Medicine From The Trenches

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

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

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


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

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

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

SOAP is NOT “The Scramble”

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

SOAP should not be your primary residency application

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

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

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

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

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

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

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

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

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

Things that generally DO NOT enhance your chances of matching

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

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


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

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

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


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

Strategies for Conceptual Learning (undergraduate and professional school)

Many students enter healthcare with the idea that they will “memorize” their way to academic excellence. This strategy is useful for short-term memory of things such as pharmacology formulas that one can write down quickly in the exam margin until needed or a pneumonic such as “Mrs. Ass” for remembering whether a heart murmur is systolic or diastolic. Yes, rote memorization can get to a certain level but strong academic performance and life-long learning requires mastery of conceptual learning.Conceptual learning involves linking of information and building upon a knowledge base. When I entered medical school, my school’s curriculum was “classic” in that first year we learned “what was there”; second year we learned “what can go wrong” and third year we learned how to fix things that go wrong. (Fourth year was refinement of first, second and third year). First year set the concepts and basis for our mastery but we had to build upon those concepts and integrate learning from second, third and fourth year in order to have the tools to become competent and knowledgeable physicians.

Conceptual learning starts with a very strong undergraduate experience. I use the word, “experience” because one should acquire the tools to master conceptual learning as an undergraduate. Sure there are plenty of people who will say that they “party all of the time” and then “cram” right before the test so that the material is “fresh” in their minds. My suspicions, borne out by some of those people’s test scores, especially on exams of applied knowledge, supports that they don’t know and can’t remember concepts. In short, they crash and burn- usually stating “I can’t do standardized tests”.

The experience of concept mastery can start with that first pre-med course where one utilizes the syllabus to identify concepts for mastery. Your textbook can also provide valuable information as to conceptual mastery. Many textbooks will summarize concepts at the beginning of a chapter or at the end of a chapter. This doesn’t mean that one sits and memorizes the concepts as a list but it does mean that one utilizes the list of concepts as a “check off” in terms of mastery of a chapter or mastery of material for an exam. Sure, you can “cram” in information for undergraduate work but once one enters medical (or physician assistant) school, the volume of material tends to favor conceptual learning as opposed to rote memorization. For example, you may be studying the treatment of viral illness in particular course block. You have to understand the concepts of viral structure, viral pathogenesis, immunological barriers and cellular reception/structure. After one couples that information with viral transmission and resistance characteristics (host & viral), one gets a pretty good idea of how viral diseases are diagnosed and treated. One also gets the concept that antibiotics are useless against viral illness. As you are standing at the bedside of a patient who is suffering from a viral illness such as influenza, you understand the characteristics of the symptoms reported and the signs that you are observing. You add those to your clinical experiences in terms of a differential diagnosis and treatment plan which is your key to efficiently treating your patient.

In short, if any of the conceptual knowledge is missing, you will not become an efficient clinician and you will find yourself constantly “behind” in terms of “shoring up” your knowledge gaps. This is the main reason that many people become “overwhelmed” quickly by the volume of material that must be assimilated in a short period of time. For example, about the second week of the first year of medical school, I start to see some of the more obsessive/compulsive students begin to “unravel”. Later on, often after the first exam block, I see some of the more “laid-back” individuals start to up their “game” and make adjustments to their learning strategies.

The people who have the shortest conceptual learning adjustment periods are the folks who have been conceptual learners as undergraduates. They are usually the most disciplined students and they are generally the students who seek assistance when needed and they tend to have less “emotion” when it comes to the materials that they need to learn. In essence, they are just building upon a foundation rather than trying to memorize a stack of words and phrases. No matter how a concept is tested, they are ready for the challenge. No matter how complicated the patient disease presentation, they systematically take that presentation apart and develop strategies for patient care.

I recall my experience with Organic Chemistry, one of my least-favorite courses as an undergraduate chemistry major. My passion lie in analytical and physical chemistry rather than carbon chemistry but my goal was to become an excellent chemist. My career plans were not medical school but graduate study in Analytical Chemistry. Since organic chemistry was far from the math-based chemistry disciplines that I loved, I approached this course from a purely conceptual (and practical level). In short, I probably spent more time organizing this course for my learning style than my other chemistry courses but I had the assistance of excellent professors, whose office hours I frequented, and I sought their experience and assistance with my organization of this coursework. To do otherwise in any discipline or course as an undergraduate took away from the knowledge base and experience that I knew that I would need as a professional chemist. In the end, Organic Chemistry was one of my strongest course performances even though I didn’t plan on becoming an organic chemist. (I ended up in graduate school studying Biochemistry and Molecular Biology).

As a physician, I am required to participate in continuing medical education (CME) for the maintenance of my license and for the maintenance of certification in terms of my medical specialty. It would be difficult to participate in my CME/MOC activities if I didn’t have a strong conceptual basis for this coursework. Most of my CME/MOC activities involve week-long conferences with testing at the end in order to receive my certificates. If I did not have the knowledge base, I would not be able to add the new knowledge and assimilate it quickly. Many of my CME/MOC activities center around evidence based medicine which means that I have to know how to keep up with scientific/medical literature and either incorporate into my practice or reject what I am reading or studying. As an academic physician, I am charged with keeping my scientific knowledge up to date and accurate in both my research/teaching and my practice. This takes a strong conceptual basis for efficiency and accuracy.

As an example, new pharmaceuticals are entering practice weekly and one has to make decisions as to whether one will prescribe a newer pharmaceutical versus a pharmaceutical treatment that has been present for years. Drug company representatives will furnish practitioners with plenty of literature – supporting their new and most likely expensive pharmaceutical but one has to have the knowledge base or ability to quickly acquire the knowledge to fully evaluate drug company claims. We have seen plenty of examples where the newest drug is not always the best drug for treating certain disease entities.

Finally, how does one become a conceptual learner? The steps are generally:

· Look at your course syllabus for the course content and objectives. A well-designed syllabus should give you plenty of ideas as to how the information for the upcoming course will be organized and tested.

· Look at your textbook and determine how the textbook will supplement and reinforce the concepts of the course.

· Look at how the material will be tested. Will there be examinations (essay, multiple choice or oral)? Will there be performance criteria for mastery? How does any laboratory exercises and material fit into the grading/testing of the material?

· Take emotions and “what grade you have to have” out of the learning process. If you master the concepts, the grade will take care of itself. If you focus on what score you have to have on any particular exam, you will generally come up short. It’s a waste of time trying to figure out how to “beat the curve” rather than focusing on what you need to learn and how to get it mastered.

26 April, 2013 Posted by | academics, difficulty in medical school, physican assistant, study skills, success in medical school | 3 Comments

What do I have to know in medical school?


If you are asking the question,”What do I have to know in medical school?” then you have already started at a disadvantage. Medical school is not about “what” you “have” to know as much as it is about application of a body of knowledge to problem-solving. Sure, you can sit down and attempt to memorize a bunch of lecture notes so that you can repeat them verbatim but that isn’t going to get you past USMLE (any of the steps) or through residency. Medical school provides a foundation of knowledge that you can build upon. The more solid your undergraduate preparation, the easier you can add to your knowledge foundation that will enable you to treat patients.

Many medical students get into the “whine” about why they have to know so much detailed information when vast information resources are available at the “whisk” of a finger. In truth, the internet is as much of a blessing as it is a curse. No amount of information at your fingertips is going to be very useful unless you know how to evaluate that information and how to apply that information to clinical problems. While many undergraduate institutions are adept at getting students into a mode of being able to “memorize and regurgitate”, they fall far short in terms of providing a solid foundation in research and problem-solving. While there is no lack of information, learning what information to utilize and how to utilize the information that you learn is the biggest hurdle for most pre-clinical medical students. In short, all of the things that are on the internet are not useful or helpful when it comes to patient care.

Becoming an efficient learner in preclinical medicine

Many students start out with the idea that they are going to go home every night and re-copy their notes in order to memorize them for the upcoming exams. They quickly find that this strategy is neither useful nor efficient. The notes are generally an outline of what needs to be mastered in detail with the details largely coming in the form of the information that is stated in class between the bullet points on a lecture outline. Simply recopying notes will largely get one to the point of being a good “clerk” but generally doesn’t provide much of a basis for the depth of understanding that is needed for knowledge base mastery. In short, the Powerpoint lecture notes and the review books are just not enough by themselves for a thorough understanding. One just cannot “memorize the bold heading” and expect to be ready for board exams or course exams for that matter.

What is “efficiency” in learning pre-clinical medicine?

Efficiency is largely making the most of your attention span plus making sure that you synthesize and incorporate new knowledge within the context of the knowledge that you came into to school with. Many students who didn’t major in the sciences will lament that they just don’t have the background that their fellow students would have in subject A or subject B but an efficient learner will not only have the background regardless of major but will be able to add to that base with ease. In short, everyone who takes the pre-med coursework, has the background knowledge base to do well and be efficient in medical school.

If a person majored in biology as pre-med, the upper division biology courses required General Biology as a pre-requisite the same as Gross Anatomy and Biochemistry only require General Biology and General Chemistry as pre-requisites -note that I didn’t mention anything about Organic Chemistry as Biochemistry is far more related to General Chemistry than Organic Chemistry. If a first-year medical student didn’t major in science, they are at no more of a disadvantage as long as they know how to add to their pre-med base and build upon that base. In short, it’s a good idea to stop “talking” or “thinking” ones self out of a strong performance because of perceived perception that upper division science courses give an advantage. In short, the upper division science courses are only advantageous to folks who anticipate graduate school in that  subject matter.

In one wants to become an efficient learner, the subject matter is fairly irrelevant but the study techniques are quite relevant. One has to have an approach to new information that is devoid of emotional reaction, self-deprecation and a willingness to adapt to whatever comes next. Adaptability is a very useful characteristic for learning new material and thankfully, your brain is “wired” to adapt to new situations if you allow it to do the job without emotional checking. One has to have the confidence to dive into what needs to be learned, master what needs to be learned and to readjust if their first attempt at mastery falls short.

Confidence, the best learning tool

When I speak of confidence, I don’t mean that one boasts or constantly “pats their own back” but I mean that one has to have the ability to move past and learn from those myriad of small mistakes that will come with adjusting to any type of professional school. Some folks mistakenly believe that once they achieve a “high” board score or a good grade on a course exam, that they are in the upper echelons of medicine and can’t make any mistakes. Being able to bounce back and learn how NOT to do something is a valuable as knowing HOW to do something.  In every aspect of medicine, it’s the experience that will trump anything read in a book or in lecture notes but with experience should come making mistakes and making adjustments from those mistakes. In surgery, for example, skills are honed from practice and more practice but experience with practice is the best teacher and the best method of learning.

Learning in isolation

I hear over and over from medical students that they are just “not group studiers”. In medicine, one has to learn to interact, learn from and teach other members of the healthcare team. Nothing in medicine is done in isolation which means that the sooner one gets used to working with a variety of others both friends and colleagues, the better they become as physicians. I always remind the residents who are rotating with me on my service that it was a physician assistant who taught me the skill of closing the chest. This PA had spent years doing chest closures and knew how to teach in a manner that was great for a resident who was in the learning stages. My thoracic surgery attending was brilliant and guided me in many ways but that cardiothoracic PA taught me how to handle sternal wire efficiently and safely in the step-by-step manner that a junior resident needs to be taught. In short, the best physicians learn to appreciate knowledge from any good resource and learn to appreciate anyone on the team who is dedicated to the perfection of their craft. This holds most importantly for pre-clinical medical students as well as residents who are further along in their learning. Work with anyone at anytime who is willing to share their knowledge with you or who needs the benefit of your counsel. The ability to work with others and learn from them  will pay back in the years to come.  One cannot afford isolation in any part of medicine.

Getting along with others

While most of your learning is your responsibility, you have to be able to work with potentially any number of diverse people on a health care team. I vividly remember overhearing one of my fellow medical students  who was from India talk about a resident who was from Kenya. This medical student joked about how he “had it made” because the attending on the service was from India and the resident’s opinion wouldn’t really “count” in his grade for the rotation. Well, that medical student was pretty surprised to find out that his “honors” didn’t materialize because he just wasn’t receptive to learning from a resident whose ethnicity was different. He appealed his grade to the attending and to the dean of education but it stood because he wasn’t ready to work professionally with another person who had earned the right to be a resident and who attempted to teach. In short, professionalism means that one has to be able to work with a broad range of people and treat a broad range of people with respect.  The first mistake that many medical students will make on a rotation of any sort, is believing that they can’t learn from anyone except the attending physician who is in charge of the service or that they can treat anyone associated with patient care in a manner that is disrespectful.  I will often question nursing assistants, environmental service workers and nursing staff about the manner that students and residents treat them on a day-to-day basis. In short, everything on a clinical or in pre-clinical coursework always “counts”.  It’s just as easy to treat everyone  with respect (becomes a habit after a while) and not have to worry about offending  (or impressing) anyone.

So what DO you have to know in medical school?

You have to KNOW:

  • How to be an efficient and self-directed master of course materials.
  • How to work within a very diverse population of patients and healthcare workers.
  • How to make adjustments after trying something that didn’t work as well as you thought.
  • How to recognize that every experience is a learning opportunity and be open to the learning.

13 December, 2011 Posted by | academics, difficulty in medical school, medical school | | 4 Comments

Getting Through The Semesters (or what if I Fail Something?)

“The Thrill of Victory or the Agony of Defeat”

The Drama of Human Competition as the opening lines of ABCs “Wide World of Sports” promised. By now, many students have had their first blocks of exams in medical school. Some people have done very well and some people have “breathed a sigh of relief” that they passed and some people have not passed one or or more of their exams. To fail an exam at this stage can be a huge personal blow but your actions after discovering that you have not passed (I am going to avoid the word “failure” here) are critical to figuring out what you need to do to get “above the yellow line”. Sure you NEED to do a bit or mourning in terms of the loss of those wonderful feelings that infused during orientation week but don’t let the mourning phase go on longer than a couple of minutes. Replace mourning with a very objective strategical look at what might have gone wrong and how you are going to fix the situation.

There is something in medical school that will throw every person. It may be that first round of exams, that USMLE score or a patient contact that just did go well. The important thing is that out of every experience, good or bad, you learn something about yourself and what you are capable of achieving. It is out of experience that you will learn to treat your future patients so let your experience become your teacher and move forward from here. Not passing an exam just doesn’t feel good and can play with your “head” in terms of how your look at your future. My point here is that nothing except that round of exams is over at this point. You mourn a bit and then you push forward because (and I am not wrong on this), the material for the next round of exams is already upon you.

As soon as you know that anything has not gone well for you academically, ask for help. Your first action should be reviewing the test and trying to figure out where you went wrong. Do you need to rely on more detail? Did you move too fast and not answer the question that was asked? Did you neglect to read every answer choice with a more correct answer further down? Did you not fully understand the material? Were you distracted by something outside of school such as a relationship or illness and not put in enough time studying? In short, try to figure out what went wrong and take steps to make sure that you don’t repeat your mistakes.

What if I fail a whole course, like Biochemistry?

The consequences of failing an entire course in medical school are largely school-dependent. Some schools will want you to retake only the material that you did not pass while others will have you go through an entire summer remediation course. In any event, look at your remediation/retesting as an opportunity to hone this material well. You definitely want a strong knowledge base for your upcoming classes and you will have made some steps toward review in terms of preparation for USMLE. In this light, having to retake or remediate is not totally the worst situation that you can find yourself going through.

Plunge into your review with total concentration on the subject at hand. If you have one course or one area of subject matter, this is easier than if you have multiple subjects to remediate. Your only resolve in this situation is to not miss this golden opportunity to thoroughly master this material. You are not a “lesser person” because you need a second review and keep in mind, that you are reviewing at this point. In most cases, you have learned the material on the first shot but this review gives you insight into the material that you likely previously missed.

I am always more concerned about those students who “barely” passed than the students who failed and are re-mediating. In most cases, the student who re-mediates does not carry a knowledge gap forward while the student who barely passed likely has gaps in their knowledge base. It is those who barely pass that will need the most intensive review and preparation for board examinations.  I always encourage students who scored below an 80% to study for and take any optional shelf subject exams if offered by their school. These shelf exams can pinpoint knowledge gaps that can be filled in before taking Step I.

Class Attendance – Is this time well spent for me?

In some medical schools, class attendance is not mandatory. If this is the case, and you ran out of study time, try figuring out if there is one day a week that you can stay home and study the material using note service/lecture tapes or vids/textbook and syllabus reading. Many students do not attend class and find that home (or away from school study) works best for them. This may work for you but be careful if you have too many distractions at home or find that not attending class puts you behind. (Getting behind in medical school is deadly.)

If your work is not detailed enough, figure out which classes do not require the detail and which ones DO require more detailed study. In short, give each course what it demands. Many schools have integrated courses that definitely demand loads of detailed work coupled with “professional-type” courses like Practice of Medicine that are more performance-based. Try to look at your coursework from this perspective and see if you can give your integrated course a bit more time and your performance course a bit less time.

Another problem is that in many first year courses, the load of information can seem overwhelming. Resist the urge to dwell on what seems overwhelming and nibble away a chunk at a time. I always remember that scene in the movie “Shawshank Redemption” where the protagonist chips away at the prison wall over the course of 17 years with a small rock hammer. Eventually, he gets through the wall and escapes. Extreme but I think you get my drift in terms of divide your work into manageable chunks and stay on course. Keep moving forward because you can only affect what is happening now and use that to impact the future. Weekends are your friend because you can breathe a bit, relax a bit and catch up if you have fallen a bit behind your class. In the middle of the week, go to where the class is and use the weekend to “catch up”.

Wasting time and less efficient practices

I discourage students from recopying notes as a means of study. When you have volumes of material and information, you can become more of an excellent clerk in terms of producing a beautiful set of notes that you have not mastered. Organizing your material is good (can be done with a highlighter or in the margins of your notebook) but total recopying of every word may be too time consuming and not as beneficial as when you were an undergraduate student with less volume. You may need to review the material and then constantly question yourself or recite the material back to yourself rather than a complete recopy. If you can recopy your work in an efficient manner while learning and your grades are good, then recopying is working for you and don’t change your strategy.

Another problem that can interfere with some freshman medical students is feeling that they “need” to study for boards. You don’t need to take time away from your coursework mastery to do board study at this point in your career. If you absolutely feel that you NEED to do some board study, then do it during the summer between your first and second year but the best preparation for boards is to thoroughly master your coursework and then study for boards at the end of your second year. You cannot “review” what you have not “learned” in the first place. Don’t take valuable coursework study time to do board study. Board review books are most useful because they summarize material but most medical school courses require the details and not summaries. Beware of the “I am going to use a review book to summarize” method of study because it might work against you in terms of you not getting enough of the details to pass your course. The other extreme is to attempt to memorize the textbook which is most likely too much detail. In short, strike a happy medium that will work for you.

Don’t be afraid (or ashamed) to consult your instructor or your dean if you are struggling. Not to reach out for help (especially because of the amount of money that you are paying for your school tuition) is not wise. It really looks great to a residency program director to see comments from your dean or professor that state that you were able to overcome a deficiency and excel. These types of comments indicate excellent problem-solving skills which are highly prized in a physician.

Finally, tune out the boasting of your classmates who say that they “didn’t study” and “aced” their exams. They are lying period. You have to do what you NEED to do for yourself. Congratulate them for being so “brilliant” and don’t waste a second of your precious time worrying that you are somehow deficient because you studied like a demon and didn’t do so well. There is nothing wrong with you that correcting your study strategy will not solve. Just don’t add “questioning your worth” to your list of things to overcome. It isn’t necessary and it won’t get the job done.

Striking a Balance

Finally, one key aspect of medical school, residency and the eventual practice of medicine is that you will have to constantly “strike a balance” between study, personal life and professional obligations. The first semester of medical school will definitely test your resolve to keep working away at your studies until you get them mastered but this should not be at the cost of your personal integrity or sanity. Try to find ways of incorporating some stress relief (physical exercise) and socialization (away from your classmates) into your life. Nothing, including the practice of medicine is one-dimensional and there needs to be balance.

For example, if you are studying in the library and know that you won’t make it to the gym, try to walk up at least 8 floors of steps on the days that you don’t get to the gym. Take 10 minutes and take a brisk walk around the corridors to get your brain relaxed before you keep “grinding” away at your study materials. Study and pace at the same time while reciting the material to yourself in your own words. Try making some study-drill tapes and drill yourself while you are on the elliptical trainer/treadmill in the gym. Finally, picture that professor’s head when you are doing your bicep curls or on the fly machine and pound things out. You will be more relaxed, less stressed and more efficient in your studies. In addition, you can enjoy eating without worrying about gaining weight.

Statistics (and odds) state that if you were accepted to medical school, you will get through the four years successfully. Some people make the adjustment to the rigors of medical school academics faster than others but trust yourself enough to know that you will get the job done. There is very little difference in intellect between the person who graduates first in their medical school class and last in their medical school class. Residency program directors know this which is why the person who graduates last in their class is still called “Doctor”. Run your own race and get what you need.

23 November, 2008 Posted by | academics, difficulty in medical school, medical school coursework, study skills, Uncategorized | , , | 16 Comments

Playing the Waiting Game and Keeping Your Sanity


You scrambled around and made sure that every one of your writers of your letters of recommendation did their respective jobs. You started your Personal Statement early and left plenty of time for editing and corrections. You started to fill out your AMCAS application as soon as it was available and you made sure that there were no mistakes. Finally, on the first day that you could, you pushed the submit button and the “waiting game” started. You had heard that in every circumstance, early application is the best strategy for success in getting into medical school. So now, you find that it’s early summer, school is out, and you are in for the wait.

Starting the Wait

Your next hurdle is to receive word that your AMCAS is verified. This can take six weeks or more if there were no mistakes or lost transcripts and can often take much longer if things are not moving efficiently. This step has to happen and it can cause worry if things are delayed. I can tell you that, in terms of medical schools, early summer is a non-time in terms of admissions. Most of our time is spent on getting the current class underway and gearing up for the start of receipt of new applications. For us, that early lag of time between when you can submit your application and verification is vacation time, organization time and just plain much-needed down time for us in terms of application review. It is also the time when we try to put the finishing touches on the class that is set for the new year.

The best strategy for you at this period is to make a folder for each school that you have applied to. In this folder, you will place copies of your personal statement, copies of any completed secondary applications one they have been received and completed and copies of any correspondence that you receive from that school. You can also put an envelop on the front of the folder with a copy of your itinerary once you have made travel plans for your interview. In any event, start making the folders and securing a safe place for them.

The next thing to do is make an Excel spreadsheet. On that sheet, you should make a book for each school that you have applied to. You will eventually log every date and every receipt of correspondence that you will receive. You columns should go something like date received, date sent, and date of school’s receipt. (Needless to say, anything that you send to a school should be sent by certified mail with receipt notification). Repository services such as Interfolio will also post dates of when they send your materials and when they were received. You definitely want to make sure that you keep your application materials and correspondence with each school very organized and safe.

Plan B

Plan B is what you will do if you are not accepted. In the business of medical school acceptance, nothing is a certainly except you won’t get accepted to a school if you don’t apply there. Acceptance, even if you have submitted an application with a 4.0 uGPA and 45 MCAT is not assured for anyone. It is wise to have a carefully though out and planned Plan B. From experience -mine and others- the more elaborate and complete your Plan B, the less chance you will have to use it. Start planning and working on you Plan B.

Financial Aid Forms

Right after you have submitted your AMCAS, you should begin and complete your FAFSA forms. You will need to obtain a financial aid transcript from every school that you have attended whether or not you received financial aid.  If you are not applying for scholarship or financial aid for medical school, you can skip this step.

When you complete your FAFSA, have the results sent to every school that you have applied to. This will save you time in the long run. If you are not accepted, having your financial aid information sent is not going to make a difference one way or the other. If you are accepted late, having your financial aid information already in place can save plenty of headache when school starts.

Senior Year

If you are an undergraduate, you want to plan a strong senior year. I know that “senioritis” sets in and you are tempted to want to coast because you are done with MCAT and done with the majority of your courses but don’t do this. Take some seminar courses and expand your knowledge base or take some research courses and pick up some valuable skills. My senior year of university was spent writing and presenting my honors thesis work. This was actually great experience for me and propelled me into the world of research scholarship. Use that senior year to shore up any possible deficiencies that you might have and to finish strong.

This is also a prime time to begin a solid exercise program. My biggest regret in medical school was that I didn’t stay in good physical condition. If I had kept up with my conditioning, I would have been an even more efficient student and a student with far less stress. Take this time to start and hone a solid aerobic exercise system that you can complete in 30 minutes to 1 hour each day. It can be as simple as taking three 10-minute brisk walks or climbing a couple of floors of stairs until you work up to 14 floors daily (only up direction counts). Even today, I make sure that I do at least 14 floors up every day. I can find steps pretty easily and do a couple of floors between cases or when I need a break from my desk.

Early Fall

By this time, you should be keeping your senior coursework strong and completing all secondary applications within one week of receiving them. Another thing that you need to do is go to a professional photographer and have some professional head shots taken of you in your interview attire. You will need these for many secondary applications and you will need them later for things like USMLE application. Don’t use a cheap “Passport photo” service. These cheap services will take photos that make you look like you have been in prison. Use a professional photographer and groom yourself as if you were going for interview. That secondary application should look polished and professional. Once you have chosen a good photo from the proofs, have several passport-sized sheets made and keep these in a safe place.

Again, as soon as you complete and post a secondary, make a copy and place this in the folder for that school. It’s a good idea to make a copy of everything that pertains to each school including things from their website (names of deans of admissions, names of admission coordinators) along with dates of any phone conversations. Also place copies of any e-mails that you have received for each school.

Interview Time

Most schools spend July and August reviewing applications and interviewing Early Decision applicants. You can expect to receive notification that you are complete but not much more information from your schools. Early Decision applicants have to be notified by September 1 so their applications are processed first. After the first couple of weeks of September, some of the earliest regular applicants that have completed interviews may be notified of acceptance  or if not interviewed, notified to interview by some schools. If you receive a notification of invitation to interview at this time, this is great but don’t read anything into not receiving an invitation to interview. At this point, it is way early and you should be either working on Plan B or working diligently on your coursework. In short, don’t start obsessing about timing.

Many schools will not even begin interview session until late October and early November. Again, if you applied in early June, it will have been a long time. Don’t get crazy and don’t begin to call schools. If you have received a “complete” notice, then you wait. Find something else to do. If you have an interview notification, then work on your travel plans and logistics. Elsewhere on this blog, you will find posts about traveling to interview.

If you haven’t heard from any school by the end of October, consider applying to more schools. If you were in the very early applicants, you may need to broaden the number of schools that you have applied to. A major mistake that many applicants make is overestimating their competitiveness for medical school. If you are not securely above the averages for matriculants (uGPA 3.65 and MCAT 31) then you likely need to add more schools. If you are above those averages, you can hold but you probably should have head from schools by now. If not, make sure that your application materials have arrived.

Holiday Time

You applied early and haven’t received any interview notifications. Yes, it’s easy to fall into the trap of being depressed  but this is the time to plunge into the holidays and not get insane. Yes, I know that it’s only your future here but you cannot do anything more at this point. I will repeat in all caps for emphasis, YOU CANNOT DO ANYTHING MORE AT THIS POINT. If your application is complete then you have to wait. It’s a good time to plan your trip home for the holidays and take a breather from coursework. Tell you family member and friends that “things are on track” but don’t look desperate or you will ruin your much needed holiday.

January and February

These are very heavy interview months. You may find that the interview invitations will roll in at this time. Again, there is still plenty of time to receive an interview and receive an acceptance. This is also a time when many of the early interviewers will begin to receive acceptances. If you have done a couple of interviews but received no acceptance, don’t panic here either. Again, work on and finalize your Plan B.

If you are a dedicated reader of The Student Doctor Network, don’t obsess over the fact that others have been accepted but you are still waiting. Timing is out of your control and dependent on things like the number of applications received by the schools that you have applied to and the competitiveness of those applications. The only thing that you can do at this point is WAIT (dread).

March and April

By the beginning of April, some folks will find themselves on wait lists and without an acceptance. This is not entirely a bad situation though you may want to make a decision as to whether you will begin to collect the things you need for reapplication. If you need to do things like re-take the MCAT, you need to have gotten started on your study and planning for the test. You can’t wait too late and you can’t do a re-take without some significant review and preparation. The worst thing that you can do is post an MCAT retake with a mediocre score.

If you are on a wait list, remember that there is a huge wait list movement on and after May 15th. May 15th is the date when people cannot hold multiple acceptances. I always advise folks to release acceptances as soon as they have either been accepted by their first choice or when they have made the decision as to where they want to attend. I released my acceptances by the third week of February because I had made my decision. I am sure that five people were grateful that I did that because they were able to get in that year.

May and later

In general, after May 15th, you are not likely going to gain acceptance. There are exceptions, especially the schools with rolling admissions but by this time, you should either have an acceptance or gathered your materials for reapplication. You can look at my previous post on when to give up on application to medical school but if you don’t have an acceptance by now, you likely need to take an objective look at your competitiveness and do some application upgrading.

If you need more coursework, this is a good time to get registered for post bacc work. If you are planning to enter a SMP (Special Masters Program), then you need to get busy fast. These SMP programs have deadlines too. In short, these may become your new Plan B and you need to get to work. If you are on a waitlist at this point, it will not hurt you to go ahead and plan on reapplying. Sure, you will lose the money of submitting your application but if you are not accepted off of a wait list, you will be happy that you reapplied early.

If you reapply, change everything that you can change about your application. Do not apply to the same schools with the same application materials. We do compare old and new applications. If you were unsuccessful and submit the same unsuccessful application materials, you are most likely not going to be successful next year either. The average matriculant uGPA and MCAT scores have always gone up. Also, unless a school tells you that you need more extracurricular activity, you likely don’t need to add more here either.


You may want to look into the following:

  • Getting the services of a professional pre-med counselor. For nontraditional applicants who have been unsuccessful, this is money that will be well spent.
  • Taking more undergraduate coursework to raise your uGPA. If you are significantly below 3.5, you likely need a year or two of more coursework.
  • If you have an MCAT score below 28, you need a re-take period if you are applying to allopathic medical schools.
  • Making sure that you have applied to a wide range of schools. If you only applied to schools in the Northeast, you may want to go out of that region. You need a minimum of 10 schools if your are a strong applicant and 15 to 20 if you are less than competitive.
  • Don’t thumb your nose at osteopathic medical schools. If you are under the averages for allopathic but your uGPA is above 3.2 and MCAT above 27 but less than 30, you stand a good shot at osteopathic medicine. If you get into osteopathic medical school, you can have the same career as attending allopathic medical school. If you want to be a physician, they are definitely the way to go.

3 October, 2008 Posted by | difficulty in medical school, medical school, medical school admissions | Leave a comment

Academic Excellence

For many people in both medical school, graduate school and undergraduate school, this is the beginning of the second semester (or quarter). If you are new to your academics, then you finished the first semester/fall quarter with some academic achievements (good or bad) and learned some things about yourself. Since this blog is about strategies for success in medicine (getting into medical school, staying in medical school and other things associated with medical school), I though I would post a note or two about making changes that can enhance your Academic excellence.

Doing well in academics is something that can be mastered with practice. It comes out of having a strong and solid approach to what you have to master in terms of knowledge and it comes out of having a high comfort level with the learning process. If you always feel that you are somehow “not going to be able to get everything learned” or that ” the course is too hard”, then your beliefs can become a self-fulfilling prophecy. There is no task, no matter how great or how formidable, that cannot be approached by taking small steps every day until it is conquered. You have to be willing to “chip away” on a daily basis and note your progress on a daily basis in order to see that you are handling the larger task in smaller steps.

 Let’s take Organic Chemistry for as an example. At the beginning of the year, your professor hands you a syllabus that outlines the lecture schedule, laboratory schedule and exam dates in addition to what is expected in terms of how you will be graded in the course. Usually your grade is the result of your grades on some combination of exams and projects. Armed with this information, the first thing that you need to do is make a master subject calendar of lecture topics and test dates. Also include things like “one week to Exam 1 ” and “2 weeks to Exam 1” along with “3, 2 and 1 week to project due”  so that when you look at your calendar daily, you know exactly how much time you have to master the knowledge for the material on your exams/projects.

The next thing to do is look at your reading and problem assignments each week for your lectures/topics. Some topics have many problems and some don’t have so many problems. Divide and conquer here by looking at the amount of time alloted for each topic. This should give you a good idea of the importance of each topic. Your textbook is a good resource in terms of looking at how much time and space it devotes to a particular topic. For example, look at functional groups of organic compounds. This is a topic that can be divided into families with the simpler families being presented first and the more complicated families being presented later. You can use your text to add upon your knowledge base.

The other thing that you want to do is be sure that you are prepared for each lecture. Don’t go to class with the idea that you can sit there, listen to the lecture and learn what you need for mastery. You need to know something about the topic before you hear the lecture. The best way to do this is to read about the topic before you hear the lecture so that you know something about the items that will be presented. Don’t every walk into a lecture “cold” as 50% of your actual studying can be done in your preparation for you upcoming lecture. The other 50% comes in your digestion of both the reading and lecture in addition to any problems that were assigned.

A point about problems and problem solving. With any problem that you are given, try to figure out what learning concept is behind the problem. For example, look at the wording of a problem and then review the concept that applies to that wording.  Consider the problem, in diabetic ketoacidosis, glycerol is primarily used for what? To answer this problem, you need to know something about the biochemical derangements that take place in diabetic ketoacidosis. In diabetic ketoacidosis, the patient is acidotic which implies that ketone bodies have been released and have lowered the pH of a patient’s blood. What else do you need to remember? You need to remember that while the blood sugar is high, the patient does not have adequate insulin which allows glucose to enter the cells and undergo glycolysis and be used for fuel. That leads you to thinking about why the ketone bodies are out in the blood stream in such high quantities in order to cause acidosis. This because the brain primarily, needs to have a constant fuel supply and in the face of a huge amount of glucose in the blood, none of it can be used by the brain because there is no insulin to allow the brain cells to take up the glucose. Now what do you need to know about diabetic ketoacidosis in addition to the above and that is that fat is being catabolized into acetyl Co-A that is being used to make the ketone bodies and that the fat comes from the breakdown of stored triglycerides into fatty acids and glycerol. The fatty acids can undergo beta oxidation to acetyl Co-A and then shunted into ketone bodies but the glycerol goes to the liver as a substrate for gluconeogenesis or the making of glucose. In the face of large amounts of glucose in the blood, the diabetic can’t use that glucose to feed their brain and thus they are making more glucose in addition to ketone bodies which are acidic. This is the concept behind this problem and why you need to approach problems like this or questions like this from many different angles rather than just memorize the answer.  You have to be able to master the concepts so that in any manner you are questioned, you can figure out the correct answer not attempt to rely on you memory.

The next thing that you must think about is that you have all of the tools that you need to master your coursework under the conditions that work best for you. Don’t compare yourself to anyone in your class. Some people are visual learners (tend to sit in the front of the class) and some folks are aural learners (tend to sit in the back to avoid aural distractions). Most folks use a combination of both visual and aural and thus learn best when they utilize both methods. If you are a visual learner, then make a brief outline of the material to be covered in lecture and take a note here and there. Don’t try to write down every word that the professor says but watch how the material is presented and fill in your notes later. If you are an aural learner, listen to the lecture and take a note here and there. Listen for inflections in the professor’s voice. Listen for key phrases such as “in summary” or lists of important topics. If you worry that you will miss something, take a small digital recorder with you and record the lecture. You can then upload it to your lap top and it’s there if you need to review concepts.

In short, if you have managed to get through first semester, you have every tool that you need to excel second semester. You may need to adjust some of your study habits or you may need to fine tune others. The important thing is not to dwell on what anyone else in your class does but to do what you need to get the results that you want. There is no class invented that could not be mastered because after all, someone had to come up with the facts and concepts for the professor to present. Don’t go into any of your courses with preconceived notions that the course is too “touch” or is a “weed-out” course. The coursework is there for you to master and you have to figure out how you will master it.

Another common mistake that many students make is relying on their perceptions of the professor’s like or dislike of them personally. No one who is lecturing actually cares about you as a person. They don’t have a personal relationship with you, and if they do, it doesn’t matter in terms of the presentation of the material to be mastered. The material is there and it doesn’t care about you or the professor or whether or not you “like” or “dislike” the subject matter. If you spend the dollars in tuition, then that alone should be enough for you to have a vested interest in mastery of the material that is presented. In short, you need to get your tuition dollar’s worth out of this class for whatever reason. Whether you “like” or “don’t like” the way the professor talks, looks, or anything else has no relationship to how you deal with the material that is presented. The professor is not your main source of knowledge but someone to help you navigate (by their experience) though mastery of this class.  

Finally, you can decide in this very instant, that you will change your “thinking” in terms of how you approach your coursework. You can approach your coursework from a point of fear and trepidation or you can approach your coursework from the standpoint of “hit me with your best shot because I can hit it back and score”. You can decide to toss old habits of trying to “cram” at the last minute and replace them with solid organization and daily study. You can decide that you will either adapt a lifestyle and study style that will allow you to become an excellent scholar or you will continue to do what you have been doing that doesn’t get the academic achievement that you want. The key point is that you are the complete master of your thoughts, actions and reactions.

5 January, 2008 Posted by | academics, difficulty in medical school, medical school coursework, medical school preparation | 5 Comments

Surgical Clerkship 101 (Part 3)

This is the last in my series about surgical clerkship. In this essay, I thought I would address some of the things that can go wrong and present some strategies to fix them or do “damage control”.

Misunderstandings or Miscommunication – Communication in medicine – any specialty- is a key component. Learning to listen carefully to your patients, your colleagues and your teachers is of paramount importance. Sometimes anxiety or time prevents you from actually “hearing” the message. This happens to everyone and especially to people who are trying to juggle several tasks at the same time. If you make a mistake, own up to it, apologize and move on. Don’t internalize and don’t personalize anything on any clinical rotation. It is very easy to miscommunicate when you are under pressure and in unfamiliar territory. When you find that you have misunderstood something or that someone has misunderstood you, acknowledge the mistake and keep moving forward. Forgive yourself, forgive others and move on as misunderstandings/mis-communications are part of being human.

Not telling the Truth – This goes along with miscommunication and mistakes. Don’t lie about anything. If you didn’t check something, acknowledge your mistake and let it go. Make a note to yourself not to repeat the mistake and leave it at that. Many times, especially when you are tired, you will forget something. Again, make notes to yourself if you forget something or did not do something but don’t lie about anything that you did or did not accomplish. Your ”word”  in medicine is golden and your career, your patients’ lives  and you colleagues trust all depend on your word and its truthfulness.

Grave errors – I remember an incident when I was an intern. A fourth-year medical student was attempting to re-wire a central line and made a fatal error that caused the death of a patient. In the defense of the fourth-year student, he/she was not supervised and wasn’t familiar with central line rewiring. In defense of the resident on whose service this student was rotating, he/she did not know that the student had not performed the procedure unsupervised. In this case, the student and resident was reprimanded but both owned up to this grave error. The worst problem is that this student will carry this incident for the rest of his/her life.

In short, never ever perform a task or procedure unsupervised unless you are sure of what you are doing. In any procedure, especially the invasive ones, you should be able to explain the procedure to the person who is supervising you along with any complications that can arise and how you will handle them. When you are learning procedures, learn them from preparation, performance, complications and management of complications. The learning curve for things like central lines is usually 10 supervised before you do the procedure unsupervised.

Personality Conflicts – There will be people on your team (nursing personnel, fellow students, interns, attending physicians) that you will not get along with. In my opinion, personality conflicts have no role in medicine as they are counterproductive to good patient care. When I have encountered a personality conflict, I will defer my feelings as long as the care of my patient is not compromised. In short, my business and my job is to be able to work with each member of the team as professionally as possible for the benefit of the patient. As I have said in other essays, the clock ticks and you will not be around this person for the rest of your life. Be sure that you don’t burn any bridges behind you.

Another rule of mine is that I never discuss my colleagues with anyone except the person that I am having the conflict with. I don’t have time for gossip and I never allow negative comments about my colleagues from nursing or other people. One of my jobs as I have moved through residency has been to evaluate others. In these evaluations, I have readily admitted when I have a personality conflict and tried not to allow this to interfere with my evaluation. If I place something negative on an evaluation, I always cite the reason and what I believe the person can do to improve the situation. I also do not place negative information on an evaluation unless I have warned the person and asked them to correct the behavior which is the object of an evaluation in the first place. In short, check your ego at the door when it comes to patient care.

Time Management – There are 24-hours in a day and you do need rest at some point. Don’t try to ignore your body’s signals when you are tired. Manage your time so that you get some rest (it’s never going to be enough) and take care of your physical needs (eating, hydration). When you start a new rotation, you won’t be as efficient as when you end the rotation because you don’t know the procedures. Pay close attention to your interns and residents and ask for help. Never be too proud or too afraid to admit when you are overwhelmed. Also, avoid drugs to “keep you going” as these often bring on personality changes that can cause problems.

Most chief residents and interns will allow you to rest when there is nothing of educational value going on. If you are told to leave (go home), do what you are told to do. Don’t hang around the hospital but leave. If you are not tired, go to the library and study or go home and study but don’t hang around. You won’t get too many opportunities to “leave early” on most surgery rotations. If something is going on that you want to observe, ask your intern or resident before you go off and observe. Don’t ever leave one service to “hang out” with another without permission from your intern/resident and the agreement of the intern/resident of the service that you are “hanging out” with.

Helping Your Fellow Students – If your are efficient at getting your work done, help your fellow students if they need it. Your fellow students are your colleagues and sometimes they just need a hand at some small chore. If you are able to lend this hand, do so.  Share information with your fellow students if you have something that is useful to the team.  Your fellow students are not your competition at this point. Try to do what you can for the good of everyone. If someone has an emergency, offer to switch their call (let your chief resident know) and do so if you can. You never know when you might need the favor returned.

If one of your fellow students mistakenly keeps trying to manage your patients, show off to the residents and attendings, speak to this person about their behavior. If they continue in this aggressive behavior, let the intern/resident know what is going on. I can tell you from experience that quite often, the chief resident is aware of what is happening and will deal with the problem. Your job on any clerkship is to learn as much as you can. If someone, fellow student or resident, is interfering with this process, the clerkship manager/dean should be made aware of the situation. Ask for a meeting and come prepared with examples of how your education is being compromised. Offer solutions to the problem too. As I said above, personality conflicts have no role in medicine but nothing should interfere with your learning. Make sure that you outline that problem and depersonalize it before you present it. Most of the time, learning interference problems can be solved by good and honest communication as opposed to “running to the clerkship manager/dean”. Reserve going outside the team for things that you cannot solve within the team.

Beware of the fellow student who is “going into surgery” and feels the need to scrub any cases that he/she deems interesting. Do the cases that are assigned to you and don’t let your fellow students take your cases. If this is happening on a regular basis, that is, you have scrubbed 15 hernias and nothing else while your colleagues are getting all of the interesting cases, check with your chief resident. On the other hand, if you are just scrubbing the “easier cases” so that your inpatient list is short, your grade may suffer. Don’t be afraid to tackle a complex patient and a complex case. You will be surprised at how much you can learn by digging in and taking on the assignment.

Attitude – I have said that attitude is everything in clinical medicine. Approach each rotation with the attitude that you will master what you need. You don’t have to “love” everything that you are doing but you do need to be able to give your patients your best work regardless of whether or not you love the rotation or anticipate entering the specialty.

Ask for feedback early and often. No one was born knowing how to perform on a rotation. A five-minute “how am I doing conference” with your intern and resident is not a bad idea early in the rotation. Listen to what they have to say and make notes of what you need to improve. Practice your skills and add to them. Keep a running list of procedures that you have done complete with the names of patients, date of procedure and supervising physician.

Problems in the OR – Don’t get into a ”pissing match” with any of the Operating Room personnel. If a scrub person tells you that you are contaminated, step away from the field and take care of it with a “thanks for pointing this out” attitude. I can tell you from personal experience that some OR personnel will try to ”get to you” because you are male, female, human, and other characteristics. Let this stuff go as long as they are not interfering with your knowledge. As an assigned medical student, you have a role in every case that you scrub. You are not to be ”pushed out of the way” by anyone. If this happens, discuss it with your attending or chief resident after the case but don’t get into a shoving match during a case. This rotation is part of your medical school education and you are paying good money for this experience. Don’t allow anyone to compromise your learning experience.

If you feel “faint” in the OR, step back from the table. You can just say, “I need step back” and everyone knows what is happening. The circulator will usually stick a stool under your before you fall. It also goes without saying that you should never go into a case with a full bladder or an empty stomach. Keep some kind of a snack in your coat pocket and keep hydrated too. If you are feeling ill, don’t scrub especially if you have a fever. Explain the situation to your resident/attending and don’t scrub the case. If you are “sick” for every case, your grade may suffer but on at least one occasion, students DO get sick and should not be in the OR.

Remember that too much caffeine will make your hands shake. I have found from experience that caffeine doesn’t alleviate fatigue and doesn’t make you more alert if you are exhausted. Things that help me fight fatigue are rest, hydration, good physical conditioning and fresh air. A cup or two of coffee/tea is not going to hurt you but downing cases of cola or pots of coffee/tea will not help you and may compromise your health, not to mention the diuretic effect of caffeine. Use this drug with caution and avoid overuse.

Grades – You should know ahead of time, how your grade is going to be calculated for any rotation. Be sure that you are not neglecting the projects and performance objectives of your rotation. Go back and look at your clerkship objectives weekly to be sure that you are accomplishing what you need to accomplish. If you have been assigned to a Cardiothoracic team, be sure that you are not neglecting your reading when it comes to hepatobiliary conditions. Your shelf exam is going to cover all aspects of general surgery, trauma, critical care, orthopedics and cardiothoracic surgery. Be sure that you neglect nothing.

Be sure that you continue to hone your diagnostic skills. Even if you are going into primary care, you need to be thoroughly familiar with the diagnosis and treatment of the acute abdomen. In short, you need to be totally familiar with the instances where you need to “consult” surgery. Every case of abdominal pain does not require a surgical consult and you will quickly lose the respect of your surgical colleagues if you consult them before you have done a complete work-up. Be sure that you know why and what you need from any consultant and are not using them to do your work.

Physical Limitations – If you have physical limitations that do not permit you to scrub the longer cases, the let you chief resident know ahead of time. If you have a chronic condition such as diabetes, multiple sclerosis, cerebral palsy or other physical limitations, these should have been discussed with your clerkship preceptors and the residents should have been made aware of your condition. These should not be done in front of the rest of the team but you should make sure that the people who need to be aware of your condition are aware. This is especially true if you are pregnant and are having complications. If you become pregnant during your surgical rotation, be sure that your preceptors knows what is happening and is made aware of any problems that encounter. Again, this rotation should not place you (or your/your unborn child’s health) in jeopardy. I have had medical students who were physically challenged who contributed more to the success of my surgical team than some students who didn’t have these limitations. In these cases, I didn’t run the stairs with the team or make that person scrub the ten-hour cases without a break.  In the end, it all evens out.

Remember that your chief resident and attending physician preceptor are not your enemies. You need to have a good working relationship with them and good communication with them. You also need to be proactive about your learning by keeping up with your reading and adding to your skills whenever possible. General Surgery often moves very quickly and decisions must be made with incomplete data gathering. If you don’t understand how a decision was reached, ask the resident to go through this with you.

Have the attitude that you are going to be a valued team player because you are. You are not the “scut person” and you are not on a team to be the “butt of jokes” by your residents or fellow students. Pitch in and refuse to be alienated by things like occasional “locker room humor”. Don’t personalize anything and learn from your mistakes.

12 August, 2007 Posted by | academics, difficulty in medical school, medical school coursework, surgery, surgical clerkship | 4 Comments

"Bottom-ranked" medical schools in the USA

Well, the time finally comes around for you to apply to medical school. How do you choose a medical school to apply to? What factors should be considered? What about those US News & World Report rankings? What about pass rates for USMLE Step I? What about Match Lists?

You may want to consider location as your first priority. Medical school can be a very expensive undertaking but add in the cost of a few cross-country airline flights each year (you do want to come home for Christmas don’t you?) and you can add significantly to your costs of attending. You may also want to look at the cost of living in some of the cities that have medical schools. Cities like Washington, DC, New York and San Francisco can be quite expensive to live in while other cities like Cleveland may have substantially cheaper housing.

Your first step in choosing a medical school is to look at your competitiveness as an applicant. The 2005 (last year that we have numbers) averge GPA and MCAT for medical school matriculants was 3.65 and 29. You can simply look at your numbers and figure if you are above average, average or below average in terms of matriculants across the country. You can also consult the MSAR (Medical School Application Requirements) and look at the averages for individual schools. Again, are you above their average, at their average or below their average.

The next thing to look at is curriculum types. Most schools have some variation of an integrated (systems-based) or classical curriculum. Some schools also have problem-based learning (PBL) integrated with a systems-based curriculum or classical curriculum. The classical curriculum requires a fair amount of self-integration of the material for USMLE (all steps intergrated). The intergrated and system-based curriculi require less self-integration but may pose problems if you are a slow starter and find that you missed key portions of an important system.

Depending on your learning style, you may find that PBL is not going to be a good “fit” for you. PBL demands strong individual initiative and proactivity in terms of getting the information that you need. If you are not a natural leader or work poorly in group situations, PBL is going to prove problematic. PBL is also fairly dependent on good faculty who thoroughly understand its concepts and implementation of those concepts. In short, some people become lost in the PBL process and find recovery difficult.

How about “ranking” of your medical schools? It is not so much the rank of your school but how well you perform there. The high performers at any medical school are going to go further than the low performers at a high ranked school. If you are uncomfortable or stressed (money, housing, study space) in the environment of your “high ranked” school, you are not going to perform well and thus, the ranking of your medical school is not going to help you very much in terms of your performance.

Your medical school environment should provide adequate access to study rooms and materials, adequate lectures and access to the faculty that presented those lectures, adequate access to the information that you need for doing well in your coursework and a safe environment for you to come, go and stay late for study. If your faculty are not available during office hours or there are no study rooms available either in the library or in the school itself, you are going to have a difficult time mastering the material that you need to become a good physician. Again, this has little to do with the “prestige” of your medical school and more to do with the quality and ethics of your faculty. Strong medical schools may not be highly ranked by US News & World Report and the best medical school for you as an individual may not be ranked #1 by the rest of the country. In the end, your individual performance will determine how well you do on licensure boards, in your coursework and how much control you have over your choice of residency.

16 February, 2007 Posted by | choosing a medical school, difficulty in medical school, medical school admissions | 2 Comments

Preparing for the Medical College Admissions Test (MCAT): Aim High!

A significant step in towards your goal of becoming a physician is taking the Medical College Admissions Test. This test, now offered on computer 22 times per year, is one of most significant hurdles for any prospective applicant. Your score on this exam in conjunction with your UNDERGRADUATE grade point average, will be the most significant factors in determining whether or not you will be accepted into medical school.

Now why did I put the word “undergraduate” is all capital letters? For significance and emphasis. Your undergraduate GPA is the grade point average that is most significant. Obtaining and pursuing a graduate degree in order to attempt to “shore up” an uncompetitive GPA is not going to be helpful.

Post bacc programs may allow graduates with no science or weak science backgrounds to obtain these courses and are quite useful for doing undergraduate “damage control”, but a graduate degree will not perform the same role. A special master’s program will enhance your application but often the pre-reqs for these programs are a competitive undergraduate GPA and thus if your undergraduate grades are weak, you may still need significant post bacc work to get yourself competitive for a Special Masters.
Now, back to the MCAT. This test will examine your ability to use the knowledge presented in the pre-med subjects (General Biology, General Chemistry, Organic Chemistry and General Physics) to solve problems. These “problems” as presented on the MCAT do not test your regurgitation of facts (in the manner that many undergraduate courses test) but require that you are able to do secondary thinking. You must apply your knowledge base to a problem.
Often students make a very grave mistake in thinking that obtaining an “A” in all of the pre-med courses ensures a competitive MCAT score. Because the testing manner of the MCAT is far different from the testing manner of most colleges, practice and preparation with the types of questions and the manner of questioning of the MCAT is required. Quite simply, the MCAT tests both your knowledge base and your test-taking skills base. The MCAT tests how you “think” and “evaluate” information as much as it tests your basic knowledge and fund of information. It is no surprise that the MCAT tests how you will evaluate information for the rest of your career in medicine.
Your preparation should include making sure that your knowledge base is adequate. This may be done with any means of good MCAT review books and commercial courses (expensive). The commercial MCAT-prep courses will provide their students with outlines of the subject matter that is tested on the MCAT. These courses also provide plenty of practice exams for making sure that their students are thoroughly with the MCAT testing procedures and manner of questioning.

In addition to the commercial preparation courses, the MCAT website offers full-length MCAT practice tests for $35 each. There are currently five practice tests available for purchase. They are actual “retired” items from the paper-version of the MCAT. Purchasing one or more of these practice tests and taking these tests under actual exam conditions, can give you a very good idea of where you have weaknesses and where you should place your preparation emphasis. Again, a knowledge deficit can be strengthened with review of topics that you need. A test-taking skills weakness can be strengthened by taking test-taking skills courses (offered free at most universities).

A common mistake is for students to feel that they must “memorize” every test question presented in a book or course. By taking this approach, students wind up with major “burnout” by the actual test day. You simply cannot memorize every potential question that the MCAT can produce or offer.

Another common mistake is believing that there will be grammatically incorrect answers to questions that will be easy to spot. The MCAT is not constructed in this manner. Looking for patterns of answers will not be helpful in taking this exam. While you do need to be extremely skillful in your reading comprehension and observations, you still need a significant knowledge-base in order to to well.

Many students make the mistake of not actually reading the full question and all of the answer choices. They read the question, come to an answer choice that they think is correct and move on to the next question. There may be an answer further down the choices that is MORE correct and thus you need to read all of the possible solutions.

Another useful skill is being able to solve quantitative problems by using order of magnitude. Let’s say, you are presented with a physical science question that requires knowledge of a formula. If you are familiar with units and the order of magnitude of the numbers that go into a formula, you won’t need to do a complete calculation in order to choose the correct answer. In the case of more than half of the questions that I encounted on the physical sciences portion of my MCAT exam, I didn’t need to do the complete calculation once I looked at the answer choices.
In terms of the Verbal Reasoning and Writing Sample portions of the test, you want to have plenty of practice with reading and writing. It never fails that good readers are also good writers. Practice with the editorial pages of your local newspaper. See if you can pick out the arguement and propose a counter arguement. What is the hypothesis and what evidence does the writer show in support of that hypothesis. What is the writer’s conclusions and how does the writer tie all of his/her evidence that leads to a conclusion?
When you write your answers to the questions in the Writing Sample, the outline is Introduction where you present your thesis, evidence (next paragraph), evidence (next paragraph), counter thesis for arguement against and conclusion. You should write about 1 and 1/2 pages total on each of the subjects. You want your subjects and verbs to agree and you want your ideas as crisp and logical as possible. Again, spend some time in the Writing lab of your school where you can get critiques of your writing style.
Remember that you study for your coursework and review for the MCAT. If you have not completed your coursework, do not spend time away from your studies attempting to review material that you have not learned in the first place. Put your emphasis on thorough mastery of your Pre-Med courses while you are taking the class. When your class is complete, you can start your review if you wish. Allow plenty of time for review. This step cannot be rushed.
If you find that your review is not going according to schedule, cancel your test. It is far better to lose the testing fee than post a low grade. Again, allow yourself plenty of time to prepare, make a schedule and stick with it. If you cannot make a reasonable schedule and get your prep done, don’t register for the test.

Your planning for taking the MCAT should be one take and that’s it. DO NOT take the MCAT for “practice” and repeat for “actual grade”. The MCAT is not a practice test. One test take when you are thoroughly prepared and you are done. An application killer is several mediocre MCAT test attempts (whether released or not) and a mediocre score in the end. This is a huge “red flag” on your application.

You also cannot talk yourself out of a good performance. “I hate standardized tests and I am no good at them” can be self-fulfilling. If you thoroughly prepare and are thoroughly familiar with the MCAT testing manner, you can do well on this test no matter what you have done in the past. Talk yourself “into” a good performance rather than talk yourself “out” of a good performance. Also, don’t let the fact that the test is computerized unnerve you. The computerized test has the same knowledge requirements as the old paper exam and thus you still need the same knowledge base. If you have found this website, you have all of the computer skills that you need to take the computerized MCAT.

Resist the urge to believe that if you do not spend $1,500 in an MCAT preparation course, you are doomed to a low score on this exam. If you prepare thoroughly and analyze your performance on the practice exams ($35 each), you can do quite well on this test. If you NEED to have the experience of sitting in a prep classroom and taking their tests, then that $1,500 expenditure will be worth the money. Make no mistake, you DO NOT need a prep course but you do NEED solid preparation.
Finally, “Aim High”. The average MCAT score of medical school matriculants for 2005 was 29. That’s an average score. You don’t want to be “average” you want to be “above average”. Shoot for that 45. If you wind up with a 35, you are still well above “average”. Bottom line: “Aim High”.

10 February, 2007 Posted by | difficulty in medical school, MCAT, MCAT preparation | 3 Comments

Difficulties In General…

No matter where you are in your medical career, difficulties are bound to show themselves. In my experience, they make you stronger and make you appreciate that this career is a journey much like your family vacations. Some folks struggle to gain that medical school acceptance; praying through every organic chemistry exam or physics exam. Other folks struggle through coursework during the first and second year of medical school and some folks manage to do fine until residency when the demands and responsibilities become overwhelming.

One of my best friends has struggled with passing her first board exam in medical school. She did well in her coursework but has not been able to get past Step I even at the time that I am writing this blog. She has missed a pass by less than five points on every attempt. Needless to say, she is struggling and even questioning whether medicine is in her future. (In order to become a licensed physician in the United States, three steps licensure boards must be passed).

Many may ask, “How can she do so well in her coursework and yet not be able to pass Step I?” “How good a physician would she make if she couldn’t pass boards on the first try?” The answer to both of these questions is, “an excellent physician” because passing board exams, while necessary for licensure, does not measure one’s ability to treat patients. There are many excellent physicians in practice today who struggled with Step I, Step II or Step III of liscensure boards.

On the other hand, there are far more poor physicians in the United States that sailed through board exams. The bottom line: You have to pass three steps of licensure boards in order to obtain an license to practice medicine. Passing all three of these steps may be a struggle but they must be passed. Whether it takes two or three tries on each step, once all three are passed, your license is issued and it’s up to the individual to practice excellent medicine or not. The practice of excellent medicine has more to do with work ethic than board scores.

Another class mate of mine struggled with several courses in medical school. She is dyslexic and had difficulty with physiology and pathology. She too struggled with one step of her licensure board exams but prevailed. She has been discouraged at times but she is one of the best physicians that I have ever observed. She is certainly a far better physician that I who didn’t struggle with passing board exams. Her patients love her care and flock to her office. It is very evident that she has a high level of medical knowledge and is gifted in her application of that knowledge. She just struggled with boards.

We had members of my class who repeated a year of medical school (first or second year). In every case, they excelled with they started their clinical years and are establishing practices at this point. It was in the struggle that most of them truly learned to appreciate the journey. They also learned that sometimes “things” happen in your life that are totally beyond your control. These “things” must be taken care of before you can move on with your studies. It’s not the way you planned for your career to work out but it’s the career that you have been handed and you make the best of it.

Often I listen to folks who anticipate attending medical school who just KNOW that they will be a neurosurgeon. Just the mention of neurosurgery causes them to sit up more straighter in their seat or breathe a bit deeper. These budding neurosurgeons discover a wonderful course called Neuroscience and their plans for neurosurgery take a hike. Sometimes they get past the neuroscience but hit surgery clerkship in their third year and discover that there is nothing about surgery or being in the operating room that interestes them. The whole mystique of the OR or the “prestige” of the specialty that drove their interest in medicine will leave and often leave them depressed or unhappy about their choice to study medicine in the first place.

On the other hand, my classmate who sat behind me first and second year, always knew that he wanted to be a neurosurgeon. I had the pleasure of doing a case with him when I was on my pediatric surgery rotation. He was the neurosurgery resident and I was the pediatric surgery resident. It was great. We have since worked together on Trauma service too. It’s neat to see how our careers have developed respectively.

If you find that you are struggling with undergraduate or medical school, figure out a way to get some help. Your performance is not diminished by the fact that you ask for help or attend tutorials. I remember an MD-Ph.D candidate who was a pharmacist before he started medical school. He spent hours helping all of us with our pharmacology during medical school. He was awesome and a very gifted physician scientist. There are loads of us, myself included, that owe him a debt of gratitude for taking the time to point out the finer lines of pharmacology.

If you fail something or repeat a year of medical school, remember, that no patient is ever going to ask you how many years it took for you to get through medical school. If it takes you five years instead of four and you are a good physician, then every second of those five years was worth it. In the end, the job is all about taking the best care of your patients that you can. Sure, you are not on the schedule that you set for yourself but it’s the endpoint that is really your goal. Pat yourself on the back for hanging in there and know that the experience with struggle and strife only makes you more resiliant.

2 February, 2007 Posted by | difficulty in medical school, medical boards | 7 Comments