Final Tips for Making Your Match List

Applicants must have their rank order lists certified by 9 pm EST this Wednesday (March 2). As I've mentioned in a previous post, the algorithm for the Match is relatively simple.

The bottom line:

1. Rank programs so they represent your true preferences. Your first choice should be first. Your second should be second and so on. Do not try to "outthink" the system, as it will only be to your disadvantage.

2. Because of the way the Match algorithm works, what programs think of you (or what you think they think of you) should have zero bearing on how you make your rank order list. 

3. Except in highly usual situations, rank all programs at which you interviewed. If you would truly rather not match than be at a specific program, then that program should not be on your Match list; however, do think carefully about the prospect of not matching, entering SOAP, and possibly having to reapply next year.

4. Prioritize your happiness.

Medscape's National Physician Burnout Report 2021 is out - and it's Troubling

The Medscape National Physician Burnout & Suicide Report 2021 is now available, and it seems rather evident that the pandemic has negatively affected physicians who were already under a lot of stress, especially those in critical care medicine.

More than half of critical care physicians report being burned out (51%), and critical care ranks as the highest specialty in the burnout questionnaire, followed by rheumatology (50%) and infectious disease (49%). Those numbers compare with last year's report at 44%, 46%, and 45%, respectively. This year, my field of emergency medicine (EM) was at 44%, which sounds high, but, sadly, EM was not even in the top ten burned out specialties. That gives you an idea of the severe scope of the problem.

Women reported burnout at 51% compared to 36% for men, and while this disparity has been present for many years, the discrepancy between the genders was greater in this most recent report.

Seventy-nine percent of those surveyed relayed that their burnout started before COVID, while 21% reported after. Bureaucratic tasks and too many hours at work were the major reported contributors to burnout.

Take a look at the Medscape National Physician Burnout & Suicide Report 2021 slide deck yourself for more interesting details, and check out my Kevin MD piece on EM burnout here.

Your Residency Application: Six Factors to Prioritize When Creating your Rank List

Creating your Match rank list can be absolutely agonizing because it feels like so much is at stake. Sometimes it helps to step back and look at the big picture. Below, I briefly note a few important considerations when making your list:

1. Make sure you understand how the NRMP algorithm works. See my previous blog post regarding errors to avoid at all costs. The key is to rank in the order you want - first goes first, second goes second, etc.

2. Consider your happiness and life balance. Blasphemy perhaps, but I would argue that they are more important than the strength of the training program.

3. Reflect on the culture, geography, size, and even maturity/age of the program. Think about whether you will fit in.

4. Consider whether you could spend your whole life at the institution or in that program's location. It's a lot to grapple with, but many residents graduate and stay for the rest of their careers.

5. Decide whether you liked the program director, chairperson, and faculty generally. They could make or break your happiness and success.

6. Realize that most programs will train you well if you work hard. Their prestige and quality may be more similar than you think. For that reason, note that your personal preferences and intuitions are paramount.

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, your third third, etc.

In other words, your most successful approach is to create your list in order of your real preferences. Although the Match algorithm is mathematically quite complicated, because the process always begins with an attempt to match an applicant to the program most preferred on the applicant's 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 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 strategy.

Flight of the Conchords' "The Most Beautiful Girl (in the Room)"

I'm a huge fan of Flight of the Conchords - both the show and the comedy duo themselves. Bret McKenzie and Jemaine Clement sing a hilarious tune called "The Most Beautiful Girl in the Room" whose lyrics include

...Looking 'round the room
I can tell that you
Are the most beautiful girl in the... room
In the whole wide room (ooh)
And when you're on the street
Depending on the street
I bet you are definitely in the top three
Good lookin' girls on the street, yeah
Depending on the street, ooh...

The lyrics proceed from there, consistently qualifying Jemaine's crush's beauty:

...You're so beautiful
Mm, you could be a part-time model
But you'd probably still have to keep your normal job

I thought of this song recently when a wonderful client asked if he should let a residency program know it was one of his top two choices. While very well-meaning, that type of endorsement can fall flat. I would also avoid phrases like "one of my top" picks.

Instead, you can say (or write) 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 can stay honest while not shooting yourself in the foot.

Here's the "Most Beautiful Girl" video. It's hilarious.

What to Do in the Summer after Your First Year of Medical School

A super nice client of mine who is currently a first-year medical student recently emailed me to ask my suggestions for what he should do this upcoming summer. The summer after the first year of medical school is – unless you take a gap year – the last free one you will have for a while, so it's important to use it wisely. Of course, it's hard to plan with COVID, but generally, the advice I give is that if someone plans to go into a highly competitive specialty like dermatology or neurosurgery, research is probably the best bet. Those specialties require a significant early commitment to the field and a lot of investigative experience/ publications. 

For less competitive fields, research is still an option, but other opportunities should be considered. If you know you're not going into a highly competitive field, you have a bit more flexibility. After my first year of medical school, I participated in Harvard's Urban Health Project and spent my time shadowing a physician in an underserved clinic.

Of course, I would not recommend spending the summer at Club Med :), but I would try to make sure you are happy over the summer – near family or friends - no matter what specialty you are seeking.

Ten Ways to Improve your Medical School Application

As we know, New Year's resolutions are notoriously hard to realize. But there are smart tips for executing them, including making sure goals are specific and truly achievable within a reasonable time frame. That's why starting early with your candidacy for medical school is important. The beginning of the year is a great time for pre-meds to redouble their efforts toward their medical school goals. This past cycle, applications to medical school increased again, so the process has gotten even more competitive.

As always, I recommend a very focused approach that allows you to do more of what you want and less of what you don't. Think research will help your candidacy but don't like being in the lab? Consider public health or clinical investigations. Think volunteerism will bolster your application but don't like being one of a crowd in a group project? Start your own social justice initiative.

There are definitely necessary elements to any robust medical school candidacy (clinical experience, strong grades), but being a pre-med can also be fun, mind-broadening, and career-affirming.

Here are ten ways to improve your medical school application that will give you direction but also leeway to be a happy applicant - not just a strong one.

Responses from Program Directors are as Valuable as the Email They're Written On

A residency candidate asked me to review an email a program director (PD) had sent him after interview day. The candidate wanted to know if I had any insights into the PD's intent: Was the PD sending a generic note or was he really interested in the applicant?

I told the applicant honestly: Who knows and who cares?

I wasn't trying to be dismissive. The point is that it's impossible to know what a PD is thinking. Unfortunately, I've seen applicants heartbroken by false hope they read into a PD's comments. More importantly, what a PD says should not affect your rank list anyway. The algorithm requires you to put your first choice first and your second second, etc. (More on that in an upcoming January blog post.)

As they say, kisses aren't contracts and presents aren't promises. Don't put deep thought into those PD notes because they don't guarantee a thing and, as we say in clinical medicine, they don't change management.

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'd 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.

When you interview for medical school or residency, you want the faculty member you've met to leave the table 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 responses to potential questions. 

As an aside, I would strongly recommend Krauss' History of Love, Great House, Forest Dark and To Be A Man.

I'm Worried about Emergency Medicine

While my career has been a good one until now, I'm increasingly worried about the field of emergency medicine. See my October 21 blog on the current dearth of emergency medicine jobs. The American College of Emergency Physicians (ACEP) recently published a report on the future of the field's workforce, concluding that there will be nearly 10,000 too many emergency physicians by 2030.

Dr. Thomas Cook published a piece recently called A Few Feasible Solutions to EM's Workforce Crisis. He demonstrates a healthy skepticism for the possible solutions that ACEP proposed. See his piece here.

In the meantime, corporate emergency medicine is depleting some physicians. A group has even considered unionizing.

In addition, burnout has been a big problem for the field - even before the pandemic. 

Medical students, as great as the specialty of emergency medicine is in many ways, I would be remiss if I didn't tell you to consider these issues seriously when making a decision about your future field.

AAMC Report on Residents 2021

 The AAMC recently published their Report on Residents 2021. Of note,

• The percentage of medical residents who identify as Black or African American and as Hispanic, Latino, or of Spanish origin has increased since last year.
• Women make up the vast majority in obstetrics and gynecology (85.2%) and pediatrics (72.7%).
• Only 27.0% of the 2020-21 graduates intended to train in the specialties they had listed as their preference when they began medical school.
• The majority of medical residents (57.1%) who completed residency training from 2011 through 2020 practice in the state where they completed their residencies.
• In a tip of the hat to my favorite state, physician retention after medical residency is highest in California (77.8%).

There are more goodies; the information is summed up in this table.

Medical School Interviews: Preparing for your Virtual MMI

While the majority of medical school interviews are traditional, an increasing number of institutions (including dental schools) are using the MMI platform. The MMI (multiple mini interview) is a format that uses several timed stations to assess applicants' interpersonal skills and judgment. Despite the virtual approach, a number of schools are still using MMI. 

A few things to note about MMI interview questions:

1) They are not always medically related. You may be asked to manage an everyday problem (e.g. a disagreement at the supermarket).

2) They are not always situational. You need to be prepared for conventional questions too (e.g. What are your three greatest strengths?).

3) Schools are trying to assess whether you can skillfully employ important techniques and demonstrate professionalism. Underlying topics might include your ability to offer effective counseling, your understanding of patient-doctor confidentiality, your ability to diffuse a heated situation, or your capacity to admit wrongdoing, etc.

4) Make sure you know what structure the school is using and employ the right mindset: Working with an actor is different from executing a group project (especially remotely!), which is, in turn, different from answering questions about your opinions. 

5) Practice MMI questions before you "go" to your interview. Even if you have excellent social skills, there are techniques you should hone to expertly manage the challenging MMI format. 

Contact me for help. 

The Residency and Medical School Application Process: Moving Past Impostor Syndrome

First described by psychologists Drs. Suzanne Imes and Pauline Rose Clance in the 1970s, impostor phenomenon occurs among high achievers who cannot easily internalize their successes. They often externally attribute their accomplishments to luck and worry that others will eventually realize they are frauds.

Recognize this phenomenon of self-doubt?

You are not alone. Although many people suffer in silence (as they do not want to be revealed for what they perceive to be major deficiencies), the syndrome is quite common, especially in medical school. According to one 2016 study, almost a quarter of male medical students and nearly half of female students surveyed suffered with impostor syndrome. The phenomenon can be associated with depression, burnout, and anxiety. The American Psychological Association offers a few tips for overcoming impostor syndrome including speaking to mentors, recognizing what you excel at, and talking to a professional if necessary. 

Here's a fun article on imposter syndrome by Joelle Borhart MD, the Associate Program Director at Georgetown University. I also recommend Amy Cuddy's TED talk with over 63 million views. 

Perils of the Virtual Match

I've written before about the benefits of virtual interviews - both with regard to finances and equity. However, the ability to easily hoard residency interviews now has led to an unintended consequence of online access: An increase in qualified applicants who don't match. Thomas Cook MD, an emergency medicine program director in South Carolina, covers this topic in his piece "The Virtual Match is Like the Toilet Paper Rush." In it, he points out that when superior candidates accept a very large number of interviews, there are serious negative consequences for their peers. Cook has a suggestion for a potential remedy based on transparency. The piece is worth a read. 

Love Letters and Janet Jackson

Letters of interest (LOI) - or what some applicants jokingly call "love letters" - can be used in several types of situations:

1) Residency and medical school applicants who want to make an impression post-interview before decisions are made about their candidacies.

2) Medical school and residency applicants who have not yet been invited to interview.

3) Medical school applicants who have been waitlisted.

When writing your letters of interest, you should have the following goals:

1) Restating your strong interest in the institution
2) Positioning yourself as a distinctive candidate who can contribute fully to the institution

The biggest errors I see in LOIs are:

1) Too much content about a specific institution's advantages. There is no reason to spend a paragraph or more telling a PD or medical school admissions member what makes their institutions special. Using your precious space this way is an opportunity cost, keeping you from fully showcasing what makes you a compelling applicant.

2) Writing about how the program or school will help you. The focus should be on how you will be a contributor to their institution. (It's the "What have you done for me lately?" Janet Jackson principle.)

Finally, let me say that I find the term "letter of interest" to be better than "letter of intent" because, generally, I don't recommend you let institutions know what your intent is (since it might change). Note that with a letter of interest you can create one general letter that you modify and send to different institutions with different goals (i.e. requesting an interview or demonstrating your interest post-interview). You can also modify the letter and send it to your top choices because, if you are not making commitments, then you can honestly use it for multiple institutions. 

For those of you interested in LOI assistance for medical school or residency applicants, please contact me.

Happiness

As you interview now for medical school, dental school, residency, or fellowship, it's important to think about what will make you happy in the next phase of your career.

When I was a medical student applying for emergency medicine residency programs, a well-meaning dean gave me some bad advice. I was determining the order of my rank list and was particularly concerned about one program that had an excellent reputation but was in a city I didn’t like. The dean told me, “You’ll be so busy during residency it won’t matter where you live.” Luckily, the advice rubbed me the wrong way, and I wholeheartedly disregarded it. Where you live for your training is as important as the quality of your training program. The reasons are several-fold:

1. Training is time-consuming, and you want to be in a city you can enjoy fully when you’re able to blow off steam. 

2. Training is stressful, and you want to be in a city where you have social support.

3. Training is not completed in a vacuum. Your personal life continues. If you’re single, you may meet someone and end up staying in the city where you've trained for the rest of your life. If you’re in a long-term relationship, you may decide to have children (or already have them); down the road you might not want to relocate your family.

Not everyone gets the opportunity to train at an institution in a city s/he likes. But prioritizing your contentment will increase your opportunity for well-being and career longevity.

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. A third recently told me that, after calling in the morning, he was offered an interview by the afternoon. (Generally, I recommend calls over emails 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. Shockingly, 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, of course.

An additional strong option is to send an effective update letter or letter of recommendation from an influential writer (alumnus, for example). I do edit letters of 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).

Medical School Admissions and Residency Applicant Rankings: It's Not Personal

When I was in my second year of medical school, a third-year student (who later also went into emergency medicine, as I did) came to speak to our class about being on the wards. He gave an animated talk about how important it was to recognize that when residents, attendings, or nurses hollered at us on our clinical rotations, 99% of the time, it wasn't personal. He likened the situation to Boston traffic - how drivers lean on their horns for little cause because they are simply frustrated about their days. 

It's not personal, he said.

I say the same to those I mentor. Candidates get an interview at one highly ranked institution but rejected at what is considered a lesser one with no clear cause. Faculty interviewers mix applicants up with one another. Some turn up wholly unprepared - reading students' applications for the first time during the interview itself. Remember: It's not personal. This process is arduous and long, and most candidates, faculty, and program coordinators are tired and doing their best. 

When things are rough, give others the benefit of the doubt. It will help you get through this stressful process with your sanity intact. 

Your Residency Application: Program Directors Don't Want Headaches

If you were a program director (PD), you'd be trying to avoid two big headaches as you assessed a residency candidate:

First, a PD doesn't want to field complaints from patients, faculty, or other services about his/her residents. Therefore, every far-seeing PD asks him/herself the simple question: Will this person be competent and collegial?

Second, a PD doesn't want to see the day when s/he's scurrying around to fill a residency slot and the consequent open call schedule. So, the oracular PD asks the simple question: Will this person leave the program prematurely?

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, extracurricular 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.

Just making sure the PD knows you are not going to cause him/her pain is half the battle.

Emergency Medicine: A Career That's Currently Taking a Lot of Hits

Having been in the field of emergency medicine since I started my residency in 1996, I can tell you that the discipline has had its ups and downs. Currently, the specialty is facing a lot of challenges: COVID has driven some physicians out (to utilization review, administration, research) and has adversely affected others emotionally. Additionally, there's a tremendous dearth of positions currently for emergency physicians. I've had friends and colleagues lose promised hours or their jobs entirely in the last 18 months. 

Here's a short piece on the job scarcity issue. Those choosing a specialty must consider the atmosphere of the job market (while recognizing it might improve in a few years).