Medicine From The Trenches

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

Getting Into Routine

Since the nature of medicine (and life) is change, getting into the best routine to greet and excel in a changing environment is being in the best mental and physical condition possible. It’s very easy with study, long hours of duty and other demands, to gravitate towards anything that bring rest and relaxation/lack of stress. My challenge for those who are starting school, getting ready to start school, starting a new year of clinical duties or any changes; is to have a routine with good stress that allows for optimal performance within the context of changes and challenges.

For many in medicine, stress is the bane of our existence. We are stressed with long hours that often demand the good performance in early morning hours, as most of the population sleeps. We are stressed with keeping up with our academics and studies that mark our ever-changing profession. We are stressed with keeping a sound balance in life that will enable us to enjoy our personal lives in addition to our professional lives. This sound balance is as vital to having a great career and general well-being but finding that balance is not easy or quick.

As the summer has always been the time that I try to improve on my routines and make changes, I will invite you to consider making small changes that will help you deal with the mental and physical challenges to come as your careers change. These challenges need not derail your health and mental resilience but might enhance the enjoyment of your career at any stage.

Good Nutrition

When one is tired physically, mental acumen wanes and one becomes both mentally and physically exhausted. This mental and physical exhaustion can lead to choosing foods that are high in sugar or fat which might lead to a quick energy fix but weight gain in the long run. Trust me, carrying extra weight around doesn’t help with mental or physical exhaustion, often leading to more of both.

Eating a well-balanced diet that has more fresh fruits and vegetables with less fat and refined sugars helps keep your weight under control in addition to keeping you healthier. You can make small changes in terms of grabbing a piece of fresh fruit for a snack rather than relying on the high fat alternatives of the vending machine. Also cooking a week’s worth of healthier food that you pack rather than eating the burger and fries in the hospital/school cafe can help make small changes.

Small changes can lead to larger changes or that routine that becomes more comfortable for you. While I love an occasional burger and sharing fries/chips with my friend (the only way I indulge in these), I keep these occasions as special and not routine. Not only does eating a healthier diet help my immune system, my healthier diet helps me avoid long term chronic disease such as obesity, atherosclerosis and diabetes.

Regular exercise

Exercise tends to be one of those activities that suffers when one enters a demanding profession. It is easy post call, to come home, drop on the sofa and rest. This was my routine in medical school where I gained significant weight after being robustly active during my graduate school years. It took years of work to rid my body of the excess weight but once regular exercise became my routine, I found that I had more energy and more time rather less.

Today, I am a distance runner, using that time on the running trail to work out problems, meditate and simply enjoy myself. I have strength and energy for my work and for recreation. I also have a greater capacity for dealing with stress and the physical stress of a 10-mile run helps everything in my life. Running is quite solitary which appeals to me but anything that gets your heart rate up at least 30 minutes 5 times per week is better than nothing.

My workout time is as precious as my work time. I have mapped out running routes around my hospital, in my neighborhood and when I travel. I keep running gear in my locker (running shoes and shorts) so that I have no excuse not to move. I also try to get my workout done in the early morning before I start my day.

You don’t need to block hours of time for a bit of an aerobic challenge as you can run up a flight of stairs several times per day; park the auto further away and walk briskly to your workplace; take a brisk walk for 10 minutes as a time over lunch with a friend. Distance running isn’t for everyone but most of us can do something as simple as walking. Incorporate small changes which can become a habit that becomes part of your life.

Avoiding excuses (reasons)

As one becomes mentally stressed and physically exhausted, reasons for not adhering to healthy habits abound. For each of us, there will always be challenges that take us out of our routines. Take a moment to reflect on what reasons/excuses become commonplace and how you might meet or avoid them. For me, I looked at every hour of my day and examined where I could make small changes. Those small changes became my routines.

For example, I wanted to have more time for journal reading thus I looked for where I could set aside 30 minutes daily for my journals. I ended up finding at least an hour for my journal reading which became a welcome habit. I looked at where I could “sneak in” a workout even on my busiest day. I also left time for complete relaxation when I needed that too.

Staying in good physical condition is the best way to stay in good mental condition. As I look around me, those friends who are physically fit are the most mentally resilient too. In my life, my good physical condition has been a key to many successes in my career. As my physical capacity increased, with a combination of endurance and strength training, the greater my capacity to work and play with my pleasures coming from enjoyment of craft beer, good food and fellowship with friends and colleagues.

Final Thoughts

Take a moment and look for the following:

  • Where you might incorporate small changes that will increase your physical conditioning.
  • Where you might substitute better food choices in terms of avoiding high fat and high refined sugary foods for foods that are whole grain, fresh fruits and vegetables with leaner meats.
  • Where you might take time for small tasks that enhance your professional development.
  • Where you can find some time for pure recreation and enjoyment of life.

Make the changes today, that will help your life and enjoyment of life in the long run. It’s easier than you imagine as you don’t have to become a spartan or fitness nut. Your studies and your mental health with be much stronger which is the key to success in today’s world of medicine.

18 July, 2017 Posted by | academics, medical school, practice of medicine | | Leave a comment

Listening to Your Patients

At one point or another, we are required to interact and communicate with our patients. In general, when a patient presents to our care, we obtain a history although in today’s world of physician pressure to see as many patients as possible during a patient encounter, the check form history has become commonplace. Often, we scan that check form, history form before we are face to face with the patient. It has become my experience to scan that form but pay closest attention to the reason the patient has sought my care, i.e. the chief complaint.

Often the chief complaint may not be readily evident from that check list form but becomes more evident as you communicate directly with your patient or observe your patient when you enter the room or see them on the stretcher in the emergency department. This first impression, is quite useful in addition to listening to your patient’s voice, observing their demeanor, posture or simply observing their state of dress, interactions with others, such as family members who may be present. I try to use every second of my interaction in order to gain the most accurate assessment of their reason for being in my care.

Listening with your ears while observing with your eyes can be an important skill to hone as you see patients. When what you are hearing matches what you are observing, you naturally feel more confident in your ability to get to the root of the patient’s problem but don’t forget to challenge yourself to look at the encounter from as many directions as you can. Having a strong sense and comfort level with consideration of alternatives is a skill to hone.

As I have challenged myself to spend time with my colleagues in theater arts and acting, I have acquired some skills in patient observation. Additional, my theater colleagues and self-imposed exposure to stage and film productions has enabled me to appreciate good dialogue and words. Sure, my actor/director friends make fun of my fledgling efforts to understand their crafts, far more complicated that I imagined before watching them but my best friend, a professor of theater arts has increased my knowledge of how to observe human beings, most important, how to listen to my patients. I would encourage those who are undergraduates or applying to medical school, to take theater arts coursework as it will be very beneficial in your future patient encounters.

As physicians, we should return to our history-taking skills course and directions even if our medical school experience is quite remote. If we revisit our Physical Diagnosis course notes and directions from time to time, coupled with our experience with every patient encounter over the years, we get better in our listening skills. In short, anything that we practice, we tend to hone.

It’s no accident that patients tend to prefer older and more experienced physicians, often feeling apprehensive in the presence of younger physicians.  This apprehension can be addressed by the younger appearing physician/medical student by conveying a sense of interest in what the patient is saying. Listen to every word, reflect out loud on what your patient is saying and repeat your patient’s words to make sure that your are fully understanding what they are communicating.

Full understanding, good eye contact and conveyance of a sense of relaxed interest by you, the physician can greatly increase getting good information from your patient. By making sure you clarify anything on that history check form with what you observe and hear within the context of exploration of the chief complaint/reason for the encounter is also necessary.

It’s no accident that patients tend to associate better care with better communication and with physicians who have good listening skills. In today’s world of shorter patient encounters, it becomes our tasks as physicians to become something of actors in making sure that our patients feel comfortable enough to give us the information that we need to solve their problems.

We also have to develop our observational skills, visual and aural, that will allow us to make sure that we are as accurate as possible in treating our patients. For me, even as I have become one of those old gray-haired surgeons, to consistently and constantly improve my connection/communication skills. The more impaired or confusing patients in my care, the greater my satisfaction in getting their problems solved.

Yes, listening with my ears, observing with my eyes and in many cases, noting smells have all contributed to my connections and communications with my patients. For me, this is some of the most satisfying aspects of medicine. My warning is to not let being rushed to get through your patient volume, interfere with your ability to connect and communicate one by one. In the long run, you don’t save anytime if you are not getting the patient’s problems solved one on one.

13 July, 2017 Posted by | life in medicine, medical school, practice of medicine | | 1 Comment

An Addict With Alzheimer’s

This wonderful post is from a master clinician/neurologist who is a very gifted poet and author. This post is very timely. He has captured something that all of us will see in some of our patients. Remember this post and remember his words because they are very accurate for many these day. Enjoy and reflect!

The Wooded Path

He made himself known in the
bathroom of a halfway house
where by the bed he’d lost
his borrowed dime store glasses
with bottle thick lenses through
which his crooked world was framed
and missing the mark like something
he thought less than man or woman
he tottered downcast and blinded
toward the bed to wait for Mama’s
forehead kiss and trusted tucking
safe into the feathered shell of night.IMG_2399

View original post

4 July, 2017 Posted by | medical school | Leave a comment

The Boobs Have It

When I read this wonderful post from a fellow physician blogger, I knew I had to reblog this. I felt exactly the same as my very gifted colleague during my surgical intern year on my Breast Surgery rotation. Yes, it’s been a long time since I have referred to breasts as “boobs” out of respect for the miracle that is the human body and all its parts. Enjoy this wisdom.

Behind the White Coat

Display in museum in New York City
Do you know how many breasts I have touched?

Thousands of them.

It is staggering when I reflect upon it.

So many breasts. So very many. All shapes and colors and sizes. Hairy. Not hairy. Moles and rashes and skin tags galore. Droopy. Perky. Somewhere in between.

During breast exams I have for years and years referred to the exam as the “boob check.” Whenever I made reference to my breasts of anyone else’s I nearly always called them boobs or boobies.

To be honest, I thought it was cute.

Touching another woman’s breasts makes me uncomfortable, maybe even a bit embarrassed. I feel the same when someone else is looking at or touching mine in a nonsexual, clinical sort of way. So I made fun of breasts and joked about the situation. It took some of the sting out of the situation to act goofy.

One of the many…

View original post 301 more words

21 June, 2017 Posted by | medical school | 1 Comment

Heading into Residency!

It’s that time of the year when many recent medical school graduates are in the heat of getting things organized for the beginning of residency. Residency is the next phase of medical education in the United States and as such, is a period of rapid change and learning. You will be fairly independent in your care of patients; studying in a different manner from your medical school coursework but definitely getting your style of learning and practice honed.

This is a time to drop any pretenses of being the perfect “intern” and let yourself learn and absorb as much knowledge from those in your program who are more experienced. If you have traveled to a position that is different from your fourth-year medical school hospital, you have to learn how the place works as well as how you will work within your locale. When your ward work starts formally, you want to have your organizational system in place, know your way around and have your most important home location settled and ready.

For example, you should have made sure that all of your training licensure materials have been taken care of. You need to make sure you have your paperwork completed long before your program starts “New Resident Orientation”. There will be many details that need to be presented thus you don’t want to add to things by not having your paperwork completed.

For many, USMLE Step 3 will come into play rapidly. For this exam which becomes something of a nuisance for many, myself included, you have to have a date in mind to complete this test. For my residency, which was in General Surgery, I knew that my in-training exam was in January, thus I set a goal of taking Step 3 within the next two months after my in-training exam. I knew that I wanted to place most of my emphasis on my surgery exam, thus I dedicated about 30 minutes per day on reviewing my medicine for Step 3. I set this schedule into my schedule of reading so that it became a habit.

In terms of reading, I asked my second-year residents which books and papers would be best to start my reading for both my in-training exam and Step 3. Again, I wanted to rely on the experience of those who were immediately above me in my program. I also sought the wisdom of my faculty adviser in my baseline reading too. If there was anything that I didn’t count on, it was that I wasn’t able to set up a regular physical conditioning program, something that would have made my PYG-1 year more efficient.

In other posts, I have emphasized the importance of taking care of your physical conditioning. Not only is being in good shape helpful for stress-reduction, good conditioning is most helpful on those very long nights when call seems to go on forever. If you are in good aerobic condition, you perform better even when you are exhausted. Figure out a way to eat well, low fat and low sugar foods along with doing at least 30 minutes of aerobic exercise five to six days per week. Your rest and your brain with be grateful.

If you haven’t figured out how you will keep track of your patients, look into any system that might work for you. At this time, you can do a little experimentation and make adjustments when you begin seeing patients. I had to alter my patient tracking system from the one I used as a fourth-year medical student because my residency hospital patient tracking/health record system was different. It’s easier to make adjustments than find yourself overwhelmed because you didn’t have a system to begin with.

Make your home your sanctuary of solitude in any way you can. For me, my solitude involved investing in dark curtains in my bedroom that I could close on a bright sunny day post call. I found that I needed the darkness and cool for rest and relaxation. I also found that I functioned best post call when I didn’t encounter another human being for a few hours. Figure what works best for you and stick to it.

I made a schedule for my post call days so that I could do routine chores such as laundry and grocery shopping as part of my relaxation. Grocery stores that were open all night became wonderful for me. I planned my menus for the week, cooked on weekends that I wasn’t on call and kept my freezer stocked with meals that I could pop into the microwave rather than hitting the fast-food establishments. I have continued this practice even today because as I have aged, good nutrition is very important.

I used one of my spare bedrooms as an office. In my home office, I kept my textbooks, computers and study materials, much as I had done in medical school. Since I kept a regular reading schedule, I checked off book chapters and topics as I completed them. Even with a regular reading schedule, I always felt that my fellow residents were better read than I was, even though it probably wasn’t the case.

Finally, I had to schedule in time for my friends and family. Residency is a very hectic time but family/friend time is as important as reading and study time. Most Sundays, if I was able, I attended church if for no other reason, to thank my Higher Power for giving me the strength to stay on top of my work. Find a religious institution in your location and attend once in awhile if you don’t belong to any particular religion. It’s just another outlook and fellowship with people who are likely not hospital folk-good for your brain.

My favorite hobby, outside of sleeping on my rare days off, was going to the movies. My restless brain needed to enjoy some pure entertainment. While television can be tempting at home, especially since you can be in your “jammies”, it was better for me to get out of the house for a couple of hours and watch a movie or attend a concert. Football, lacrosse and soccer were also great getaways for me too.

In conclusion, residency is going to be a time of learning, reading and stress. Most of the stress will be self-imposed because any new situations are stressful for most humans. You will be learning about your patients in depth, trying to anticipate their needs and keeping your senior residents/attendings up to date on how you are caring for the patients on the services.

Again, try not to take yourself too seriously in terms of forgiving yourself for making mistakes but learn from those mistakes. The people who are more experienced on your team only expect that you do your share of the work and that you learn from your mistakes. It turns out that this is a great way to learn what you need and sets you up for getting the best experience for your program.

17 June, 2017 Posted by | intern, life in medicine, relaxation, residency | | Leave a comment

Hospital Haiku

“hospital moonlight

cacophony of machines

teardrops cascading”

As we come to the end of National Physician’s Week and today, National Physician’s Day, I related this haiku from one of my most gifted and amazing friends. Some years back, he suffered a  critical and life-threatening illness that resulted in profound changes in his life with some time in the intensive care unit. This illness changed a man who is talented beyond belief, a brilliant creative genius and professor in ways that few of us can relate or even imagine. Still today, he’s affected by his illness and the events that surrounded it.

I share this haiku because it brings to mind, something that we as physicians must always remember about our patients. They place their health, their trust and many of the most intimate aspects of their lives in our hands. With our hands, we have to care for them; relate to them, in many ways hold them, and be mindful of the honor and privilege of having them place their lives in our care.

As such, we also have to be mindful that illness changes their reality and in many cases their lives profoundly especially when they are critically ill. We have to reach out and extend more comfort over the “cacophony of machines” that becomes the background of their intensive care and sometimes hospital care experience. We have to block that “cacophony” whenever and wherever we can.

I remember watching a tear roll down the side of the face of one of my ICU patients who appeared comatose. The nurses were bathing him and chatting with each other as they turned him. I saw the tear; asked them to speak with him over the ICU noise background. I asked them to play music in his room and I always held his hand when I entered the room to examine him. I am sure that my soul could feel his soul even though he didn’t ever speak to me. I never saw that tear again, after we began speaking and focusing on him, holding his hand, touching his face, and playing his favorite music even though he did not recover from his illness.

I seek to connect with my patients without exception as that is my honor as a physician/surgeon. I spent years learning the science and techniques of medicine and surgery but in these, the later years of my clinical practice, my focus is on the art of medical practice. Within that art is my chance to give some of my heart to those who have placed their trust in me (and my training). I strive to be more human and more comforting. To do less of the science and more of the art is great joy for me. My joy is in the connections; kind of strange for a surgeon.

On this National Doctor’s Day, I am honored to be a physician and grateful for all that this profession has given me. This profession has given me far more than I can give back but I will spend as much time as possible giving as much as I can to those who are in my care.

30 March, 2017 Posted by | medical school, medicine, practice of medicine | , , | 2 Comments

A touch of tenderness (Reblog)

Here’s is a great post to remind us that touch may be the best medicine out there for our patients. Don’t be afraid to touch your patients and connect with them. This is the true “magic” of medicine. Touch is needed more today than ever.

Sue Vincent's Daily Echo

The Cathedral by Rodin.

My son gleefully squeezed harder at the knotted muscle in my shoulder, with a ‘Now I’ve got you’ as I groaned in agony. We have established and agreed that he has a slightly sadistic tendency where I am concerned. It may have something to do with my knack of getting just the right spot on the painful muscles as we got his body working again. Day after painful day, for months on end. So now it is payback… and he appears to enjoy it. He still manages to lay the blame squarely on my aching shoulders, muttering something that sounds vaguely like ‘hereditary’.

He is a little more squeamish than I. His face screws up in horror as my wrist bones crunch back into place when he applies traction. It is, however, nice to regain freedom of movement occasionally. So I make him do it…

View original post 1,189 more words

25 March, 2017 Posted by | medical school | 3 Comments

Great Post from “Life of a Med Student”

“Beyond the H&P” A Guest post by Jessica Morgan It’s 4:00 pm on a Thursday: time to present at teaching attending rounds. I have prepared my presentation and know about the patient’s pathology, but I can never help myself from being incredibly anxious for these moments. I gather my papers and begin…

via Beyond the H&P — #Lifeofamedstudent

24 March, 2017 Posted by | medical school, residency | | Leave a comment

You Have Matched!

A hearty “Congratulations” to all who matched! This is the next step in your medical career no matter where you matched. On Friday, you will find out where you matched; some taking the news with tears and fears. Make no mistake, if you didn’t match, the future becomes more uncertain but certainly not bleak. As I have stated in other posts, those who didn’t match should be aware of the current S.O.A.P process and should be working on getting a training position for next year.

If you have matched, some things to work on as soon as you can:

  • As soon as you know where you will be training, get in contact with one or two of the senior residents to find out which textbook(s) is (are) the major reading material for your program. Purchase the book(s)(electronic or paper) and start reading.
  • Make a list of the sentinel journals for your specialty and start reviewing articles. You need to practice evidence-based medicine. Getting a head start on your journal reading helps to make journal reading a habit.
  • Start a physical conditioning program if you have been relatively sedentary during medical school. Aerobic exercise (30 minutes per day) can help reduce stress, help with stress and keep you healthy. Make physical exercise a habit along with journal reading. Even on your on-call days, you can walk/run the steps for a quick work out which will keep you more efficient in the long run. You will also sleep better if you are in good condition. Add some strength training too.
  • Find a place to live if you are moving. Don’t put this off because you need to be comfortably in your residence before orientation week in your new hospital. Your home should be simple, convenient for commuting to the hospital, restful and useful for your lifestyle. Though you won’t be spending tons of time at home, you need for your home to be your haven in your off hours. Make sure you have a washer and drying in your residence. You don’t want to be heading to a laundry room when you need to be sleeping.
  • Get your paperwork done for your training license as soon as you get information from your program. Some states have many tasks for you to complete before you can be licensed for training purposes. The sooner you get this done, the better.
  • Take a week or so off but do this long before you start your program. You need to have a bit of fun but using too much time in vacation before you start your PGY-1 year can be a problem too. Complete off time is great but not an escape.
  • When you get your residence, scout out several routes to the hospital so that you know how to get in even if there is a problem with weather, roads and other mishaps. Make sure your car or bicycle is in good repair with a good back-up plan.
  • Learn how to cook and take your meals into the hospital. Trust me, hospital food in most cases, is not great for keeping you healthy. I cooked on my days off, put a week’s worth of meals in the freezer and carried them in for my call days and nights. Good nutrition is key to good learning and training.
  • Learn a good organizational system for your ward work. I used an Excel program complete with dropdown menus for my sign-outs; still use this system. Learn to make check-off sheets to stay on top of your patients and their needs (lab tests, radiographic studies).
  • If you can, arrive a couple of days early to get familiar with your hospital’s physical layout, systems for dictation and record-keeping. Do a recon mission that will save you time in the long run.

Finally, this is a great time of learning and professional development. Having some organization is key to keeping your head in the right place. Enjoy the experience so that you can take advantage of every minute of residency with a positive attitude. Don’t underestimate the value of a smile on your face because you are learning the tools that will make you a good physician.

14 March, 2017 Posted by | medical school, organization, residency | | 5 Comments

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

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

Introduction

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).

Summary

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.

11 March, 2017 Posted by | difficulty in medical school, Match Day, residency, scramble | , | 1 Comment