk in terms of producing a beautiful set of notes that you have not mastered. Organizing your material is good (can be done with a highlighter or in the margins of your notebook) but total recopying of every word may be too time consuming and not as beneficial as when you were an undergraduate student with less volume. You may need to review the material and then constantly question yourself or recite the material back to yourself rather than a complete recopy. If you can recopy your work in an efficient manner while learning and your grades are good, then recopying is working for you and don’t change your strategy.

Another problem that can interfere with some freshman medical students is feeling that they “need” to study for boards. You don’t need to take time away from your coursework mastery to do board study at this point in your career. If you absolutely feel that you NEED to do some board study, then do it during the summer between your first and second year but the best preparation for boards is to thoroughly master your coursework and then study for boards at the end of your second year. You cannot “review” what you have not “learned” in the first place. Don’t take valuable coursework study time to do board study. Board review books are most useful because they summarize material but most medical school courses require the details and not summaries. Beware of the “I am going to use a review book to summarize” method of study because it might work against you in terms of you not getting enough of the details to pass your course. The other extreme is to attempt to memorize the textbook which is most likely too much detail. In short, strike a happy medium that will work for you.

Don’t be afraid (or ashamed) to consult your instructor or your dean if you are struggling. Not to reach out for help (especially because of the amount of money that you are paying for your school tuition) is not wise. It really looks great to a residency program director to see comments from your dean or professor that state that you were able to overcome a deficiency and excel. These types of comments indicate excellent problem-solving skills which are highly prized in a physician.

Finally, tune out the boasting of your classmates who say that they “didn’t study” and “aced” their exams. They are lying period. You have to do what you NEED to do for yourself. Congratulate them for being so “brilliant” and don’t waste a second of your precious time worrying that you are somehow deficient because you studied like a demon and didn’t do so well. There is nothing wrong with you that correcting your study strategy will not solve. Just don’t add “questioning your worth” to your list of things to overcome. It isn’t necessary and it won’t get the job done.

Striking a Balance

Finally, one key aspect of medical school, residency and the eventual practice of medicine is that you will have to constantly “strike a balance” between study, personal life and professional obligations. The first semester of medical school will definitely test your resolve to keep working away at your studies until you get them mastered but this should not be at the cost of your personal integrity or sanity. Try to find ways of incorporating some stress relief (physical exercise) and socialization (away from your classmates) into your life. Nothing, including the practice of medicine is one-dimensional and there needs to be balance.

For example, if you are studying in the library and know that you won’t make it to the gym, try to walk up at least 8 floors of steps on the days that you don’t get to the gym. Take 10 minutes and take a brisk walk around the corridors to get your brain relaxed before you keep “grinding” away at your study materials. Study and pace at the same time while reciting the material to yourself in your own words. Try making some study-drill tapes and drill yourself while you are on the elliptical trainer/treadmill in the gym. Finally, picture that professor’s head when you are doing your bicep curls or on the fly machine and pound things out. You will be more relaxed, less stressed and more efficient in your studies. In addition, you can enjoy eating without worrying about gaining weight.

Statistics (and odds) state that if you were accepted to medical school, you will get through the four years successfully. Some people make the adjustment to the rigors of medical school academics faster than others but trust yourself enough to know that you will get the job done. There is very little difference in intellect between the person who graduates first in their medical school class and last in their medical school class. Residency program directors know this which is why the person who graduates last in their class is still called “Doctor”. Run your own race and get what you need.

Failing USMLE Step I and how to get beyond it.

For many second year medical students, the prospect of taking USMLE Step 1 is looming “large” on the horizon. You have completed three semesters of pre-clinical science and the first step toward licensure as a physician rapidly approaches. Along with the exam and its preparation comes the thought of what will happen if you fail this exam. Statistics show that somewhere around 1/4th of people who take this exam, will not pass on the first try. While failing this exam happens, it’s better to consider that 3/4ths of the people who take this exam will pass.

So what happens if I fail?

If you fail, you generally have the option of re-taking the exam. Most medical schools in this country will have you do some remedial work and will have you sit for the exam a second time with little consequences (from the school’s standpoint) other than damage to your ego. If you fail Step I once, you can still practice medicine and you can still graduate from medical school. You have likely knocked yourself out of the moderately competitive to competitive specialties but you can still have a very satisfying career in the less competitive specialties.

The first thing that you have to do, if you open your test score report and find that you have not passed, is immediately figure out where you were deficient. The USMLE score report comes with a breakdown of where you lost points. You should immediately start your review in your weakest subjects/items. The next thing that you want to do is speak with your Dean of Education so that you can get an idea of the time frame that you have to submit a passing score. Some schools want a passing score on Step I before you can begin third year clinical rotations and some will allow you to complete a rotation that you have started.

Don’t make the grave mistake of attempting to do clinicals and study for Step I. If you failed this exam once, you need to put your entire attention into a thorough and adequate preparation for this exam. You can’t afford two failing scores here and thus, drop/delay your clinical rotations until you have passed Step I. It’s not going to be easy or quick it terms of preparing for a retake so don’t try to rush this process. As bad as one failing score looks, two failing scores can really kill your chances for a solid residency match.

Get the idea out of your head that you “are not good at standardized tests” or “that your career in medicine” is over. You just cannot afford this type of thinking. Your whole attitude needs to be focused on the task at hand, which is, passing Step I. If you cannot focus for a couple of days, then take that time to relax but depending on your school’s schedule, you likely need to get back into the study mode fairly quickly. Take some time to come to terms with your non-passing score but don’t let a non-pass set you into a “tail-spin” that prevents you from doing your best on a second attempt.

The other mistake that many medical students will make is believing that because they were able to do well in their medical school coursework, they are a “cinch” to pass Step I. This is not always the case as since I have been involved in academic medicine, it’s not always the students with the weaker academic records that fail but those who have a “false sense of security” because of their academic record. Make no mistake, Step I takes some preparation and review no matter how you scored in your coursework.

Another thing that you likely need to do is enlist the assistance of your Dean of Academic Affairs. There is no medical school in this country that has never had a student fail Step I. Your Dean of Academic Affairs can offer some assistance in getting your study methods on track. There may be great resources available at your school that you will be able to access since you have a failure on Step I. Be sure to find every resource (many likely free) that is available to you.

Another mistake that many students make is looking at the pass rates of a previous class and thinking that there is no way that you can fail. If the Class of 2008 has a 100% pass rate and you are the only member of the Class of 2009 that fails, that 2008 pass rate hasn’t helped you much. Passing or failing Step I is a personal matter and not class (or school) dependent. Either you have prepared well and performed well or you have not. These are individual characteristics and not school characteristics.

What kind of residency can I get with a failure on Step I?

If you pass on the second try, score some solid performances in your clinical rotations and perform well on Step II, you have a shot at a very good residency. No, you are likely not going to match into Derm, Ortho, Rads and Ophtho but you have a shot at solid programs in just about everything else if you post a good performance in things after your failure. Sure, it’s not the best situation that you have failed this very important exam but your career is not over. There is still a substantial amount of “medical school” in front of you that will provide an ample opportunity to show that a non-pass on Step I (on your first attempt) was an aberration rather than a characteristic of how you perform. Some options may not be there for you but more options exist than you would believe. You simply have to get this behind you and move on with what you have left.

Getting and keeping your head together

Again, your first priority is to do whatever you need to do to pass this exam. You cannot afford to wallow in blame but need to gather your reserves and get busy. Sure, it seems like everyone you know passed without difficulty but you didn’t pass and you have to pass this exam. The thing “is what it is”. The reality is that while this hurts; it’s not fatal. You can take this opportunity to learn what kind of reserve you have and how to thrive in adversity. These are characteristics that any residency program director would be happy to have in an incoming resident. Get your thinking together; enlist the help of your Deans and get this exam behind you.  Performance on one license exam does not define your entire medical career unless you allow this performance to define your and your career. Sure, it’s important but in terms of percentages, most people pass comfortably on the next try and move on to good clinical rotations and residency spots.

Final Thoughts

If you find that you failed Step I, get your resolve together to:

• Get in contact with your academic Dean and Dean of Students.
• Find out what options are there for you to allow you to focus on getting ready for your retake.
• Put that non-pass into perspective and behind you; what have you learned “not” to do?
• Get the idea that your “medical career is over” and that you can’t match into a good residency program out of your head.
• Prepare efficiently and properly so that you do not find yourself failing your re-take (or any other licence step ) exam.

This is not about you as a person, physician or anything else. You simply didn’t pass Step I and you resolve to prepare and pass on the retake.

Playing the Waiting Game and Keeping Your Sanity

Timing

You scrambled around and made sure that every one of your writers of your letters of recommendation did their respective jobs. You started your Personal Statement early and left plenty of time for editing and corrections. You started to fill out your AMCAS application as soon as it was available and you made sure that there were no mistakes. Finally, on the first day that you could, you pushed the submit button and the “waiting game” started. You had heard that in every circumstance, early application is the best strategy for success in getting into medical school. So now, you find that it’s early summer, school is out, and you are in for the wait.

Starting the Wait

Your next hurdle is to receive word that your AMCAS is verified. This can take six weeks or more if there were no mistakes or lost transcripts and can often take much longer if things are not moving efficiently. This step has to happen and it can cause worry if things are delayed. I can tell you that, in terms of medical schools, early summer is a non-time in terms of admissions. Most of our time is spent on getting the current class underway and gearing up for the start of receipt of new applications. For us, that early lag of time between when you can submit your application and verification is vacation time, organization time and just plain much-needed down time for us in terms of application review. It is also the time when we try to put the finishing touches on the class that is set for the new year.

The best strategy for you at this period is to make a folder for each school that you have applied to. In this folder, you will place copies of your personal statement, copies of any completed secondary applications one they have been received and completed and copies of any correspondence that you receive from that school. You can also put an envelop on the front of the folder with a copy of your itinerary once you have made travel plans for your interview. In any event, start making the folders and securing a safe place for them.

The next thing to do is make and Excel spreadsheet. On that sheet, you should make a book for each school that you have applied to. You will eventually log every date and every receipt of correspondence that you will receive. You columns should go something like date received, date sent, and date of school’s receipt. (Needless to say, anything that you send to a school should be sent by certified mail with receipt notification). Repository services such as Interfolio will also post dates of when they send your materials and when they were received. You definitely want to make sure that you keep your application materials and correspondence with each school very organized and safe.

Plan B

Plan B is what you will do if you are not accepted. In the business of medical school acceptance, nothing is a certainly except you won’t get accepted to a school if you don’t apply there. Acceptance, even if you have submitted an application with a 4.0 uGPA and 45 MCAT is not assured for anyone. It is wise to have a carefully though out and planned Plan B. From experience -mine and others- the more elaborate and complete your Plan B, the less chance you will have to use it. Start planning and working on you Plan B.

Financial Aid Forms

Right after you have submitted your AMCAS, you should begin and complete your FAFSA forms. You will need to obtain a financial aid transcript from every school that you have attended whether or not you received financial aid.  If you are not applying for scholarship or financial aid for medical school, you can skip this step.

When you complete your FAFSA, have the results sent to every school that you have applied to. This will save you time in the long run. If you are not accepted, having your financial aid information sent is not going to make a difference one way or the other. If you are accepted late, having your financial aid information already in place can save plenty of headache when school starts.

Senior Year

If you are an undergraduate, you want to plan a strong senior year. I know that “senioritis” sets in and you are tempted to want to coast because you are done with MCAT and done with the majority of your courses but don’t do this. Take some seminar courses and expand your knowledge base or take some research courses and pick up some valuable skills. My senior year of university was spent writing and presenting my honors thesis work. This was actually great experience for me and propelled me into the world of research scholarship. Use that senior year to shore up any possible deficiencies that you might have and to finish strong.

This is also a prime time to begin a solid exercise program. My biggest regret in medical school was that I didn’t stay in good physical condition. If I had kept up with my conditioning, I would have been an even more efficient student and a student with far less stress. Take this time to start and hone a solid aerobic exercise system that you can complete in 30 minutes to 1 hour each day. It can be as simple as taking three 10-minute brisk walks or climbing a couple of floors of stairs until you work up to 14 floors daily (only up direction counts). Even today, I make sure that I do at least 14 floors up every day. I can find steps pretty easily and do a couple of floors between cases or when I need a break from my desk.

Early Fall

By this time, you should be keeping your senior coursework strong and completing all secondary applications within one week of receiving them. Another thing that you need to do is go to a professional photographer and have some professional head shots taken of you in your interview attire. You will need these for many secondary applications and you will need them later for things like USMLE application. Don’t use a cheap “Passport photo” service. These cheap services will take photos that make you look like you have been in prison. Use a professional photographer and groom yourself as if you were going for interview. That secondary application should look polished and professional. Once you have chosen a good photo from the proofs, have several passport-sized sheets made and keep these in a safe place.

Again, as soon as you complete and post a secondary, make a copy and place this in the folder for that school. It’s a good idea to make a copy of everything that pertains to each school including things from their website (names of deans of admissions, names of admission coordinators) along with dates of any phone conversations. Also place copies of any e-mails that you have received for each school.

Interview Time

Most schools spend July and August reviewing applications and interviewing Early Decision applicants. You can expect to receive notification that you are complete but not much more information from your schools. Early Decision applicants have to be notified by September 1 so their applications are processed first. After the first couple of weeks of September, some of the earliest regular applicants may be notified of acceptance by some schools. If you receive a notification of invitation to interview at this time, this is great but don’t read anything into not receiving an invitation to interview. At this point, it is way early and you should be either working on Plan B or working diligently on your coursework. In short, don’t start obsessing about timing.

Many schools will not even begin interview session until late October and early November. Again, if you applied in early June, it will have been a long time. Don’t get crazy and don’t begin to call schools. If you have received a “complete” notice, then you wait. Find something else to do. If you have an interview notification, then work on your travel plans and logistics. Elsewhere on this blog, you will find posts about traveling to interview.

If you haven’t heard from any school by the end of October, consider applying to more schools. If you were in the very early applicants, you may need to broaden the number of schools that you have applied to. A major mistake that many applicants make is overestimating their competitiveness for medical school. If you are not securely above the averages for matriculants (uGPA 3.65 and MCAT 31) then you likely need to add more schools. If you are above those averages, you can hold but you probably should have head from schools by now. If not, make sure that your application materials have arrived.

Holiday Time

You applied early and haven’t received any interview notifications. Yes, it’s easy to fall into the trap of being depressed  but this is the time to plunge into the holidays and not get insane. Yes, I know that it’s only your future here but you cannot do anything more at this point. I will repeat in all caps for emphasis, YOU CANNOT DO ANYTHING MORE AT THIS POINT. If your application is complete then you have to wait. It’s a good time to plan your trip home for the holidays and take a breather from coursework.

January and February

These are very heavy interview months. You may find that the interview invitations will roll in at this time. Again, there is still plenty of time to receive an interview and receive an acceptance. This is also a time when many of the early interviewers will begin to receive acceptances. If you have done a couple of interviews but received no acceptance, don’t panic here either. Again, work on and finalize your Plan B.

If you are a dedicated reader of The Student Doctor Network, don’t obsess over the fact that others have been accepted but you are still waiting. Timing is out of your control and dependent on things like the number of applications received by the schools that you have applied to and the competitiveness of those applications. The only thing that you can do at this point is WAIT (dread).

March and April

By the beginning of April, some folks will find themselves on wait lists and without an acceptance. This is not entirely a bad situation though you may want to make a decision as to whether you will begin to collect the things you need for reapplication. If you need to do things like re-take the MCAT, you need to have gotten started on your study and planning for the test. You can’t wait too late and you can’t do a re-take without some significant review and preparation. The worst thing that you can do is post an MCAT retake with a mediocre score.

If you are on a wait list, remember that there is a huge wait list movement on and after May 15th. May 15th is the date when people cannot hold multiple acceptances. I always advise folks to release acceptances as soon as they have either been accepted by their first choice or when they have made the decision as to where they want to attend. I released my acceptances by the third week of February because I had made my decision. I am sure that five people were grateful that I did that because they were able to get in that year.

May and later

In general, after May 15th, you are not likely going to gain acceptance. There are exceptions, especially the schools with rolling admissions but by this time, you should either have an acceptance or gathered your materials for reapplication. You can look at my previous post on when to give up on application to medical school but if you don’t have an acceptance by now, you likely need to take an objective look at your competitiveness and do some application upgrading.

If you need more coursework, this is a good time to get registered for post bacc work. If you are planning to enter a SMP (Special Masters Program), then you need to get busy fast. These SMP programs have deadlines too. In short, these may become your new Plan B and you need to get to work. If you are on a waitlist at this point, it will not hurt you to go ahead and plan on reapplying. Sure, you will lose the money of submitting your application but if you are not accepted off of a wait list, you will be happy that you reapplied early.

If you reapply, change everything that you can change about your application. Do not apply to the same schools with the same application materials. We do compare old and new applications. If you were unsuccessful and submit the same unsuccessful application materials, you are most likely not going to be successful next year either. The average matriculant uGPA and MCAT scores have always gone up. Also, unless a school tells you that you need more extracurricular activity, you likely don’t need to add more here either.

Finally

You may want to look into the following:

• Getting the services of a professional pre-med counselor. For nontraditional applicants who have been unsuccessful, this is money that will be well spent.
• Taking more undergraduate coursework to raise your uGPA. If you are significantly below 3.5, you likely need a year or two of more coursework.
• If you have an MCAT score below 28, you need a re-take period if you are applying to allopathic medical schools.
• Making sure that you have applied to a wide range of schools. If you only applied to schools in the Northeast, you may want to go out of that region. You need a minimum of 10 schools if your are a strong applicant and 15 to 20 if you are less than competitive.
• Don’t thumb your nose at osteopathic medical schools. If you are under the averages for allopathic but your uGPA is above 3.2 and MCAT above 27 but less than 30, you stand a good shot at osteopathic medicine. If you get into osteopathic medical school, you can have the same career as attending allopathic medical school. If you want to be a physician, they are definitely the way to go.

Why I chose Surgery (Part 1 and Part 2)

Part I (an earlier post)

I can vividly remember starting my third year of medical school. My school chose our third-year schedules for us and I remember some of the angst of my fellow classmates when our schedules were posted during the summer between our second and third years. I was in the midst of a wonderful Pathology fellowship that I had received for scoring very high in my Pathology course. I was assigned to various Medical Examiners offices and to the Pathology Departments of a couple of very large teaching hospitals. I had been spending the summer doing everything from crime scene investigation to transfusion medicine to bone marrow transplant. It had been a great summer. I was very strongly considering Pathology and Transfusion Medicine as my specialty.

I stopped by my Dean of Academic Affairs office and was told to wait for my USMLE Step I scores. The school had received them before I had received them. I took a deep breath because I really hadn’t prepared myself for facing the prospect that I might have failed that test. I sat in a chair outside the Dean’s inner office and ran a couple of scenarios as to what I would do if I had failed. I would quickly sign up for a retest and I would only miss one rotation at the start of third year. Since I was doing Pathology, I could study in between cases and get my preceptors to help me with covering the material.

The Dean came out and handed me a sheet of paper. I had to just sit there in disbelief. Not only had I passed, I had done extremely well. I was on my way. It was hard to hold back the tears of joy because I had studied about two and a half weeks for Step I. My fellowship had the requirement that I take Step I by the second week in May and my last exam from second year was on April 28th. I would be starting third year and I would be starting third year on Pediatrics with one of my best friends as my rotation partner. Life was good… I found out later that two people from my class did not pass USMLE Step I. It was very sad because one girl ran down the hall screaming and sobbing when she received her score. That put loads of people on edge.

I started third year on Pediatrics. It was a good rotation and I received Honors. I really enjoyed taking care of patients and I was very popular with the residents because I could place IVs and draw blood. I had also spent loads of time with an excellent pediatric pathologist so I knew my congenital defects inside and out. I could interpret cath reports and I was quite comfortable in the Pediatric Intensive Care Unit. I had been a Pediatric-Perinatal Respiratory Therapist before starting medical school so the interns found me quite useful.

My second rotation was Psychiatry. This was one of my best required clerkships. I knew that I wasn’t going into Psychiatry (you know these things early) so I was free to enjoy the rotation and pick up anything that I could. My preceptor was an excellent Consultation-Liaison Psychiatrist who exposed us to everything from the wards for the criminally insane to hard-core substance abusers to schizophrenics and other stuff. I earned another Honors grade and got some excellent experience. I learned above all that I was not crazy, my friends are not crazy because I spent loads of “quality time” around people who were genuine crazy.

My third rotation was Family Medicine. I had a great preceptor who even delivered babies. This rotatations was entirely office based but I learned to do prenatal exams and care for entire families. I also learned how and when to refer which is great stuff to know. My preceptor was extremely brainy and “pimped” me on just about everything. Turns out this was a good test for USMLE Step II because we either discussed or I had to report on most everything in Family Medicine that was on the shelf exam or on USMLE Step II. I received Honors for this rotation but decided that I really did not enjoy being out of the hospital too often. I also did not enjoy the slow pace of the office.

Holiday break came and I was happy to be done with shelf exams and rotations for five weeks. I knew that Surgery was coming up and my friends had warned me to be ready for two months of pure hell. The rotation is designed so that you spend your first month on General Surgery on one of two services: Trauma or General Surgery. I drew Trauma out of the hat and I received the condolences of my classmates. I figured, “you can do anything that you want with me but you can’t stop that clock.” No matter how bad, in four weeks, it would be over.

I was hooked on Surgery from my first case. It was a total colectomy with four females operating. My chief resident was female, the junior resident was female, the attending was female and I was female. We talked about shoes and Chanel suits during the case. I tied tons of knots and helped the junior resident close the incision. It was heaven. I found out that I loved Trauma and I couldn’t wait to be on call every third day. I had the time of my life and I loved everything about surgery.

My next month was spent on ENT and then on Cardio-thoracic and Vascular Surgery. I scrubbed every case that was assigned to me and many cases that were assigned to some of my colleagues. I became hooked on Vascular Surgery during that rotation. I loved the detective atmosphere on Vascular and loved taking care of the patients. My chief resident on Vascular taught me some great pearls about making sure that even with an amputation, fashioning a well-constructed stump can make the difference between ambulating and not ambulating for the patient. It was great stuff.

After Surgery, I rotated through OB-Gyn. I hated everything about this specialty. This rotation became my only High Pass during third year. I just couldn’t get into delivering babies and I wasn’t thrilled with tubal ligations. I wasn’t thrilled with spending too much time in the clinics and offices. The one bright spot was the Gyn surgeries which I excelled at. I learned the surgical anatomy like a sponge but I knew that this was not going to be the specialty for me.

I finished up on Medicine and Neurology. This would be my final sixteen weeks of third year. I was fortunate to have medicine last because this made study for USMLE Step II a snap. I totally enjoyed Medicine and Neurology but my heart was back in surgery. All of my Pathology experience really paid off because I aced these rotations and moved onto fourth year.

My faculty adviser was chairman of surgery and helped pave the way for my entry into this specialty. I was also co-president of the Surgical Society during my fourth year which also helped. My USMLE scores were good so this helped too. I had some awesome interviews and I landed at a great residency program. My experiences began there and they keep on.

As I continue to write, I will be posting more of my experiences.

Part 2 Why I chose Surgery.

As I moved through medical school, I knew that any specialty that I would enter had to have the following aspects:

• Ability to have long-term relationships with patients
• Ability to see every type of patient under a variety of circumstances
• Practice in office, clinic, hospital, intensive care, operating room and emergency department.
• Ability to handle a wide variety of clinical conditions
• Ability to deal with both acute and chronic conditions
• Ability to perform many procedures

The only specialty that met all of those requirements for me was Surgery. I also loved the aspect that I had to utilize my knowledge of both medicine and physiology to the surgical patient both preoperative and postoperatively. This was very appealing for me. I also utilize pathology and biochemistry to a great degree especially in my teaching of surgery and surgery practice. Again, this made surgery a very attractive specialty.

I definitely started out in residency with a strong interest in vascular surgery. Not only were the vascular surgical patients among the sickest in the hospital on any given day, I also loved seeing the immediate aspects of my work. Once you increase blood flow to an extremity that had previously been lacking blood flow, you see the immediate effects both good and bad. I also liked becoming very familiar with wound care and the healing of chronic wounds.

I had heard about the “surgical personality” and that some surgeons were very difficult to deal with but that never became a factor in my choice of specialty. I don’t care if the devil himself is teaching me if the teaching is good. Fortunately for me, that was rarely the case and my knowledge base expanded exponentially with every year of training. Good teaching is good teaching and good faculty allow you to grow and learn from both them and your mistakes in a constructive manner. I also found that I could profit from the mistakes of others at time too.

The other factor that did not deter me from surgery was the horror stories that I had heard about the residency experience. Yes, sometimes I had to work long hours but those long hours yielded some of the best teaching of my life. Yes, I did miss parties and social events but that happens with any aspect of medicine and comes with the territory. Physicians often work long hours taking care of patients who are sick. If you don’t like to take care of sick patients, medicine/surgery is not the career for you.

Finally, I have a very good life. I do something that is very interesting and I give my patients 100% at all times. I have encountered some physicians who were psychotic, neurotic, dishonest, unprofessional, racist, sexist, anti-Semitic and just down right stupid. The interesting thing is that I am none of those things and my life is good.  Good will goes out from me to my patients and it come back to me in droves. Yes, I work very hard and under extreme conditions at times but I have been blessed with an even temper and a love of my fellow humans.

If you choose a specialty, choose for what you know that you will enjoy doing in most aspects for the rest of your life. If not, you have many years of misery ahead of you. Conditions of practice will change and your income is largely based, not in how hard you work, but on what third-party payers are willing to pay for your services. If you can’t deal with this aspect of your chosen profession, get out as soon as you can.

If you choose a specialty because the rest of your classmates were in awe of you, you are likely going to be very unhappy in that specialty. Specialty choice is personal and your classmates will not be entering residency or practice with you. You, and not your classmates, will be the person at 0400h who is admitting that patient with the chronic condition, thousands of medications and multiple needs. You have to love that aspect of medicine/surgery as much as you love the other aspects of medicine/surgery.

Finally, you have to be a ethical and honest person. Showing up at the church door every Sunday does not make you a moral person if you know that deep inside yourself, you couldn’t be honest with yourself, your patients or your colleagues. You may not ”like” everyone that you work with or work on but you have to have respect for them and give them your best. In short, you can’t be having a “bad day” unless you are on vacation. If you are prone to allowing external influences to influence you internally, you are going to have a difficult time medicine/surgery.

Especially with surgery, you will find yourself multi-tasking, juggling six or seven balls at once, shifting up and shifting back on a daily basis. That’s the nature of the work and the challenge of the work. If you can’t do this, surgery is going to be tough for you on a regular basis.  In short, I have never had a day that was strictly “routine” unless I was just teaching for the entire day.

Finally, take some time and get to know yourself and your career needs because after all, this is YOUR career. Your parents, your significant other, your classmates or anyone outside of yourself, can’t make this decision for you. You have to know your competitiveness for certain specialties (forget derm if you struggled with every aspect of medical school including boards) and you have to have a good idea of how competitive you are for programs within that specialty.

Also, remember that while residency is when you will hone your skills, it is a short period out of the length of time that you will actually practice those skills. Again, I heard that surgical internship was the worst time on earth but I actually enjoyed my experiences during internship. I heard that surgical residency was the worse time on earth but it wasn’t. No residency program is going to be perfect but unless you encounter dishonest or illegal activity, you can live with residency. The clock is always ticking and time passes (quickly in most cases).

Residency requires hard work and hard study. In my case, during my first two years of residency, I studied far more than at any point in medical school in addition to getting my work done. At times, I was “bone tired” but I made myself read and study (minimally for 30 minutes daily). No, I didn’t get to the gym as often as I would have liked and I didn’t hang out late at night (outside the hospital) but I did live pretty well and my significant other saw as much of me as he could stand anyway.