A Bad Prognosis for Emergency Medicine

I read a fascinating piece by Dr. Thomas Cook in the December edition of Emergency Medicine News. In it, he cites work done by Cameron Gettel, MD who devised an interesting way to assess the attrition rate of emergency physicians (EPs): Gettel and his colleagues used data from the Centers for Medicare and Medicaid Services (CMS), noting which healthcare providers stopped billing CMS for emergency medical services. Gettel used this information to calculate the attrition rate for EPs. What he and his colleagues found is that the EP attrition rate was approximately 5% prior to the pandemic while it shot up to approximately 8% in urban spots and more than 11% in rural areas during the first year of the pandemic.

Using information from the American Board of Emergency Medicine, Gettel found - shockingly - that the median age of attrition for male EPs was 53.5 years and for female EPs was 43.7 years in 2019. This means that the median EP career was around 23 years long for men and fewer than 14 years long for women. Wow!

It's absolutely critical that medical students who are considering a career in emergency medicine think about what their professional trajectory might be, considering the short median lifespan of the typical EP.

For more information on this interesting topic and how attrition might affect the job market, the need for physician personal finance training, and who applies to emergency medicine, see Dr. Cook's piece here.

For Pre-Meds Applying in the Next Cycle, What IS Solid Clinical Experience Anyway?

Getting into medical school has gotten so competitive that it's increasingly important to have a strong candidacy with excellent grades and robust extracurricular activities. As I've mentioned in previous blog entries, one mistake I see pre-meds make is that they are so focused on leadership and research, they forget a critical component - clinical experience. To prove you want to be a doctor, it's essential you obtain clinical experience for a significant period of time - not just a health fair or two. Good grades will not make up for a lack of clinical experience. Here are some ideas for obtaining strong clinical experience:

EMT (some universities have EMT classes and/or jobs on campus)
Participate in a good hospital clinical care extender program
Work at a low-income clinic
Certified Medical Assistant
Certified Phlebotomist
Certified Nursing Assistant
Work at a hospice
Scribe (usually a full-time job)
Veterinarian's Assistant (a great way to get hands-on procedural experience)
Volunteer for a crisis text/phone line (might need to be paired with an in-person clinical experience)

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 strategically delineate your clinical experience in your written materials.

If you're not excited about getting clinical experience, it's time to question your interest in a career in medicine... which is exactly what admissions committees will do if they don't see that experience.

Do your research before accepting a "clinical" job so you ensure you'll really get a satisfying experience and show admissions committees you can handle the heat.

Medical School and Residency Admissions: 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 cruel, and most candidates, faculty, and program coordinators are tired and doing their best in a dysfunctional system. 

The AAMC Will Expand the FAP to Include Some Residency Applicants

The American Association of Medical Colleges has announced that they will expand their Fee Assistance Program to certain residency applicants starting with the 2024-5 ERAS application season. At that time, the FAP will include residency candidates who were previously approved for the program during their medical school application process. The qualifying candidates will receive a 60% fee discount on up to 50 ERAS applications. This is great news for medical students who have severe financial needs. The AAMC reports that it will be providing more information in the following months.

Is Getting into Medical School Harder than It Was Before or Does It Just Feel Like It?

Last cycle, over 52,000 brave candidates applied to medical school, with just under 23,000 matriculating. While getting into medical school is extremely competitive, the number of applicants has actually decreased from two years ago when over 62,000 individuals applied to medical school (and the number of matriculants/spots has stayed almost the same). People attributed that peak in applications to the Fauci Effect, a trend that motivated individuals to simulate medical leaders and contribute to the health of society in the setting of the pandemic. In reality, it's unclear why numbers rose significantly that year. But since, applications have declined. The problem for candidates is that the number has decreased only to levels that are about equal to those pre-pandemic and still higher than the 2014 cycle when there were under 50,000 applicants. 

Having said that, there are more open medical school slots than there were in the past. In the 2014 cycle, 20,343 individuals matriculated out of 49,480 (41.1%). This past year 22,981 matriculated out of 52,577 applicants (43.7%).

None of these statistics take into account the fact that a more competitive applicant pool may have emerged over the course of the last decade. In other words, the whole achievement level of the application cohort may be stronger than it was in the past.

Bottom line: Looking at numbers alone, it is easier to get into medical school than it was during the anomalous cycle two years ago. Furthermore, although there were more applicants, it is slightly easier to get into medical school now that it was about a decade ago because there are more spots. 

That conclusion is likely reassuring for upcoming applicants, while at the same time, maddening for any of this year's candidates who have received a recent rejection. 

Either way, getting into medical school is extremely competitive.

Beware: Smart People Can Offer Dumb Advice

Thanksgiving is a time for gratitude and reflection. It's also a time to consider what will make you happy in the future.

When I was a medical student applying for emergency medicine residency programs, a well-meaning, smart dean gave me foolish 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. I would argue that where you live for medical school, residency, or fellowship is as important as the quality of the institution. The reasons are several-fold:

1. Medical education/training is time-consuming, and you want to be in a city you can enjoy fully when you have a few moments to blow off steam.
2. Medical education/training is extremely stressful, and you want to be in a city where you have social support.
3. Medical education/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 may already have them. Down the road you might not want to relocate your family.

Not everyone gets the opportunity to go to medical school or train in a residency and fellowship program in a city she likes. But you can make choices that will increase your chances. Consider these options - and your happiness - as you practice gratitude this week and make professional decisions this coming year.

How to Turn the Elephant in the Room into a Cuddly Kitten

No application to medical school (or residency) is perfect, which is why it's important you have a well-considered strategy for managing interview questions about gaps in your candidacy. Addressing a bumpy freshman year or a suboptimal first MCAT attempt with aplomb can make a big difference in how an interviewer and admissions committee perceives you.

Check out this KevinMD article I wrote a few years back that specifically addresses how to be upfront about a major deficiency in your candidacy and how to demonstrate — with evidence from the remainder of your application — that the weakness is not representative of your abilities.

AAMC MCAT Prep Workshop – November 8

The AAMC is offering a free webinar "Preparing for the MCAT® Exam" on November 8 at noon PST/3 PM EST. They're publicizing that the session will include tips for creating a study plan, low-cost prep resources, a demo of their free MCAT Contact Outline Course, and time to ask questions. You can register here. (You will need to create a free AAMC account if you don’t have one.)

As an aside, if you believe you qualify for the AAMC Fee Assistance Program (FAP), make sure to apply for it early. This year's deadline is December 8. The FAP covers the MCAT, but the grant is not retroactive.

Pay Inequities Based on Gender and Race Persist in Emergency Medicine

This piece by Dr. Starr Knight on discrepancies in pay for women and black emergency physicians is important but disturbing. The problem has been long-standing and continues, according to recent studies cited in the piece. One 2023 survey found that the average annual income of women emergency physicians was more than $43,000 less than that of their male counterparts. 

Of note, some have argued that differences in hours and part-time versus full-time status account for the pay discrepancies, but a 2017 paper using multivariate linear regression models demonstrated that those reasons are not a valid explanation for the discrepancies. 

See more sobering data in Dr. Knight's article.

Congratulations and Congratulations

I've heard from several clients who have already been accepted to medical school this cycle. Congratulations! I've also heard from several clients who have been waitlisted. Congratulations! The waitlist can feel like a disappointment, but it's important to see it for what it is – a potential acceptance.

One of the hard parts of being on a waitlist is the uncertainty. We humans like to be in control! One way to alleviate this discomfort is to do something. Assuming the school you're waitlisted at allows communication through their portal, email, or snail mail, I recommend sending a letter of interest (LOI).

When writing your LOI, you should have the following goals:

1. Restating your strong enthusiasm for the institution
2. Positioning yourself as a distinctive candidate who can contribute fully to the school
   
3. Showcasing any updates to your candidacy. (If you don't have updates, you should still write the LOI.)

LOI errors to avoid:

1. Don't include generic content about the institution's advantages, meaning don't waste valuable "geography" telling a medical school admissions officer what makes his/her institution special. Using precious space this way is an opportunity cost, keeping you from fully showcasing what makes you a compelling applicant. Instead, a good technique is to link one of your particular accomplishments with a distinctive opportunity at the institution. For example if you've done cancer research, make sure to showcase it and point out that you'll contribute to the renowned oncology center the institution is associated with.
2. Don't focus on how the school will help you. ("Your medical school will assist me in reaching my career goals.") Your angle instead, should be on how you will be a contributor to their institution. For example, you can detail how one of your leadership experiences has given you the tools to make you a future leader at this 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 the old jargon "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 multiple institutions with different goals (i.e. if you are placed on another waitlist, to request an interview, or to demonstrate your interest post-interview at another medical school). You can also modify the letter and send it to your top choices because, if you are not making a commitment to one school, then you can honestly use it for multiple institutions. 

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

Highly Recommended, Paid Summer Opportunity - AAAS Mass Media Fellowship

I was an American Association for the Advancement of Science (AAAS) Mass Media Science and Engineering Fellow in 1995 (during medical school). The program was truly fantastic and life-altering.

The 10-week summer program places science, engineering, and mathematics students at media organizations around the country, including National Public Radio, the Los Angeles Times, and WIRED. Fellows learn to communicate complex scientific issues for the lay public. They are provided a stipend of $8000 for the summer, plus travel expenses to and from AAAS and their media sites.

I worked at the Oregonian in Portland and had a tremendous time learning how to write and edit effectively. I also gained an appreciation for the impactful influence journalists can have on medical and public health topics. The Mass Media Fellowship is really an amazing program.

Applications for this year's AAAS Mass Media Science and Engineering Fellowship just opened on October 1 and will remain available through January 1, 2024. Check eligibility requirements and apply here.

Medical and Dental School Interviews: Preparing for your MMI

Although the majority of medical and dental school interviews are still traditional, some institutions utilize a multiple mini interview (MMI) platform. The MMI is a format that uses several timed stations to assess applicants' interpersonal skills and judgment.

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, an ability to diffuse a heated situation, a capacity to admit wrongdoing, or reporting an impaired supervisor.

It's important that you practice MMI questions before you go to your medical or dental school interview. Even if you have excellent social skills, there are techniques you should hone to expertly manage the challenging MMI format.

Get y'ERAS in Gear

Last week (on Wednesday, September 27) program directors began reviewing MyERAS applications and MSPEs. Residency applicants often ask me about the timing of ERAS submissions. These are my thoughts:

1. Yes, getting your ERAS in early helps. As one of my program director friends points out, since the residency application is arguably one of the biggest steps in one's medical career, getting the application in as early as possible should be a given. 

2. On the other hand, if your application is not in its best shape, then waiting a week (meaning this week) is preferable to submitting a suboptimal ERAS that will be tossed into the "do not invite" pile. I would suggest not going past this week, however.

Contact me for help with residency mock interviews.

AAMC Virtual Medical School Fair

For those of you applying to medical school this year or next cycle, the Association of American Medical Colleges (AAMC) is holding an online medical school fair on October 17 and 18. Topics for the first day include financing medical school, combined degrees, and a timeline for application. On the second day, medical schools and student groups will be available to answer questions. I'm registered and looking forward to the conference. Of note, if you've not yet subscribed to the Medical School Admissions Requirements (MSAR), you should wait until you've signed up for the fair, as your registration will include a 15% discount on the MSAR database.

15 ERAS Tips to Boost your Residency Candidacy

Below are tips I've cultivated over the years for crafting the best ERAS Experience Section. (Please remember that this year's ERAS is slightly different from past years'. For more information on the changes, click here.)

1. Include relevant pre-professional accomplishments from college. If you conducted research, for example, list and describe it. Do not include high school achievements unless they were truly unique (worked at the White House, sang on Broadway, published in Nature ;)).

2. As of this year, you have only 10 slots, so avoid minor activities (like an afternoon health fair). 

3. Write in a streamlined fashion. Avoid verbiage. Of note, as of this year, you can choose three most meaningful activities, but you only have 300 characters for each. So while you want to explain why the activity was impactful, you'll need to keep your writing here especially tight.

4. Use full sentences. It’s a formal application, and you want to make your written materials as readable as possible.

5. Avoid abbreviations. Ones you think are common might not be familiar to the reader.

6. Avoid contractions; they are too informal for an ERAS. 

7. Make sure you spell out your accomplishments clearly. If your reader doesn’t understand an activity, you won't get “full credit” for what you’ve done. Make no assumptions - not even that the reader has reviewed the experience's introductory information (position title, location). 

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

9. Use numbers to be persuasive. Saying that the conference you organized had 500 participants says a lot.

10. 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.

11. Do your best not to leave the "Medical School Awards" section blank. Even if you have to simply include clerkships in which you obtained honors (or high honors), fill that section out.

12. If you have not already, consider joining your specialty's national organization and listing it under the "Membership in Honorary/Professional Societies" section. If you are applying in two fields, take this advice, though. 

13. Try to end your entries with a sentence about how the experience you just described will help you as a future specialist. Making that connection for the reader furthers your candidacy. 

14. As with all good writing, avoid redundant language. Having the word "research" three times in two lines is distracting and demonstrates a lack of originality. 

15. Get help. Don't submit your residency application without having it reviewed by someone with a lot of experience. You do not want to put forward suboptimal materials for a process that is this important and competitive.

 

AI-Generated College Essays

"I hope this letter finds you well..."

When my family and I played around with ChatGPT - asking it to craft silly letters to different people – every ChatGPT response started with that phrase. I quickly realized that originality is not ChatGPT's strong suit.

On top of the fact that most institutions consider AI-generated essays to be unethical (even plagiarism, at Yale), an applicant's ability to write something distinctive (and persuasive) is really what demonstrates his or her worthiness for competitive university spots.

I found this amusing New York Times piece called, "We Used A.I. to Write Essays for Harvard, Yale and Princeton. Here’s How It Went" reinforced my strong distaste for AI-generated personal statement writing.

Although challenging to craft, your written materials are a tremendous opportunity to showcase your creativity and further your candidacy.

Medical School Interview Tips: What Do Admissions Officers Really Want?

Congratulations to those who have already been invited for medical school interviews. It's early in the season, so if you're an applicant who hasn't been invited yet, don't be dismayed.

Getting into medical school has gotten so competitive; the interview is critical. But what are medical schools looking for during the interview process?

1. They are seeking someone distinctive. Your goal is to distinguish yourself from all of the other applicants by showcasing your accomplishments. Anyone can say s/he wants to help people or is hard working. Fewer candidates can prove it with their pre-professional achievements.

2. They want to ensure you're committed to medicine and that you have an idea of what you're getting yourself into. Medical school is tough; the institutions are not seeking someone who is ambivalent and might quit. Giving examples of your clinical experience can help.

3. The schools want to ensure you're reasonable. They want to see that you don’t have a problem personality, aren’t going to harass your colleagues, aren’t going to cause them embarrassment or extra work. Being professional during the interview day and having strong letters are important.

4. They want to hear you're particularly interested in their institution. You can convince them of your interest by knowing specifics about the school and city.

One would never take the MCAT without practicing first and yet, countless applicants go to medical school interviews without preparing. If you are interested in working with me, please hire me soon, as I'm booking up for September. 

How Might the Supreme Court Decision about Affirmative Action Affect Medical School Admissions

The American Medical Association (AMA) recently sponsored an interesting webinar on how the Supreme Court affirmative action decision might influence medical schools. Invited faculty included representatives from the AMA, Accreditation Council for Graduate Medical Education, Association of American Medical Colleges, University of California (UC) Davis Medical School, and Meharry Medical School. I recommend listening to the recording or reading the transcript. (You can get CME credit for doing so, as a bonus.) 

There are a few points I found particularly interesting: 

1. An African American physician has a likelihood of seeing African American patients at a rate that is approximately 23 to 24 times that of a white physician.
2. Among first-year medical students, 62-63% of African American pupils say that serving an underserved population is what they want to do when they finish their education, whereas white and Asian students are in the twentieth percentiles in reporting that they want to serve those same populations.
3. UC Davis Medical School is employing multiple, creative techniques to improve diversity at their institution, including implicit bias mitigation training and the implementation of a medical school track called Avenue M – focused on applicants who went to community colleges. Consequently, at UC Davis, over 50% of students coming from disadvantaged or underrepresented-in-medicine backgrounds make up their classes.

You can find the AMA webinar and transcript here.

Medical Debt Can Be Crushing

I recently saw a short piece in US News that reported that the average debt among medical school graduates who borrowed for their medical education was $184,000, excluding undergraduate loans. 

There are many reasons to think hard about a career as a physician, and monetary ones are first or second on the list. For those with severe financial need, the AAMC offers their Fee Assistance Program (FAP). (Please note that I also offer a discount for those who have a current FAP grant.)

Most applicants, however, don't qualify for the FAP and may be looking at hundreds of thousands of dollars of debt after they complete their medical education. For many reasons, make sure that a career as a doctor is the right one for you.

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.