Snow from the Sky

Janna-header3

“Wow! It’s snowing from the sky!” A novelty for those of us that only see snow spraying up from the ground at ski resorts. My husband and I (we got married over Christmas break) traveled to Kettering, Ohio for our inpatient internal medicine rotation. We had an amazing experience, learning lots and meeting many new people.

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On our flight over, we met three cool fourth years––Chas, Amanda, and Stephanie––who helped show us the ropes on how to prepare for rounds. Julie Dicken had everything we needed from food, transportation, housing, and our schedules organized and readily accessible. Dr. Fershko also met with us on our first day and was an enthusiastic proponent for our education. The residents also kindly took time to go over our notes and give mini-lectures, and our attendings guided us through patient management and relations.

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Throughout our stay, we saw a diverse patient population from drug seekers and ruled out chest pain to AML and SLE. We experienced patients who loved us and those that might have loved us if we had given vitamin D or “dilala” (dilaudid). We were able to celebrate with patients that recovered and for those that passed away, tried to stay strong for the families left behind. Our academic knowledge and interpersonal skills drastically grew in three short weeks.

All too soon, we were heading home. Bundled up to avoid the 5 minute frostbite (Anthony looks better with both ears), we drove through the snow, falling from the sky, our white Christmas for the year. We were sad to end our great experience and say farewell to our new friends.

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Dating and Letters of Recommendation: An Allegorical Tale

Ryan, Fourth Year Medical Student

One of the main components of the residency application package is the Letter of Recommendation. In orthopedics, programs require at least three, with one being from the Department Chair of your home program. Some require four. Other letters, besides the Chair’s letter, are accrued from other faculty and from the rotations at other programs. But getting a letter of recommendation is much easier said than done. When I did it, I had post-traumatic flashbacks to being an awkward high school (and college) student asking a girl on a date. Let me explain.

The first one is by far the most difficult. First, you have to pick your target. Most likely it will be the person you spend the most time with, or the person who is most valued by other people.

This is something important enough that it should be planned. You find yourself focusing on the little details. “When is the best time? I should wait until she’s in the best mood. Maybe after a good case. What if she says no? Will it be awkward the next morning? Should I save it until the last day I’m going to see her for awhile? But then what if she’s in a bad mood?”

You finally decide the day you’re going to ask, and as the time approaches, you watch for opportunities. You know you should try to catch her alone, preferably in a private place, and with no other potential suitors around (though be careful not to come across as creepy!). This will lighten the pressure to say yes, because it’s important to give her an out.

Aha, the perfect opportunity! A conversation with a coworker has just ended, and she is collecting her things to leave. You approach, forcing a confidence to your step. Just as you are about to open your mouth, another person speaks up from across the room. Thwarted!

Now you have no other reason to be standing there. You grab a nearby chart and act as if you are brushing up on a history. But your heart is pounding so loudly in your ears you can barely hear when she’s done talking. “Are they winding down? Should I interrupt?” you ask yourself.

You’ve planned your words, planned to phrase the request in a way that lets her know you’re serious and interested, but that it’s ok for her to say no. You know what you look like saying it because you’ve practiced it in the bathroom mirror. Don’t put your hands in your pockets. Stand up straight. Stop blinking so much.

Finally, she’s alone. You look both ways and cross the office. Your voice cracks. Should have taken a sip of water right before. But is a crack better than a slurping sound? Will this hurt my chances? Too late now.

You call out her name with an expectant upswing at the end. She turns, and you see the look on her face. She knew it was coming. Expected it even. Is that good or bad?

There’s the falter, the stutter, and finally the request. “Of course” is the answer, as if it was silly of you to even ask. “You’re great” is all you hear, and you stammer out an awkward “so are you.” The details are worked out, and she extends her hand. You pull it out of your pocket, the only place that could hide the nervous shake. You turn and walk quickly away before she changes her mind.

Success!

Fortunately, it gets better after the first time. It’s still nerve-wracking, but at least you’ve seen what works (or what doesn’t…).
By the second letter you’ve refined your words, but the setup is still awkward.
By the third, you’ve gotten your timing and your ice-breaker down pat, with a clincher statement and a winning smile. The success of the previous two yes answers has gotten you to the point where your voice no longer cracks.
On the fourth try you change your inflection so it’s not so rehearsed and wooden.
The fifth time is just about tweaking your body posture.
By the sixth, you will have enough confidence to walk up to any attending and say “Can I get your letter?”

The best, though, is when you are offered one.

My Secrets to 4th Year Success

Christine, Fourth Year Medical Student

Hello!  If you have been following along with my posts, you already know that I am a 4th year medical student here at Loma Linda University.  I recently matched to Loma Linda University Preliminary Internal Medicine and University of California San Diego Neurology Residency, and I am still super excited!  It feels great knowing that my lifelong dedication has paid off.  Throughout the year, some students have been asking for my advice, and I have been doing my best to share what I know.  Honestly, I’ve gotten overwhelmed by all the questions, so I decided to make a MEGA post to address the topics that I feel are important for success in the 4th year of medical school.  Anything not on here that you want to know, I suggest you find on official sources.

Note: Please take my words with a grain of salt.  I consider it important to be prepared for worst case scenarios, so I give people practical advice.  These are all my opinions, not necessarily the opinions of Loma Linda University, any particular faculty members, or my classmates, and my opinions may not apply to everyone.  For more of my thoughts, please read my past posts.  What I write may not work specifically for you, but this is what worked for me.

The best thing you can do is figure out your game plan yourself.  Talking to your deans, faculty advisors, and residents is helpful.  However, don’t count on anybody to spoon feed you information about every little thing.  Look at the official NRMP, ERAS, specific program websites, etc. to give you the basics.  If you got into medical school, you are smart enough to find these resources and use them to your advantage.  It will be your personal interactions at the interviews and discussions with your loved ones that will help guide your decisions.  This is your future; grab hold of it.  Now that I’ve successfully matched, I am excited for my upcoming graduation and to start my journey as a medical doctor!

Before 4th Year

This is a no-brainer, but I suggest you study hard on all your classes and rotations.  You will be amazed how much better you understand clinical care with a strong basic science foundation.  In addition, grades and comments from basic science and clinical years will be on your Dean’s letter that is sent to the programs you apply to.  Your Step 1 score and class rank do matter, especially if your goal is to match to a well-known institution and/or competitive specialty.  It’s not all about scores and grades, but some programs will not know how awesome you are unless you pass their filters.  There are way too many stellar applicants from all over the country vying for the same spots.  Red flags, such as failing a year of medical school, will limit you.  Unfortunately, if you have a red flag, you do not have the luxury of being picky.  Don’t expect to match to a top program if you are not a top student, but of course, you can always dream and apply everywhere to see what happens.  If you can afford it, go for it because it is hard to predict what programs are looking for.  God does work miracles.

Always strive to learn and improve.  Be appreciative of what God has given you.  Not everybody is given the chance, nor the capacity to be a medical student.  While you are in medical school, find some time to give back to others if you can.  Offer whole person care to every patient that comes your way.  It does take more time, but touching a patient’s life in a special way is invaluable.  Being a doctor is not just about having an immense amount of knowledge, but also taking care of people.  At the same time, don’t prioritize extracurricular activities over academic difficulties.  Achieving a balance is difficult, but that is something that you will have to learn to do.  Unlike other professionals, a physician’s job does not end when the clock ticks a certain time.

4th Year Schedule

What electives should I take?

Honestly, 4th year is your time to do whatever you want, and nobody really cares what you do with your schedule as long as you meet the requirements to graduate.  During your 3rd year, you will receive an information packet on the requirements you need to meet.  Read that carefully.  Refer to my first blog post, Exciting Choices in 4th Year, if you want to know what electives I chose.  However, my schedule has changed several times, so don’t worry if you are not exactly sure how you want to schedule everything.  I did not finalize my entire schedule until February 2013.  Some of my other posts also detail experiences from electives if you want to know more of what I think.

When should I do sub-internship/specialty of interest rotations?

You should do your rotation early enough to solidify your interest in a particular specialty and get recommendation letters.  The earliest you can submit residency applications is mid-September, so anytime in July or August is good.  Doing it early is also helpful if you are unsure of what specialty you want to go into.

Should I do an away rotation at a program I am interested in?

This is entirely your decision.  It may or may not help.  I have heard stories from both sides.  Some people matched at places they did away rotations.  Some people did not even receive an interview at places they did away rotations.  I didn’t do any away rotations for neurology programs, so I don’t know what it would have done for me.

When should I schedule vacation?

It’s up to you how to schedule.  Interviews can be anywhere between October and February. The majority of interviews are in November, December, and January.  I took off 2 weeks in November and 2 weeks in December.  Most students also take off April or May for traveling or just having fun in general.

When should I schedule tests, Step 2 CK and Step 2 CS?

Schedule them whenever you feel you will be ready.  They just need to be taken by LLU’s deadlines.  Refer to your information packet.  I took Step 2 CK in July to get it over with and so that it would be available before I submitted my residency applications.  I held off until December for Step 2 CS because I needed more time to get ready.  I think I might have written about these tests in a previous post as well.  All the information about these tests are on the official websites.

How should I study for Step 2 CK?

If you already took Step 1 and successfully made it through 3 years of medical school, you should know your study strategy.  What worked for me was practice questions from USMLE World and a review book, Step up to Step 2.

How should I study for Step 2 CS?

The most important thing to do is practice.  Grab a classmate and grab a book with practice case scenarios, such as First Aid to Step 2 CS.  Time yourself through the practice sessions.  You want to be done with the history and physical portion before the 5 minute warning.  After the H&P portion, time yourself writing a physician’s note.  Compare it to the book’s examples.  Another important aspect of Step 2 CS is empathy.  Treat the standardized patients like a real patient that you care about.  If you need more help, talk to the PDX office.  They are great at offering tips and helping you improve.

Applying for Residency

How much money should I save?

Interviews and 4th year in general are expensive. First of all, Step 2 CK and CS are about $2,000. Applying to programs can be about $500. You can check the prices on the ERAS website. I think it’s better to apply to more programs than you need to because it is hard to predict who will offer interviews.  I think it’s reasonable to save at least $5,000 for travel. It’s better to have more money and not use it than to have to cancel an interview at a place you really want to go to.

When should I create my CV?

ASAP.  There are sample CVs in the Dean’s office.  They also give you a sample copy during your 3rd year.  Follow that format.

When should I write my personal statement?

Do it early.  Start before September.  An articulate and well thought out personal statement actually takes longer than you expect.  I gave some advice about personal statements in my previous post, 4th Year Rotations and Residency Applications.

Who should I ask for recommendation letters?

This may vary, depending on your specialty. At least 1 letter must be from your specialty of interest.  1 should be from a core rotation like internal medicine, surgery, peds, etc. if you can get a strong one.  If not a strong letter, then choose whoever can write you a strong letter.  The last can be from any doctor.  Quality is very much more important than quantity of letters.  3 letters is good enough.  My advice would be to ask for them early.  You need to have a CV and personal statement ready by August, so that you can give them to letter writers.  If possible, the goal should be for the letters to be available by the 1st day of submission.

When should I start my application?

Start it before the first day of submission.  It can take at least a few hours to complete.  Make sure you double, triple, etc. check it before you submit.

When should I submit my application?

Submit it on the first day if possible.  I suspect that interviews are given on a rolling basis.  I submitted my application on the day that it opened, September 15, and I got my 1st interview invite on September 18.

What programs should I apply to?

My main advice would be to apply broadly and realistically.  Although I matched to an amazing spot, I didn’t even get interviews at some of the top programs I applied to.  As someone who prepares for worst case scenarios, I think it is extremely important to also apply to non-competitive spots.  That means outside of desirable areas in California, outside of the Ivy League, outside of any place that most people would be impressed with.  What is considered non-competitive also depends on your individual Step 1 score and grades.  This information can be found on the NRMP reports and talking to the experienced deans/faculty advisors.  Some people in my class did not match, and unfortunately, I don’t think that every student found a job in SOAP.  Your goal is to make sure that you apply smartly and go to enough interviews.  Yes, it is all expensive, but if you don’t get a residency position, you won’t have a job.  A job in some random place is much better than no job at all.

How many programs should I apply to?

This depends on what specialty you are applying to and how reputable the programs you apply to are.  For any specialty, I would recommend applying to at least 20 programs.  This is assuming that some of the programs you apply to would impress a layman.  I tend to be more on the cautious side, so I think you should apply to as many programs as you can afford.  If you are applying to well-known places, you need to apply to extra.  As a warning, just know that no matter how competitive an applicant you are, you will inevitably get rejected by programs.  Consult your deans and faculty advisors if you need help.  They have years of experience in helping students succeed.

What do you think about neurology programs?

Well, I think that neurology is the best specialty!  Some programs are categorical with all 4 years.  Some programs are advanced and also need an intern year.  You need to weigh the advantages and disadvantages yourself.  Applying to advanced programs means you have to spend extra time and money interviewing for preliminary spots, so prepare for that if you are planning to do so.  It is all personal preference, and no one can tell you what you should do.  After learning about different neurology programs, I found most programs are more or less the same with differences of prestige and location.  I thought that every neurology program I interviewed at was great in their own ways.  Everybody has different reasons for why they like or dislike something.  This is something that you will have to figure out on your own.

What are my chances of getting an interview and/or matching at a certain program?

I don’t know.  If I could predict the future, I would be rich by now.  The only way you will know is to apply.  The top programs obviously favor applicants with high board scores, above-average class rankings, and no red flags.  If you are not restricted by finances, then apply and leave it up to God.

Interviews

How much money should I expect to spend on interviews?

For local interviews, it will be gas price unless you stay at a nearby hotel, which could be $50-100/night. I think West Coast interviews by plane with hotel/ground transportation is may be about $300 each. Midwest and east coast may be about $500 each. It depends on if you can get some deals. Southwest was usually cheapest for flights, but for flights and hotels, it’s good to shop around. Look at the company’s site, priceline, hotwire, hotels.com, etc. to find the best deals. If possible, you can try to group interviews in the same region but it’s hard and doesn’t usually match up, so don’t count on it.

How many interviews should I go on?

I don’t have a clear answer, but I recommend aiming to go on at least 10 interviews.  The worse of an applicant you are, the more interviews you should go on.  If you get fewer than 10 interview invites, you should go to all of them.

How should I prepare for interviews?

Be yourself.  I wrote about interviews in a previous post, What It’s Like to Go on Interviews.  You can refer to that if you’d like.  There is also a practice interview session offered by LLU.  Go to that.

Should I contact programs after I have interviewed?

It is up to you.  I sent some thank you emails and some thank you cards.  In the end, I don’t know if it made any difference.

Match

How should I rank programs?

This is entirely your decision.  Please read the Match algorithm on the NRMP’s website if you are unfamiliar with how the Match works.  It explains things better than I possibly can.  Pros and cons of each program need to be decided on by you.  Don’t depend on others to spoon feed you their opinions.  Everybody has different personal reasons.  I ranked programs based on my overall feelings and desire to attend them.  This is not something I can describe, but you will have to experience it for yourself.

How does the SOAP work?

I do not know, and I do not want to know.  Luckily, I did not have to know.  I’m sure you can find this information on the NRMP website if you want to know.

What is Match Day like?

Please read my post, Some Thoughts on Match Day! for my thoughts on Match Day.  Also, watch the Match Day 2013 video, which is featured in my last post, Ice, Eyes, and Nice Comments!  Match Day is just simply the best day of medical school for me.

How do you feel about your match?

I am very happy!  I can’t believe I matched to such an awesome place!  I am excited that I get to stay in Southern California and be near my family for all of my residency training.  I feel blessed to match to UCSD’s neurology program.  I also feel blessed to stay at LLU for my intern year.  After 20+ years of nonstop schooling, I will finally start my first job soon, so I am grateful that I get to have my parents around to support me with my transition to the working world.  I know that this is where God wants me to be, and I am thankful for His wonderful plans for me.  I feel great knowing that all my dedication and hard work have paid off and that my dreams of becoming a doctor are coming true.  At the same time, I feel like wherever I matched, I would be a bit sad that it wasn’t one of the other programs because I enjoyed all my interviews and loved meeting people everywhere.  In a way, I’m glad that I’m not the one who makes the tough ultimate decision of where to train next.  Overall, I feel like this is the best time of my young life so far.  I am looking forward to many more special events to come during my lifetime. 🙂

My Final Thoughts

Making it to 4th year of medical school is already an accomplishment.  The first 3 years of medical school are very difficult, and only people who have been through it will understand what it takes.  Be prepared for new challenges in your final year.  Never stop learning.  You still need to give it your best on every rotation.  Treat every patient like they are a VIP.  You will also have more well-deserved free time than in other years of medical school, so spend time with those you love.  This is the last year for a long time in which your time is truly your own.

When seeking residency positions, it is better to play it safe, but reach for the stars if you can afford it.  Even if you think you are a desirable candidate, not everyone will agree.  The money you lose from applications and interview experiences is extremely miniscule compared to the huge disappointment of not matching.  Have fun on interviews.  Be nice to everyone you meet.  Be yourself.  Form your own unbiased opinions.

Enjoy 4th year.  Have fun.  Do things that make you happy.  Hang out with your family and friends.  Don’t worry about every little thing.  Get comfort from the ones who will be there when no one else cares, your family and God.  Remember that God has brought you this far, and He will be faithful.  No matter where you end up matching and even if it does not work out the way that you want, remember that what God chooses for you is even greater than what you choose for yourself.

How To Have Fun

Kari, Fourth Year Medical Student

I’m going to admit something that makes me feel kind of lame: I think I’ve sort of forgotten how to have fun.

The swing at the playground by my apartment.

Don’t get me wrong, I’m completely enjoying my life, but these final months are kind of a weird time in our lives. We fourth years are pretty much done with interviews (see my post on that here), and lots of us are doing electives that are of interest to us.

Now when I go to work I’m excited to be there and when I come home, sure I’m reading on my patients, but I’m not trying to keep up with a mountain of classes or study for a Board and there’s nothing left to do for applications but wait for Match Day in March.

And so I have free time.

Like, daily. 

What? Yes it is weird.

We worked really hard to reach this point. Long long hours in the hospital, overnights, never seeing the sun, so many tears shed over Pathophysiology––I know it’s not just me––and so much stress and travel to get that rank list ready.

And now I find myself startled by the small amount of stress in my life. Which looks SO silly when I type it, but it’s really brought home for me the fact that it’s been a long time since I had time for fun hobbies and I’m not even quite sure of what I really like to do. But I am completely caught up on quite a lot of TV shows right now, and I’m doing my best to try new things.

I might be mostly alone in this, but in case I’m not, I just wanted anyone else who’s feeling this way to know that it’s okay that we don’t remember what we used to do to have fun––we’ve been busy.

And now?

I get to see my friends outside of the hospital AND I get to see my husband.

I’m training for another half-marathon. This was the view from Smiley Heights on my run this morning.

I also bought a fish. It’s a baby betta. If we don’t kill it, it’ll grow up. Her name’s Victoria Dragonslayer, but I really have no idea if she’s actually a girl.

And sometimes I bake. I got out the Kitchenaid Mixer we got for the wedding and it made some sweet banana bread.

These are mostly things I’ve liked to do throughout my time in med school, and I feel weird but completely blessed that I have some time for them as we come up towards the end of these 4 years.

After all, residency will come soon enough.

Back to the Basics: Senior Anatomy Project

Does one ever truly forget the scent of phenol & stainless steel of the anatomy lab? It had been 3 years away from that distinctive aroma, but I got a good reminder 2 weeks ago  when my senior anatomy project kicked off. Apparently I am one of three seniors whom are the first batch to undergo a project this school year. I highly recommend this Basic Science elective, as I spent a whole lot of time lounging in the anatomy library fiddling around on my computer (and working on my presentation, I swear).

4th year students are required to choose a 2 week Basic Science elective. This could be in Anatomy, Pathology, Pharmacology, Pathophysiology, etc. Typically the surgical-minded people opt for Anatomy, as you get to dissect & perform procedures without the risk of mortality. For this elective, you choose one of our esteemed Anatomy professors, propose a project of whatever you desire, and then present your work to the Anatomy department at the end of the 2 weeks. You get to work at your own pace, as long as everything is done by the second Friday.

For my elective, I chose Head & Neck with Dr. Nava. Being that I am a bit squeamish working around the no-longer-living bodies, I tried to pick a project that would keep me away from the face, as working face-to-face can be a little ……. unnerving. I asked around to other students and a few surgery residents about which project to pick and finally decided upon a two part project: tracheostomy + central venous line placement. Still located in the neck, but I could keep the face covered up while I worked. My proposal was accepted and I got straight to work.

Ah, that strong chemical scent, which I soon realized I was quite possibly allergic to. Regardless, I spent the vast majority of the beginning of the first week attempting to shove a central venous catheter into a rock hard subclavian vein. I was unsuccessful,  so I had to stage it for the photos (fake it ’til you make it). One of the most important parts of this project is meticulous documentation. You need to take many, many photos of each and every step (even if those steps don’t really work out). These photos make up the basis of your final presentation, and without a decent variety of pictures, the presentation will lack pizzazz.

Unfortunately, all the bodies we had available had already been trached by the Emergency Medicine department, so I had to wait on a new body being pulled for the second part of my project. This gave me plenty of time to work on my final presentation, and leave me some much needed free time during the weekend. After just completing 12 weeks straight of fairly intense Surgery electives, this elective has been wonderful. No waking up at 3:30 am, or returning home past 7:00 pm. 3 meals a day as opposed to 1 meal and maybe a scarfed down granola bar between OR cases. Now, don’t get me wrong, I thoroughly enjoyed those rotations, but I have also enjoyed catching up on my sleep deficit!

During my second week, I was able to work on a different body for the tracheostomy portion of my project. Malcolm was working on the other end, so together we made a pretty good team. The body ended up with a simultaneous trach, hysterectomy, and a sub-urethral sling, but both of us received great working knowledge of neck & pelvic anatomy.

Overall, I would say all of the final presentations went very well. A GYN attending came in to assist Malcolm Hardy with a hysterectomy & sub-urethral sling, and Eden Yoon (who is going into Opthalmology) dissected an orbit to show off the relevant anatomy. Since I am unable to post photos of our dissections, I wanted to get a few pics of our presentations. Unfortunately, dimly lit room + old iPhone = grainy/blurry photos. And Dr. Nava, bless him, just couldn’t quite get a perfect shot of us 3 amigos. But even blurry, you can see the smile of satisfaction on our faces of an elective successfully completed.

Pneumothorax – one of the many complications from placing a central venous line.

Explaining the “digestant” system.

A gift from a classmate from a LA 99 cent store. Last time I checked, the duodenum didn’t connect directly into the transverse colon…

Dr. Escobar’s face after I graciously offered her the chance to use the “digestant” system as an anatomy lab teaching aid. Clearly the rest of the professors are equally thrilled.

Malcolm giving a great run-down on how to start a C-section.

The three very blurry amigos: Malcom, myself, and Eden