Medicine From The Trenches

Experiences from medical school, residency and beyond.

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

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

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


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

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

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

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

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

Conquering Hard Goals

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

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

Look from a different perspective

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


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

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

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


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

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

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

SOAP is NOT “The Scramble”

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

SOAP should not be your primary residency application

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

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

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

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

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

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

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

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

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

Things that generally DO NOT enhance your chances of matching

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

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


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

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

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

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

Everybody is doing better than I am doing…

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

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

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

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

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

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

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

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

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

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


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

First Year Medical Students

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

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

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

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

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

Second-Year Medical Students

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

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

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

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

Third Year Medical Students

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

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

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

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

Fourth Year Medical Students

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


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

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

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


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