Medicine From The Trenches

Experiences from medical school, residency and beyond.

Great Post from “Life of a Med Student”

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

via Beyond the H&P — #Lifeofamedstudent

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

You Have Matched!

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

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

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

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

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

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

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

Introduction

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

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

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

SOAP is NOT “The Scramble”

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

SOAP should not be your primary residency application

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

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

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

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

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

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

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

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

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

Things that generally DO NOT enhance your chances of matching

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

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

Summary

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

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

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

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

Meeting the Challenge

I continue to train for an upcoming marathon. Making the change from middle distance to long distance has been a great mental and physical challenge. My goal is to complete the 26.2 miles even if I find that I am walking part of the distance. To complete this challenge is my goal that I have contemplated, trained and taken steps toward. I have to have the confidence to continue to train and make positive movement toward this challenge/goal much as I have met other challenges in my life.

Yes, thoughts of not being successful creep into my head from time to time but the sheer pleasure of my longer training runs has been of great comfort. I can’t say with certainty, that I will cover the distance. A shorter run this past week was uncomfortable (cold damp weather) and difficult to complete. Each mile was harder then the previous mile but my mind would not allow me to give up. Even if I am the last person to cross the finish line, I was determined to finish and I finished standing up. I learned a bit about my mental toughness and I greatly appreciated those standing along the route who cheered me on; gave me Hi Fives and were so affirming.

Losing the friendship of one of my best marathon advisers weighed heavily on my mind in a couple of my training runs. I was saddened by his rejection of my friendship but I respect his wishes. Respect is something that I have to keep for him. He is brilliant, sensitive and not in medicine/surgery which is why I can respect his wishes. If we were good friends , as I thought, time will allow us to resume communication at some point in the future but for now, I run, I study, I read and I keep moving forward, one step at a time because that is what my nature and my work requires me to do.

The loss of my friend was heart-breaking but my work is of great reward. I found myself assisting others more than I could imagine this week; a task that brought affirmation for me professionally. I found myself renewed in my search for excellence in everything that I touched. I found myself looking back into why I considered medicine/surgery in the first place. These “look-backs” and self-examinations are great for renewed energy when work seems to become a bit routine or even stressful. As I have said in other posts, nothing about medicine/surgery is ever routine because we touch the lives of our patients (and students, residents) in ways that we can’t imagine.

Sometimes I am prone to forget that the practice of medicine is a great privilege. I have been given the opportunity to put excellence in my work and see the results of that excellence. A bad day or week here and there, is the price that I pay for the privilege of my medical practice. There are journals to be read; studies to be reviewed, a book chapter to be completed and student work to be assessed and graded. I want to be fair and accurate in my reviews and grading which can cause long hours on my part.

I also have a trip coming up that will put me in contact with some of my residency professors whom I have not seen in more than 20 years. To see these gentlemen scholars, both of whom are great teachers/mentors will be a wonderful experience. I am looking forward to seeing how much they have changed and allowing them to see the changes in me. These men profoundly changed how I practice and how I approach my patients. I am grateful for all of the training and “busting of chops” that these men put me through during residency. Since they didn’t “kill” me, they made me stronger and resilient; I suspect that they know this fact well.

One of the greatest joys of a professor is seeing their trainees move into practice and develop. Much of medicine and surgery is learned from mentor to trainee in a one-on-one manner but overall, there is great joy in seeing the results of that one-on-one relationship. I don’t want my trainees to be exactly like me for I want them to take what they can from my teaching and flourish in their own style. I want my trainees to go as far as they wish and I wish them “Godspeed” in what they accomplish and in their triumphs.

To this end, there is no ego on my part but only a sincere wish that they do more, accomplish more and move past my training. Training under me is such a small part of all that they will do as any training period is just preparation. In medicine we put much emphasis into getting into medical school and getting into a solid residency training program but actually, the emphasis should be on the daily practice and keeping it from not being routine.

After all, we as physicians can never know the impact that we have on those around us. This impact is the best part of the practice and it is the part over which we have the most control. This is why I take each day for the wonder that it is, as this is the challenge that I must meet daily.

1 May, 2016 Posted by | medical school, residency, surgery | | Leave a comment

New Year and new things!

We have changed into a new calendar year and some of you will be taking on new challenges in academics or medicine. The important thing to remember is that challenges are to be looked upon as a chance to change anything that needs to be changed but keeping a good course if your course has been fine. Change is inevitable in life and medicine thus embrace the change/challenge and keep your perspective.

Your perspective must include facing each challenge/change as it comes and doing your best. If you need help, don’t be afraid or so caught up in your ego, that you don’t reach out if you need to reach out. At the first sign of a problem, analyze situation and take care of it, seeking help when you need help. I am always amazed when residents or students tell me that they were afraid of what I might “think” if they sought help.

What I actually “think” is that if you need my assistance, ask and it will be provided. No one was born knowing everything in medicine. I certainly seek the assistance of my colleagues when I need them and never give a passing thought because the welfare of my patient is my only concern.

This tactic applies in academics too as you need to seek the help of your faculty even if you believe you are on the right track. Check your understanding to make sure that you are on course. If nothing else, you make get a better perspective and do even better. Faculty office hours are there for you to get help, get an understanding check and to keep you on course for your best performance. I can’t emphasize this fact with any more emphasis.

Your faculty are experts in their subject matter without exception. Take full advantage of that expertise and strive to get the best instruction possible. You are paying good money for that expertise so get everything that you can. It is far easier to be proactive concerning your studies than to do “damage control” because your ego was in the way of your judgment.

If you are starting clinical rotations, remember that your evaluations will be subjective. A good first impression can often make more of a difference in your clinical grade than anything else. You don’t have to “fake” an interest in everything clinical but you do have to learn to perform your best in a clinical situation. Be enthusiastic about the learning even if you don’t plan on entering a particular specialty. There is a baseline clinical knowledge that every clinician needs thus you need to be sure that you are well above that baseline.

I entered medical school with the idea that I would be a pediatrician, as I had an interest in adolescent medicine. I savored all of my tasks on my pediatric rotation (my first). Midway through clinical year, I found that I loved surgery more than anything I would ever do but that pediatric, family medicine and psychiatric knowledge (the rotations that I did before surgery) have been very useful in my career as a surgeon. In short, while you may change your mind as you are getting clinical experience, everything clinical is useful. Listen, learn, read, learn and ask questions as you go.

My last clinical rotation was Neurology/Neurosurgery. I learned to perform an accurate and thorough neurological exam. These skills have proven to be invaluable in the treatment of trauma and burned patients. In short, all clinical knowledge is useful for a physician or a physician assistant. In the middle of the night, that sound clinical base may make the difference in a patient’s outcome.

Again, mastery of the knowledge of a discipline is useful at the pre-med or pre-PA level too. Don’t approach a course as just something that you have to get an “A” in but look upon those courses as learning practice and useful for your future patients. I remember when I remembered that exogenous insulin did not contain Peptide C (cleaved out when endogenous insulin is synthesized by the body) thus checking a Peptide C level is a good idea in a patient who appears to have high insulin levels. If the Peptide C levels are low and the insulin levels are high, that insulin is coming from outside the body and not from something like an insulinoma (insulin-secreting tumor). I learned about Peptide C as an undergraduate student at university; reinforced in medical school.

Also remember that your faculty, undergraduate, graduate or medical school is there to see you successful. No faculty member gets “points” by having a high number of students fail to navigate their coursework. As a faculty member, my job is to help my students and residents to become the best professionals that they can become, without exception. I can’t “dumb down” the curriculum but I can give you every strategy that I know, to help you get the material mastered. My only hope is that you seek out help and get any assistance that you need.

My next point is for you to try to put yourself in the place of your patient. They are putting their health and trust in you to give them the best care that you can achieve for them. For me, this is the honor of being able to practice. The trust of a patient is something that I cannot violate under any circumstances. I might not have all of the answers but I have the stamina and the resources to get those answers. As I said above, I do not hesitate to consult a colleague when I need their expertise for my patient.

Finally, take time on a regular basis, to relieve the stress of being in an educational system. As a faculty member, I place a premium on my stress relief. For me, physical activity in the form of running, has been great for stress relief. I use that time for meditation/prayer, problem-solving and for the sheer enjoyment of pushing myself to the limit of my stamina. When I feel as if I am too tired to exercise, I go to the gym (or for a run) and I always feel better. If you can’t do 30 minutes, do 10 minutes but do something physical.

Trust the process because the process will get you where you want to go. Trust yourself and your feelings along with the process. If you find that your anxiety level is too high, do something to alleviate the stress. School or residency is not torture but a chance to see something new or learn something new. I can promise you that even a jaded old surgeon as myself, learns something new everyday!

 

 

5 January, 2016 Posted by | medical school, physican assistant, residency, stress reduction | , | Leave a comment

Suicide

I have wanted to push this post out for many months. This is very difficult to write about because I am still so close to the raw emotions and feelings. I want my readers to understand how much many of us who take on the task of teaching others medicine care about our teaching and our students/trainees. This was very close to me and stays with me because the young person that I write about left behind two young sons and a young spouse who is somewhat adrift even today when I spoke with them.

I met this young resident physician when they entered the program where I teach. That first day when everyone met and introduced themselves as we all sat around a large oval table. The PGY-1s and the faculty members who would get to teach them and get to know them. The resident was full of hope and anticipation being so happy and grateful for a match into our program. Everyone was so hopeful even knowing that residency pushes one to limits physically and intellectually in the case of surgery. Many believe that the major test of medical school is the measure of a physician but residency is where practice begins and starts the foundation of what will be a life of practice and learning. While medical schools gets one ready for residency, the experience of managing patients and performing surgical cases first as surgeon junior and then as resident is the making of a surgeon.

This resident started out on a ward-intensive rotation under a chief resident who was a patient teacher and generally supportive of the junior residents and medical students who were on the service. All reports were good and the resident was progressing well-not superior but more than adequate. All PGY-1 residents need to sleep more, read more and get out of the hospital as much as they can. The faculty in our program work with the chiefs to make sure that the workload is challenging but not oppressive. I love to do patient care along with my residents because I love taking care of patients. On many weekend mornings, I round, write my own notes and inform the chief of what I have been doing so that the junior residents and medical students are not so burdened.

By the end of the first half of the first year, all of the new interns (PGY-1 residents) seemed to be getting into a groove. The major services: general surgery, colo-rectal surgery, minimally invasive surgery and surgical oncology, were humming along well. The specials: vascular, pediatric, thoracic, critical care, cardiac and plastics were well-covered with interesting cases and patients. It seemed like the year was going to roll along in that predictable manner so that we could all gather at the end and make fun of ourselves while sending the graduating chiefs off in appropriate fashion.  Mid-way through this year, one of the new interns started to unravel a bit. I was asked to do a bit of counseling and unloading. I am happy to play this part for the program.

It is a general fact that most interns will not ask for help when they are getting overwhelmed, especially in a surgical program. There is the code of the surgeon being tough and resilient, thriving under pressure and invincible. Some of my fellow attending physicians still subscribe to this code of conduct but I am having little of this. I love showing my vulnerable side, and often do,  because it enables me to show my strong side at the same time. Yes, I am a human being that is the same as my patients and those I train. I learned from a very wise surgeon colleague that I have to allow those who encounter tragedy and stress to decompress immediately and to keep decompressing. As a leader, I owe this to those who work with me in this profession.

The intern seemed to have a difficult time dealing with the night float where one has to shift rapidly to cover the incoming patients. On my call nights with this intern, I would generally cap their load so that some rest and learning could take place. I calculated the average for the past week and capped when that number was met. Anything over the cap, I admitted, worked up and handled with the chief resident. This generally didn’t amount to many patients but it created a sense of teamwork and accountability for all of us. I loved presenting new patients in morning rounds and having the chief question me (same as the interns) about management. This is a great experience for all of us and continues today.

Along with difficulties on the night float service, personal problems at home began to creep into the picture. The spouse was having an affair and the children were feeling the effects of the strained marriage. Being single, I am surely not equipped to counsel anyone on marital stresses but I did strongly encourage this resident to seek some outside counseling. I assured this young physician that I would be as supportive as possible in making sure that my colleagues understood the grave nature of the home front problems without betraying any confidences. I know of great love and feeling for another person and the loss of that person can be raw. I also know that every person deals with loss in different ways and that with the stresses of a surgical residency, seeking some marital counseling is probably a sound idea.

Three week later, this intern was still trying to balance work and family struggles. Things were unraveling and I suggested taking a leave of absence for the remainder of the year. When things can’t be worked out and work can’t be done, a leave of absence is often the best solution. This was arranged by the program director with an offer for this resident to attend teaching conferences and educational classes as much as possible. We offered a research position that had been left by another candidate so that this resident could have some income. We all offered support and fellowship but substance abuse came into the picture.

I don’t know how substance use began but I noticed the smell of alcohol during one of our educational conferences. I immediately asked the resident to leave because the smell of alcohol can’t be on any physician who is in a clinical area without exception. I was deeply disappointed but asked to chat the next day when possible. The resident never contacted me. Later an admission for overdose of opioids (deemed accidental) along with alcohol. I rushed to the emergency department to find the resident semiconscious and unable to communicate. Clearly, as I spoke with them later, I emphasized the need to spend some extended time in counseling but I could sense a drift away. The shame of losing a training license and a residency position was more stress and deeper into a despair that I was not equipped to handle. I begged this fellow human being to reach out for the sake of the family and children.

Medicine and medical school into residency and practice attracts a person who becomes comfortable with work toward long-term goals. One has to have a high degree of comfort with the long term process because the journey is long. Along the journey goes the family and friends but the resident is the common factor. I know that my colleagues who have families are happiest when they spend as much time as possible with those families. One of my colleagues always says that he can’t understand where my recharging takes place (my spirituality, my adventures and my sheer wonder of all things as I go through this life). This experience rattled my entire experience with medicine and still does.

When this resident committed suicide, I plunged into a depression that only my faith could keep me going. I prayed myself to put one foot in front of the other one so that I could get out of the door of my house in the morning.  I know intellectually that I couldn’t force another adult human being into making better choices but I still can’t fathom leaving behind precious children. It is my firm belief that children can weather the disintegration of a marriage if the spouses involved are dedicated to raising them. I also believe that children only want your time and unconditional love (my experience with my nephews). In honor to this resident who felt so much pain and was unable to get the help needed, I listen intently to my trainees. In honor of this resident, I search intently for any shred of hopelessness in my colleagues, residents and students. In honor of this resident who was kind to their patients and to others, I strive to be kind to others. In honor of this resident, I try to learn the lessons of life and to be thankful for life.

30 June, 2015 Posted by | general surgery residency, intern, residency | , | 19 Comments

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

Introduction

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

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

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

SOAP is NOT “The Scramble”

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

SOAP should not be your primary residency application

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

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

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

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

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

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

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

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

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

Things that generally DO NOT enhance your chances of matching

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

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

Summary

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

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

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

29 November, 2013 Posted by | applying for Residency, Match Day, residency, scramble, USMLE | 28 Comments

How do YOU land at San Francisco International Airport?

Many procedures in medicine are like landing a plane at an international airport. You have to learn “how” to perform the procedure safely, know the complications and obtain informed consent. If any of these things go wrong, well, the Asiana flight at SFO comes to mind. Enjoy this post by a very articulate airline captain who explains how to land at San Francisco International Airport. Use it to think about how you perform procedures.

The JetHead Blog

sfo 2

Here’s how you land at San Francisco International. First, the view over your left shoulder as you cruise “downwind” for your arrival into San Francisco International. You’ve arrived from the Pacific side of the airport, so you can plan (they’ve probably advised you already) on landing on runway 28L, which is the runway you’re paralleling on downwind. Yes, there are 2 runways that you are paralleling, but the logical one for you is the one on the left. Here’s what the airport diagram looks like, with an arrow pointing to 28 Left:

sfo 10-9a

Let’s talk about all of the runways at San Francisco International (SFO), because their are simultaneous operations on all four runways, so your landing runway is not operating independently or simply–nor are you as a pilot landing at SFO. Those two runways intersecting your landing runway will be launching aircraft out of SFO even as you are landing:…

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17 July, 2013 Posted by | medical school, residency | 2 Comments

Applying for Residency

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

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

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

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

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

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

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

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

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

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

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

To Recap:

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

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

The Power of the Positive Inner Voice

Every year, many of my students start a new semester with the aim of changing anything that will make them more successful with their upcoming coursework. If there is one thing that you can change in the very next instant that will make the greatest difference in your performance, it can be that “inner voice” that tells you, “you are not good enough” or “this is a hard subject that I can’t do well in” or “I am not going be able to get all of this work done”.

It seems to be much easier to have an inner voice that is negative rather than positive. Many people are quick to employ the negative rather than the positive because the negative seems to be more believable. Most people are taught that a positive inner voice is the same as “patting your back” for non-achievement but the truth is that a positive inner voice is more about self-confidence than false self-aggrandizement. It is the confidence that one has to master in order to keep moving in a positive direction with any long-term goal. One has to believe that you will reach your goal in a series of small steps toward it on a daily basis.

Since you have total control over your “inner voice”, you can change anything that is negative such as “you are not good enough” to the positive such as “you are as good as anyone else” or make the change from “this is a hard subject that I can’t do well in” to “this may be a challenge but I will have small victories every day and get help the moment I need it”. In short, you can decide in the very next second that you will not listen to the voice that tells you what you “can’t accomplish” and replace that voice with one that tells you “what you have accomplished” and how you will keep accomplishing to meet any challenges head on.

Yes, students will fail exams and quizzes but learning from those failures will help make failing the complete course more remote. If you have never failed at anything in your life, you haven’t actually been tested. People who are untested do not develop the skills to learn from their failures and put them behind so that they can keep moving forward. If you keep spending precious time telling yourself what you “can’t accomplish” because of one set back, then you are likely to fulfill that negative inner voice that seems to be so tempting.

You can control how you react to a grade on a test or quiz. You can look at what you missed and make a careful assessment of what you need to work on so that you don’t keep making the same errors and master the material in a different manner. If you are only focused on the numerical score and not on mastery, you are likely to have difficulty integrating concepts and keeping concepts in your long-term memory (your goal for professional practice).

As I have stated many times on this blog, there has never been a course of study developed by one human being that another human being cannot master. Mastery of your studies does not take any super-human mental feats or membership in high-IQ societies but does take diligent and disciplined study for efficiency. If you use large amounts of time worrying about the rigor or the amount of material that you must master, you lose a great amount of efficiency. In the long run, your learning time for tasks and concepts becomes longer rather than shorter.

For example, as a junior surgical resident, I had to master many surgical procedures. If I had made a list of all of the procedures and cases that needed to be mastered, I would have been overwhelmed at the first case. Instead, I took each case as it came and worked on the fine points after I had mastered the major points. In short, by “divide and conquer”, I was able to master my procedures. I didn’t have the luxury to “think” about non-mastery as I ticked off things as they came under my review.

In residency, there is no person or class that pushes one to undertake daily reading and study. As the hours grow longer, it becomes easy to get behind unless one is vigilant. I set a goal of a minimum of 30 minutes of journal reading and 30 minutes of textbook reading per night with 2 hours on each Saturday/Sunday. I told myself, that I could get my goal accomplished and would get my reading goal accomplished. Like brushing my teeth, I quickly embraced my reading “habit” which meant that I was never behind when review for our yearly in-training exams came around. On same days, I did more because the habit made the task easier and more efficient.

During my residency research years, my reading schedule time tripled during the weekdays and was cut in half on the weekends because my time schedules changed drastically. When I went back to clinical work, it was difficult to stop reading and study because the habit had become so ingrained. I was amazed at the exponential learning that my solid reading schedule had afforded me during those research years. My reading and study efficiency had increased exponentially during this time which was the same exponential reading and study efficiency increase that I had experienced when I started medical school. In short, anything that becomes a habit becomes more ingrained/grooved and more efficient.

One can work on increasing confidence and from that one step, increase efficiency in almost any area of life that needs improvement. This improvement is invariably the result of one good habit leading to improvement in other aspects of one’s life. Just as when one starts a daily work-out program (can start with as little as 10 minutes per day), as the habit grows and becomes honed, other aspects of one’s life such as eating healthy and sleeping better start to improve.

What works for physical fitness can also work for mental fitness too. It always follows that people who are generally physically fit will experience less stress and more efficiency in their mental tasks. There have been plenty of scientific studies that show overall improvement in mood and health with increased physical conditioning. If you add mental conditioning in the form of adherence to a daily positive mantra, you are likely to see improvement in all aspects of your life too.You can start with one small change and keep reinforcing that small positive change on a regular basis.  It only takes a change in the very next instant to embrace the positive and confidence that you can keep going which will keep you on the right track.

4 September, 2012 Posted by | academics, medical school coursework, medical school preparation, residency, stress reduction, study skills, success in medical school | 3 Comments