Accomplished, Not Lovely

Pre-pandemic, I went to hear the author Nicole Krauss speak about her novel Forest Dark. I'm a big fan of Krauss' writing. The day I heard the author speak, she had published an opinion piece in the NYT Sunday Magazine called "Do Women Get to Write with Authority?" In the article, Krauss highlights the lack of power women writers have compared to men, and specifically, how female artists' work is often characterized as "lovely," a word she describes as lacking in "independent power."

I must admit that I sometimes use the word "lovely" (both for women and men) when I like someone. But Krauss made me think about the word in the context of achievement - not personality - and her point is well-taken.

With medical school interviews starting soon, you should keep in mind that you want the faculty member you've met to leave saying you were "accomplished," not "lovely." Many applicants miss this point: You don't want to simply be liked; you want to be seen as worthy. It's critical that you focus on that important goal as you practice for interviews, crafting strategic, substantive responses to potential questions. 

I would strongly recommend Krauss' History of Love (her best book in my opinion), Great House, Forest Dark and To Be A Man.

Four Thousand Weeks

I'm currently reading a fantastic nonfiction book called Four Thousand Weeks: Time Management for Mortals by Oliver Burkeman. Four thousand weeks is how much time the average human has on this earth. That doesn't sound like a lot.

I'd highly recommend the book to those of you who are productivity geeks, folks who are trying to be as efficient as possible with their time - all the time. I'm certainly one of those people.

Unlike other authors, Burkeman recommends that you surrender to the fact that you cannot get everything done and that traditional time management strategies, which are supposed to help you multitask, will fail and cause anxiety. He recommends recognizing that our lives are finite and that we should be in the moment. The author does a fantastic job of persuading even someone like me how important it is to recognize that even if you get your list done, there will always be more items on your next list. 

I'm not much into self-help, but I do recommend this intelligent book.

Important Updates to the Residency ERAS

Other than implementation of the supplemental ERAS for select specialties, the residency ERAS hasn't had many modifications over the past decade. However, this year the AAMC overhauled the application in several significant, positive ways:

1. In past years applicants could include as many activities as they wanted, which put a big burden on both candidates and faculty readers. Applicants didn't know if they should include activities as far back as college (or even high school) and were afraid to leave anything out. Faculty were faced with some applications that were excessively long, chocked full of unimportant information or remote accomplishments. 

This year candidates can focus on as many as 10 experience entries - but no more - and can designate three as their most meaningful (like the AMCAS) with a short, additional description for each. 

2. Applicants will also be able to choose from more "experience types" than they had in past years and will be asked to provide more descriptive information about their activities. 

3. Candidates will have the opportunity to complete an "impactful experiences" section where they can describe any hardships (family, financial, education, etc.).

4. Applicants can communicate their preference for a particular geographic division or for a rural versus urban setting.

5. Candidates applying to specialties and programs who opt in can participate in "program signals" to express particular interest in a residency program. 

In general, I find these changes constructive and helpful. 

For more information, take a look at this summary from the AAMC. Contact me for personalized ERAS help. 

How to Excel During Your (Emergency Medicine) Rotation

Many medical students just starting their fourth years are coping with specialty-specific electives and sub-internship rotations. What are the tricks to making a good impression during these clerkships? Here's a piece I wrote on how to succeed in your emergency medicine rotation; many of the tips translate to other specialty rotations as well. 

A Novel Approach: Reading throughout your Rotations

I had a thoughtful advisee years back who told me about an interesting plan she had made for herself: As she rotated through different specialties during medical school, she read a book appropriate to each field. For internal medicine, she read "Being Mortal," by Atul Gawande. For neurology, she read the classic "The Man who Mistook his Wife for a Hat," by Oliver Sacks. For surgery, she read "When Breath Becomes Air," a beautiful book by Paul Kalanithi. The list goes on.

I was impressed by this contemplative approach to third and fourth year. So many of us are understandably focused on Shelf Exams and letters of recommendation that we don't give ourselves a chance to comprehensively reflect on our subject matter and patients' experiences.

If you have a moment, please check out a few book recommendations I have for those in the medical field. Perhaps my advisee's stellar plan can be one that other medical students adopt. (You'll see that I strongly recommend Cutting for Stone. Dr. Abraham Verghese has a new book out that I'm reading right now called The Covenant of Water.)

"Optional" Secondary Essays: Are They Really?

I've recently received several questions about optional secondary essays and their necessity.

The beauty of an "additional comments" section is that it is intentionally vague. It's your chance to provide details, context, or qualifications that the structure of the application didn't allow you to present. For that reason, I lean toward using that space to both highlight who you are and any exceptional aspect of your candidacy that you'd want a reader to know before making an interview decision.

So, one good option for these essays is to pick something completely nonmedical that distinguishes you and is nowhere else to be found on your application. In this case, the essay can actually be fun to write.

Of note, sometimes people use this type of a prompt to explain one major deficiency in their candidacy. I only recommend that if there's a big elephant in the room: In other words, in general I tell applicants – throughout the process – to avoid highlighting weaknesses. The goal is to demonstrate distinctiveness and worthiness, so negatives are usually left out. But sometimes someone has a big problem like a low MCAT score that is an anomaly that's worth addressing head on.

Bottom line:  Since an interview isn't guaranteed, don't save your best material for an in-person meeting. Get your foot in the door. And as always, make sure your essay is substantive and not fluffy.

Don't Let ERAS Kick Y'ERAS

Just a reminder for residency applicants: ERAS tokens are now available for IMGs, and all residency candidates can start registering and submitting supporting documents on the myERAS website. Even if you aren't ready to start working on your application, I'd recommend registering and taking a look at what will be required of you. 

Additionally, I suggest you begin researching programs now, if you haven't already. Residency Explorer allows you to compare your candidacy to those of applicants who have successfully matched to specific residency training programs in the past. You can also search the American Medical Association's FREIDA database.

Getting started early will help you develop confidence and a strong plan of attack for the upcoming application season.

The Ins and Outs of Choosing a Specialty: The Generalist vs. The Early Committer

For many third-year med students, this is a challenging time of year. Preparing an ERAS can be daunting, but it's even worse if you don't know what specialty you want to practice. Here's a short piece I wrote with my colleague David Presser MD MPH called "Choosing a Specialty: The Generalist vs. The Early Committer." And here's a complementary, but non-medical, New York Times article called "You Don't Want a Child Prodigy" that's a great follow up to our piece. 

Moral Injury

It's troubling, but make sure to read this recent piece in the New York Times called "The Moral Crisis of America's Doctors" about physicians' "moral injury." The phrase refers to emotional damage caused to workers – when in the course of fulfilling their duties – they commit an act or acts that conflict with their core values. The piece argues that, in part, our profit-driven system causes doctors moral injury and, in turn, they become depressed and/or burned out.

I remember many times when I had only bad alternatives in directing my emergency patients for follow-up: If they had no insurance, our knowledgeable social workers advised us that our sole option was to send those patients to the public hospital nearby for follow-up care. This meant I would splint someone with a non-operative, non-emergency fracture and advise him/her to then be seen at another hospital's emergency department with a multiple-hour wait because that was the only way to get into the system for the affordable orthopedic clinic. I found this very upsetting and contrary to what seemed right to me: It was so hard on the patients, and it also burdened the already overwhelmed medical system.

If you're interested in recent physician burnout statistics, please see this February 2023 blog on the topic.

Toxic Work Environments Adversely Affect Those in Training

I recently came across a Medscape-sponsored discussion called "How can we make medical training less toxic?" The video is visible here, and you can log into Medscape to read the transcript. The participants – two emergency physicians and one surgeon – discuss sexism in the workplace, corrosive and inaccurate narratives about women residents, the importance of strong mentorship, and diversity training. This topic is additionally important because toxic work environments can lead to depression, burnout, and suboptimal patient care. My experience in residency was marred by sexism and sexual harassment. It saddens me that these problems are still present, but I'm pleased the issues are starting to be addressed.

  

Brevity is the Soul of Wit

As Shakespeare so wisely pointed out, being concise is critical for good writing. I've edited a lot of personal statements over the last few months, and I deliberately recommend a word count of 800 or fewer for a couple of reasons:

First, I've found that 750 to 800 words is just the right balance of content and streamlining: Over that number lends itself to a meandering admissions essay. Second, your reader is likely reviewing scores of applications. S/he is looking to limit time, while still getting a good flavor for your candidacy. Don't burden your reader with verbiage.

Having trouble being brief? Here is some guidance:

1) Avoid flowery language. You can omit many non contributing phrases or sentences if you follow this guideline.

2) Read through your writing aloud. Oftentimes doing so will make clear what can be cut.

3) Imagine AMCAS, AACOMAS, or ERAS are charging you $10 per word. How would you keep costs down?

4) Avoid constructions like "I was able to..." and "I chose to..." Instead of "I was able to publish...," try "I published..."

5) Cut out unnecessary prepositions: "As a volunteer at the university..." can change to "As a university volunteer...."

6) Use abbreviations to your advantage, but only after you define them the first time they are introduced: "At the University of Southern California (USC), I wrote..." Then, you can use "USC" to your heart's desire, avoiding unnecessary characters.

What to do Once Your AMCAS is Submitted

Tomorrow - May 30 - is the first day applicants can submit their AMCASes. Please see my recent blog about the advantages of submitting an optimal application on the earlier side. 

Once your AMCAS is submitted, take a deep breath, relax for a few days, and then start thinking about your secondary essays. Here are a couple of blogs on secondaries, including how to get started on the "Why Our School" prompt and how to approach a diversity prompt. 

Also, once the AMCAS is in, take a moment to do some soul searching about what you're seeking geographically, philosophically, and educationally. You want to make considered decisions when the time comes.

Finally, you can start practicing for your interviews. Here is information on my mock interview services.

Get "Full Credit"

This past week I attended a high school program that included mock admissions case studies for college. Sample, fabricated applications were presented and then discussed in small groups led by a college admissions officer.

Of note, one of the individuals who led the program mentioned something that translates to medical school and residency applications: If the reader doesn't understand, the candidate will not get full credit. It's important to explain awards, for example, and not just name them. The illustration the admissions officer gave was "The Titan Award," a hypothetical prize, but one that the admissions officer noted is not interpretable unless an explanation is given.

I echo the sentiment that if candidates don't clearly define their accomplishments, those applicants may be overlooked. Make sure you detail anything that would not be readily recognizable to a reader who is not familiar with your geography, institution, or focus of study. You deserve full credit for your very hard work. 

CASPER

I've been fielding questions about the CASPER test recently. The examination is aimed to assess empathy, emotional intelligence, and professionalism. CASPER is multifaceted, and I would recommend you look here for information about the components. There are some useful, instructive videos on the site.

Of note, CASPER is not required for all US medical schools, so it's important to determine whether you need to take the examination at all. If so, when you have to take the test is dependent on different institutions' due dates (which is frustrating).

If you do need to take the examination, please plan to prepare even if you feel you have a high emotional quotient. I've had some applicants in the past take the CASPER without reviewing in advance, and many of them were surprised by their suboptimal performance. Applicants cannot retake in an admissions cycle. 

The FAQ page here is helpful.

AMCAS: What's the Big Deal about Rolling Admissions?

This year's AMCAS application opened last week, and candidates will be able to submit beginning May 30. 

Because of rolling admissions, submitting a complete application early in the cycle has distinct advantages at many schools. That doesn't mean you should present suboptimal written materials; instead, you should start early enough (like, yesterday) that you're showcasing your best work.

Rolling admissions means that a school takes applications in the order in which they are received and makes decisions about interviews and then acceptances, accordingly. So, as time goes by, there are fewer interview and admissions offers remaining to be made. Think of an auditorium whose doors open to allow guests in. Those in the front of the line get the seats, and those who come later may not have a chair to sit in.

If your application is not complete, your candidacy may not be evaluated early when there are more opportunities for interviews and admissions. So, if you have not already, get started immediately. It could make a huge difference in your available opportunities.

Ten AMCAS Mistakes You Absolutely Want to Avoid

Here's a quick and dirty list of AMCAS Work and Activities section errors to avoid at all costs:

1. Don't write to write, and don't fill to the maximum character count unless necessary. While you want to include many strong achievements, you do not want your AMCAS to be so wordy that your reader is tempted to skim.

2. While you need to be brief, don't write in phrases; use full sentences. It’s a formal application, and you want to make your written materials as readable as possible.

3. Don't assume your reader will carefully study the "header" section (including the title of the activity, hours, etc.). Make sure your descriptor could stand alone: Instead of "As an assistant, I conducted experiments..." use "As a research assistant at a Stanford Medical School neuroscience lab, I conducted experiments..."

4. Don't be vague or trite. Make sure you spell out your accomplishments clearly and substantively. If your reader doesn’t understand an activity, you will not get “full credit” for what you’ve done. Make no assumptions.

5. Avoid abbreviations. Again, you want to be formal, and abbreviations you think are common might not be familiar to the reader.

6. Write about yourself and your role – not an organization. For example, don’t use the space to discuss Doctors without Borders. Use it to discuss the specifics of your role at Doctors without Borders.

7. Avoid generalities and consider using numbers to be persuasive. Saying that the conference you organized had 300 participants says it all.

8. Don't merge the descriptors with the most meaningful paragraphs because they are separate sections: You can complete descriptors for up to 15 activities with up to 700 characters each plus up to three most meaningful paragraphs of up to 1325 characters each.

9. Unless your PI won the Nobel, avoid using supervisors' and/or doctors' names in your descriptors as they will be meaningless to the majority of your readers.

10. Choose the right category for each activity, so you get "full credit."

Bonus: Get help. Do not submit your medical school application without having it reviewed by someone with experience. You do not want to showcase suboptimal materials for a process that is this important and competitive.

Letters of Recommendation: Lead the Witness

When pre-meds, medical students, residents, nurses, and physician colleagues asked me to write them letters of recommendation (LORs) when I was Assistant Residency Director, the first thing I requested was that they send me background information to make my letter robust…and my job easier. Accordingly, whether you are applying to medical school, dental school, residency, or fellowship, I strongly recommend you create a “LOR packet,” which can include the following:

1. A brief, well-written cover letter defining all of your important accomplishments
2. Your curriculum vitae (CV)
3. Your personal statement in its final form and/or
4. Your transcripts.

With regard to the cover letter, keep it streamlined: Thank the writer and highlight your pre-professional achievements on one page. The point of the cover letter is to supplement a writer’s knowledge of your candidacy and offer flattering content for inclusion. A college professor may know  you made the only A in an organic chemistry class, but her LOR for medical school will be more complete, and she will demonstrate a more intimate familiarity with you if she knows enough to write that you volunteer regularly at a homeless shelter.

With regard to the CV and personal statement, these make useful supplements to the LOR packet only if they are in professional and final form. Don’t include rough drafts. Poorly organized background information leaves your writer with the impression that you are a disorganized person. Also, only include the transcript if it bolsters your candidacy, demonstrating academic achievement. Don’t shoot yourself in the foot if you have some bad grades you’d rather not showcase.

Bottom line: An applicant who offered me a list of her accomplishments in a tidy, accessible package was more likely to get a strong, comprehensive letter that was submitted promptly. She also distinguished herself from the majority of candidates who requested letters without demonstrating a comparably sophisticated understanding of the demands this process made on my time. If you can make a letter writer's job easier, your forethought is likely to pay dividends in the letter you receive. The savvy applicant can take subtle advantage of her ability to "lead the witness."

Match Results 2023: Why Did Emergency Medicine Do So Badly?

Emergency medicine has had its ups and downs over the years with regard to desirability. Soon after the show "ER" became popular, emergency medicine programs also were suddenly in vogue. Over the interim years, the field's cachet has declined and increased, but up until recent years, emergency medicine programs routinely filled 99% of their available spots in the Match.

The fact that 554 emergency spots went unfilled in this past Match was particularly distasteful to many emergency physicians, accordingly.

The reasons for this plummeting interest in the field is well described in a recent piece in ACEP Now. (ACEP stands for the American College of Emergency Physicians.) The authors note multiple issues, including burnout, decreasing remuneration, and systemic problems in the emergency healthcare system that frustrate clinicians. 

Of note, these issues have driven out many middle-aged emergency physicians, as well.

Even if you are not interested in becoming an emergency doctor, take a look at the piece here, keeping in mind that certain factors may soon adversely affect other specialties as well.

(I'd like to give a shout out to my old friend Jonathan Fisher MD MPH who was one of the reporters on this article.) 

Changes in the AMCAS

Premeds applying this cycle will notice a few changes to the AMCAS. There are no drastic modifications, so don't worry, but it's worth knowing what to expect.

Back in 2012, an important, new addition appeared on the AMCAS: Applicants were being asked to identify their most significant extracurricular experiences (up to three) and support their choices with more writing. Now the Most Meaningful Paragraphs are par for the course, but the change was a big surprise back then.

This year the updates are comparatively minor. One difference is the Other Impactful Experiences section. It is not an addition, however. It replaces the Disadvantaged Status section, allowing for a broader understanding of challenges that can adversely affect an applicant's life and candidacy.

To their credit, the AAMC also changed the "other" pronoun and gender identity categories to "another pronoun set" and  "another gender identity."

Please see this short article from the AAMC regarding other changes in this year's AMCAS.

BS/MD Programs

Here is an AAMC piece about BS/MD programs. While these curricula do provide some benefits to students with an early interest in medicine, I am generally not a proponent of the BS/MD option, as it really precludes most participants' ability to take full advantage of the college experience; the caveat may be 8-year programs (like Brown or Tufts) that don't accelerate students, as much as give them early assurance of admission to medical school (assuming individuals maintain their grades). 

My bias is that taking more time - for example, a gap year - is a way to enjoy the school experience and approach medical training with maturity and career choice confidence.