Pre-Meds (and Others): Don't Make a Promise you Simply Cannot Keep

My mom told me an interesting story recently: She is a retired lawyer - not in medicine - but her anecdote resonated with me:

Years ago, a legal job applicant indicated on his resume that he spoke two languages, in addition to English. Unplanned, the interviewer to whom the candidate was assigned also spoke those languages and proceeded to speak to him in those languages during the interview, only to find that the candidate spoke both poorly at best.

As you can imagine, the applicant was not hired.

I frequently see applicants indicate on their curriculum vitae or their AMCASes that they speak languages fluently. If you do speak a language in addition to English, good for you and great for your candidacy. However, if you indicate that you are fluent, please be ready for your faculty interviewer to conduct your entire medical school interview in that language if s/he pleases.

The Rank Order List Deadline Is Imminently Approaching: Check Yourself Before You Wreck Yourself

This is an important reminder that Wednesday (February 21) at 9am EST is the rank order list certification deadline. I'd recommend submitting today or tomorrow morning to be safe. Waiting until the last minute and making impulsive changes to your list is not a great idea.

Please make sure to avoid simple missteps in creating your rank order list. Improving written materials and interview skills is important, but all of that work can go to waste if applicants do not understand basic strategies for the Match. In November or 2015 the NRMP published an article called, "Understanding the Interview and Ranking Behaviors of Unmatched International Medical Students and Graduates in the 2013 Main Residency Match" in the Journal of Graduate Medical Education. The data is especially important for IMGs who represented the majority of unmatched candidates.

Sadly, the authors found that some applicants made strategic errors including the below:

- Not attending all interviews, thus failing to capitalize on every opportunity to market themselves.

- Declining to rank all programs at which they interviewed or not ranking all programs they would be willing to attend.

- Misunderstanding the Match and ranking programs at which applicants did not interview.

- Failing to rank programs based on true preferences or ranking programs based on the perceived likelihood of matching.

It kills me to read about these mistakes :(. Here is an explanation of the Match algorithm. If you do not understand how the Match works, it is absolutely critical that you learn about it to avoid destructive errors.

Yes, Sleep is a Medical Necessity

I found this short piece, "A Call for Sleep" to be an interesting and honest read. Throughout my life, I've had non medical people tell me that I should be used to a lack of sleep because of my training and night shifts (which I, thankfully, no longer do). If someone has fasted before, that doesn't mean she doesn't get hungry when she doesn't eat!

For applicants, I'll again say that it's critical to consider lifestyle and priorities when choosing a specialty.

Read the Fine Print

A few years ago, a medical school applicant told me the following story:

This pre-med decided to write follow up notes to all the schools at which he had interviewed, usually a good idea. However, he was upset to receive a brusque note from one of the institutions telling him that a) he should have read their policies; they do not allow post-interview contact and b) he was rejected from the school.

I found the school's note pretty severe, and I strongly suspect the post-interview contact was not related to his rejection. (As an aside, he successfully and happily matriculated at another school.) But this story is a reminder that it's important to read institutions' policies about post-interview contact. Most places welcome written updates, but it's essential to confirm before you send.

No One Wants to be your Second Choice for High School Prom Date

Imagine you're back in high school, planning to ask out a fellow classmate to the prom. You approach your potential date, "Would you be interested in going with me to the dance? You're my second or third choice." 

Not very compelling...The same is true for letters of intent: I've had several applicants ask me if it's okay to say that an institution is their "second or third choice" or "one of my top" picks. 

That does not sound very flattering. Instead you can say something like "I would be thrilled to be at your institution," or " I’m confident I can make a positive contribution." In other words, you don't need to lie (which I never recommend); but you don't have to shoot yourself in the foot either.

I do edit letters of intent and have been busy with them this season. Let me know if you need assistance.

After Your Residency or Medical School Interview: Is there Value in a Second Look?

After interviews - if permitted by the institution - there are several ways you can communicate with a medical school or residency. My favorites are brief thank you notes and well-written letters of interest.

But what about the "second look?" I've had many mentees ask me if re-visiting a school or training program after the interview day is valuable. Unfortunately, there may not be a definitive answer to this question because how a second look is perceived varies by institution.

The cons of the second look are cost and time. And perhaps even worse, there is the risk that you are imposing on the school or program. You don't want your request for a second look to work against your candidacy. On the other hand, the pros of a second look are a demonstration of interest and enthusiasm that many schools and programs are seeking.

If you are a pre-med and are wait listed at a medical school, I would generally recommend a second look if you can swing it. After all, you have every right to visit the institution you may be attending. If you go for a second look in this scenario, make sure to do a formal visit: Let the admissions office or Dean's office know you would like to spend the day and ask if you might have an opportunity to meet with students and even an admissions officer to support your candidacy.

If you are a residency applicant, it's hard to say if a second look will help or not. A residency director friend of mine says that a visit from someone who travels from far away might improve a candidate's standing by a few slots on the rank list at her program. That sounds like a tepid endorsement at best... If you are considering a second-visit, make sure to speak to the program coordinator. S/he might advise you against it or, on the contrary, let you know it's appreciated by the residency director.

As we all know, the residency and medical school interview scene is already stressful and expensive, so unless you are a wait listed pre-med - with all other things being equal - I generally would not push yourself hard to do that second look.

Pre-Med? Avoid a Big Mistake

Several years ago I was hired by a re-applicant who wanted to better understand why she did not get into medical school the prior year. She had a 3.9 GPA and a 40 on her MCAT (100% percentile). Yet, she had been rejected from all medical schools.

I looked through her materials and discovered the problem. The applicant had no clinical work at all. She had never been in the room with a patient. Many of you know that I like the saying, "No one wants to hire a chef who hasn't been in the kitchen." She had fallen prey to exactly that adage.

We talked, and I advised her regarding options she had for obtaining clinical experience. Fast forward a year: The client completed a robust clinical activity and was readily accepted to medical school (and felt more confident about her career choice).

If you are a pre-med, note that robust clinical experience is critical. Working as an EMT, in a good clinical care extender program, formally as a scribe (where you can also make some money), or in a low-income clinic are just some ideas for obtaining excellent clinical exposure. (Although you might think free clinics would be thrilled to have a pre-med volunteer, many understandably require one-year commitments.) Shadowing is a mixed bag: Medical schools don't know whether you're second-assisting in the operating room or just standing in a corner being ignored. If you choose to shadow, make sure you highlight any true clinical experiences and skills gained in your written materials. Other popular options for clinical experience include international work (although the activity is usually short-lived, which makes it less robust) and working as a volunteer in a hospital (although it might be more clerical than clinical, depending on the position. Do your research before accepting a "clinical" job). I've also had advisees who became certified, practicing phlebotomists and others who worked in veterinarians' offices to obtain procedural skills.

More important than getting into medical school (gasp), getting robust clinical experience will help you ensure you've made the right career choice. Simultaneously, you'll demonstrate to admissions officers that you can handle the heat.

Residency Applicants, Thinking about How to Create your Rank Order List? Check out this easy advice.

For those of you who are starting to think about your Match rank order list, please make sure you follow this (simple) strategy: Rank your first choice first, your second second, etc. The Match algorithm is mathematically quite complicated, but because the process always begins with an attempt to match an applicant to the program most preferred on the applicant's rank list, you do not want to try to "game" the system.

For example, I've had applicants tell me that they plan to rank a less preferred institution higher because that program has more residency slots. That's a no-no. The applicant will actually be harming him/herself with that strategy.

Here's a video the NRMP created this year to better explain the Match algorithm. Here's also a less-than-one-minute Guru on the Go© video "NRMP Ranking to Avoid a Spanking" to emphasize your optimal ranking strategy.

A Novel Approach: Reading throughout your Rotations

I have a thoughtful advisee who told me about an interesting plan she 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 neruology, 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.

Happiness: Part 2

Last week I posted about happiness. Unfortunately, I have recently spent a lot of time at an academic medical center with a sick family member. The hours I’ve spent there have made me think further about contentment in medical school and residency.

What I noticed about this highly academic hospital is that the care is outstanding, but the atmosphere is much more collegial than the setting in which I trained. The doctors and nurses are extremely bright and competent. They are also kind and approachable.

The institution at which I trained (and it may have changed in the 12 years since I left) did not have this culture. I experienced unchecked sexism, arrogance, and standoffishness. As I interacted with the physicians and nurses recently, I realized that I probably would have been much happier at an institution that better matched my personality. (Having said that, I met many of my dearest friends and my husband during medical school, residency, and as an attending, and I would not change any of that.)

Bottom line: Yes, reputation is a factor, but culture is really key. You can oftentimes train at an equally excellent place where you will happily fit in.

After all, we’re talking years of your life here. 

Happy Medical Training: An Oxymoron?

Medical school and residency training usually decrease one's happiness for several reasons. Happiness researchers have demonstrated that a feeling of control and the amount of spare time one has both correlate with happiness. Both of those factors are limited during med school and residency. Relationships are also correlated with happiness, and those can be squashed during medical training as well.

I'm not trying to be a downer here! I want to encourage applicants to consider this happiness quotient when selecting an institution and training program. If you are able, maximizing your contentment by choosing an institution that fosters your greatest happiness is key. Geography; proximity to family, friends and community; and a location that provides an opportunity to enjoy hobbies during limited free time is significant.

Excellent training is important, but, in the end, many programs turn out equally qualified clinicians. At least consider your well-being as a factor in selecting where you might be for the next three plus years of your life.

Do-It-Yourself Exit Strategy: How I Stitched Together My Own Golden Parachute

Over a decade ago, I was seated in the emergency department with a colleague when I inquired about another one of our physician co-workers I'd not seen in a while. “Oh, she’s on the Mommy Track,” my colleague said and picked up another chart, without giving his words a second thought. To me, selecting a career path that sacrificed career advancement for more time to raise children was legitimate. My colleague’s pejorative “Mommy Track” made it clear that to him, it was not.

At that sad moment, I resolved to pursue a non-clinical supplement to my emergency department work, colloquially known as an “exit strategy.”

Read more on Student Doctor Network here...

DO vs. MD

Thinking about a medical school application for 2018, I’ve had a few industrious pre-meds ask me about DO school. There was an excellent article in the New York Times a few years ago about what doctors of osteopathy do and how their admissions criteria are different from allopathic schools’. It’s here and worth a read.

The topic of DO schools is an enormous one. A few quick points many candidates don’t know about DOs:

1. Many doctors of osteopathy practice medicine just like allopathic doctors do. I do per diem emergency shifts at Kaiser and work with many DOs. Candidly, I usually do not know which colleagues have osteopathic degrees and which have allopathic ones unless I see a prescription blank or a signed computer note.

2. If applying to osteopathic school, candidates are generally better off with at least one (strong) letter of recommendation from a DO supervisor.

3. Osteopaths currently take the COMLEX for their board tests, instead of the USMLE. If an osteopathic medical student wants to enter an allopathic residency, s/he may need to take the USMLE in addition to the COMLEX. On the other hand, there are many allopathic residencies that accept the COMLEX. Also, there is talk that in the future (when exactly is unclear, however) there may be just one board test that both groups take.

4. The osteopathic Match occurs before the NRMP Match, a fact that can be difficult for osteopaths applying to both types of residencies. If those applicants are successful in the osteopathic Match, they cannot enter an allopathic residency. If, on the other hand, they wait and enter the NRMP Match, they run the risk of simply not matching.

Again, this topic is complicated and nuanced, but the DO option is a great one for some applicants.

Haven't Heard Back from a Medical School or Residency Program? Here's What to Do.

One of the more frustrating aspects of the medical school and residency admissions processes is the lack of response from some institutions. There is no obligation for medical schools or residency programs to reply to a candidate, which leaves applicants in limbo.

If you have not heard back from medical schools or residency programs to which you've applied, I recommend that you contact (preferably call) the institutions to inquire about your status.

After I offered that advice to a residency applicant I was advising, she emailed me to say she obtained an interview in a competitive specialty with a phone call. Another said she received two preliminary interviews with simple emails. (I recommend calls over emails, however, because it's hard to ignore someone on the other end of a phone line. Still, if you simply can't bring yourself to call, an email can be effective.)

I've seen this phone call strategy work for medical school interviews as well: Several years ago I helped a strong applicant who had been rejected by a top medical school. He thought he was a very good fit for this particular institution, so he called the school to make his case. Surprisingly, after the applicant's phone call, the school granted him an interview, reversing their original rejection. Ultimately, after being initially rejected, this applicant was admitted to that top school. Of course, this is an exceedingly rare occurrence. But to me, the moral of this story is that it is worth being assertive in the application process.Now, if the school or program explicitly asks in written materials that you don't contact them about your status, then calling is not a good idea.

An additional strong option is to send an effective update letter or letter of recommendation from an influential writer (alumus, for example). I do edit letters of update/interest for medical school and residency applicants, but even if you choose not to use my services, I recommend sending a well-written, strategic note in addition to making a phone call.

This process is an uncertain one, but asserting some small bit of control can be useful (and comforting).

Some People Have Real Problems

The residency and medical school application processes are anxiety-provoking, but in honor of Thanksgiving, I'm posting this guest blog from CrispyDoc David Presser about a truly stressful, heartbreaking choice a patient recently had to make...

Years ago, I bought an album because the title caught my eye: Some People Have Real Problems. I was browsing used CDs in a music store back when both of those existed, and I felt the universe trying to restore perspective to my personal pity party.

Fast forward a decade, and I had fallen off the wagon again into whining doctor mode: headed into my second weekend night shift in as many days. The first night had been a killer, where the spigot of patients opened to a steady gush around 1 A.M. and all four of the late shift docs stayed several hours past the end of their shift to flush the proverbial toilet that our waiting room had become.

 

Read more of this article...

So Easy for You to Do: Medical School and Residency Interview Thank You Notes

A few years ago a medical school applicant wrote me to say that the dean of the school at which she had recently interviewed called her to tell her that he was impressed with her candidacy and the hand-written thank you note she had sent. The client thanked me for my help and the thank you note tip I had given her. As you might have guessed, she was admitted to that medical school.

Writing a thank you note after a medical school or residency interview is so easy for you to do, and it can go a long way. 

Now, I get asked by clients what the best way to send post-interview thank you notes is - email or snail mail. I strongly advise sending your thank you note by good old USPS. The reasons are:

1) Email may be viewed as lazy. Handwritten notes demonstrate you've put some time into being appreciative.
2) Email can be deleted without much thought. Emotionally, it's harder to throw someone's handwritten note in the trash.

Get your handwritten thank you notes in quickly. The night after you've completed your interview or the next day is a good time to write and send.

Emergency Medicine: Queen, Rodney Dangerfield, and George Clooney All Rolled into One

Check out the below, a great post called "We Are the Champions?!" written by Crispydoc (Dr. David Presser) on burnout in emergency medicine, a field that towers over the others in burnout statistics:

It’s official: a study published in the Mayo Clinic Proceedings showed that as of 2014, Emergency Medicine (EM) took the top slot for physician burnout (59%).  Suck it, critical care (50%). In your face, OB/GYN (56%).  We’re #1, we’re # ...huh?

How did my beloved field of EM win the race to nowhere?  When I was in medical school, the pioneering faculty insisted that EM’s reputation for early burnout was based on the fact that those docs who’d burnt out had trained in another field, couldn’t hack it in their chosen specialties, and ended up woefully underprepared to spend their careers in EM.  As a medical student, I saw EM transform from Rodney Dangerfield disrespected to George Clooney sexy.  A full 13% of my class at UCSF matched in EM.  We smugly believed we knew what we were getting into, and we took for granted our ability to work as lifers.

Read more of this article (and see an awesome Queen video to boot)...

Your Residency Application: What Do Program Directors Really Want?

Imagine that you're a program director (PD) going through scores of ERASes and interviews. What questions would you ask yourself as you assessed each residency candidate to avoid big headaches?

1) Can this person do the job? Is s/he competent?

2) Will this person "play well with others" and not create complaints from patients, faculty, or other services.

3) Will this person stick with the program and not leave prematurely? A PD does not want to scurry around to fill an open call schedule/ residency slot.

As you approach your interviews, consider how you can demonstrate your competence and collegiality, as well as your commitment to the field and the residency program. For the former, ensure you showcase academic successes, extra curricular activities that demonstrate teamwork, and - if asked - hobbies and reading materials that demonstrate your personality. For the latter, highlight research projects in the specialty, sub-internships, and knowledge about the program and city.

Making sure the PD knows you are not going to cause him/her trouble is at least half the battle.

White Coat Investor Scholarship Winners Announced

For the past few years, the White Coat Investor has funded a scholarship for full-time professional students, including those in medical, osteopathic, dental, law, pharmacy, nurse practitioner, physician assistant, optometry, and podiatry schools. The goal is to both reduce the winning students' debt burden and spread "an important message of financial literacy throughout medical, dental, and other professional schools."

This year's first place winner's essay is here. It's great and worth a read. Second through fifth places can be found here. Keep your eye out for next year's contest. The financial support is significant. 

I Believe

I was recently speaking to a friend who is a law professor at a prominent institution. He teaches first-year law courses and thus, meets students when they are just entering their careers and not yet polished. He was telling me that he is taken aback by how many of his students use "I believe" before their statements in class. The preface "I believe" diminishes the student's point; my friend is looking for persuasive pronouncements, not thin opinions. 

Consider this issue when interviewing. Note the difference between "I'll make a strong medical student" and "I believe I'll make a strong medical student." The latter introduces that inkling of doubt you don't want to impart.

I have advisees who worry about saying "um" or "uh" during interviews. (I advised a pre-med who, in preparing for interviews, asked his girlfriend to gently slap his hand every time he said "um" so he'd experience negative consequences. Yikes!) As I tell my mentees, I'm not worried about an "um" or an "uh." (Note President Obama, well-known to be an excellent orator; he inadvertently uses vocal pauses when he speaks.) 

Instead, the key to a persuasive interview is to have confident responses that are bolstered by persuasive evidence.