Medicine From The Trenches

Experiences from undergradute, graduate school, medical school, residency and beyond.

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

Introduction

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.

Summary

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.

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

Study Skills (Part VI)

Introduction

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

Set goals and objectives for your study session

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

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

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

Reading

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

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

Journal Reading

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

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

Weekends

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

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

Social Media, Television and so forth…

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

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

Meetings

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

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

When things come undone

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

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

Before you shadow…

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

Do Your Homework

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

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

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

Arrive Early

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

Proper Attire

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

Follow Directions

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

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

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

Take names!

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

Enjoy yourself!

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

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

Applying for Your Residency

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

wellnessrounds

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

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

Match Statistics hhttp://www.nrmp.org/data/index.html This will give you an idea about the qualifications of candidates that match into each specialty.

ERAS https://www.aamc.org/students/medstudents/eras/.This website is for applying to residency programs.

NRMP http://www.nrmp.org/.This website is for submitting your rank list.

FREIDA https://freida.ama-assn.org/Freida/user/viewProgramSearch.do. This website gives some very basic information about individual programs, but overall is not very useful.

Residency Program Director Survey (38% response rate) http://www.nrmp.org/data/programresultsbyspecialty2010v3.pdf.  This gives you an idea about what program…

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