Residency interviews: Terminal velocity

In this post – my last post about medical school – I want to focus on how I approached residency applications and interviewing. Your school will have their advice and approach, but it’s important to put everything in perspective. It’s you applying, not your mentor or your school. You are personally responsible for your life and your match. Do your research and know your timelines from the original sources (e.g. NRMP, ERAS, ECFMG, etc.).

Electronic Residency Application Service

With that said, I think it’s paramount to put your best foot forward when prepping your application on ERAS. Step one requires some planning, but if you can, have all of your papers and exams and scores in before submission time. My CS and CK were both completed and scored before apps opened up. When you submit, you want as complete of an application as possible. Moreover, you want to submit on the first day possible. Just as programs may filter you out of their interview pool because you’re not from their state, they can filter you out for not being punctual enough to submit on day one. Obviously, this isn’t to say that you won’t match if you don’t do this, but it’s a small step that helps immensely in terms of getting interviews from my personal experience, and anecdotally as well.

With that, in the experiences section, it’s solid to have some sort of publication or research on your application. It serves two points – one: it shows you are capable of producing quality work, and two: it gives you something to talk about during interviews. Plan ahead; it may take 3-8 months to push something through a publication pipeline. Participate in poster sessions. Volunteer. Enter everything as directly as you can on ERAS, as it will likely be read and checked by the institutions you’re applying to and reviewed beforehand.

Another, more critical, item that requires some planning is securing good sources for letters of recommendation. There are many strategies to this, and it suffices to say that three unflinchingly strong letters at minimum are needed. Letters are a finicky topic, especially when you’re starting out clinicals and have no tangible value to the team. Here are some tips:

  • Ask for more than you need so you can have a backup letter or two.
  • Be aware of the specific program requirements; some programs require up to 2 dedicated letters from a certain specialty (e.g. surgery).
  • If you feel it’s appropriate, you may preface your time spent with your preceptor by stating your intentions – “I’m going into a certain specialty, and I intend to work hard and hopefully get a letter from my experience with you this month.”
  • Ask for a letter even if you don’t know how to get it uploaded. A fresh impression of you is much more important and will yield a better letter than a stale one.
  • Lastly, put yourself in the shoes of the letter writer. What would they expect to see from someone for whom they were writing a letter?
    • Hours and hours of time will always be rewarded – be well-read, always present, and always willing to do tasks.
    • As you progress through your rotations, you’ll be able to make an impact on the team you’re on as well as impress your mentors. I’m saying you’re more likely to get a good letter near the end of your third year rather than fresh after USMLE 1.

Next, the daunting personal statement. I would suggesting writing from the heart, and writing 2 or 3 versions. This is going to be a fair amount of work, especially if you’re not a very expressive writer. Once you have your multiple PSs ready, get ready to have your heart torn out. Send it to your friends and peers for editing, and always ask which one they like better. After a few rounds of this you’ll have something worth submitting. Write your story, write why, and know why you want this next phase of your life.

Those are the major components of your ERAS app – the scores, the letters, the personal statement, and the open-ended ‘experience’ section where I listed any publications, posters, volunteerism, or other stuff. Additionally, there’s a sort of nebulous ‘Hobbies’ section on ERAS. I’d recommend sounding colorful and not generic. It’s a small section that you might overlook, but adding a bit of spice to it goes far – it’s pretty much there so you can put stuff that might be too silly for the formal experience section like you’re into sumo wrestling or whatever.

Program selection

Simple principle here, with some caveats. A larger net catches more fish. Cast a wide net. The rule of thumb is for every 10 places you apply to, expect 1-2 interviews. I would say this held true for me. If you have a few specific geographic areas, you can focus on apps there rather than apply all over. It’s very specific to who you are and what you want – are you willing to live there for the next 3-7 years? I applied very broadly, which was costly. I felt it was needed in my case, though, because I applied to Radiology, which can be a mixed bag in terms of competitiveness.

The thought, which I discussed with my significant other, was that we’d rather go matching anywhere than go unmatched overall. I suspect most rational people have the same logic. Our preference was in the Midwest, where we had largely done our respective clinical years. I knew I did not want to go into any other specialty, so I committed and only applied to Rads.

Submission

Submit on day one, have everything in, and don’t forget to register for NRMP, which was (when I did the 2017 Match) separate. Additionally, don’t forget to update your NRMP ID in ERAS once you register.

Interviewing

Respond in a timely fashion to interview invites. They can go fast, and some places have the dubious practice of sending out more invitations than there are spots available, allowing for waitlisting for the people who check the invitation later. That being said, you’ll hopefully hear back with a steady flow in invitations. It is quite a feat to juggle travelling and scheduling all the dates and times and travel. The most I managed was 3 interviews/week in different cities. More than that and it would have been too tight.

  • Realize that there are only a finite amount of days and spots that you can travel to and interview, so if somewhere you want to go to more comes up, try and switch dates around, Programs are flexible when you call and ask in person.
  • Uber and Lyft are your lifelines.
  • If you can group together a geographical area, renting a car can save costs.

Perhaps one of the finer points I can make is that it’s critical to send out emails reiterating your interest in programs. I sent out over a hundred emails to program directors and GME offices. Again, this takes some time and effort, but it gives you the best shot at landing an interview short of rotating there or someone vouching for you.

There are plenty of resources on how to interview, so I’ll skip that bit, other than to say be natural and talkative – no one is going to hire the quiet, surly applicant.

Rank Lists and Match

Sometime in February, you’ll finalize your list of places. Go with your gut instinct as to where you fit best. It’s hard to find a metric otherwise. I suggest you check out the NRMP stats on your likelihood of matching based on the number of places you rank to give you a realistic sense of what will happen on match day. Certify your list and wait as the sands of time slowly seep and creep until Match Day arrives.

Hopefully on that Monday you’ll get some good news. You’ll then wait until Friday for the real results.

Closing thoughts

It’s an exhilarating process to go through, with such a candid mix of emotions you’ll feel. You will grow as a person after exploring the country on a quest to find a program you like, and you’ll see what the world has to offer. You’ll come away with stories and experiences of your own, to cherish and to laugh at. You will come to a crossroads and feel doubt. You will feel indecision. You will overcome this by the virtue of the process. And, with the weight of the culmination of toilsome years of medical education, you will rise and succeed: to smile and feel the warmth of tangible success in your chest at the end of it, and to continue your personal odyssey of self-realization and healing.

The thespian’s exam: USMLE Step 2 CS preparation and thoughts

USMLE Step 2 CS is a fruitless sort of charade, but nevertheless it remains as a necessary component to becoming licensed. My school mandates a practice exam through Kaplan before taking the real exam. While I initially disliked this idea, it was a good primer and once you’ve gone through the thing once, the real one seems much more manageable. Here are some pearls:

  • Use First Aid Step 2 CS: This is a well-organized book that is probably overkill but once you go through it, you have the general gist of the idea. If you don’t have a partner, go through and do the mini-cases by covering the half of the page that shows the diagnoses and orders.
  • Practice with a partner: Either through Skype or in person, interaction is the best way to ease into the weird pseudo-clinical patient scenario. Practicing with another person lets you try your intro and closing in real time, which is probably the hardest part of the exam.
  • Have a script: I used a some sort of acronym to make sure I covered my bases in order to maximize the points I hit.
  • Have a plan: Probably the best change I made with my CS approach was to already have a list of three differentials before going into the room. This way you can ask question to rule thing in and out (pertinent positives and negatives) and include those tidbits in your note.

I took the exam fairly shortly after Step 2 CK and it’s good to know what to order and the sort of classic signs and symptoms because the obvious players show up on the real exam. Overall I’m one step closer to the goal.

Persistence of memory: USMLE Step 2 CK preparation and thoughts

During the months of May and June, I had dedicated study time for my second board exam, USMLE Step 2 CK. Truthfully, preparation was ongoing throughout M3 year, and my dedicated prep started in March when I was studying for my Surgery shelf exam. I took the exam June 1, 2016.

I had one goal for USMLE Step 2; to beat my USMLE Step 1 score. If I could do that, I would be satisfied. Anything on top of that would be considered style points. I had a secondary goal of beating my score by 10.

In March, aside from general surgery review, I began redoing the IM portion of UWorld, and I completed the entire IM question bank during April, my FM rotation. After this, I began to redo the rest of the questions, subject by subject – Ob/Gyn, Peds, and Surgery. I also had my prior notes assembled for each subject’s shelf exam, which I reviewed in tandem with each subject. Whatever text I had used for the shelves were reviewed for contentious topics – Case files and Pestana for Surgery, Case files and APGO uWISE for Ob/Gyn, and MKSAP and Pretest for IM.

I did not review each text in its entirety – instead, whenever I missed a question and needed review, I looked it up (notably, the algorithms for workup of a thyroid nodule are different in Case files Surgery and UpToDate). Also, because I had not yet completed my Pediatric clerkship, I made particular effort to be thorough with that subject.

Aside from UWorld, which is the staple of preparation, I used the few other essential resources above and below for questions and reading. Similar to the prior board exam, here are my recommendations:

  • My first wisdom is to have a solid foundation. I completed UWorld once and the bulk of my shelf exams before starting review. Only after this should you reset your question bank.
  • My second wisdom is to re-build stamina. Just like Step 1, I timed my tests, simulated exams, and pushed myself to the limits of my concentration in order to ensure that I wouldn’t lose focus on the real deal.
    • This time, there was a week where I did 5 blocks a day (with review) in order to make sure I kept focus. It was rough, but necessary.
    • Because this exam was after Step 1 training, it wasn’t as hard to regain testing stamina because the muscle memory was there. Within 4 weeks of training I was at peak performance levels.
    • Overall I did about 5,500 q’s leading up to the exam.
    • Breakdown:
      • UWorld: 2,300
      • USMLE-Rx: 1,900
      • MKSAP for students: 500
      • Pre-test IM: 500
      • APGO uWISE: 50
      • NBME 4: 200
      • UWSA: 200
    • One note I’d like to make is that unlike for USMLE Step 1, I did not rely heavily on the NBME’s for predictive value or review. There are 4 available, and one of those doesn’t even have feedback.
      • The feedback is not particularly useful either.
      • When you have limited time, you want to be able to learn and digest rather than shock and awe.
      • I didn’t like NBME 4 and didn’t think it was a conducive use of my time, so I decided against buying more of them.
      • Also, the NBMEs for Step 2 are notoriously unpredictive and can easily give you false hope or burst your bubble of confidence.
  • My third wisdom is to use UpToDate. It is the most comprehensive resource that gives definitive management in a digestible summary form. Review texts are great, but U2D is the bread and butter for learning and review. I unofficially attend U2D SOM.

I got my score, 262, while on the beach with my fiancée. I am happy to say I achieved my primary goal, though was a bit shy of my secondary goal. Regardless, I am happy with my outcome.

A guide to M3: The clerkships and SHELF exams

I made this post to help guide study efforts (for NBME Shelf exams) during M3 year. I found that there was a mix of information as to which sources were the best sources to use during core rotations, and given that you have limited time to dedicate to studying, it is imperative to use it well. That being said, everyone, including myself, has their own sets of resources they used that they will claim is the best. It should be stated that the best prep for any rotation is working up patients and looking up their best treatment and management regimen on UpToDate while on the wards. Here’s my additional study plan:

  • Internal medicine
    • UWorld is the staple for prep – about 1400 q’s. This will take a considerable amount of time but is worth it in the end if you can finish it during your rotation.
    • MKSAP for students (aka IM essentials) – another key learning tool. The explanations are better than UW in my opinion. It takes a lot of effort and doesn’t simulate your exam, but it’s great for building a foundation of clinical IM knowledge.
    • Pre-test IM – a few wonky questions and many are too short or easy, but this book gives you some random factoids that might help in tricky stems (e.g. CHF is more likely to cause R-sided pleural effusion). I did about 10-20 q’s every morning to get through the book.
    • MKSAP audio – probably a bit overkill, but I like listening to audio lectures rather than reading, so I went through the sections on cardiology and GI. I love this series, and listened to the bulk of it throughout M3. Great for the gym and commuting. Not great when you’re driving with people though, haha.
  • Obstetrics and Gynecology
    • APGO uWISE – plenty of short quizzes on high yield topics. The problem is that you’re going to miss a lot of questions if you don’t already have a solid foundation of knowledge. This is the best source hands down.
    • Case Files Ob/Gyn – I used this to sort of learn the basics of Ob/Gyn and get a foundation. It’s a good text without too much filler or fluff. Even some of the more esoteric topics in the book came up on the shelf. To note, I never used Blueprints.
    • UWorld – a staple, but not enough. I think it is better to save these q’s for 2-3 weeks before your shelf to use as a gauge.
    • Dr.Chapa’sObGynPearls: Texas A&M College of Medicine – this is the best audio source for this rotation. Go to you podcast app and subscribe. Usually about 7-12 minutes a piece on high yield topics (e.g. endometriosis), covering every salient point (e.g. MCC, presenting symptom). If you learn the material for each topic, you’ll be able to present with some competence and actually have a discussion about stuff.
  • Surgery
    • Pestana – a great ‘cover your bases’ review of many topics. The staple for this rotation. Has some questions in the back.
    • Case Files Surgery – I used this extensively, but be warned that some things might be outdated if you don’t have the latest version (I was burned on thyroid nodules). Overall this was my second staple.
    • UWorld – not many q’s, but you should supplement by re-doing some of IM. Many IM topics are bound to show up. Spleen and GI questions come up a lot.
    • Pestana audio – this was my favorite resource. He reminded me of one of my pathology professors from Basic Science years.
  • Psychiatry
    • UWorld – this covers most bases. There will be a few esoteric topics on the shelf exam that you won’t find anywhere.
    • First Aid Psychiatry – A good thing to review if you have nothing else to do and want to read something.
    • Lange Q and A – I wish I had known about this beforehand – i did some of these and they were good quality questions
  • Pediatrics
    • Honestly, I had little time or patience at this point in my M4 year for this exam – I was more focused on interviews. There are likely better places for advice on this topic
    • UWorld – solid “cover your bases” approach with a decent amount of questions
    • Pretest – more filler questions if you have time
    • UT HSC video review – this was the majority of my studying

Family Medicine: The nucleus

During April I rotated through my mandatory family medicine ‘elective.’ About a year prior, I began my first rotation ever, and, of course, I had formed many opinions of rotations and specialties before I even had them scheduled. Rotating through M3, you hear the stories of other students and their trials and tribulations, misfortunes and misgivings. Everyone’s a pariah. Somewhere along the line, I had formed the opinion that FM was among the more banal rotations, and, naturally, this was supported by mountains of anecdotal evidence.

However, regardless of my preformed inclinations, I always try go into a rotation with an open mind and an eager spirit because there are great teachers everywhere, and prejudgment leads more often to disappointment than substance. I was taken aback by the versatility and welcome of the program I rotated through. It was ideal for a student, and the residents were excited and genuinely caring and kind. The attending physicians were surprisingly well-attuned to listening, and were receptive to our presentations. The structure of the rotation was also well-designed; two weeks of clinic, one week of inpatient nights, and one week of inpatient days.

The population served had abundant pathology and disease, and I was thrown into the thick of it during my first overnight shift when a patient coded and I performed compressions. That memory will stay with me for some time – the code itself was successful, but, I had asked myself that night, at what cost? After the fact, I learned that the patient was on her way to hospice care and her daughter had wavered that day on a Do Not Resuscitate (DNR) order. The code was grisly. Throughout the whole ordeal there was brown seemingly feculent material streaming out of the patient’s mouth. I performed compressions as the resident valiantly attempted intubation, intermittently suctioning. The large laparotomy wound on her abdomen that was leaking serosanguinous fluid was held together tenuously by staples; these began to tease apart during only the second round of compressions – by the fourth or fifth the thing had come undone. The anesthesiologist intubated, and I was rotated out of the compressions, and that pause let me absorb the scene. Somehow we attained return of spontaneous circulation (ROSC), though the patient was unresponsive.

Other memorable events included management of post-surgical hemorrhagic shock overnight, textbook rheumatoid arthritis, and of course, clinic. The abundant clinic time gave me comfort in that setting and I was able to see the wide swathe of patients that FM encompasses; from routine pediatric visits and obstetric patients to idiopathic pulmonary hypertension and sepsis, FM is the first line for many encounters. I remember suturing supervised with a resident’s and attending’s guidance in one clinic encounter – never during surgery had that ever happened.

In short, I had a great time on FM. I learned much, was actually able to get up close and involved with some of the management aspects of ward medicine, and worked with extremely kind and caring physicians in a clinical setting.

Surgery: A sense of duty

Last week I finished my surgery rotation; two months of general surgery followed by a specialty elective. I, of course, have my thoughts.

“Love is a better teacher than a sense of duty.”

– A. Einstein

Surgery is, in many ways, the quintessential human realm. At its most basic level, it is straightforward: there are problems that can be dealt with surgically, and there are those with the surgical acumen to help. This sentiment is lost in the reality of the upkeep of a surgical service. The truth is that surgery is the intersection of many interests, with divergent and convergent goals. There is the attending, the resident, the student, the scrub tech, the circulator, the anesthesia team, the company representative, and, of course, the patient.

From this blog, there is the vantage point of the student: my perspective. The surgery clerkship is, in the words of one resident I worked with, “a rite of passage” for all budding doctors. That being said, many who graduate with an MD after four years of studies do not pursue further surgical training. While I will not seek a career in surgery, I can appreciate the rigors of what such a path would entail. Being a student on the service gave me insight into the daily schedules and demands of life as a surgery resident, from PGY1 to 5. Life seemed to drain out of some of the residents. Many were abrasive. The gentility I had encountered during my medicine clerkship was largely absent. Stern looks and long silences were not uncommon.

The operating room, however, was its own beast. I was introduced to the O.R. in my Ob/Gyn rotation, and the romanticized ideas I had of it were quickly dissuaded and replaced with an understanding of my role in the surgical hierarchy and my total lack of surgical skills. My initial reticence waned as the months passed, and by my fourth month of surgery on orthopedics (after urogynecology, general surgery team 1, and general surgery team 2) I was competent with a needle driver and suturing. Moreover, I was not afraid to ask to be more involved with cases even if I would likely be turned down.

There is a certain thrill one receives in the O.R. when properly executing a technique under guidance from a mentor that is almost unparalleled. For me, that thrill alone is not enough to push me to pursue a lifetime of surgery. One wise surgeon I spoke with described surgery in two ways; one as an addiction and one as a duty. He said to truly embrace being a surgeon “you have to be addicted to it – you have to want to be there at all times.” The other side of the coin (and this is where that quote at the beginning of this post comes in) is that surgery (for the surgeon) should feel like (and is) an obligation. Per that surgeon, there should be a strong sense of duty involved in surgical training and practice – “it’s like the military, really,” with its structure and commitments. I think that duty, while a strong motivator by any means, is far surpassed by love; by that I mean that passion should be the prime motivator for action. For some, it may be enough, and I’ll leave the operative interventions to them.

I think when I came into surgery, I had grandiose notions of what I would encounter. There a sense of authority that comes with surgery; it is the final measure in the eyes of many, and the acuity of surgical problems is keener. That said, I would be remiss if I did not mention the sense of pride you carry when you say you were “in a case for __ hours” and were able to help or perform part of the operation, albeit minor.

A few good people is often all it takes, and I can say there were a few residents and attending surgeons I was lucky to work with that were very accommodating and eager to teach. There were a few days I was able to be first assistant to the attending surgeon while on general surgery, and these experiences were particularly fun.

By far the most experience I got with actual surgical tasks was during my month of orthopedic surgery; it was a pleasure to rotate on that service (despite the NBME surgery shelf exam looming over my head). The residents were very enjoyable company and generous teachers, patiently walking me through the fundamentals of some techniques and giving good feedback. Oh, also – the residents’ knowledge of orthopedic surgery really seemed inexhaustible. That month the variety of cases I saw was excellent. I’m sure if I had been there for another month some of the cases would have seemed repetitive, but some of the bigger cases like hip and knee arthroplasty were so involved and fascinating that I enjoyed the multiple exposures.

That’s my surgery experience in a nutshell. On to the next one.

Obstetrics and Gynecology: Of birthing, surgery, and nights

Whew, I just finished my OB/Gyn rotation. After those two months of medical exposure, I truly feel like I have only begun the marathon that is MS3/MS4. Both months were challenging in their own ways.

In November, I was introduced to the revered O.R. My inauguration was brief, and much of the mystique and wonder I had built up dissipated within the first week of my month of gynecological surgery. The surgeons and residents I was privileged to work with were focused and skilled, and I have the utmost respect for their craft. Surgery, I found, was demanding in ways I had not anticipated. The focus, diligence, and dynamic coordination required for the routine tasks of surgery was largely new to me in a medical setting. Internal medicine, to contrast, was steeped in speed, intellectual fastidiousness, and static coordination. The O.R. is the here and now; the floor is what was and what will be. The distinction is dramatic, and after experiencing both I can begin to understand the schism between the two disciplines. Moreover, I also can appreciate that while IM is more of a science (to some extent), surgery is an art. The control of every decision in IM guided by evidence cannot readily be replicated in the nuanced motions and subtleties of incisions, cautery, and knots.

“We are all fixing what is broken. It is the task of a lifetime. We’ll leave much unfinished for the next generation.”

Part of me finds dissatisfaction in this. There is an inner desire for certainty in the actions I take. The certainty in art of surgery stems from lifetimes of experience, against which my 25-year old self has comparatively paltry assuredness. And, really it’s a cop out. At its essence, I’m saying there are too many variables in surgery. That’s tantamount to saying there are too many variables in life. There are infinite aspects of in any situation, not simply surgery. I think it’s my engineering background that gives me this aspiration for an ideal action or solution at every turn.  Does medicine simplify many variables into digestible forms that are more interpretable? Blood pressure? Temperature? Possibly. I am not able to determine that. Maybe no one is.

In December, I was exposed to the practice of Obstetrics. In line with the discussion above, the field of OB has similarly a handful of cardinal variables that are critical to its practice – cervical thickness, dilation, contraction frequency, etc. Once mastered, the decision trees are fairly intuitive. Anyways, I was really tested on this rotation. Half of my month of OB was nights, one of the most demanding experiences I have had in medical school thus far. The nights were mixed – some were action packed, some were slow, some haphazard. The adjustment to a nocturnal lifestyle was not smooth, and I found myself craving sleep at times. The best part and the worst part of the rotation was its unabashed spontaneity – at moment’s notice, a C-section case could (and did, many times) step through the door. That readiness required was daunting, and often times, I found myself dreading action towards the end of my shift.

This dread stemmed from a very concrete (and mildly embarrassing) experience I had while on my first week of nights. A patient required a C-section at around 3AM and the team was notified. I had about an hour of sleep at that point, and also had not eaten dinner. I had a vasovagal episode and had to sit down on the floor of the OR in the middle of the case (in the middle of the night), later to be wheeled out against my requests. The ignominy of that event was replayed when the resident reenacted the scene in clinic.

As an aside: one particularly sad part of OB was being part of unsuccessful pregnancies. Intra-uterine fetal demise was unsettling and I cannot begin to fathom the feelings of the patients I saw that underwent such an ordeal.

This rotation was the one I learned the most from during the rotation. My basic science curriculum did not address the nuances of the management of pregnancy; I knew little of pregnancy and its clinical aspects. The hands-on experience I was afforded bridged much of that gap in my knowledge base, and I can say I appreciated it.