Medicine From The Trenches

Experiences from medical school, residency and beyond.

Applying for Residency

Each year since 1952, seniors in US medical schools have applied for first-year, post-graduate-1 (PGY-1) positions through the National Resident Matching Program (NRMP). Prior to 1973, these positions were termed “internships” but now, the term PGY-1 (and in some cases PGY-2) positions are more accurate. This service is open to several applicant types who are divided into the following categories: seniors of US medical allopathic medical schools, previous graduates of US medical schools, student graduates of Canadian medical schools, student graduates of osteopathic medical schools , US citizen IMGs and Non-US citizen IMGs and student graduates of fifth-pathway programs. In the last year (2012) that the match was held, there were more than 26,000 positions offered with about 38,000 registrants vying for them. Most of the positions were for PGY-1 positions and a small number were for PGY-2 positions.

By far, US graduates were successful in terms of securing a position (more than 95%) and this meant that fewer positions were left over for the scramble [now SOAP] (open to those who were not able to match). This also meant that US graduates held a distinct advantage when it came to securing positions in the SOAP. It also means that applicants who enter then 2013 application and match need to be very savvy in terms of making sure that they are competitive for the specialty that they seek, that they are competitive for programs within that specialty and that they don’t make any mistakes in their applications that might cost them a position.

The “lifestyle” specialties, Anesthesiology, Dermatology, Emergency Medicine, Radiology and Orthopedic Surgery had fewer than 10 unfilled positions and far more applicants vying for those positions. These specialties filled almost 100% with US graduates who had USMLE Step 1 Board Scores well into the 230+ range (three-digit score) which is considerably above average in terms of performance on that exam. Also key to being successful in matching into the more competitive specialties was membership in Alpha Omega Alpha (AOA) which indicated a high level of scholarship in medical school.

With the numbers of applicants higher but the number of post-graduate positions staying about the same, would mean that academics, grades/USMLE scores are very important for securing a position in the match.  Additionally, making sure that one obtains the best advice from reliable and trusted resources at your medical school become crucial in this process. To go into the process of residency application without the best and more reliable advising can mean costly mistakes that will affect a process that is more crucial to your career as a physician-more crucial than selection of a medical school in the first place.

The other aspect of the application process is that an applicant has to be as realistic as possible in choosing a specialty and program for postgraduate medical training. Similar to medical application, seeking and applying to residency programs where you are far from competitive doesn’t enhance your chances of securing a PGY-1 position in the Match. While it’s great to “dream” of entering a particular specialty or program, you have to make sure you are 1) competitive and 2) suited to a particular specialty or program.

If your medical school academics, licensure board scores and general performance are less than those of people who generally match into a particular specialty, you are not going to secure an interview or secure a match. If you are choosing a specialty because of “what you heard” without regard for whether you have the interest, ability and temperament for said specialty, you may find that you are in for a miserable time and career.

Specialty choice is the most subjective portion of your career in a couple of significant ways. First, you choose a specialty that you know you will love for the rest of your career. This means that you have to love that specialty at 3AM when you are exhausted. This means that you love the scope of practice and the patient population that you will treat. Second, you have to be a good “fit” for the reasons that I have outlined above. You have to be able to enter a training program and thrive in the learning environment that is provided. This means that you have to be suitable for a particular program and they have to be suitable for you. Your medical school may open some doors in this process but in the end, you have to like the program and they have to like you (and your application).

If you are a pre-med student, this post has little reference or impact on what you need to be getting taken care of. Your first task is to get into a medical school where you can thrive in the atmosphere of learning provided by that medical school. Looking at match lists and specialties of the graduates of a school that you have yet to enter will have no impact on your career. Your performance in medical school and on licensure exams is not tied to previous graduates of a particular school. Work on your application/undergraduate coursework and leave specialty/residency selection/residency application for a more appropriate time. If you don’t get into medical school, specialty/residency selection/residency application won’t figure into your life.

If you are a first-year medical student reading this post, your immediate job is to make sure that your academics are as strong as possible. If you are struggling with coursework, you have to get your coursework under control before worrying about what residency you can get into at this point. In short, you have to take care of the tasks that are immediately on your plate at this time.

If you are a second-year medical student, you need to keep your academics strong and make sure that you enter third-year with an open mind. Keep in mind that you may have an idea of what you might like in a specialty but you may find something that you love more once you get to the clinical years. You also need to be thinking about your timing for reviewing and taking your licensure board exams (USMLE or COMLEX Part 1). You don’t want to take this exam too late to have a passing score before you enter third year or too early so that you don’t do well.

If you are a third year medical student, you should have some idea of what you want to do and you should be “scouring” your medical school for as much information as you can find on the residency application process. If you haven’t chosen a specialty at this point, I would encourage you to seek out trusted faculty advisers who can get your selection process underway. I would also encourage any third-year student not to make a specialty choice because they had a “good time” on a particular clerkship.

To Recap:

  • Take “dreaming”, “wishing” and “hoping” out of this process and replace these items with “research”, “realism” and “sound advice”.
  • Make sure that you have comparable or that you exceed the characteristics of applicants that have been successful in matching into a particular specialty/residency program or choose something else.
  • If you are currently in medical school, be proactive about learning as much about the specialty selection process, residency application process and keeping your academics strong.
  • Resist the urge to choose a specialty based on its competitiveness or lack of competitiveness because you just want to impress others or “get a job” because you don’t have any “do-overs” in this process. You have to choose something that you love and for which you are competitive.

14 February, 2013 Posted by | applying for Residency, residency, summer school | , | 10 Comments

How to use the ophthalmoscope

Starting this week, I will be teaching my students how to use an ophthalmoscope  and how to perform an optic fundus examination as part of mastery of the physical exam. Many of my colleagues never mastered the use of this instrument and tend to dismiss fundal exams as not necessary in today’s world of modern medicine. As I begin to teach this skill, I am reminded of how my professors in medical school, placed importance on having this skill in my toolbox of weapons against disease. At my medical school, we saw plenty of people who were morbidly obese, hypertensive and diabetic. Being able to examine their retinas was a cheap and simple task that might make a difference in helping them to better health by  control of their weight, blood pressure and blood sugars. In short, a fundal exam is a tool that can make a difference in the prevention of the complications of chronic diseases that afflict many people today.

As a vascular surgeon, I am happy to have ophthalmoscopic skills because an exam of the vessels in the retina can give me valuable information in terms of the condition of a patient’s peripheral arteries. The retina is often the first indication of lack of blood sugar control in Type II and Type I diabetics and after a couple of decades with Type II diabetes, just about all patients will show some retinal changes. Without careful blood sugar control, these changes can go on to blindness which is a huge complication of diabetes. In my trauma patients, retinal examination can give a clue to increased intra-cranial pressure right in the trauma bay if one knows how to look for the early signs of papilledema.

I first have my students learn how the ophthalmoscope works. This is an instrument that must be held properly and used properly for best results. The ophthalmoscope is not an instrument that one can simply pick up and use right away. The student needs to learn how to turn the diopter wheel, how to adjust the light for the best results and how to choose the proper aperture for viewing. Many people attempt to look through the instrument with their corrective glasses in place (the diopter wheel corrects for both you and the patient) or will start with the biggest and brightest light (believing that this will result in better visualization). If one starts with a smaller light spot and dimmer light, one get more time to look around before the patient becomes uncomfortable. Additionally, the brighter the light, the more reflection off the cornea  which is quite distracting to a new user.

Many people forget to darken the room and forget to ask the patient to focus on a spot over the examiner’s shoulder. both of these techniques need to be utilized in order to see anything. In the dim light, one should place their other hand on the patient’s eyebrow to help the patient keep their eye open. I utilize this technique because when my head touches my other hand, I have moved into the proper position/distance, which is very close to the patient. Many new examiners are quite uncomfortable with the closeness that this exam requires but just as one needs to be pretty close to a door “peep” hole in order to see out, one needs to be close to the patient in order to see into the eye through the very small pupil. (Breath mints are handy so that you don’t have to worry about being too close).

The new “Panoptic” ophthalmoscope head allows for a longer distance from the patient but one needs to learn how to hold and use the “Panoptic” score in much the same manner as learning to use the conventional scope. The Panoptic scope gives a wider view of the retina which is helpful too. The Panoptic ophthalmoscopic exam is easier to learn but Panoptic heads are quite expensive and not readily available in most clinics. If you have a Panoptic ophthalmoscope, then you need to guard it carefully because these expensive instruments have a way of “disappearing” from their owners on a regular basis. It’s also very easy to learn how to use a Panoptic scope if you have mastered the conventional ophthalmoscope.

One of the biggest mistakes that teachers ( and medical students) will make when learning to use the ophthalmoscope is believing that you are going to see the pictures in your physical diagnosis textbook. You are first going to see only the “red reflex” which you will learn to follow in as your learn to visualize a retinal vessel (see these when you learn to focus by turning the diopter wheel). Once you see a vessel, you can follow it into the optic disk. Once you see the optic disk, you can move your eye and body so that you can examine the entire retina.

You won’t master the ophthalmoscope unless you look into every patient’s eyes on every exam. If you don’t stick with attempting to learn (frustration levels are high at first), you will not master this instrument. I can’t tell you how many of my students “give up” before mastery and join the legions of “naysayers” who don’t believe an optical fundal exam is a necessary part of a physical examination. Many of my colleagues will just send their patients to the ophthalmologist for ongoing retinal exams which is a better strategy than not following retinal changes. It’s good to know what your patient’s retinas look like for yourself because you are going to see those patient’s more often than the ophthalmologist will see those patients. It’s a good idea to find changes earlier rather than  later.

A technique that I teach my students for them to practice using the diopter wheel as the move in closer and closer to the patient is to put a small dot on the palm of their hand. Then practice keeping that dot in focus as they move their hand closer and then more distant from the ophthalmoscope. If they can turn the diopter wheel and keep the dot in focus, then try doing the same thing with text in a book as you move in and out keeping a letter in focus. Once the student can see a red reflex (right eye of patient and opthalmoscope in examiners right hand) the examiner can move in closer to the patient and keep the red reflex in focus.

As you learn to use the ophthalmoscope properly, keep practicing with this instrument. At first you will only see a red reflex; then follow that red reflex as you move in (might see a vessel at this point). If you can keep a vessel in view, you can follow it into the optic disk. If you can see and focus on the optic disk, you can keep practicing until you learn to detect things like copper wiring, cotton wool spots, neovascularization , flame hemorrhages and other pathological findings. You will also learn to appreciate the different pigment changes from patient to patient which can be pretty interesting too.

With any new technique or procedure in medicine, one has to learn to practice to make that new procedure/skill second-nature. With ophthalmoscopic examination, the practice takes months of dedicated trial and error until you find what works best for you. The important thing to learn is not to “give up” , throw you hands in the air and then label the skill as “unnecessary” because you can’t perform it. Fundal exams are a worthwhile skill to master in order to give your patient’s the best care possible.

3 February, 2013 Posted by | medical school coursework, medical student., physican assistant, success in medical school | | 6 Comments