Medicine From The Trenches

Experiences from medical school, residency and beyond.



This is a very nice post on studying tips for Physician Assistant School. These tips work for any professional school thus I am reblogging them.

Originally posted on Pance Prep Pearls:

By LaurMG. (Cropped from "File:Frustrated man at a desk.jpg".) [CC-BY-SA-3.0 (], via Wikimedia Commons By LaurMG. (Cropped from “File:Frustrated man at a desk.jpg”.) [CC-BY-SA-3.0 (, via Wikimedia Commons


As a professor for both clinical and didactic year at 2 PA schools for 12 years, I have seen a lot of students come and go.  PA school is one of the hardest things I have done in my life, but if I had a better roadmap when I was a student, the task would not have been as daunting.  I started undergrad with 4.0 average and upon starting PA school, I quickly learned that what I did to get the 4.0 had to be DRASTICALLY remodeled for PA school or I would have kept drowning.  Here are some tips to help new PA students stay afloat and survive the medical monsoon that is PA school.  Before jumping into tips, one must have a complete understanding of the…

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25 April, 2015 Posted by | medical school | Leave a comment

The Rectal Exam- perhaps a microcosm of health care


And there we were, sitting in orientation in medical school, contemplating our futures as physicians. Sure, there were the warnings, “Look to your left and look to your right…” but we were anxious to get on with the business of becoming physicians. We would change the world one patient at a time and we would have instant intimate relationships with our fellow human beings so that we can solve their health problems and get them on to healthy life styles. As we moved from orientation to our first courses in medical school: Cells and Tissues, Professionalism along with a healthy dose of “you can’t learn it all”, we were introduced to the science of learning how to study the diseases and structures that would make up our careers in the future. Nothing in those preclinical science courses prepared us for some of the intimate probings that we would have to learn to perform on our diverse patient population. For many of us, we lost the art of doing a complete and thorough physical exam largely because we say that we don’t have the time or we don’t want to embarrass the patient because we just met them.

My early experiences

Let’s look at how I learned to perform the rectal exam. My first experience with the rectum was in my studies of gross anatomy, microbiology, histology and pathology. If I even do a mind stretch, I can say that my first experiences were back when I was a child, recently toilet-trained, thanks to my older brother (age 8) who was a master at using the “porcelain convenience”- even at that age, he sat in there for hours reading comics and contemplating his life. I, on the other hand, was fascinated with how things would disappear in the swirl of blue water, never to be present in my life again. Some things, fecal matter, vomitus and urine, were great to get out of my life but my hair brush and toothbrush, things my brother and sister would lovingly flush when they were angry with me, were things that I wanted to keep around but would have to be replaced once they were flushed.

My earliest experiences with urine and feces, by smell, let me know that these were things that were not wanted as keepsakes. My parents were adamant, “Don’t let that dog poop in the house!” “This place smells like an out house, why didn’t you let the dog out when she was at the door?” What was in “dog poop” that was so awful and even more interesting, what was in my fecal material that encouraged me to flush as soon as I detected odor so that I wouldn’t be teased by my siblings? Being a budding scientist, I obtained a sample of my feces (very small sample) and my dog’s feces so that I could examine them closely. I even had a microscope where I examined these items very carefully and made notes. Yes, I grew up in a household with three physicians (my uncle, my aunt and my father) who encouraged me to explore all parts of my environment and log what I saw. I could ask questions or even better, go to the library (we had one in our house) and look up the answers. So, I asked what was in feces and looked for the answer. The encyclopedia and a couple of medical books stated bacteria (accounted for the smell), sloughed intestinal cells and indigestible materials from food that was eaten earlier.

Later experiences

As I moved through my undergraduate coursework (chemistry and math major), I learned about chemical compositions of biologic materials and bacterial physiology. These courses came in handy for my graduate study in biochemistry and molecular biology. There was nothing about the human body that I couldn’t break down into elements and macromolecules; the bacteria, the indigestible materials, the bilirubin and sloughed enterocytes. In short, the process of digestion and peristalsis (loads of study of neurotransmitters), vomiting, formation of urine and feces could be studied scientifically and eventually broken down into biochemistry. Yes, I have found the keys to all things in life and they are chemical elements with chemical characteristics. All things in life could be studied, characterized and explained by their chemical characteristics and properties. This was heady material for a budding biochemistry and molecular biology researcher. I would go on to design my experiments with these elements in mind and a healthy dose of skepticism that all scientists must cultivate. In short, there is likely alternative explanations for what I am observing and I should make sure that I look for them.

Medical School

As I moved into my first year of medical school, we were required to rotate in a clinical area. I chose Emergency Medicine and the Emergency Department because I was pretty sure that I would not be entering Emergency Medicine but I wanted the experience of working in this area without doing a 4th-year elective.  My clinical preceptor wanted us to get the most didactic learning out of our experience but knew that we had only been in medical school for one week (orientation week). He knew that we didn’t have much basic science background, outside of what we had brought into medical school with us. Trust me on this, for the vast majority of us, the pre-med courses in science are a good basis but not enough to understand complex pathology.  He opted to teach us how to elicit a solid history from a patient which is an exercise that anyone can learn without much clinical background. “You want to know why they are here and what convinced them at this point in time, they should head to the Emergency Room”, he told us in the beginning. “Besides, anyone can ask questions and those who don’t have preconceived notions are the best questioners so I want you to dive in and try to figure out what is going on with your patient”.

He taught us the proper form to write up a patient history and most importantly, he taught he to relay clinical historical information to an attending physician in a form that is useful. This was a fabulous experience for me because our medical school was located in an inner city with a very diverse patient population. We had a diversity of ages, sexes and ethnicities with a dose of religious diversity thrown in. Everyone, regardless of age, socioeconomic status, ethnicity, sex or religion gets sick and all human beings want their clinical problems solved, especially those that are in the emergency room. As novice history takers, we started out with the patients that had been triaged to the “non-critical” areas which gave them something to do and provided valuable experience for us.

What I learned right away

Patients interact with their gastrointestinal tract on a daily basis and under many different occasions during that daily interaction. When we are frightened, we may have an urge to run but also an urge to defecate. We feel disappointment “in the pit of our stomachs”. We may eat something new that causes the experience of nausea or we may experience nausea and vomiting by eating something that is contaminated or cooked improperly. We can have an allergic reaction to a food or we may have an adverse reaction to a medication that is gastrointestinal from difficulty swallowing a tablet to stomach upset to diarrhea along with rash and swelling. In short, the GI tract can give important information as to the systemic condition of a patient or can give clues that the GI system itself is the source of pathology.

It is up to the physician to ask the patient about gastrointestinal symptoms if they don’t volunteer this information. A patient may tell you that they have a stomach “ache” which may mean that they have nausea, intestinal cramping or heartburn (may be reported as chest pain too). Patients need to be asked about fever, chills, vomiting, diarrhea in addition to difficulty swallowing, eructation, changes in the color of their urine/feces (darker colored to lighter colored) with or without mucus or blood streaking.  Are they experiencing bloating, vomiting blood or blood streaks on the bathroom tissue. Is there rectal itching present or increased passage of intestinal gas or a feeling that they are not emptying their bowels completely? Do they have pain with defecation or does defecation relieve their pain? Have they noted a change in the size or odor of their stool? Have they developed problems with certain or all foods that were usually a part of their diet? All of these symptoms especially those that deal with defecation may not be volunteered by the patient.

Cultural Barriers

Some patients, especially young and older men are not going to want to discuss their bowel habits with a female physician. Perhaps their religion will not allow them to speak with a female or they feel embarrassed and will reluctantly give any information at all. I have encountered male patients that would not consent to an examination by me, a female surgeon even though they were in pain from an incarcerated hernia. I make every effort to safely accommodate their wishes but sometimes, especially if I am the only surgeon on call, I have to explain the situation and the danger of delaying the examination.

Some of my physician colleagues will not perform rectal exams on patients. I vividly remember my physical diagnosis professor from medical school saying that the only reason not to perform an indicated rectal exam is that the patient doesn’t have a rectum and you don’t have a finger. Indications for a rectal exam are any suspected acute abdominal pathology or as part of a screening physical examination. I can’t relay the sadness of finding a rectal tumor that has metastasized through the rectal wall that is within the reach of a finger in a patient that hasn’t had a rectal exam in several years. This situation is commonly encountered in elderly nursing home residents especially those who with poor mobility and limited ability to communicate. Often these patients have pages and pages of physical exam findings but “deferred” when it comes to the rectal exam.

Medical Care

Your patients entrust their health in your hands. When it comes to their health, language and cultural barriers on the part of the patient or the physician must not delay or defer good medical practice. It is incumbent upon the physician, who is the professional to present sound clinical reasons for any exam and alleviate any embarrassment on the part of the patient. No, rectal exams are not fun but they are necessary and in some cases, they are life saving. A physician is not performing a rectal exam to make the patient more uncomfortable but to make sure that the patient gets the most complete care possible. To defer a necessary test because one does not want to “bother” the patient is not sound medicine. In today’s world of pushing patients through offices and emergency departments as quickly as possible, to skip something that is warranted is equivalent to not giving care at all. We as physician are entrusted with the care of our patients and in many cases, we have to explain that our care may be uncomfortable or embarrassing but it will be complete and necessary.

The Rectal Exam

As with any aspect of a patient’s examination, we perform what is necessary for the alleviation of a patient’s clinical problem. If a patient stated that they had a sore throat, would you allow them to leave your care without ever looking at their throat? If a patient has gastrointestinal symptoms that warrant a rectal exam, will you allow them to leave your care without performing a rectal exam because they talked you out or it? Will you allow your patient to talk you out of doing what you know is sound medical care?

18 April, 2015 Posted by | medical school, physiology, surgery | , | 1 Comment

Why would anyone want to do this job???

I hurried to get my last notes typed in because I had ordered a CT Scan on a patient with a new fever whose recovery had been very long and complicated.  I had notified the floor that I wanted to be called as soon as the CT Scanner was free and that I would personally accompany this fragile patient to the scanner. He had been making steady progress and had been out of the surgical intensive care unit for two days but still needed plenty of watching and care because of his complicated course. I had spoken with the chief resident earlier this morning and we both agreed that we needed the scan because we were worried that the graft, inserted because of an abdominal aortic aneurysm, might be infected at this point. I finished my note, grabbed a cup of coffee to get through the latter part of the afternoon (my one vice- caffeine but no later than 2pm) and off I went to the floor to check on my patient’s progress.

As I rounded the corner to the surgical floor, I heard the dreaded words “Code Blue CT Scan”. As I burst through the door to the ward, and entered my patient’s room, I saw an empty bed pushed to one side. They had moved my patient to the CT Scanner without notifying me and now I knew that the “code” had to be my patient. I dashed down the back steps glad that gravity allowed me to move even faster and into the back entrance of the CT Scanner. Yes, it was my patient, still on the stretcher and in full arrest. One of the intensive care physicians had already placed an endotracheal tube (for airway and ventilation) while the CT technician was doing chest compressions.

“He just went down as soon as we got here”, said the transporter. The chief resident came in and asked why no one from the surgical staff had been notified that the patient had been moved to the scanner. He pushed a round of drugs into the central line that I had placed and looked at the vital signs on the chart. The monitor, which had now been placed showed ventricular fibrillation which meant that we were going to defibrillate; a slow sinus rhythm with a very low blood pressure. “Let’s get him moved to the ICU”, the intensive care physician said. “We can’t get the scan now”. I  headed back up to the floor, my patient now in the hands of the intensive care staff. I wanted to find his wife and let her know that he would be moving back to the intensive care unit.

I found her sitting in the waiting room of the floor. “Is it him?” she asked me when she saw my face. “Yes, it’s him and he’s being taken back to the intensive care unit right now”, I said. “Let’s go down there so you can see him.” We took the elevator down one floor to the surgical intensive care unit and I asked her to wait until I found where her husband had been taken. When I entered the room, they were pushing drugs, ventilating and performing chest compressions. “I am going to bring his wife in now”, I said. She needs to see him now. The intensivist agreed with me and I brought his wife into the room from the hallway. “Please stop”, she said. “I don’t think that he can take any more”. Immediately, everyone stopped what they were doing and looked at the intensivist who said, “Stop everything and give us a moment please.” The frail woman walked over to her husband’s bedside and took his hand. She said, “I have loved you for 45 years and now, it’s time for you to go”. “I will be OK and it’s OK for you to leave now”. The intensivist and I stood in the doorway for a second but then backed out into the hallway. The nurse silenced the alarm which was picking up the very slow heart pattern and then turned off the monitor and left the room.

The wife stood by her husband’s bed for about 3 minutes and then came out into the hall way where we all were gathered. “He was tired of fighting all of this and had given it all”. “I know that he would have kept on fighting but we had so many good years.” ” He’s at peace and I am OK”. This is why this job is very difficult. It’s not difficult for me to get up at 4AM every morning. It’s not difficult for me to read 30 journals each week to keep up with changes in medicine. It’s difficult for me to watch an elderly woman stand at the bedside of her newly deceased husband and tell him that it is OK for him to move on. She and her sons later thanked all of us for everything that we had done.

At the Mortality and Morbidity conference, we presented reviewed findings and concluded that the graft was likely showing early signs of infection with the fever spike but with no post mortem exam, we couldn’t be sure. This is where this job is difficult. Were there any signs that we missed? Could we have moved any faster? Probably not but still, it is difficult not to question every time we looked at that chart and every vital and physical sign that we reviewed. As I keep doing this job, I never allow myself to forget that everything I do affects the lives of my patients and those who love them. The death of a patient is never routine and I remember something of every patient that I have lost.

It’s not just the loss of life because death is very much a part of life. It is what is left behind with me and with the family and friends that are left behind. My chief resident and I talked about this patient with the junior residents and medical students. “What did you feel when you were standing there in the intensive care unit when the wife came in?” “How does that affect you, as a physician and as a fellow human being?” “Do you believe that there is a life after this one?” “Do you think that it is a good idea for a family member to be present when we are resuscitating a loved one?” “Do you want to keep having these types of conversations even if it’s not on the occasion of losing a patient?” They all answered a resounding “Yes”.

7 April, 2015 Posted by | emergency, medical student., medicine, surgery, surgical clerkship | | Leave a comment

(Re-post) The Supplemental Offer and Acceptance Program (SOAP) Process

I am re-posting a previous post because Monday of Match Week is coming up. People may need to learn about the Supplemental Offer and Acceptance Program (SOAP) process very quickly. It is not anticipated that there will be huge numbers of positions available in this program but one does need to know how the program works and how to make it work for you. Good luck to all of those who match and those who are going through the SOAP process this year. It’s stressful but it’s exciting to move forward with the next career steps in medicine.


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.

14 March, 2015 Posted by | applying for Residency, Match Day, medical school | | 4 Comments

Christmas 2014

This Year and This Time

As I sit here in my office, I want to share that I have experienced a profound loss in my life. I now, fully understand, how profound loss can be for my patients at this time of the year. When everyone else seems to be so joyful, a painful loss can zap every bit of the joy of the season and fellowship from the person who is suffering the loss. I am fully human and I fully understand life’s challenges but I am not immune from mourning.

I am meditating on Walter Anderson’s quote: “Bad things happen: how I respond to them defines my character and the quality of my life. I can choose to sit in perpetual sadness, immobilized by the gravity of my loss or I can choose to rise from the pain and treasure the most precious gift  have — life itself”.  I keep repeating this quote over and over so that I have some sense that I will be able to move past the holidays and celebrate the joy of others in this time of the season. I can say that right now, this is one of the hardest experiences that I have faced in my life.

My Shared Humanity

I know that many people are anticipating major changes in their lives at this time. Some people are nearing the end of the residency selection process (rank lists go in soon) and some people are eagerly awaiting that first interview invitation or medical school acceptance letter. If those things don’t come, there will be a period of mourning the loss of what you expected life would hold for you in the future that you envisioned in your mind. As Mr. Anderson so elegantly states, you can “choose to rise from the pain”, because loss of anything is so gut-wrenchingly painful.  I share these words with you because I am trying so hard to live them with my loss (and it’s so hard).
We are human beings and we will go through experiences in life. I have always been an advocate for learning as much as possible from those experiences, good or bad, as one is able to learn. We always hear, “how can you appreciate the good things in life if you don’t experience some bad things in life”? Well, those “bad things” hurt very deeply and I am going to say that I understand and share that hurt with so many people right now.

My Patients and My Medicine

I have always said that one of the greater aspects of medicine and its practice is that one can look around the hospital and see people who are dealing with issues that are far greater than any issues that you, as a practitioner, will have to deal with in your medical practice.  I want to also add that dealing with a personal loss can connect to with your patients in ways that are deep and profound. Medicine allows one to see patients in times of great sorrow, at the beginning of life and at the end of life. When things are catastrophic for our patients, we have to find ways of letting them know that we are connected to them; not suppressing our feelings and using outside means (chemicals, self-destructive behaviors) to numb ourselves of those connections. Yes, it sounds a bit “corny” but we, as good physicians, have to allow our patients to see that we are connected even in these times of less time spent with the patient and more revenue generated.

Trying to deal with Loss

To live life is to have experiences of loss. It’s the nature of life to have changes and those changes will deal with frustration, loss, joy and hope. Anytime one anticipates the future, there can be some change from that anticipated future that will involve a loss. With that loss can come mourning of what might have been but in essence, one only has the present. The past does not predict the future though when dealing with medical school acceptance (past grades) and residency selection (past board scores and medical school grades), it would seem that the past in inescapable.

If one does not find a residency or if one does not get into medical school, there will be a loss of the future plans that one has been anticipating. It is very understandable to mourn the loss of that anticipated future. It is very human to mourn the loss of that anticipated future and that humanity/humility is just the thing that will connect you with your fellow humans.

I applaud anyone who has never known loss as they are indeed fortunate but I would also say that never to know loss is never to be completely human.  I want my patients to see my human side and appreciate that I experience loss and hurt as deeply as they would. I want to be as human as possible and feel the joy with my colleagues and patients when experiences are going well.

Right now

Right now, I am meditating and writing because I feel that my experiences are worth sharing with my blog readers. I am secure in my role as surgeon and teacher but I have been shaken in my role as human being. I also know that it is up to me to find what will make me stronger so that I can get past this painful loss. I also know that this painful loss has made me a better physician/surgeon and my hope for the future is that my patients will see this in me. In this sense, I have been given a gift.

25 December, 2014 Posted by | medical school | , | Leave a comment

Residency Interviews and Choosing a Residency Program


At this point, most people have completed most of their residency interviews. Many programs tend to go on “interview hiatus” until after the holiday season. At that time, there isn’t much time left to interview because rank lists will be submitted. Here are some things to consider if you have an interview coming up or you are trying to make a decision as to how to rank programs.

Interviews (What’s important and what is not important)

Once you have interviewed, you should make a point of sending out thank-you notes to the program director and the administrative staff that made your interview day a success. It takes a bit of planning and work to make sure that everyone gets interviewed and everyone gets a good experience. Be sure to let the staff and program director know that you appreciated their efforts on that day.

The next thing that you need to consider is if you want to go back for a “second look”. This may be most important because one has to remember that on interview day, your schedule is largely governed by the person(s) who organized the day. Sometimes it is good to have a look on a day that isn’t so organized. It’s also good to try to see what the department is like on a “regular” day especially conferences and educational items. These become vitally important as in-service exams are going to be coming up rapidly once you get settled into your program. All good programs will extend an invitation for a “second look” where you can get a chance to spend some long hours with the residents because they will be your colleagues.

Things to consider from your Interview Day

It’s wonderful for folks to rave about where they “scored” an interview and most of us are no exception to wanting to let everyone know that a high-powered residency program is interested in us. The first thing to think of is not so much the reputation of the program but your feelings about the program as you went through your interview day. How does the faculty and residency staff get along with each other? Do the residents look overwhelmed, especially the PYG-1 folks? Remember, you will be in their shoes in a few short months and looking weary at this point in the year is not great. People may be tired especially post call but they should not be exhausted and frustrated. That is a harbinger of a non-supportive environment.

Make sure that you look at some of the places that residents from your program of interest live. The program may be great but you have to have a safe and secure place to live and sleep. There are fabulous programs in older and larger cities but if you are in constant fear of your car being vandalized/broken into or your possessions being stolen, you are not going to perform your best in your residency program. Make sure you have a good idea of housing and its costs because your life is going to be the hospital and your home for the most part during residency. You won’t have much money for much entertainment other than sleeping in your own bed which needs to be secure and comfortable.

How did you fit in with the rest of the residents especially the folks who will be the chiefs next year? This is vitally important because you will be learning so much from your more senior residents. If you are not a good fit (you should have met some of them during your interview), then you won’t be a good match. Besides providing much of your day-to-day education, your more senior residents will become your colleagues and your friends. You want to make sure that you are a good fit with the rest of the crew so you can pull together for each other and help each other. Residency is hard enough without having to deal with personality disorders and problems getting along with your chiefs.

Your vital education

Yes, you made it through medical school but as most of us know, it will be your residency that determines your style of practice. You want to make sure that your environment is educationally supportive and conducive to learning as much as possible. Is there protected time during conferences? Are the conferences well organized and informative? (It would be good if you had a chance to attend some of the conferences during your interview).

If you observed that the residents spend too much time taking care of patients and “extending” the attending physicians, at the expense of their education, then you may want to consider ranking another program. The best programs make sure that residents have ample opportunities and support for educational activities (good library and protected time during conferences) as well as good resources for research (vitally important if you are interested in fellowship).

Your professional development

A good residency program will have faculty that is interested in your professional development. It’s great to have an assigned mentor and supportive faculty. I can say that my assigned mentor had very little in common with me during residency but I found plenty of “unofficial” mentors in the faculty that were priceless. A mentor does not have to be in the same area of your main interest but it helps to find at least one faculty member that can guide you along with your chief residents. Usually the best faculty members for mentors are the new faculty who are close to their training. They have the latest information and educational strategies, thus it is good to seek them out for guidance.

You want to look at where graduates of a specific program wind up. There should be a good mix of general practice folks and fellowship folks from your program. Not everyone wants to enter a sub-specialty but the option should be there should you find that this is your aim. You should have spoken with the folks who are the present chiefs so that you can get an idea of where they will be headed next year.

Consider how you were received by the faculty that interviewed you. I can tell you that one person who interviewed me, spent most of my interview time on the phone dealing with a personal matter. This is not a good situation and I requested to be interviewed by someone who wasn’t so distracted. I thanked him for his time but I also felt that if he couldn’t give me his attention for a majority of my interview time, then I needed to be interviewed by another person. Fortunately for me, that program was not high on my list of places that I wanted to match.

Some final words…

If you are at this point and you don’t have at least 10 places to rank, you will likely have a difficult time matching. Remember that many people will go unmatched because the number of medical school graduates has increased but the number of programs has stayed static. If you find that you don’t have enough places to rank at least 10, then you need to have a solid plan for getting a job if you don’t match. Now is a good time to work on that plan because there just isn’t much interview time left before the rank lists go in.

You also need to look at the Supplemental Application Process (SOAP) which is not a “scramble”. You should not rely on this process for finding a job as the number of places that you can apply to is limited. Have a back-up plan should you not find a position in the SOAP or match outright.

Be sure to consider your competitiveness within the context of the people that interviewed with you. It’s great to shoot for a “dream” program but make sure you realistically rank programs where you would be a great fit.

10 December, 2014 Posted by | academics, applying for Residency | | Leave a comment

The Advent Season, a time to prepare for that which is “coming”.

Advent 0r a time of that which is to come

As I write this, the Advent Season begins in many of the western churches such as the Roman Catholic Church. The word “advent” mean “coming” as many who celebrate the season prepare spiritually for the coming of Jesus Christ. This does not mean that one has to be a christian or spiritually prepare for the birth of Christ but one can use the season to spiritually prepare for the new year and all of the possibilities that it will hold. For most of us, the Fall semester has (or is close) to coming to a close. This means that the Spring semester will be coming after the Christmas/ New Year holidays/recess and there is a chance to begin again. Anytime one is given another chance to begin (in my case to reinvent myself), I always think about taking advantage of that chance.

If you had some difficulties in your previous semester (academically or clinically), take advantage of the decorations and the festive atmosphere around the school (or hospital) to think of things that you can change in your approach to your work. If you want to change anything in your life, you have to change yourself because you have control of you and your thoughts. As I have stated in many previous posts, it is always easy to focus on the negative but you can change your focus to the positive and build upon the positive. If you struggled, you probably did far more things and tasks correctly than incorrectly. Think of your incorrect tasks as opportunities to learn and put them in the most positive light. If you compared yourself to others, then change your thoughts to comparing yourself today to yourself even yesterday rather than to another person. You can’t know the thoughts and feelings of another but you do know your thoughts and feelings thus put your focus there instead of wasting precious time and energy trying to deal with something you can’t influence.

As the season unfolds

Make a list of things that you feel you would like to change and put them in an order that will allow you to take them one at a time. Again, don’t just throw up your hands and say that “nothing worked well” but take an honest appraisal/ inventory of what worked and didn’t work as you make your list. For example, as I study and prepared for lectures, I ended up with a pile of books and papers stacked on and around my desk. My first task is to put order in my work space starting with the top of my desk and then filing all of those papers that I won’t be using the next semester. If you can get one area ordered and uncluttered, that usually means that you can focus on another small area and soon you will have an orderly and efficient space to begin the next semester’s work.

I have also made a small list of  things that I want to accomplish in the upcoming year. Under each of those things, I have put the smaller steps that will lead to the accomplishment of my larger goals. One of my goals is to eat more fresh and unprocessed foods. While this means that I will have to make some preparations each week so that I have fresh fruits and vegetables available for my meals, then I have made a system to make sure that I purchase what I need on a weekly basis rather than just dashing out of the door in the morning and relying on the hospital cafeteria for food (processed, high-fat).  I know that I have far more energy with a diet that is higher in vegetables and fruits (raw mostly) with less meat and nothing processed.

Another goal is to begin something called centering prayer. I have been practicing daily mindfulness but I wanted to incorporate my western faith into my eastern practices. In short, I have found that when I am still and quiet, I have gotten to know myself and to change myself from with. Advent represents a positive beginning for me thus I want to incorporate change in my spiritual as well as my physical self. I have recently been reflecting on doing things that can allow me to be more open to listening and contemplation. For me, listening and contemplation are the most important elements that I incorporate into my practice of medicine; integral to my practice of medicine. These are elements that I find that I must constantly work on and refine. These elements lead me to the observations that lead to my best decisions.

Taking a Step Forward by Standing Still

It often seems that there are a thousand tasks demanding your attention in your processes of daily living. Often many of these tasks are done with multitasking which means that you are not giving your total attention to one thing at a time. I would invite you to be still and live in each present moment rather than trying to analyze the past or the future. If one takes each task for what it is, the future has a way of working itself out in surprising ways. For example, I had been listening to my favorite band (Pantera, specifically Vulgar Display of Power) with a focus on each instrumental element of each song on the album. Every time I listen for an specific element, I find something new in the music which is why I enjoy metal for the most part. No, metal rock isn’t for many people but it adds much to my contemplative life these days. By standing still and appreciating every element of this complex musical genre, I have great admiration for this talent.

In this holiday season, the opportunities are often there to take the time to appreciate those that you have worked with or not seen if you have been away at school. This is one of the best parts of the holidays because you can express your appreciation for those many little tasks done by family, friends and coworkers that have added to the richness of your life over the past year. For me, the ladies in environmental services always leave an extra comforter in my call room which is the most welcome item when I am cold and tired during a busy weekend of call. I make sure that I leave something for all of them to share (this year it’s fudge) because that comforter makes me feel appreciated in a very tangible way. It’s such a little element but it means so much to me. Be sure to take time to thank everyone from your loved ones who miss you because you are away long hours to those folks who keep the call rooms comfy to the Pharm D’s who happily answer my questions and offer excellent suggestions. Take the time to stand still and think of all the folks who keep things going for you.

Medicine gives you more than you can ever give back

This season is a great time to think of why you seek to enter or stay with this profession. Just this past week, I found myself attempting to explain the special, almost sacred, relationship that I have with the patients that are under my care. One task that has fallen to me from time to time has been attending to people who are at the end of their life. I have always been able to never allow any of my patients to die alone even if I am the one that sits at their bedside. From the first death that I pronounced to the last that I attended just a few days ago, I have always made sure that someone was present with a person making the transition into death. I can say that bearing witness to a person dying allows me to see the dignity and wonder in being simply human.

The contemplation of Advent, that is the arrival of the season, the end of the year and the beginning of a new year is a great time to think of ways to get back to that which is so special about this profession. This profession is far from perfect but it allows a window into some of the most basic and intimate moments of our patient’s lives both sorrowful and joyful. It should never be “lost” in the performance of those thousands of tasks of the day in and day out practice that it is because of the role that we play in our patient’s lives that our life can become enriched.

6 December, 2014 Posted by | medical school | Leave a comment

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 spent 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


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