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. 

2023 Match Data

The NRMP recently published data regarding the most recent Match. Of note, emergency medicine – my specialty – had a whopping 554 positions that remained unfilled. Ouch! Additionally, although the numbers were better than last year, IMGs still struggled: US citizen IMGs saw only a 67.6% Match rate and non-US citizen IMGs had only a 59.4% Match rate.

There is a lot of data to review, so take a look here if you want more information on DO Match rates, specialty competitiveness, and SOAP. 

USMLE Performance Data 2022

The National Board of Medical Examiners (NBME) publishes USMLE performance data year after year, and the most recent information regarding the 2022 testing cycle is particularly interesting. Frankly, I'm not sure what to make of it, but performance on Step 1 is notably worse than years prior (e.g. 2021 compared to 2020; 2020 compared to 2019). I'm not sure if this is related to the pandemic, changes in the test itself, or some other factor. Here is the data.

What Coursework is Really Required for Medical School?

While there is a core curriculum that is a prerequisite for medical school, certain schools require additional coursework or competencies (like the CASPer exam). The AAMC does a good job of keeping up a database of that information, listed by school. An applicant can sort through to see what each institution requires. You might have to do a little bit of digging once you open a school's link, but the information is usually accessible.

Of note, if a course is required for admission, it's probably best not to take the class on a pass/fail basis.

Start Your Engines...

The medical school application cycle is revving up soon, so it's time to get started on your candidacy. Here's an article I wrote for Student Doctor Network a few years back called "Ten Ways to Improve your Medical School Application." The piece includes statistical truths, strategies for optimizing your approach, and philosophical guidance. It covers grades, clinical experience, letters of recommendation, where to apply, the MCAT, the personal statement, and your happiness, among other critical factors. Enjoy!

Your Residency Application: Five 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.

How Race and Gender Affect Medical Specialty

The AAMC published an interesting piece recently showcasing the results of their Physician Specialty Data Report on the interplay of race, gender, and specialty. 

It's worth combing through the data yourself, but here are a few takeaways:

Doctors from underrepresented groups are more concentrated in primary care fields. These specialties are extremely needed and noble, but since primary care is less well remunerated than surgical specialties, it's worth thinking about the disproportionate density of minority physicians.

Women make up the majority of medical school students for the fourth year in a row.  

Women represent a significant minority in surgical specialties like orthopedic surgery (5.9%), thoracic surgery (8.3%) and neurosurgery (9.6%). Ouch.

Focusing on another demographic, the doctor workforce has grown older. Over 46% of active U.S. doctors are 55+. That number was ~38% in 2007. 

For more details, read the report here.

What to Know about the AAMC Fee Assistance Program

Now that the 2022-23 medical school application process is on the horizon, I want to remind candidates about the Association of American Medical Colleges' (AAMC) Fee Assistance Program (FAP) and Insider Medical Admissions' available discount for those with a current FAP. The FAP is designed to offer help to individuals with financial limitations who cannot pay the MCAT registration and/or AMCAS application fees without financial support. (Of note, there also exists an FAP for  dental school candidates through the American Dental Education Association.)

If you think you are eligible, it's worth applying for an FAP grant early: When applicants submit their AMCASes prior to receiving decisions on their FAP applications, those candidates are ineligible to receive the FAP benefits for the AMCAS even if their FAP grants are approved. In other words, the FAP is not retroactive. You snooze, you lose.

For more information on the FAP, please click here. I offer a significant discount on one non-package service for any applicant who can demonstrate financial hardship through a current AAMC FAP grant. After researching the issue, I believe Insider Medical Admissions is the only medical consulting company that currently supports a discount for FAP grant recipients. (I apologize if I'm missing a company.) Once you have been granted the FAP and thus, can prove receipt, please feel free to contact me for more information.