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Ask Uncle Panda
1. Say, Uncle Panda, what exactly do you like about Emergency Medicine? I thought the hours were crazy and the burn-out rate was high. What about it?
From the perspective of residency training, Emergency Medicine is far superior to any other specialty. First of all, it’s the most like a regular job of any residency. With the exception of off-service rotations which will fill roughly a third of your three year training (most programs are three years long) you will be working set shifts with a pre-determined start and finish time. (Although you shouldn’t expect to get out exactly when your shift is over as there are usually things to either tie up or sign out.)
To my mind, there is nothing more annoying than coming in early to pre-round on patients only to round on them again with the attending. A tremendous waste of effort. I’m also not exactly sure why we need to come in early on rotations like internal medicine. It’s not like the patients are going anywhere. What invariably happens is a short burst of frenzied activity from 6 AM until ten followed by large patches of dead time until around four…at which point there is usually another burst of frenzied activity. I’m sure this pattern is inevitable but that doesn’t mean I have to like it.
As to burn out, I don’t know. I’m new to the profession and I will have to defer to the opinions of my more senior colleagues. It is my understanding that “burn-out” is greatly exaggerated. Emergency Medicine self-selects for people who like variety, working weird hours, and making quick decisions with incomplete information. While this would quickly burn out someone who likes a more deliberative pace, EM physicians look at this as routine and a good trade for working fewer hours and fewer days.
No questions that the pace is a lot more intense than most other specialties. In a busy emergency department the residents are working all the time. Productivity is critical in the “shop” and second and third year residents are expected to see and “dispo” at least 2.5 patients per hour. On a twelve hour shift this works out to 30 patients which is a lot. It is true that some patients have relatively minor complaints which don’t take that much time but as often as not the next three will be very sick with multiple comorbidities. Not to mention the traumas that roll in periodically. The net result of all this is that a good Emergency Medicine resident has to learn how to juggle multiple patients. If you can’t prioritize, organize, and keep track of multiple plans for many different patients you probably won’t like Emergency Medicine.
As to the hours, they are indeed crazy. While most programs make an effort to accommodate your circadian rhythm, when all is said and done you will be working a lot of nights and leading a vampire-like existence. On the other hand you will be driving opposite rush hour traffic, the banks will be open when you get off work, and academic teaching hospitals are a good deal more laid-back after normal working hours.
Does Family Practice suck?
No, of course not. I didn’t like it but that’s just me. As it emphasizes long-term management of chronic diseases it is not for those with ADD, short attention spans, or who get bored easily. I want to dispel the myth, however, that Family Physicians have some sort of leisurely, non-demanding lifestyle. The fact is that like any other job, productivity is important. In family medicine where the reimbursement for the usual visit is low, patient volume is important. A Family Medicine resident may see as many patients in a day as an Emergency Medicine resident. On the other hand he is unlikely to be working on more than two or three at a time, the presenting complaints are usually less acute, and the chances are good that the resident has seen the patient before and can skip some of the usual history taking.
It is also an unwritten but very real expectation of patients that their family doctor spend some time chatting with them. This is a very important part of the art of medicine but it does add to the time for a patient encounter, especially the family medicine patients that want to talk about everything and who will not shut up. A good family physician masters the art of redirecting the conversation without appearing rude and winnowing down a long list of complaints to the most pressing without appearing callous.
In the Emergency Department it is all right to be a little more brisk as the situation demands.
Just a random thought, maybe if they changed the name of the specialty it might attract more guys. Let’s face it, Family medicine has a decidedly feminine, non-threatening ring to it and calls to mind images of gentle, sensitive men nurturing woman and children. This is not how most guys see themselves. What most of us really want to do is get in touch with our inner Cro-Magnon, not our inner child.
Can a Physician have an Opinion?
You No Like?
Although the comments posted by the readers of this blog have been generally positive, you may as well know that I have recieved quite a few irate private communications about my impression of Duke, Duke’s now defunct family medicine program, and Family Medicine in general. I say “irate” but perhaps dismissive would be a better word, the general tone being that as I was just an intern I don’t know what I’m talking about.
Some have even suggested that I am jeapordizing my professional career by publically criticising such a behemouth as Duke. I can’t get this image out of my head of Don Vito Corleone using all of those good empathy tricks to engage me, communicate his interest in me, and make me feel like I was a person worth his time before he had one of his heavies whack me.
I’m not going to belabor the obvious by chanting the mantra about this blog being just my opinion. Of course it is. And of course I am right about some things which makes it both my opinion and fact at the same time. Family Medicine is unpopular among American medical school graduates and the approach taken by Duke is not going to change this. The first statement is objective fact and the second is educated opinion. You can scream all you want, call me ignorant, insensitive, and a know-nothing but the community medicine experiment didn’t pan out, at least from the point of view of physician involvement, and I would suspect that other programs, particularly at my Alma Mater LSU Shreveport, who are either implementing or considering the Duke model are now having second thoughts. Either that or bureaucratic inertia, being the one unstoppable force in this bad old world of ours, is carrying them to their ruin.
As for not liking Duke, well, that is just personal opinion. This is going to sound trite but when I eat lunch with my collegues I like to talk about interesting things. At Duke, all anybody ever wants to talk about is medicine. Hey, I like medicine. It is interesting but it ain’t that interesting. Or rather, listening to somebody pontificating about it is not that interesting, particularly when they start throwing the results of studies at me.
Eyes glaze over. That’s why I do my own reading every day. It is more efficient, I learn more, and I am not trapped in a lunch conference looking at power-points eating organic chicken wraps. What I really like to do for lunch (if all of my patients are taken care of and nothing needs to be done) is drink a Cherry Diet Coke and listen to Rush Limbaugh.
Is that a crime? Just like I believe that sleep should not be a privelege and therefore call blows, I also believe that a break every now and then is not a sign of weakness but merely a desire to refresh the brain by contemplating other things besides work or even nothing at all. Unless you are a surgeon, the day is not so chock-full of activity that we can’t enjoy a pleasant meal together where we talk about sports, movies, or girls we’ve banged.
So the thing I dislike about Duke was that everybody was so obssesive, to the point that it was nearly impossible to hold a normal conversation. I actually witnessed, on many occasions, interns pimping other interns. This happened to me at lunch once when the conversation inevitably turned to medicine and one of my fellow interns turned to me and said, “Hey, Panda, what’s the differential for painless hematuria.”
“Your mother,” was my prompt reply.
Hey, I’m eating here. I don’t want to talk about or contemplate genitourinary issues. Is that too wierd?
ICU
Waiting for a Miracle
“You understand that if your father’s heart stops we’re going to be pounding on his chest and shocking him to try to get it started,” I say to the family of Mr. Green, “There will many people in the room who you have never met inserting lines in his veins and arteries, drawing blood, giving him fluids, and it will be controlled chaos. If we get him back he will just be even more critically ill than he is now and the next time his heart stops we will repeat the same routine.”
Mr. Green is eaten up by cancer which has metastasized everywhere including his brain. It seems difficult for the family to understand the connection with this and the large fungiating, bloody melanoma on his right big toe. (“Can’t you just amputate his toe?”) He is on the ventilator and is also on a pressor drip (levophed, or epinephrine) to maintain his blood pressure. To say he is not doing well would be an understatement.
“We understand that, Doctor, but we’re praying for a miracle.”
This is by far the worst part of this ICU rotation. Everybody likes to deliver good news but in the ICU it is often necessary to concede defeat. Resident or not, whatever your level of experience you become the point-man of the whole medical profession and it is your job to explain that whatever propaganda the family may have heard, there is no cure for death and when it’s time to go, it’s time to go.
“I’m a religious man myself,” I begin, carefully choosing my words, “And I believe that God watches over all of us and will not abandon us in our time of need. But I also know that any further treatment for your father is only going to put off the inevitable. I can’t tell you how long he has. It may be twenty minutes, it may be a week. I don’t know. But I can say with certainty that we have come to the limits of our ability to do anything but briefly prolong his and your suffering.”
Distressed look from the family.
“So I believe that the best thing to do is to keep him comfortable,” I continue, again choosing my words very carefully, “Trying our best to preserve his peace and dignity.”
“Do we have to decide right away?” asks Mr. Green’s oldest daughter, “We would like to get more of the family involved.”
“Please, take all the time you need. Have the nurse page me when you come to a decision.”
The decision is to change his code status from “full code,” meaning that every effort will be taken to restart his heart and support his breathing, to “Do Not Intubate/Do Not Resuscitate (DNI/DNR).” A simple decision from the point of view of the physician and nurses but incredibly painful for the family who have a lifetime of history with Mr. Green.
A critical care physician once related to me the story of a patient of his who at the age of 82 and after a lifetime of diabetes had developed renal failure requiring dialysis three times a week. He was completely blind, a triple amputee, unable to speak as a result of throat cancer, and had right-sided heart failure from COPD. He had recently undergone a partial colectomy for ischemic bowel and had a colostomy. He was fed via a PEG tube (Percutaneous Endoscopic Gastrostomy) and breathed through a tracheostomy on supplemental oxygen. As one last insult he had recently suffered an MI which burned out a significant portion of his left ventricle dropping his ejection fraction, already low from the right sided heart failure (which drops cardiac output by decreasing amount of blood to the left side of the heart) to something barely compatible with life. But he clung to life and communicated that he wanted every measure taken to keep him alive.
“You know,” The physician said to me, “In Europe they would have let this guy go five years ago. There’s no way they would expend the kind of resources we have to keep him alive.”
“What do you think about it?” I asked.
“I think it’s a tremendous testament of the will of the human spirit to live and I’ll do everything I can for the guy.”
So there’s the problem. When do you keep a patient alive even when treatment appears to be futile? In the case of a patient who can make his own decisions the answer is clear. You do what he asks. When the family acts as a surrogate the decision is a lot more complex. In the case of Mr. Green, the oldest daughter took me aside and confided to me that her brother and her father had had a falling out several years before and had never patched things up. The brother was the strongest advocate for taking all possible measures to keep his father alive.
It would not be too much of a stretch to believe that guilt played some role in the son’s attitude towards his father whose death would leave a lot of important things unsaid, perhaps an apology and a reconciliation.
But that’s how it goes in the ICU. Some patients get better. Some get worse and die despite your best efforts. And some come in and make you wonder why they were admitted because nothing can be done beyond comfort measure.. The ICU shouldn’t be a place for hospice or palliative care but it is sometimes used for this purpose.
I Will See You On the Flip Side
Well, I’m moving. Consequently blogging is going to be light for at least the next month as once again I will load our house into the biggest moving van that Uhaul rents and drive 800 miles to Lansing with nobody but my Black Lab, Persephone and my Catahoula Spotted Leopard Dog, Daphne for company. Hector, a funny kind of terrier-mix will be riding in his cage in my towed car with the windows rolled down.
My wife will follow a few days later with the kids and the other two dogs, Zoe and Penelope.
I appreciate your reading my humble blog and please keep checking back every now and then.
Now I Don’t Feel So Bad About Leaving
They Shoot Horses, Don’t They?
As many of you know, I am a family medicine intern at Duke University, at least until June 9th which is, thankfully, my last day after which I start my Emergency Medicine residency. (The entire saga is recounted in previous posts for those who are interested.) As you also know, the Family Medicine residency program has been closed. We received an urgent email from the Program Head last Thursday “strongly advising” us to attend a noon meeting for all residents and staff. Lunch, we were informed, would be provided which lent a pleasant air of normalcy to what sounded like impending bad news.
I mean they’d probably have the ubiquitous ceaser chicken wraps. How bad could it be? Still, the program had not been doing well of late. After an internet smear campaign waged by several of the eight residents who have quit in the last two years as well as a general lack of enthusiasm nation-wide for family medicine, the program only matched two out of a possible six positions and scrambled for an additional two. Not very good results for a program at one of the most prestigious medical centers in the world.
Naturally I didn’t attend the meeting as I was rotating on OB. Since I am leaving I figured it was just another one of those meetings they are always calling to get some more resident input on how to fix the program. Generally speaking there has been little interest in anything but complete agreement so why bother? Besides, we were getting slammed and I delivered three babies that day just in triage. (Precipitous deliveries, you understand, when you reach in and feel the babies ears.)
So I forgot about the meeting until a lull in the action when I checked my email and found a message from a program director in California offering me her condolences that the program was closing and also offering me a position in her program.
So what happened? You can go here http://cfm.mc.duke.edu/News.htm and read the usual bureaucratic drivel. Let me give you my opinion.
Family Medicine is hugely unpopular as a specialty. I’m sorry if this is offensive but it’s the truth, at least as reflected by the small numbers of your classmates who will go into it compared to the ready availability of family medicine residency positions, a large portion of which go unfilled in the match every year. Whether it’s the low salary of family medicine physicians compared to specialists, the lack of prestige of the specialty, or the lack of interest in chronic care, medical students run away from family medicine as fast as they possibly can.
This is unfortunate because a good family doctor is an asset to the community and often the only physician you will ever meet who can see you in the big picture and not just as a life support system for a pair of kidneys or a shell through which the GI tract runs. There are also many outstanding family medicine programs which offer a very high level of training to their residents in both disease management and procedures.
Duke Family Medicine, however, as a program has been doing everything in its power to drive away residents by deliberately marginalizing the role of the physician, watering down their skills with irrelevancy, and assigning them roles which detract from their principle function.
The culprit is something called “community medicine,” a noble enough sounding concept that was even used as a selling point for applicants. Community medicine as envisioned at Duke, however, is nothing more than a capitulation to the idea that the physician is redundant in family medicine. This is certainly the idea you get at Duke where the clinic is staffed by Physician Assistants and other mid-level providers and where we are not even referred to as “doctors” or “physicians” but as “providers” to avoid offending the non-physician providers. Or they call us “learners,” a particularly odious term the offensiveness of which the faculty remains oblivious to despite many complaints.
On my first day in clinic I shadowed a PA. Not his fault of course but it shows you where the program’s priorities are.
Community medicine is integration of social work with medicine. In addition to diagnosing and treating their illnesses, we must now follow the patients into the community, identify their barriers to care, plead and beg them to take their medicines, and even if necessary wipe their asses for them. The patients, in short, are helpless pawns of fate who we must treat like children in our attempts to save them from themselves. In this we patronize them in a manner that is truly shameful. And racist too, as the underlying assumption is that blacks and other minorities are somehow unable to make good decisions.
I’m not saying, however, that we did a lot of social work, just that this was the zeitgeist of the program and the traditional practice of medicine (diagnosis, treatment, and management of disease) was definitely subordinate to it. One of the goals of the program, for example, was to have the residents staff a clinic at one of the local high schools. While I have no doubt that somebody needs to pass out condoms and give the fourteen-year-old girls their Depot Provera shots, is this really a good use of a resident’s time and, more importantly, is this a high yield educational activity seeing that the job could be easily handled by a school nurse or a moonlighting PA student?
The emphasis on social work was also reflected n the poor quality of the program’s didactic learning. The conferences were incredibly weak, usually on some subject that was only peripherally involved with medicine, and as they were directed to the mid-levels and social workers as much as the physicians were mighty thin gruel.
Mighty thin.
Contrast this with a program like Internal Medicine which has morning report, well-attended noon conferences on highly interesting medical topics, and weekly Grand Rounds given by physicians on the cutting edge of research. This kind of education is almost as important as your clinical duties and good programs don’t skimp on this. Many of the interns recognized early that we were being short-changed in this regard and suggested that the schedules be re-worked to carve out a set block of time every week for resident education. It is pretty difficult when you are doing off-service rotations to make it to noon conference at your program, especially as the Family Medicine center is some distance from the main hospital. Generally you attend the conferences of the specialty where you are rotating. This is fine, of course, but what’s the point of training for a specialty if you never get any training in it?
Many programs do carve out time for teaching residents. This time is “protected” and except when on critical care rotations the residents are excused from all clinical duties. Emergency medicine does this. It is complicated for all of the involved services and I’m sure that the services don’t like having their cheap help pulled for one afternoon a week but part of leadership is looking after your own troops and having the nuts to tell the other services to pound sand.
This suggestion, like most suggestions, went nowhere. It was probably because of the complexity of scheduling but it is also likely that having all of the residents in one spot at one time receiving specialized training would emphasize the distinction between physicians and mid-level providers when the goal of the program seems to be to erase this distinction.
The Empire Strikes Back
Parsing carefully the chairman’s statement detailing the reasons why the Family Medicine residency program was closed, we find the curious assertion that clinic patients were receiving inconsistent care. Apparently the insanity had gone on long enough and it was time to stop the madness before those darned residents killed someone.
Even in defeat the first instinct was to blame the residents which is typical of the program. Although every other program at Duke has continuity clinics where the patients receive the same kind of “inconsistent” care from residents who have large blocks of their time dedicated to inpatient rotations, this is apparently only a problem at Family Medicine.
Obviously someone didn’t get the memo that the purpose of a teaching hospital is to train physicians and this is done by allowing residents to see patients. I’ll be the first to admit that an intern is not usually a model of efficiency with all the answers at his finger tips. On the other hand the patients accept this and are usually pretty tolerant. Many actually prefer residents because what we may lack in experience we make up for in our genuine interest in their condition and in the amount of time we spend with them, usually considerably more than the five minutes or so you can expect in private practice.
I suspect that one of the reasons the residency program was closed was because it was interfering with clinic operations. Duke Family Medicine, as I was told on many occasions, is a money-making enterprise. Nothing wrong with this of course but I also suspect that because there is not much love for the family medicine residency program at Duke, the positive cash flow provided the only leverage to keep it going. Delivering health care through interns and residents is unavoidably inefficient and this probably was hurting the bottom line.
You will note that Duke Family Medicine is not closing. It will continue as a faculty-run clinic staffed by attendings and the usual assortment of mid-level providers. (The Sports Medicine fellowship is not effected by the closure of the residency program, by the way, and the plan is to expand the fellowship offerings.)
Out of Control Bureaucracy
Let us recap. Until a few years ago, Duke Family Medicine was a well respected program which, although effected by the general decline in popularity of Family Medicine, always managed to fill its quota in the match (although to be fair the program was shrinking, going from 18 residents per class in the seventies to six when I signed on). It was the implementation the chairman’s vision of Community Medicine which sank the program, beginning several years ago when almost a third of the residents either quit in disgust or were driven away after their concerns over the effect of this on education and training were dismissed.
You’d think that this would have given someone pause but apparently the reaction was “good riddance” and the program continued towards the iceberg which it hit two weeks ago. And, to continue the metaphor, the deck chairs were being re-arranged while the program sank as numerous Task Forces, working groups, and committees were set up to explore such life or death questions like a new form to evaluate the preceptors and all other manner of things which may be important but which don’t really require this kind of frenzied activity. None-the-less, several bureaucrats from the department’s extensive stable were delegated to solve the program’s problems, one evaluation form at a time. If they could only get a handle on “metrics,” if only cultural competency could be more adroitly addressed, and if only the residents would get on board and sing the praises of the Five Year Plan things were going to be all right.
Paradoxically, for a program that was very intolerant of dissenting voices they made something of a fetish about soliciting input from the residents. The process is the thing, you see. As long as we ask for your opinion we can get all warm and fuzzy about how much of a team we are without actually taking you seriously. To this end there was a constant demand for evaluations and they were deadly earnest about them.
The expectation that the house staff are responsible for solving a program’s problems of which the constant demand for evaluations is one symptom can be demoralizing as it sometimes indicates a lack of leadership. Everyone likes to be consulted and good programs listen to reasoned criticism from their residents and take appropriate actions to correct problems. Still, it is not necessary to get resident buy-in on every decision. Those who are in a position of leadership need to lead and eschew the SWOT groups and Task Forces which dilute responsibility under the guise of gaining consensus.
Consensus is great but as the program was run in a top-down authoritarian style rather than a consensus-building team approach the attempts at collective decision making had something of a politburo flavor as there is definitely a party line to which we must adhere.
Don’t get me wrong, as a former Marine I am all for the authoritarian style of leadership in which responsibility and authority are clearly delineated and all suggestions and orders flow through a well-defined command structure. I just think that asking for our input and then either ignoring it or harassing the critic confuses the house staff and leads to unnecessary friction. Better to just proclaim the policy, offer the door to those who don’t like it, and soldier on. This is under the theory that acting boldly on a mediocre plan (and community medicine is definitely a mediocre plan) is better than vacillating and wringing one’s hands while trying to think up a perfect plan.
What we had, I repeat, was a failure of leadership. I think the program’s problems were obvious. Surely everybody in authority must have known what they were. But instead of stepping up and owning up to some bad decisions the defense mechanism was to spread the blame by making everyone, through the polite fiction of evaluations and task forces, responsible for the eventual outcome.
A Sense of Impending Doom
Did the emphasis on community medicine hurt me? Not really. I was an intern and consequently spent most of my time rotating off-service. Some people are surprised to learn that Family Medicine residents rotate on general surgery, medicine, and MICU. These plus inpatient and outpatient pediatrics, cardiology, obstetrics, gynecology, and a few weeks of urology and otolaryngology make for a very busy and somewhat traditional intern year of the kind suffered through by the majority of residents in almost every specialty. I had a half day clinic every week (which was very well precepted I have to add) and I kept my head down and did my job. I attended a few of our program’s conferences but as they were usually pretty weak and there was no requirement that interns attend I was happy enough to sit in on my host service’s didactic sessions.
So I got pretty good training. Other than that as I was somewhat preoccupied with the match I had a few more important things to worry about than bureaucratic in-fighting. Remember that by switching specialties I had committed myself to moving my wife, three kids, and five dogs for the second time in a year. Not to mention the struggle to interview around a rather inflexible schedule.
Still, it was hard not to get the sense that things were falling apart at the program. Every time I went there people seemed on edge and disgruntled. Nobody made eye contact, if you understand what I mean. Did this bother me? Not particularly because as an intern you are always rotating off-service and have your own set of problems and challenges keeping you occupied. Time flies like you wouldn’t believe. You put your head down on the first rotation of the year and when you come up for air it’s October. Then you blink and it’s February. Additionally the call schedules and work requirements of the interns are so erratic that it’s difficult to get all of them together to build camaraderie.
So before I knew it match day had rolled around and after a tense week of nail-biting I found that I had matched. After that it just didn’t matter. In no way did I drop my pack and I think everyone on every service where I rotated would report that I was gung ho and as bushy-tailed as possible for an intern. That’s just the kind of guy I am. I will confess thought that I have been dragging for the last couple of weeks. My only clinical duties have been a few clinics and other than that I have been definitely smelling the greener pastures.
I have also avoided any criticism of the program until now so as not to hurt their chances in the match but it doesn’t matter anymore. You may view this article, long-suffering reader, as either a cautionary tale, gossip, muckraking, or just something interesting about the medical profession.
Whistling Past the Graveyard
Family Medicine as a specialty, for various reasons, is not doing well and seems to be headed for extinction. In it’s place is a new model of care in which a highly trained physician is both uneconomical and unnecessary. The Chairman of the Department of Community and Family Medicine admits as much in his rational for closing the residency program. His vision is to have an army of low-skilled providers fan out into the hinterlands like so many Chinese barefoot doctors. Of course, he doesn’t say it quite like that but whether he is bowing to the inevitable or he sincerely believes it, he doesn’t think the physician is important enough in the specialty to support a residency program.
I received a letter today from the North Carolina Academy of Family Physicians calling attention to the closure of the Duke Family Medicine residency program. The money statement was this: “The Academy leadership does not believe Duke or any other university can implement these new models of care by eliminating family physician training and only relying on mid-level providers.”
Well, that’s sort of the point. Whether the academy leadership believes it or not, the “new model of care”is being implemented without Family Medicine physicians. It’s almost a done deal.
A Few Closing Thoughts
1. Family Medicine is declining in popularity among American medical student. Short of socializing medicine and forcing people to work where they don’t want to, I can see no encouraging trend indicating that students will slap themselves on the head and say, “Eureka! I want to spend my career working like a dog for low pay in Corn Hollow, Nebraska nagging my patients about their weight while referring out all of the interesting cases.” It just ain’t going to happen. There is a genuine demand for family practice physicians but other specialties are in even greater demand. I also don’t see salaries rising to meet the demand so the demand my be over-stated.
2. Increased empathy will not compensate for decreased knowledge. In other words, spending time on empathy training, cultural competence, and all of the fuzzy things is fine except that it might take away from the serious study of medicine. Most of the fuzzy things don’t need to be taught to most people anyways. What usually ends up being the case is that these topics become a sounding board for the political views of organization doing the teaching. I happen to believe, for example, that personal responsibility is an ideal towards which every social program should be aimed. Mention personal responsibility at Duke Family Medicine and you are asking for a reprimand or an attempt at re-education.
It’s just a philosophical difference. The program can point to countless patients who even I will admit are incapable of doing anything for themselves. On the other hand I can say, with some justification, that it is the very social programs advocated by the program which contribute to this state of affairs and make it unlikely that anything will ever change.
3. I’m just one guy, the lowest guy on the totem pole at Duke, and these are strictly my opinions. You may have different opinions which I am perfectly willing to consider. If you are offended by my opinions then you have the entire internet on which to associate with people who can reinforce what you believe and there is no need for you to trouble yourself over my small corner it.
My Personal Statement
“Mbuto.”
My African driver springs to his feet.
“Yes, Sahib.”
“Pass me another baby, I think this one has died.” I lay the dead infant in the pile by my feet. What I’d really like him to do is pass me an ice-cold bottle of the local beer. Compassion is hot, thirsty work. There is no ice in this wretched refugee camp, mores the pity, but as I’m here to help I will suffer in silence. I stare into the eyes of the African baby who is suffering from HIV or dengue fever or something gross and look out into the hot, dusty savannah and ask, “Why? Why gender-neutral and non-judgmental Deity (or Deities) does this have to happen?”
“And Why, Mbuto, is the air-conditioning on my Land Rover broken again?”
“One thousand pardons, Sahib, but the parts have not arrived.”
I will suffer. I have lived a life of privilege and my suffering serves to link me to the suffering of mankind. I roll the window down. God it’s hot. How can people live here? Why don’t they move where it’s cool? Still, I see by the vacant stare from the walking skeletons who insist on blocking the road that they appreciate my compassion and I know that in a small way, I am making a difference in their lives.
Africa. Oh wretched continent! How long must you suffer? How long will you provide the venue to compensate for a low MCAT score? How many must die before I am accepted to a top-tier medical school?
When did I first discover that I, myself, desired to be a doctor? Some come to the decision late in life, often not until the age of five. The non-traditional applicants might not know until they are seven or even, as hard as it is to believe, until the end of ninth grade. I came, myself, to the realization that I, myself, wanted to be a doctor on the way through the birth canal when I realized that my large head was causing a partial third degree vaginal laceration. I quickly threw a couple of sutures into the fascia between contractions so strong was my desire to help people.
My dedication to service was just beginning. At five I was counseling the first-graders on their reproductive options. By twelve I was volunteering at a suicide crisis center/free needle exchange hot-line for troubled transgendered teens. I’ll never forget Jose, a young Hispanic male with HIV who had just been kicked out of his casa by his conservative Catholic parents. He had turned to black tar heroin as his only solace and he was literally at the end of his rope when he called.
“How about a condom, Hose,” I asked. The J, as you know, is pronounced like an H in Spanish.
Annoying silence on the line. Hesus, I was there to help him.
“Condoms will solve all of your problems,” I continued, “In fact, in a paper of which I was listed as the fourth author, we found that condoms prevent all kinds of diseases including HIV which I have a suspicion is the root of your depression.”
More silence. No one had ever had such a rapport with him. He was speechless and grateful and I took his sobs as evidence of my compassion.
“Hey, it was double-blinded and placebo controlled, vato.” Cultural competence is important and I value my diverse upbringing which has exposed me to peoples of many different ethnicities. I always say “What up, Homes?” to the nice young negroes who assemble my Big Mac and I think they accept me as a soul brother.
“We also have needles, amigo. Clean needles would prevent HIV too.”
My desire to be a physician has mirrored my desire to actualize my potential to serve humanity in many capacities. This may be something unheard of from medical school applicant but I have a strong desire to help people. I manifest this desire by my dedication to obtaining all kinds of exposure to all different kinds of people but mostly those from underserved and underprivileged populations. In fact, during a stint in a Doctors Without Borders spin-off chapter I learned the true meaning of underserved while staffing a mall health care pavilion in La Jolla, California.
Most of my friends are black or latino and I am a “Junior Cousin” of the Nation of Islam where I teach infidel abasement techniques to the Mohammed (PBUHN) Scouts. I also am active in the fight for women’s reproductive rights except of course for women in Afghanistan who were better off before our current racist war.
As Maya Angelou once said, “All men (and womyn) are prepared to accomplish the incredible if their ideals are threatened.” I feel this embodies my philosophy best because the prospect of grad school is too horrible to contemplate.
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Welcome Aboard
What to Expect Now that You’re Accepted
One of the greatest days of my life was when I was accepted to medical school. It ranks up there with my marriage to my lovely wife, the birth of our children, the day I graduated Marine Corps boot camp and the day I was honorably discharged.
I’m not ashamed to say it. It was one of those days where the future opens up. When I was discharged from the Marines, for example, it was a beautiful April day in North Carolina. I had money in my pocket, an absolutely beautiful girlfriend who I would marry a year later, and nothing much to do until classes started in June. You feel like you can do anything at a moment like that.
Same with getting into medical school. So it is my fondest hope that those of you who have gained acceptance relish this time because the road ahead is long and you will probably have some dark moments. I also hope that those of you who will not get in this year continue to persevere, especially if you are young. Maybe I wouldn’t advise an older applicant to keep beating his head against the admission process but if you are in your mid-twenties, why on earth would you even contemplate giving up so easily after only one or two tries?
So good luck. Stand by. And here is some more unsolicited advice from your Uncle Panda.
First of all, you really don’t need to do anything to prepare. As I have said earlier, there are really no pre-requisites for medical school. I suppose it’s good that we take all of that organic chemistry and biology but I can’t really identify any area in my undergraduate education that was of any use. If you’re the kind of person that remembers everything from your sophmore biochemistry course then you probably will remember everything from your medical school biochemistry course. If you don’t even remember taking biochemistry as an undergrad then why worry about it? You will be exposed to it soon enough, you will remember it long enough, and by the end of fourth year you won’t remember enough of it to matter.
The point is you need to relax and take it easy between now and the middle of August when most of you will start. You cannot possibly cram everything you need to know between now and then. You can try, of course, but it is equally likely that absent any structured guidance you are going beat your head against subjects which will be breezed over in one lecture and never seen again. There’s just no point to cramming. Better to finish your coursework without totally dropping the ball and then take a well-deserved vacation, maybe the last time in your life that you are completely free of responsibility.
Those of you who are non-traditional or have families, would it kill you to quit your job a little early to take it easy for a while? Four years from now when you are a quarter million dollars in debt the couple of thousand bucks you wrested from your crappy job by sticking with it to the bitter end will not seem like that much money.
I was fortunate that I worked for myself and could wrap up my affairs well before my start date.
Second, and I know I am repeating myself here, do not buy anything on your school’s list of required books and equipment unless you don’t care about money. If you show up on the first day of orientation with a pen and a little piece of scrap paper to take notes you will be all right. Heck, eschew the scrap paper as you wil get reams of handouts. Besides most of what you will learn at orientation is pleasant to listen to but of no value at all once the proverbial excrement hits the fan. No need to take notes.
You see, at orientation they will fill your heads with visions of sugerplums which will dance in your head until the first day of actual class when you find that all of the happy talk and kumbayah won’t help you one bit as first year is just a grind, a pathetic slog through trivia.
Ah, orientation. It was a week of emotional masturbation during which we were told six hundred times that we were special, we were going to be empathetic, and gosh darn it, people liked us! Then classes started and people went from feeling warm and fuzzy to stressed, tired, and wound to the breaking point. Oh the bullshit they fed us, everything from “if you don’t study in a group you’re going to fail” to “get the textbooks because there will be required reading.” Har har.
So don’t believe the hype. Smile, enjoy the week (or however long your school allots for orientation) but prepare to get on it once real classes start. If you study, you will pass. If you study all the time, you may get good grades but then again you may only do a few points better than your slacker friend who studies one fifth as much as you. (Sometimes there seems to be no correlations between the amount of time you put in studying and your grade.) Study hard, keep up with the material, listen to good advice from your upper-classmen and try not to get to caught up in the touchy-feely stuff. You’ve got a long road ahead. No sooner will you start feeling like you’re in command of medical school when you will start third year and feel like the biggest superfluous, ignorant, non-essential piece of baggage to ever break the plane of the pelvic outlet.
Let me repeat one piece of good advice that one of the fourth years gave us during orientation. Be macho. No matter what happens just shrug it off as just another day. Big test coming up? No big deal. First day of General Surgery? Just another day. Step 1? Nothing to it.
Good luck.
Yes, the Hours Still Suck
There is No Prize for Sucking it Up
Residency entails long hours. You may as well accept this and prepare for it. Up until very recently however the hours were much, much worse and it was not uncommon for residents to all but live in the hospital except for the polite fiction of being allowed to go home infrequently for sleep. These were the bad old day, only a few years ago, when you worked at the whim of your program with no recourse other than to quit if you didn’t like it.
These kind of hours were insane. Nobody can function on three or four hours of sleep every other day, at least not in something as complicated and intellectually demanding as medicine. As a young Marine I regularly went several days without sleep but while being a Marine requires considerable skill and intelligence, it’s nowhere near as demanding intellectually as medicine. You really do stop caring about things as you become sleep deprived. Everything requires more effort. Concentrating on routine (but important tasks) becomes impossible and it is only the occasional burst of adrenaline that makes functioning as a sleep deprived Marine or a physician possible.
In the old days when most of your older attending were residents, things were considerably different. It’s true that they spent long hours at the hospital but the pace was a good deal slower on the wards as there were both fewer interventions and a much slower turnover of patients. These were the days when the hospital course for someone with a heart attack was three weeks. Today it is usually two days, sometimes even one if the heart cath was done early in the morning and the patient is in otherwise good health.
It is one thing to be on call on a service with a census of patients most of whom are long term and stable boarders, it is another thing to be on call on a service with rapid patient turnover and a completely new census every few days. There is simply more work to do, especially when it comes to admitting patients.
“Admitting†is the process of working up the patient when he presents to the hospital and involves the history, physical exam, assessment, and plan which we discussed in a previous post. It is also as you can imagine a tedious paper-work grind at almost every hospital as previous records are tracked down, numerous forms are filled out (many of them redundant and mainly serving the purpose of lawyer-appeasement) and extensive notes are either written or dictated. It is not as tedious in private practice as the economics of paying a physician to waste time come into play but no such restriction apply at a typical academic hospital. Not only will you shoulder the burden of this work but you will also have to clear every decision through either your upper level resident or your attending.
This is the way it needs to be, of course (I mean except for the lawyer protection paperwork) but as a typical admission on a medicine service can take hours in the case of complicated patient you can see that with the rapid turnover in today’s teaching hospitals a few admissions a night will prevent you from getting any sleep when on call. In fact, most teaching services are “capped†or limited on the number of admissions they can take in recognition that learning is impossible if you are treated as cheap labor.
So I don’t want to hear the sanctimony from the old-timers about how much harder they had it back in the day. Fewer admissions and more stable patients lead to a more stable census and more time for rest. Sorry. The trouble was that as medicine became more complex and demanding, the treatment of residents lagged far behind almost as if it were in a different century. Residents working in modern, high-turnover hospitals were treated no differently than their more relaxed collegues from the fifties and sixties.
After several important papers were published detailing the risks to the safety of both patients and residents from sleep deprivation, the Accreditation Council for Graduate Medical Education (AGCME) mandated that all residency program restrict the work hours of residents to eighty hours per week averaged over four weeks. This is a good start but it’s still only a start.
The fact that many in the medical community think it takes eighty hours per week to train you in a medical specialty reflects the general inefficiency and poor organization of medical training as well as a reluctance of some to let go of old, outmoded methods. Eighty hours is better than 120 of course, but it’s not a pleasant way to spend three to seven years of your life.
Let’s look at a typical Q4 call schedule. This means that every fourth night is overnight call. You will work three 12 hour days. On the fourth day you will work through the night until one in the afternoon (you must be released by this time according to the rules). Since you got no sleep on call your half-day is pretty much wasted as you sleep most of it. You must be allowed one 24-hour period per week free from all clinical duties but sometimes this entails being allowed to go home in the morning after call which means that your day off is abbreviated to 20 hours or so.
You will usually end up working 85 hours a week if not more because some people will not let go of the old ways and as they have no life outside the hospital have no incentive to be efficient or decisive. Your time is not valued in the slightest because anybody who cares is paying the same whether you work fifty hours or a hundred.
The worst thing is that most of your time will be spent wrestling the incredibly inefficient paperwork system which is endemic to every American hospital. You will spend most of your time as an intern filling out some sort of paperwork or another. That’s why they still call your intern year a “clerkship.†Trust me, you will spend the majority of your time wrestling with the paperwork. Important or not, there is a huge quantity of it.
So eighty hours does make for a long week and a long month. It is a violation of an unwritten rule of residency to complain, of course. The tradition is to suck it up and not look weak. Still, it is a lot easier to spend your life at the hospital if you have no life outside the hospital which is more the case than you imagine. I had a third year resident on a medicine rotation who regularly rounded in the evening on non-call nights after every other team had gone home sometimes until seven or eight with me and the medical students as her entourage. The on call team was also in the hospital handling all of the new admits so we weren’t really doing anything. She just was just very dedicated but more importantly had nothing better to do with her time.
Patient care is important. On the other hand if you can’t manage twelve patients on your service from six in the morning until six at night then you have a problem with efficiency. All your over-night orders should be written well before normal quitting time and the nurses are more than capable of following them. The labs will cook without you and all of the consultants have gone home and will only suffer to come for an Emergency, delegating their interns to cover things. The on call team, for its part, is there for Emergencies and to follow a few key items for you which you relate during sign-out.
You can go home already.
The best part was that at the start of the rotation the resident lectured me that medicine needed to be my first priority and family and personal life a distant second. This attitude is incredibly patronizing. It is just a job and like most men of my age and upbringing I take work very seriously. I’ll do what needs to be done but medicine is not the military and it should not be necessary to sacrifice one’s family life to its service. Spending time with the wife and children is not a privilege, a reward, or something for which we have to beg.
So you’re not supposed to complain but I think as more and more non-traditional students matriculate into medical school and then into residency training there will be more complaining as the older you are and the more experience you have outside of medicine the less tolerance you have for chicken shit…which is what a lot of the antiquated customs of residency are.
I think the first thing that needs to be done is to eliminate or greatly curtail call. Everybody deserves to get a good night’s (or day’s) sleep. It should also not be a privilege to get some rest. Some call is pretty benign of course. Urologists pull call but there are few real urological emergencies so they sleep pretty well. Specialties like medicine need to go to a shift system. Either that or have a night float system where one week out of the month you work at night and sleep during the day.
Another thing that can be done is to add to the length of residency training. Maybe sixty hours a week isn’t enough time to train a medicine resident. Medicine is inherently inefficient as it deals with inefficient human beings so a lot of the wasted time is hardwired into the system. Add a year. Increase the pay a little and pay overtime for anything over forty hours like anywhere else.
Research any residency program thoroughly. Talk to the residents when you interview. Get a good idea of the call schedule and the hours because some programs are more benign than others.
The Residency Match Part 4
Doing it the Hard Way
So I didn’t match last year and scrambled into a categorical position in Family Medicine. A categorical position as opposed to a preliminary position guarantees you a position for the total duration of the training for your specialty. It should be obvious that it is much more difficult to switch specialties out of a categorical position than out of a preliminary position. When you are in a preliminary position it is understood that you are either going to your primary specialty after your year is up or that you will be re-applying for the match. Your program director will not be shocked if you ask for time off to interview and you don’t have to explain yourself or apologize to anybody.
Not that you have to apologize or explain if you switch from a categorical position. You only sign a contract at any program for a year at a time so you are perfectly within your contractual rights to leave at the end of the year. However, since accepting such a position is a de facto acknowledgment that you intend to complete training your Program Director will naturally be surprised and not a little put out. From his point of view he will now have a hole in his roster which he may or may not be able to fill especially if it is a non-competitive specialty. Remember for all of the happy happy talk you may hear during orientation you are a low-paid and therefore extremely economical part of the health care team and your warm educated body is needed to by various hospital services to provide cheap medical labor. His program has service requirements which he must meet and you are kind of leaving him in a lurch.
Still, most big academic centers won’t grind to a halt if you leave. You can’t let your natural distaste for letting people down keep you from securing your own future. This sounds incredibly selfish but there it is. I just want you to see it from the program director’s point of view and add this to the reasons to let him know early when you decide to switch. Not only will this give him a longer lead time to re-work schedules but if you actually submit a letter of resignation he can start looking for someone to fill your empty second year spot.
I thought I was going to settle for Family Medicine and for the first couple of months of intern year I stuck to it even though I was becoming rapidly demoralized. I just didn’t like it that much. And if you must know I’m not crazy about Duke. Maybe once I get clear of the place and get some sea room I’ll tell you why. I decided to start filling out my ERAS application even though I hadn’t made a decision yet. In early September I asked my wife’s permission to switch specialties. I laid out my case and as certain things about the program and Family Medicine made her uneasy it was not a hard sell. Still, we had just moved three kids and five dogs along with all of our possessions across the country so she was not thrilled about potentially doing it twice in less than a year. Additionally, even though I was later of accused of never really intending to stay (using the Duke name as an “in” to other programs) we had bought a house and stood to take a bath on it when we moved.
My plan was to see if I got any interviews before telling my program. If I didn’t get any I would keep my mouth shut and suck it up as there is no point in needlessly rocking the boat. Unfortunately you do need a program directors letter so you have to tell your program eventually. By the middle of October, early in the process and before November 1st after which you can expect the bulk of your invitations to interview, I had already received four invitations which seemed to me an auspicious start. I told my program that week and then fought for the next three months to get time off to interview.
The interview season runs from roughly November to the first week in February. Unfortunately I had inpatient rotations during all those months. Inpatient rotations (or ward months) usually have call, rounding, and a lot of grunt work which needs to be done by the interns. Since your program has service requirements, basically an agreement with the hosting service to provide labor in exchange for training you, if you are absent someone from program has to cover for you. If you are sick they usually pull one of the interns off of an outpatient rotation where the presence of one intern is not so critical. I did two weeks of outpatient ENT, for example, and since all I really did was follow the attending around he was perfectly ambivalent to my presence.
One of the reason to tell your program early is to allow them time to switch the schedule around to give you at least one easy month, preferably January, in which to schedule your interviews. I was promised time off to interview, I dutifully scheduled most of my interviews as late as I could to give my program the lead time to switch the schedules, and then as January rolled around found that nothing had been done. Your program doesn’t have to do jack for you, you understand, as switching specialties is a personal problem. On the other hand you have got to interview or you will not match, simple as that.
This kind of left me in a quandary. As my abbreviated interview season rolled into view nothing had been done and no arrangements had been made. The assumption was that I wasn’t serious or that I would arrange my own time off with my fellow interns on the service switching call days here and there. This is possible but I’m not ready to stake my future on the generosity of people who are themselves overworked and whose schedules are so tight that they can’t possibly take a call day for you without seriously violating the duty hour rules. I think an attempt was made to shame me into not interviewing by threatening to make my colleagues who were on easy rotations suffer by doing my call.
This hit pretty hard because as a former Marine Infantryman if there’s one thing I never do is let somebody carry my pack. Everybody has their moral code and not burdening others is a big part of mine. Still, I had to interview so I was forced to go up the chain of command and ask for help above my program. This was not received very well.
Finally, I plainly told my program that if I didn’t interview, I wouldn’t match and if I didn’t match, there was no way I would stay in family medicine so under those circumstances I might as well just quit and go back to my original career. (Structural Engineering, as I have mentioned.) This is kind of a risky thing to do. I have been out of the engineering business now for almost five years, have an inactive Professional Engineering License, no contacts, and am five years out of practice. Getting back into business would take between six months to a year and in case you don’t know it interns are not paid that well and most of us live pretty much from hand to mouth. Besides, I left the engineering business to be a doctor. I wasn’t too keen on that option. So I was pretty leery about suggesting that I might quit. They might have said, “OK, there’s the door. Have a nice life,” at which point I could have either held my head high, shaken hands all around and said, “It’s been nice” or eaten a big helping of cold crow and groveled for my job back.
You have to understand that I really, really want to do Emergency Medicine. Ever since the end of third year I couldn’t picture myself doing anything else so it seemed worth the risk.
You do have some leverage, however, particularly at a small program with a lot of service requirements. My resignation, while not catastrophic to the program, would require the reshuffling of schedules to fill service requirements. Some services rely on the interns and there are very few spares floating around. This kind of hole in a roster has a pretty big ripple effect in the schedule for a few months. When I implied that I might quit, my program had to ask itself what it was worth to keep me. Fortunately it was worth a little schedule switching. My program director who is actually a decent guy working hard to solve (and succeeding at it) some of the structural problems he inherited squared the whole situation away.
The moral here is this: If you plan on leaving, tell your program early. They cannot fire you for wanting to switch specialties as your contract is for a year and binding on both parties. Also, think about when you will interview and if you don’t have a rotation during which you can miss a few days make sure to ask for and get a schedule change. I was not as aggressive at this as I should have been and I don’t think my program realized how serious I was about switching. I wasn’t just throwing out a couple of applications hoping for a few local interviews (I was skunked in North Carolina, if you must know, except for Duke which was a courtesy interview). I eventually went on six trips to cover nine Emergency Medicine interviews. I managed to get in one in November, under the wire as the planets aligned just right on that occasion, two at the end of December as one of my upper levels was kind enough to cover two days of night float, and the rest I did in January during a rotation where I was an “extra intern. I went on the last interview in early February when I finally got on an outpatient rotation and it was here that I eventually matched.
You just never know. I would also say that even though you are switching, you need to stay motivated for the specialty you are in and give good service for your pay. Don’t drop the ball and don’t get a short-timers attitude. I think every one who knows me will admit that I have been very gung ho and have shirked none of my responsibilities. I don’t hate Family Medicine. It is a perfectly decent specialty with it’s own complexities and focus. It’s just, as I found, not for me.
All’s well that ends well. This last six months has been quite an adventure full of red-eye flights and long road trips made in total darkness there and back. I confess that until I matched Durham has always made me uneasy. I came here, in my mind, a failure and I believed that maybe I had finally hit the wall.
Not today my friends.
The Residency Match Part 3
How Not To Match
Let me state the obvious. There are many kinds of doctors and depending on your specialty you will have vastly different experiences in your medical career. Ideally you want to select a specialty in which you are interested. It doesn’t need to be a passion or even a calling but you have to be able to see yourself getting up in the morning for the rest of your life and doing it.
The selection of a specialty is often made by exclusion. I found for example that I absolutely detested rounding so I wasn’t too keen on internal medicine. Some people dislike the OR so surgery is definitely out of the question. It is also difficult to get excited about pediatrics when children make your skin crawl.
You usually narrow down your choice of specialties to a short list of things you like and refine it from there. By “like†I don’t necessarily mean that you are crazy about it, just that the combination of the potential income, lifestyle, and character of the work exceeds some threshold. I can’t believe that most people go into dermatology because of a lifetime interest in rashes. I’m sure derm is not boring but the easy residency hours, good pay, and lack of call probably carry a lot of weight with the academic heavy hitters who match into it.
Or you can go through medical school and find that you really don’t like any of those things you swore in your AMCAS personal statement drove you to apply to medical school. Achieving sainthood seems like a good idea before you actually start working with real patient. You will pick your specialty accordingly maybe deciding that radiology besides being interesting and kind of cool limits the amount of time you will actually have to spend talking to patients not to mention managing their health problems.
Of course, you may have your specialty picked for you by default because you have not positioned yourself in medical school to match into anything other than the typical non-competitive specialties. Matching into some of them requires only a pulse and the desire. Everybody can and does match into something, just not necessarily what they really wanted to do.
A word about specialties and their competitiveness. Some specialties are notoriously hard to get into. Dermatology is one. Radiology is another. Urology, interestingly enough, is also super-competitive and they even have their own match. (Not the NRMP). I’m going to give you my limited opinion on various specialties in a later post but suffice to say that it is a combination of intellectual rigor, potential income, prestige, work hours, and the number of available programs which determine a specialty’s competitiveness. Family Medicine as an example enjoys low pay, little prestige in the medical community, and the easy availability of residency positions almost everywhere. Therefore, although there are some individual Family Medicine programs which are pretty competitive the specialty itself is not and you can always scramble into a spot if you don’t outright match into your first or second choice.
You have to use a little common sense when looking at the competitiveness of a specialty. On paper you might say that Dermatology and Family Medicine are equally competitive because almost everyone who tries to match into either specialty is successful. This is true but self-selection plays a pretty big role in who applies to what specialty. The top students in you class will apply to Dermatology programs and get interviews. The bottom feeders can apply until their computer starts smoking but they will get few if any interviews and their chances of matching are slim to none. Although they’d like to have a cushy high-paying job as much as anybody else they usually save themselves the application fee and apply to less competitive specialties.
So you see while “P=MD”, you might develop a preference for one specialty in fourth year and spending your first three years in medical school just going for the pass might limit your options when it comes to matching. Grades do matter, as does class rank. All other things being equal it is the person with the higher class rank or the higher board score who will both get the interview and be ranked higher by the program. Most competitive residency programs even screen by grades, board scores, or class rank.
The number one way not to match is to get low grades and even worse, low USMLE scores. Many people enter medical school having bought into the premise that they should do something in primary care. Good grades and high class rank are not necessary to match into most of the primary care specialties so this is used as an emotional crutch during pre-clinical years. After all, I’m just going into Family Practice, I don’t need good grades. (But bear in mind that the best family medicine programs are pretty competitive in their own right.)
If you change you mind about your intended specialty you may find yourself in a new higher weight class where you are no longer very competitive. You may get some interviews but not enough to match as you will invariably drop off the end of your rank order list. Not every interview goes well. If you only interview at a few places if one or two places decide not to rank you all of a sudden you are pinning your hopes on the one place that liked you well enough to rank but not enough to rank at a spot likely to match.
A pass is not good enough. Get the best grades you can to keep your options open.
Now. Those of you who are at the top of your class go surf for some porn or something for the next few minutes. What you are doing reading my blog is a mystery as this is the home of the average, blue-collar medical student.
When it comes to applying to programs, don’t be squeamish. Apply to enough programs to get enough interviews to increase your chances of matching. And unless you absolutely despised a program and you are certain you would only last a week or two there before you killed somebody and ran screaming into the bayou, rank every program where you interview. Seriously. When you don’t rank a program what you are saying is that if it came down to it you’d rather try to scramble into a better program, sit out a year, or scramble into one of the unpopular specialties none of which are very good plans.
First of all, if you couldn’t match into your specialty, the scramble is not exactly going to be a cake walk. Most competitive specialties fill and if they don’t there are plenty of people better qualified than you who will probably get the few open spots. I’m sorry. I’m the biggest optimist in the world (I mean I did risk everything this year to match into Emergency Medicine) but you probably won’t get the open spot for the same reason you didn’t match.
Don’t count on the scramble.
As for sitting out a year, don’t do it unless it is for something that you can justify the next time you apply. “Took a year to set up a TB clinic in Moldavia sounds pretty good. Hung around the house playing video games not so good. Almost nobody outright sits out a year if they don’t match. What most people with any sense do is scramble into what is called a transitional or preliminary year. Most Medicine and General Surgery Programs have a number of one-year positions available every year in addition to their Categorical spots. The preliminary year is separate intern year with no guarantee of any further training at that institution. The advantage of doing a preliminary year is that some programs require one and even if you had matched you would have still had to have matched (or scrambled) into one. On your next attempt you would have this year under your belt which is not a bad thing. Your preliminary year is also a time to get new letters showing that despite your class rank, you are a real hard-charger. This is not a bad thing either.
Some programs do not require a preliminary year so if you match, you will have to repeat your intern year.
What not to do, and what I am sorry to say I did after not matching, is to throw in the towel and on the spur of the moment decide to lower your sights by scrambling into something safe which you either never considered or were ambivalent towards. I never really disliked family medicine but I never liked it enough to consider it as a career. I was pretty demoralized after not matching into Emergency Medicine and as I had just had my 40th birthday I was pretty sure I was finished. So it looked like the easiest thing to do, especially as the scramble was definitely not going my way.
What can I say? I didn’t have a plan. If I had stepped back and considered things for a second I would have walked upstairs to my school’s medicine department and taken one of their preliminary spots of which they always have a surplus. What I have learned since then is that I would rather quit medicine and go back to my previous career (structural engineering) than spend my life in a medical specialty to which I was always cool toward and of which my opinion did not improve by closer association. Still , I accepted a categorical position because I felt, and see if you can spot the irony here, a preliminary position would be a wasted year and I might as well get started on my lowered career goals today.
Folks, its only a year. 365 days. For all the trouble it took to apply and interview as a categorical intern not to mention the hurt feelings and the awkwardness of appearing indecisive when I told my program it wasn’t worth it. Not by a long shot.
Another thing to consider is that you are only fully-funded by Medicare for the length of the first program into which you match. Since I matched into Family Medicine which is three years and am now going to Emergency Medicine which is also three years, I am only fully funded for two years of the new residency and half-funded for the third year. Some programs, particularly large academic institutions don’t really care about this because losing a little money on their residents is not an issue. For some smaller programs it might be a deal-breaker. I was told by several programs that they would not consider applicants who weren’t fully funded.
I am unsure of the how this rule applies to preliminary positions so do your research.
Bottom line:
1. Keep your options open. You will change you mind about specialties. Better to have the grades and scores to match into Opthalmology but decide on family medicine than the other way around.
2. For God’s sake suck it up and do a preliminary year, especially if you are young. One year measured against your career is insignificant. Not to mention that you will be a pretty confident intern if you have to repeat your first year.
3. On the first day of medical school, with the usual allowances for the occasional dumb-ass who slipped through the cracks, anybody can do any specialty. You might have to apply yourself a little harder but you can do it.
Coming Soon: My totally biased, non-scientific, take-it-for-what-you-paid-for-it opinion on various specialties in which I try to debunk some of the hype surrounding primary care.
Caution: Not to be read by zealots or compassion fascists.
The Residency Match Part 2
The Nuts and Bolts
While nothing needs to be carved in stone, by the end of third year you should have a pretty good idea of what kind of residency you want to do. This is because matching is a long process that will occupy you in one way or another for most of fourth year. The process starts with scheduling your fourth year electives. While most people elect to take it easy during the last few months of fourth year (because nothing that you do after Christmas will have an impact on where you match) it is important to schedule rotations in your area of interest early to get good letters of recommendation submitted early enough to help you get interviews.
For most of the residency programs, applications are submitted through the Electronic Residency Application Service (or ERAS). ERAS is an on-line service which greatly simplifies the application process by providing a common application form which is used by every program. It also serves as a clearing house for all of your letters of recommendations, transcripts, USMLE or COMLEX scores, and other important documents which can be accessed by the programs t0 which you apply.
You can also enter any number of personal statements which you can customize and target to specific programs or specialties if you are doing a multi-specialty match. All of these things are confidential, by the way, and can only be looked at by programs to which you apply. Programs cannot “browse” through ERAS looking for likely candidates. Personal statements and letters in particular have to be explicitelty designated for each program so there is no way for a program to know to which other programs or specialties you have applied.
It shouldn’t matter but a Surgery program might not think you were serious about surgery if you are also applying to Emergency Medicine.
It is not my intent to describe how to fill out the application. Your school will give you an orientation on this early in fourth year and you should definitely go. I have done the match twice so I have a pretty good handle on the mechanics.
I will say that you need to stary early and shoot to have your application completed with at least a few letters of recommendation designated by the opening of the application period in early September. You really only need the CAF completed to apply and it is possible to get early interview offers with nothing but this. Still, you might as well get an early start especially if you are competing for a competitive specialty (and you are competing). You can always designate letters as they come in and the programs will download them as they become available.
The letters actually go to your registrars office or student affairs office where they are scanned in and downloaded to something called the ERAS post office. Except for designating them you can not access your letters through ERAS.
Your personal statement should also be finished by the time you apply.
I regret to inform you that the personal statement is a very important part of the application and just like for the AMCAS, you will be forced to write what is usually a cringe-inducing essay about you and your career goals. I read my AMCAS personal statement the other day and literally winced in shame that I could have produced such drivel.
ERAS will also afford you the opportunity of releasing your USMLE or COMLEX scores. You don’t actually have to but not releasing them is probably a big red flag to program directors. Some Emergency Medicine programs, as an example, receive close to a thousand applications from which only 75 or so will be selected for interviews. At this stage it is pretty easy for the program director to put you in the reject pile for any reason at all.
Most programs don’t actually start offering interviews until After November 1st when your Dean’s letter is released to the post-office. The Dean’s letter is a synopsis of your medical school career and is always positive and flattering. It is so positive and flattering that a whole code language of praise has been developed to help differentiate the good, the bad, and the ugly. It is here that a weak student may be damned with faint praise. It is also here that your class rank will be either explicitly given or hinted at in code phrases understood by every program director.
So there you are. Career path selected, application taking shape, and ready to apply to some programs. ERAS makes it easy to do this. Pretty much point and click from pull down menus. A click here, a click there, designate a few letters and your personal statement and you’re in business. Hell, it’s so easy you might as will apply to every General Surgery program just to see if you get any bites.
Right?
Not necessarily. ERAS is not free and you pay for each program to which you apply. The minimum fee is sixty bucks and this pays for up to ten programs. After this there is a sliding scale for fees. For up to 30 programs the application fee is pretty reasonable. After 30 it costs 25 dollars per program. I suppose the sliding scale was implemented to prevent the kind of spam-like application saturation that ERAS makes all too easy.
On the other hand you need to apply to enough programs to get the interviews you will need to position yourself for the match. How many? Well, like everything else it depends. If you want nothing better than to match into Family Medicine in a small unknown program in Cousincouple, Arkansas you probably only need to apply to that one program as Family Medicine is hugely noncompetitive with many more residency positions than applicants.
Conversely, some specialties are more competitive and require a different approach. I applied to 54 Emergency Medicine programs which cost me close to a thousand bucks and only got nine interviews. I matched number six on my rank list so you see that it was a near-run thing. Let your conscience be your guide. If you are a strong applicant you can probably apply to fewer programs. The weaker your application the more program to which you should apply because some programs may like your CV despite a bad grade here of there or a low class rank.
I won’t say too much about interviewing. Your CV, letters, and grades got you in the door and now you need to sell yourself. Wear a suit. Be polite. Don’t try to bullshit anybody and don’t be a tool. Not much more than that. Interviewing can be fun if you don’t let yourself get intimidated.
During the application process you will need to register with the NRMP. ERAS handles the application. The NRMP handles the match. The two are separate and while your school will send you reminders, there is always somebody who almost misses the NRMP registration deadline. If you don’t register you can’t match. Period.
Towards the end of the interview season which runs from around the end of October to the first week of February the NRMP will become available to submit your Rank Order List. Nothing magic here. You go on-line, select the programs where you interviewed and rank them in your order of preference. After you certify the list you are officially entered in the match. You can change your list, either adding or removing or changing the rank of programs, pretty much at will until the deadline for submitting your final ROL which is at the end of February. Once this deadline passes if you have not certified at least one list you are out of the match and will have to scramble.
Now you wait. And wait. And wait some more as the results aren’t released until the third week of March. On Monday of this week you will get an email from the NRMP telling you whether you matched. If you fail to match then you had better have a plan because the very next day at noon EST the list of unfilled programs is released on the NRMP website to all unmatched applicants and the scramble begins.
If you match then you have to wait until Thursday at One O’Clock EST to find out where you matched. Most medical schools have a Match Day Ceremony where you open an envelope in front of your whole class. I was an independent applicant so I just waited biting my fingernails for the email.
Programs mail out contracts on Friday and fourth year now becomes a competition to see who can do the least amount of work between match day and graduation.
Next: How Not to Match
The Residency Match Part 1
The Match Described Conceptually
By now you have probably heard the ancient medical school adage that “P=MD” meaning that grades are not important and everyone who passes will be a doctor. I want to refute this and caution you to never adopt this philosophy. Grades do matter as you will see later in this series of articles from my sorry tale which fortunately has a happy ending.
The Match is a annual event during which medical students are placed into residency programs. Almost every specialty uses the NRMP match (National Residency Match Program) but some use their own match. The principles are the same whatever the case and from now on when I say “match†I’m referring to the NRMP match.
In the bad old days before the match, finding a residency program was very similar to the way that most of America finds work. You sent your resume to a program, they interviewed you, and you might be offered a job on the spot. This caused several problems. First, there was tremendous pressure for medical students to sign the first contract that they were offered because it was the proverbial “bird in the hand” even if the program wasn’t where they really hoped to go.
I just matched into Emergency Medicine (on my second attempt as you will see) and at any time this year or last if I had been offered a contract at any program I would have signed it. Sure I have preferences of where I would like to go but I would have rather had a secure spot in my specialty than risk going unmatched later.
Additionally, the programs had the similar problem of either signing an acceptable applicant immediately or holding out for a better one later and possibly not filling all of their spots. Apparently there was a lot of horse-trading and arm-twisting on both sides of the table.
The match is a system that removes the pressure from both the applicant and the program to make a quick decision or settle for something less than they could get if they held out. This, in a nutshell, is how it works. First, applicants apply to various residency programs in their desired specialty. The programs review the application and based on their own criteria (grades, for one) offer to interview the applicant.
After the interview period, the applicant submits to the NRMP a list of the programs where he interviewed and where he would accept a position. This list is sorted in
order of the applicant’s preference with his favorite program ranked number one and his least favorite last. Least favorite, that is, where he is willing to go because you do not have to rank every program where you interview. This is called the Rank Order List.
The residency program for their part submits to the NRMP a list sorted in order of their preference of all the applicants they interviewed and are willing to take. They don’t have to put every person they interview on the list (or “rank†them as we say) because while you might decide that you would never go to a certain program, they might also decide that they do not want you under any circumstances either.
The NRMP puts these lists into a computer which runs a simple algorithm that matches applicants to programs. The algorithm, which used to be cranked out by hand, draws a name from the top of the list and puts him into the program he ranked highest which also ranked him. The next name is drawn from the list and he is put into his highest ranked program which also ranked him. These people are tentatively matched and this goes on until eventually conflicts arise between who is sitting in what slot.
Try to follow me here. If you are tentatively matched at a certain program if another applicant to the same program is tentatively matched the algorithm compares how high he was ranked by the program to how high you were ranked. If he was ranked higher then you are bumped down a spot on that program’s roster. If you are ranked higher than he is put into a spot below yours. Since programs only have a set number of spots, eventually someone is going to drop off the bottom of the list onto the first spot in the list of the program in their next order of preference.
Look at it as one long roster consisting of all of the possible residency spots at all the programs into which you could match. You are initially placed as high up on this roster as you possibly can be. If you are the first in the stack of rank order lists then you will be sitting on the first spot of your favorite program until somebody knocks you down. If the algorithm gets to you later you will be placed as high as you can possibly be placed possibly knocking somebody less favorably ranked by the program down a notch.
So you can see that you can never move up the list once you are tentatively matched. There is no way but down. The strongly competitive candidate will just hold his place, fighting off challengers with his superior ranking mojo.
You can also see that the match favors the applicant as you will be paced as high up on your preference list as you can possibly be. The program might want somebody more than you but since that applicant might have ranked another program higher he’s going to sit there until he is knocked down. They may have to settle for little old you.
So what’s the worst thing that can happen? It should again be obvious. You apply to a competitive specialty with more applicants than open spots and after being forced down the roster by applicants who were ranked higher by every program which you ranked you are forced off of the list entirely.
You are unmatched and are now in a world of hurt especially if you really wanted a competitive specialty like Radiology or Emergency Medicine. Fortunately, you have one more chance at salvaging both your future career and your pride.
The funny thing is that even in a competitive specialty sometimes at the end of the match programs have spots which did not fill. They didn’t rank enough applicants either because they didn’t interview enough people or they decided for whatever reason to only rank some of the people they interviewed.
Now you have to go through something called the “Scramble” where you and every other unmatched person who wants a crack at one of the open spots compete furiously in real time waging war over the phone, the internet, and the fax machine. The match is sedate and rational. For competitive specialties, the scramble is a free-for-all and program directors quickly fill their program from the ultimate buyer’s market. The few unmatched spots in Emergency Medicine, for example, filled in a matter of hours with highly qualified candidates.
In a non-competitive specialty like Family Medicine there are usually plenty of open spots, often several in every single Family Medicine program so if you were lazy, didn’t want to interview, and didn’t really care where you went you could easily get a spot somewhere.
I know all about the scramble because I failed to match last year and as I had no chance of getting one of the only 11 (out of around 1200) open Emergency Medicine spots I threw in the towel and scrambled into family medicine. This turned out to be a costly mistake as I will describe later by telling you what I should have done.
So those are the basics. In the next posts I will describe the actual process of applying to programs and to the match. I’ll also give you some pointers on scrambling…well, not pointers so much as bone-headed things that I did from which you may draw you own conclusions.
USMLE Step 2 Clinical Skills
Highway Robbery
Might as well come out and say it. The Step 2 Clinical Skills test is a swindle foisted on medical students by bureaucrats with too much time on their hands and not enough to keep them occupied. It had its origin in the the clinical skills test administered to foreign medical graduates to ascertain their level of English proficiency and their comfort level with Western clinical skills under the theory that advocating consulting the entrails of a lizard in broken English would preclude you from practicing in the United States.
Since money could be made by making American medical graduates take the test, beauracrats hired other beauracrats to prove that we were not being taught how to interact with patients during our four years of medical school. Despite strong resistance from the medical community and medical students, money was spread around and the result was an expensive solution to a non-existent problem.
Step 2 CS is a day-long standardized patient exercise which tests your ability to take a history, do a physical exam, and write a note with an assessment and a plan. Nothing to it, right?
Right. The first time pass rate is in the mid 90 percent for American medical school graduates and very people study for it at all. So you see, and try to follow me here, if there really is a problem then people would be failing this thing left and right leading to the kind of studying we normally only see for the clinical knowledge portion of Step 2. Which does not happen. Medical schools do a good job of teaching you clinical skills. There is no problem.
Not to mention that Step 2 CS is pass/fail so it can’t even be used as a measure of anything other than your having at least the same skills as some guy from Bolivia who’s father paid the Minister of Health to get him into medical school.
But I digress. Step 2 CS is a done deal so you are going to have to take it. It was about a thousand bucks in 2005 not counting transportation and accommodation at one of the only twelve testing centers in the United States. (I took the test in Houston.)
As I mentioned, Step 2 CS is a day-long standardized patient exercise. For those of you who are not familiar with them, “standardized patients” are actors trained to pretend that they have various clinical conditions. Many medical schools use them to introduce students to the history and physical exam.
The Step 2 CS site is set up ostensibly like a real outpatient clinic. During the day you will see approximatley 12 standardized patients in a round-robin fashion moving from room to room rotating patients with your fellow examinees. Each clinical encounter consists of up to 15 minutes for a history and physical examination and then up to ten minutes to write your note. You can leave the patient’s room before your history and physical exam time is up and use this extra time for writing your note. Once you leave the room however you may not reenter.
Posted on the door of each room is a board with the chief complaint (as would be elicited by a nurse) the patient’s demographic information, and his vital signs. At a signal from the proctors, you knock on the door, enter, and begin the song and dance.
I will explain the history and physical exam in a later post (for those of you who are not in medical school yet, of course) but suffice to say that one enters the room, exchanges the usual pleasantries, elicits the Chief Complaint (CC), gets the History of Present Illness (HPI), and performs a physical exam.
To assist you the actor playing your patient may have moulage (makeup simulating an injury) as well as cards telling you the result of invasive exams like the digital rectal exam which you will not do on standardized patients.
(Some view the Step 2 CS as a digital rectal exam done on medical students.)
Now, here is the key to this portion of the test. Since this is a simulated real world clinic, you should do a focused HPI and physical exam. The patients will all have classic presentations of common clinical problems. I don’t think I will be violating the NBME’s non-disclosure agreement if I tell you that you might get a patient who’s chief complaint is chest pain and shortness of breath with exertion. In this case a complete neurological exam is not necessary, will gain you no extra points, and will eat into your time. There are no zebras on Step 2 CS.
Once you are done you exit the room and start writing your note which is essentially a SOAP note. You can write this on a form that is provided or enter it in a computer. The form has a space for the history, the results of the physical exam, your assessment and your plan. In the case of Step 2 CS your assessment is a differential diagnosis ( a list of the most likely causes for the patient’s symptoms) and your plan is the next step in the diagnostic work up.
Note that unlike on a real SOAP note your plan will not specify a treatment but only your next proposed steps in the diagnostic work-up.
In the case of chest pain with shortness of breath, your differential diagnosis might include Acute MI, Pulmonary embolus, GERD (heartburn), or PUD (peptic ulcer disease). Your plan for diagnostic work-up could be to draw cardiac enzymes, get an EKG, obtain a spiral CT scan, do a heart cath, or anything else you feel would be appropriate. You will not get any credit for suggesting treatment so save yourself the effort.
How long should your note be? Well, go look here: http://www.usmle.org/step2/Step2CS/Step2CS2005GI/appendixC.asp
Does that look like a long note? Of course not. It is not necessary to write the great American novel. I usually only needed ten minutes with the patient and five minutes for the note leaving me with ten minutes of thumb-twiddling time. Yet I saw most people leaving the room on the fifteen minute mark and scribbling furiously for the entire documentation time. They were obviously over-thinking it.
Focused history and physical. Concise note. That’s all there is too it.
The Step 2 CS exam is scored in three separate components each of which his pass/fail and all three of which must be passed. The first part is called the ICE or integrated Clinical Encounter which includes your history and physical exam skills as well as your documentation and assessment.
Communication and Interpersonal Skills (CIS) assesses your demeanor, your bearing, your use of empathy, your sensitivity, and even your appearance. Wear conservative clothes and a clean white coat.
The third tested area is English Proficiency.
All you will need for the test is your white coat and your Stethoscope. Every other piece of diagnostic equipment you need wll be in the room. PDAs and reference books are not allowed.
Do you need to study for the Clinical Skills test? I say no. I know there is a mini-industry of test prep material but your four years of medical school should be enough. Just act natural, do what you have been doing for your entire third and fourth year and don’t worry about it.