The Residency Match Part 3

How Not To Match

Let me state the obvious. There are many kinds of doctors and depending on your specialty you will have vastly different experiences in your medical career. Ideally you want to select a specialty in which you are interested. It doesn’t need to be a passion or even a calling but you have to be able to see yourself getting up in the morning for the rest of your life and doing it.

The selection of a specialty is often made by exclusion. I found for example that I absolutely detested rounding so I wasn’t too keen on internal medicine. Some people dislike the OR so surgery is definitely out of the question. It is also difficult to get excited about pediatrics when children make your skin crawl.

You usually narrow down your choice of specialties to a short list of things you like and refine it from there. By “like” I don’t necessarily mean that you are crazy about it, just that the combination of the potential income, lifestyle, and character of the work exceeds some threshold. I can’t believe that most people go into dermatology because of a lifetime interest in rashes. I’m sure derm is not boring but the easy residency hours, good pay, and lack of call probably carry a lot of weight with the academic heavy hitters who match into it.

Or you can go through medical school and find that you really don’t like any of those things you swore in your AMCAS personal statement drove you to apply to medical school. Achieving sainthood seems like a good idea before you actually start working with real patient. You will pick your specialty accordingly maybe deciding that radiology besides being interesting and kind of cool limits the amount of time you will actually have to spend talking to patients not to mention managing their health problems.

Of course, you may have your specialty picked for you by default because you have not positioned yourself in medical school to match into anything other than the typical non-competitive specialties. Matching into some of them requires only a pulse and the desire. Everybody can and does match into something, just not necessarily what they really wanted to do.

A word about specialties and their competitiveness. Some specialties are notoriously hard to get into. Dermatology is one. Radiology is another. Urology, interestingly enough, is also super-competitive and they even have their own match. (Not the NRMP). I’m going to give you my limited opinion on various specialties in a later post but suffice to say that it is a combination of intellectual rigor, potential income, prestige, work hours, and the number of available programs which determine a specialty’s competitiveness. Family Medicine as an example enjoys low pay, little prestige in the medical community, and the easy availability of residency positions almost everywhere. Therefore, although there are some individual Family Medicine programs which are pretty competitive the specialty itself is not and you can always scramble into a spot if you don’t outright match into your first or second choice.

You have to use a little common sense when looking at the competitiveness of a specialty. On paper you might say that Dermatology and Family Medicine are equally competitive because almost everyone who tries to match into either specialty is successful. This is true but self-selection plays a pretty big role in who applies to what specialty. The top students in you class will apply to Dermatology programs and get interviews. The bottom feeders can apply until their computer starts smoking but they will get few if any interviews and their chances of matching are slim to none. Although they’d like to have a cushy high-paying job as much as anybody else they usually save themselves the application fee and apply to less competitive specialties.

So you see while “P=MD”, you might develop a preference for one specialty in fourth year and spending your first three years in medical school just going for the pass might limit your options when it comes to matching. Grades do matter, as does class rank. All other things being equal it is the person with the higher class rank or the higher board score who will both get the interview and be ranked higher by the program. Most competitive residency programs even screen by grades, board scores, or class rank.

The number one way not to match is to get low grades and even worse, low USMLE scores. Many people enter medical school having bought into the premise that they should do something in primary care. Good grades and high class rank are not necessary to match into most of the primary care specialties so this is used as an emotional crutch during pre-clinical years. After all, I’m just going into Family Practice, I don’t need good grades. (But bear in mind that the best family medicine programs are pretty competitive in their own right.)

If you change you mind about your intended specialty you may find yourself in a new higher weight class where you are no longer very competitive. You may get some interviews but not enough to match as you will invariably drop off the end of your rank order list. Not every interview goes well. If you only interview at a few places if one or two places decide not to rank you all of a sudden you are pinning your hopes on the one place that liked you well enough to rank but not enough to rank at a spot likely to match.

A pass is not good enough. Get the best grades you can to keep your options open.

Now. Those of you who are at the top of your class go surf for some porn or something for the next few minutes. What you are doing reading my blog is a mystery as this is the home of the average, blue-collar medical student.

When it comes to applying to programs, don’t be squeamish. Apply to enough programs to get enough interviews to increase your chances of matching. And unless you absolutely despised a program and you are certain you would only last a week or two there before you killed somebody and ran screaming into the bayou, rank every program where you interview. Seriously. When you don’t rank a program what you are saying is that if it came down to it you’d rather try to scramble into a better program, sit out a year, or scramble into one of the unpopular specialties none of which are very good plans.

First of all, if you couldn’t match into your specialty, the scramble is not exactly going to be a cake walk. Most competitive specialties fill and if they don’t there are plenty of people better qualified than you who will probably get the few open spots. I’m sorry. I’m the biggest optimist in the world (I mean I did risk everything this year to match into Emergency Medicine) but you probably won’t get the open spot for the same reason you didn’t match.

Don’t count on the scramble.

As for sitting out a year, don’t do it unless it is for something that you can justify the next time you apply. “Took a year to set up a TB clinic in Moldavia sounds pretty good. Hung around the house playing video games not so good. Almost nobody outright sits out a year if they don’t match. What most people with any sense do is scramble into what is called a transitional or preliminary year. Most Medicine and General Surgery Programs have a number of one-year positions available every year in addition to their Categorical spots. The preliminary year is separate intern year with no guarantee of any further training at that institution. The advantage of doing a preliminary year is that some programs require one and even if you had matched you would have still had to have matched (or scrambled) into one. On your next attempt you would have this year under your belt which is not a bad thing. Your preliminary year is also a time to get new letters showing that despite your class rank, you are a real hard-charger. This is not a bad thing either.

Some programs do not require a preliminary year so if you match, you will have to repeat your intern year.

What not to do, and what I am sorry to say I did after not matching, is to throw in the towel and on the spur of the moment decide to lower your sights by scrambling into something safe which you either never considered or were ambivalent towards. I never really disliked family medicine but I never liked it enough to consider it as a career. I was pretty demoralized after not matching into Emergency Medicine and as I had just had my 40th birthday I was pretty sure I was finished. So it looked like the easiest thing to do, especially as the scramble was definitely not going my way.

What can I say? I didn’t have a plan. If I had stepped back and considered things for a second I would have walked upstairs to my school’s medicine department and taken one of their preliminary spots of which they always have a surplus. What I have learned since then is that I would rather quit medicine and go back to my previous career (structural engineering) than spend my life in a medical specialty to which I was always cool toward and of which my opinion did not improve by closer association. Still , I accepted a categorical position because I felt, and see if you can spot the irony here, a preliminary position would be a wasted year and I might as well get started on my lowered career goals today.

Folks, its only a year. 365 days. For all the trouble it took to apply and interview as a categorical intern not to mention the hurt feelings and the awkwardness of appearing indecisive when I told my program it wasn’t worth it. Not by a long shot.

Another thing to consider is that you are only fully-funded by Medicare for the length of the first program into which you match. Since I matched into Family Medicine which is three years and am now going to Emergency Medicine which is also three years, I am only fully funded for two years of the new residency and half-funded for the third year. Some programs, particularly large academic institutions don’t really care about this because losing a little money on their residents is not an issue. For some smaller programs it might be a deal-breaker. I was told by several programs that they would not consider applicants who weren’t fully funded.

I am unsure of the how this rule applies to preliminary positions so do your research.

Bottom line:

1. Keep your options open. You will change you mind about specialties. Better to have the grades and scores to match into Opthalmology but decide on family medicine than the other way around.

2. For God’s sake suck it up and do a preliminary year, especially if you are young. One year measured against your career is insignificant. Not to mention that you will be a pretty confident intern if you have to repeat your first year.

3. On the first day of medical school, with the usual allowances for the occasional dumb-ass who slipped through the cracks, anybody can do any specialty. You might have to apply yourself a little harder but you can do it.

Coming Soon: My totally biased, non-scientific, take-it-for-what-you-paid-for-it opinion on various specialties in which I try to debunk some of the hype surrounding primary care.

Caution: Not to be read by zealots or compassion fascists.

The Residency Match Part 3

The Residency Match Part 4

Doing it the Hard Way

So I didn’t match last year and scrambled into a categorical position in Family Medicine. A categorical position as opposed to a preliminary position guarantees you a position for the total duration of the training for your specialty. It should be obvious that it is much more difficult to switch specialties out of a categorical position than out of a preliminary position. When you are in a preliminary position it is understood that you are either going to your primary specialty after your year is up or that you will be re-applying for the match. Your program director will not be shocked if you ask for time off to interview and you don’t have to explain yourself or apologize to anybody.

Not that you have to apologize or explain if you switch from a categorical position. You only sign a contract at any program for a year at a time so you are perfectly within your contractual rights to leave at the end of the year. However, since accepting such a position is a de facto acknowledgment that you intend to complete training your Program Director will naturally be surprised and not a little put out. From his point of view he will now have a hole in his roster which he may or may not be able to fill especially if it is a non-competitive specialty. Remember for all of the happy happy talk you may hear during orientation you are a low-paid and therefore extremely economical part of the health care team and your warm educated body is needed to by various hospital services to provide cheap medical labor. His program has service requirements which he must meet and you are kind of leaving him in a lurch.

Still, most big academic centers won’t grind to a halt if you leave. You can’t let your natural distaste for letting people down keep you from securing your own future. This sounds incredibly selfish but there it is. I just want you to see it from the program director’s point of view and add this to the reasons to let him know early when you decide to switch. Not only will this give him a longer lead time to re-work schedules but if you actually submit a letter of resignation he can start looking for someone to fill your empty second year spot.

I thought I was going to settle for Family Medicine and for the first couple of months of intern year I stuck to it even though I was becoming rapidly demoralized. I just didn’t like it that much. And if you must know I’m not crazy about Duke. Maybe once I get clear of the place and get some sea room I’ll tell you why. I decided to start filling out my ERAS application even though I hadn’t made a decision yet. In early September I asked my wife’s permission to switch specialties. I laid out my case and as certain things about the program and Family Medicine made her uneasy it was not a hard sell. Still, we had just moved three kids and five dogs along with all of our possessions across the country so she was not thrilled about potentially doing it twice in less than a year. Additionally, even though I was later of accused of never really intending to stay (using the Duke name as an “in” to other programs) we had bought a house and stood to take a bath on it when we moved.

My plan was to see if I got any interviews before telling my program. If I didn’t get any I would keep my mouth shut and suck it up as there is no point in needlessly rocking the boat. Unfortunately you do need a program directors letter so you have to tell your program eventually. By the middle of October, early in the process and before November 1st after which you can expect the bulk of your invitations to interview, I had already received four invitations which seemed to me an auspicious start. I told my program that week and then fought for the next three months to get time off to interview.

The interview season runs from roughly November to the first week in February. Unfortunately I had inpatient rotations during all those months. Inpatient rotations (or ward months) usually have call, rounding, and a lot of grunt work which needs to be done by the interns. Since your program has service requirements, basically an agreement with the hosting service to provide labor in exchange for training you, if you are absent someone from program has to cover for you. If you are sick they usually pull one of the interns off of an outpatient rotation where the presence of one intern is not so critical. I did two weeks of outpatient ENT, for example, and since all I really did was follow the attending around he was perfectly ambivalent to my presence.

One of the reason to tell your program early is to allow them time to switch the schedule around to give you at least one easy month, preferably January, in which to schedule your interviews. I was promised time off to interview, I dutifully scheduled most of my interviews as late as I could to give my program the lead time to switch the schedules, and then as January rolled around found that nothing had been done. Your program doesn’t have to do jack for you, you understand, as switching specialties is a personal problem. On the other hand you have got to interview or you will not match, simple as that.

This kind of left me in a quandary. As my abbreviated interview season rolled into view nothing had been done and no arrangements had been made. The assumption was that I wasn’t serious or that I would arrange my own time off with my fellow interns on the service switching call days here and there. This is possible but I’m not ready to stake my future on the generosity of people who are themselves overworked and whose schedules are so tight that they can’t possibly take a call day for you without seriously violating the duty hour rules. I think an attempt was made to shame me into not interviewing by threatening to make my colleagues who were on easy rotations suffer by doing my call.

This hit pretty hard because as a former Marine Infantryman if there’s one thing I never do is let somebody carry my pack. Everybody has their moral code and not burdening others is a big part of mine. Still, I had to interview so I was forced to go up the chain of command and ask for help above my program. This was not received very well.

Finally, I plainly told my program that if I didn’t interview, I wouldn’t match and if I didn’t match, there was no way I would stay in family medicine so under those circumstances I might as well just quit and go back to my original career. (Structural Engineering, as I have mentioned.) This is kind of a risky thing to do. I have been out of the engineering business now for almost five years, have an inactive Professional Engineering License, no contacts, and am five years out of practice. Getting back into business would take between six months to a year and in case you don’t know it interns are not paid that well and most of us live pretty much from hand to mouth. Besides, I left the engineering business to be a doctor. I wasn’t too keen on that option. So I was pretty leery about suggesting that I might quit. They might have said, “OK, there’s the door. Have a nice life,” at which point I could have either held my head high, shaken hands all around and said, “It’s been nice” or eaten a big helping of cold crow and groveled for my job back.

You have to understand that I really, really want to do Emergency Medicine. Ever since the end of third year I couldn’t picture myself doing anything else so it seemed worth the risk.

You do have some leverage, however, particularly at a small program with a lot of service requirements. My resignation, while not catastrophic to the program, would require the reshuffling of schedules to fill service requirements. Some services rely on the interns and there are very few spares floating around. This kind of hole in a roster has a pretty big ripple effect in the schedule for a few months. When I implied that I might quit, my program had to ask itself what it was worth to keep me. Fortunately it was worth a little schedule switching. My program director who is actually a decent guy working hard to solve (and succeeding at it) some of the structural problems he inherited squared the whole situation away.

The moral here is this: If you plan on leaving, tell your program early. They cannot fire you for wanting to switch specialties as your contract is for a year and binding on both parties. Also, think about when you will interview and if you don’t have a rotation during which you can miss a few days make sure to ask for and get a schedule change. I was not as aggressive at this as I should have been and I don’t think my program realized how serious I was about switching. I wasn’t just throwing out a couple of applications hoping for a few local interviews (I was skunked in North Carolina, if you must know, except for Duke which was a courtesy interview). I eventually went on six trips to cover nine Emergency Medicine interviews. I managed to get in one in November, under the wire as the planets aligned just right on that occasion, two at the end of December as one of my upper levels was kind enough to cover two days of night float, and the rest I did in January during a rotation where I was an “extra intern. I went on the last interview in early February when I finally got on an outpatient rotation and it was here that I eventually matched.

You just never know. I would also say that even though you are switching, you need to stay motivated for the specialty you are in and give good service for your pay. Don’t drop the ball and don’t get a short-timers attitude. I think every one who knows me will admit that I have been very gung ho and have shirked none of my responsibilities. I don’t hate Family Medicine. It is a perfectly decent specialty with it’s own complexities and focus. It’s just, as I found, not for me.

All’s well that ends well. This last six months has been quite an adventure full of red-eye flights and long road trips made in total darkness there and back. I confess that until I matched Durham has always made me uneasy. I came here, in my mind, a failure and I believed that maybe I had finally hit the wall.

Not today my friends.

The Residency Match Part 4

The Residency Match Part 2

The Nuts and Bolts

While nothing needs to be carved in stone, by the end of third year you should have a pretty good idea of what kind of residency you want to do. This is because matching is a long process that will occupy you in one way or another for most of fourth year. The process starts with scheduling your fourth year electives. While most people elect to take it easy during the last few months of fourth year (because nothing that you do after Christmas will have an impact on where you match) it is important to schedule rotations in your area of interest early to get good letters of recommendation submitted early enough to help you get interviews.

For most of the residency programs, applications are submitted through the Electronic Residency Application Service (or ERAS). ERAS is an on-line service which greatly simplifies the application process by providing a common application form which is used by every program. It also serves as a clearing house for all of your letters of recommendations, transcripts, USMLE or COMLEX scores, and other important documents which can be accessed by the programs t0 which you apply.

You can also enter any number of personal statements which you can customize and target to specific programs or specialties if you are doing a multi-specialty match. All of these things are confidential, by the way, and can only be looked at by programs to which you apply. Programs cannot “browse” through ERAS looking for likely candidates. Personal statements and letters in particular have to be explicitelty designated for each program so there is no way for a program to know to which other programs or specialties you have applied.

It shouldn’t matter but a Surgery program might not think you were serious about surgery if you are also applying to Emergency Medicine.

It is not my intent to describe how to fill out the application. Your school will give you an orientation on this early in fourth year and you should definitely go. I have done the match twice so I have a pretty good handle on the mechanics.

I will say that you need to stary early and shoot to have your application completed with at least a few letters of recommendation designated by the opening of the application period in early September. You really only need the CAF completed to apply and it is possible to get early interview offers with nothing but this. Still, you might as well get an early start especially if you are competing for a competitive specialty (and you are competing). You can always designate letters as they come in and the programs will download them as they become available.

The letters actually go to your registrars office or student affairs office where they are scanned in and downloaded to something called the ERAS post office. Except for designating them you can not access your letters through ERAS.

Your personal statement should also be finished by the time you apply.

I regret to inform you that the personal statement is a very important part of the application and just like for the AMCAS, you will be forced to write what is usually a cringe-inducing essay about you and your career goals. I read my AMCAS personal statement the other day and literally winced in shame that I could have produced such drivel.

ERAS will also afford you the opportunity of releasing your USMLE or COMLEX scores. You don’t actually have to but not releasing them is probably a big red flag to program directors. Some Emergency Medicine programs, as an example, receive close to a thousand applications from which only 75 or so will be selected for interviews. At this stage it is pretty easy for the program director to put you in the reject pile for any reason at all.

Most programs don’t actually start offering interviews until After November 1st when your Dean’s letter is released to the post-office. The Dean’s letter is a synopsis of your medical school career and is always positive and flattering. It is so positive and flattering that a whole code language of praise has been developed to help differentiate the good, the bad, and the ugly. It is here that a weak student may be damned with faint praise. It is also here that your class rank will be either explicitly given or hinted at in code phrases understood by every program director.

So there you are. Career path selected, application taking shape, and ready to apply to some programs. ERAS makes it easy to do this. Pretty much point and click from pull down menus. A click here, a click there, designate a few letters and your personal statement and you’re in business. Hell, it’s so easy you might as will apply to every General Surgery program just to see if you get any bites.

Right?

Not necessarily. ERAS is not free and you pay for each program to which you apply. The minimum fee is sixty bucks and this pays for up to ten programs. After this there is a sliding scale for fees. For up to 30 programs the application fee is pretty reasonable. After 30 it costs 25 dollars per program. I suppose the sliding scale was implemented to prevent the kind of spam-like application saturation that ERAS makes all too easy.

On the other hand you need to apply to enough programs to get the interviews you will need to position yourself for the match. How many? Well, like everything else it depends. If you want nothing better than to match into Family Medicine in a small unknown program in Cousincouple, Arkansas you probably only need to apply to that one program as Family Medicine is hugely noncompetitive with many more residency positions than applicants.

Conversely, some specialties are more competitive and require a different approach. I applied to 54 Emergency Medicine programs which cost me close to a thousand bucks and only got nine interviews. I matched number six on my rank list so you see that it was a near-run thing. Let your conscience be your guide. If you are a strong applicant you can probably apply to fewer programs. The weaker your application the more program to which you should apply because some programs may like your CV despite a bad grade here of there or a low class rank.

I won’t say too much about interviewing. Your CV, letters, and grades got you in the door and now you need to sell yourself. Wear a suit. Be polite. Don’t try to bullshit anybody and don’t be a tool. Not much more than that. Interviewing can be fun if you don’t let yourself get intimidated.

During the application process you will need to register with the NRMP. ERAS handles the application. The NRMP handles the match. The two are separate and while your school will send you reminders, there is always somebody who almost misses the NRMP registration deadline. If you don’t register you can’t match. Period.

Towards the end of the interview season which runs from around the end of October to the first week of February the NRMP will become available to submit your Rank Order List. Nothing magic here. You go on-line, select the programs where you interviewed and rank them in your order of preference. After you certify the list you are officially entered in the match. You can change your list, either adding or removing or changing the rank of programs, pretty much at will until the deadline for submitting your final ROL which is at the end of February. Once this deadline passes if you have not certified at least one list you are out of the match and will have to scramble.

Now you wait. And wait. And wait some more as the results aren’t released until the third week of March. On Monday of this week you will get an email from the NRMP telling you whether you matched. If you fail to match then you had better have a plan because the very next day at noon EST the list of unfilled programs is released on the NRMP website to all unmatched applicants and the scramble begins.

If you match then you have to wait until Thursday at One O’Clock EST to find out where you matched. Most medical schools have a Match Day Ceremony where you open an envelope in front of your whole class. I was an independent applicant so I just waited biting my fingernails for the email.

Programs mail out contracts on Friday and fourth year now becomes a competition to see who can do the least amount of work between match day and graduation.

Next: How Not to Match

The Residency Match Part 2

The Residency Match Part 1

The Match Described Conceptually

By now you have probably heard the ancient medical school adage that “P=MD” meaning that grades are not important and everyone who passes will be a doctor. I want to refute this and caution you to never adopt this philosophy. Grades do matter as you will see later in this series of articles from my sorry tale which fortunately has a happy ending.

The Match is a annual event during which medical students are placed into residency programs. Almost every specialty uses the NRMP match (National Residency Match Program) but some use their own match. The principles are the same whatever the case and from now on when I say “match” I’m referring to the NRMP match.

In the bad old days before the match, finding a residency program was very similar to the way that most of America finds work. You sent your resume to a program, they interviewed you, and you might be offered a job on the spot. This caused several problems. First, there was tremendous pressure for medical students to sign the first contract that they were offered because it was the proverbial “bird in the hand” even if the program wasn’t where they really hoped to go.

I just matched into Emergency Medicine (on my second attempt as you will see) and at any time this year or last if I had been offered a contract at any program I would have signed it. Sure I have preferences of where I would like to go but I would have rather had a secure spot in my specialty than risk going unmatched later.

Additionally, the programs had the similar problem of either signing an acceptable applicant immediately or holding out for a better one later and possibly not filling all of their spots. Apparently there was a lot of horse-trading and arm-twisting on both sides of the table.

The match is a system that removes the pressure from both the applicant and the program to make a quick decision or settle for something less than they could get if they held out. This, in a nutshell, is how it works. First, applicants apply to various residency programs in their desired specialty. The programs review the application and based on their own criteria (grades, for one) offer to interview the applicant.

After the interview period, the applicant submits to the NRMP a list of the programs where he interviewed and where he would accept a position. This list is sorted in
order of the applicant’s preference with his favorite program ranked number one and his least favorite last. Least favorite, that is, where he is willing to go because you do not have to rank every program where you interview. This is called the Rank Order List.

The residency program for their part submits to the NRMP a list sorted in order of their preference of all the applicants they interviewed and are willing to take. They don’t have to put every person they interview on the list (or “rank” them as we say) because while you might decide that you would never go to a certain program, they might also decide that they do not want you under any circumstances either.

The NRMP puts these lists into a computer which runs a simple algorithm that matches applicants to programs. The algorithm, which used to be cranked out by hand, draws a name from the top of the list and puts him into the program he ranked highest which also ranked him. The next name is drawn from the list and he is put into his highest ranked program which also ranked him. These people are tentatively matched and this goes on until eventually conflicts arise between who is sitting in what slot.

Try to follow me here. If you are tentatively matched at a certain program if another applicant to the same program is tentatively matched the algorithm compares how high he was ranked by the program to how high you were ranked. If he was ranked higher then you are bumped down a spot on that program’s roster. If you are ranked higher than he is put into a spot below yours. Since programs only have a set number of spots, eventually someone is going to drop off the bottom of the list onto the first spot in the list of the program in their next order of preference.

Look at it as one long roster consisting of all of the possible residency spots at all the programs into which you could match. You are initially placed as high up on this roster as you possibly can be. If you are the first in the stack of rank order lists then you will be sitting on the first spot of your favorite program until somebody knocks you down. If the algorithm gets to you later you will be placed as high as you can possibly be placed possibly knocking somebody less favorably ranked by the program down a notch.

So you can see that you can never move up the list once you are tentatively matched. There is no way but down. The strongly competitive candidate will just hold his place, fighting off challengers with his superior ranking mojo.

You can also see that the match favors the applicant as you will be paced as high up on your preference list as you can possibly be. The program might want somebody more than you but since that applicant might have ranked another program higher he’s going to sit there until he is knocked down. They may have to settle for little old you.

So what’s the worst thing that can happen? It should again be obvious. You apply to a competitive specialty with more applicants than open spots and after being forced down the roster by applicants who were ranked higher by every program which you ranked you are forced off of the list entirely.

You are unmatched and are now in a world of hurt especially if you really wanted a competitive specialty like Radiology or Emergency Medicine. Fortunately, you have one more chance at salvaging both your future career and your pride.

The funny thing is that even in a competitive specialty sometimes at the end of the match programs have spots which did not fill. They didn’t rank enough applicants either because they didn’t interview enough people or they decided for whatever reason to only rank some of the people they interviewed.

Now you have to go through something called the “Scramble” where you and every other unmatched person who wants a crack at one of the open spots compete furiously in real time waging war over the phone, the internet, and the fax machine. The match is sedate and rational. For competitive specialties, the scramble is a free-for-all and program directors quickly fill their program from the ultimate buyer’s market. The few unmatched spots in Emergency Medicine, for example, filled in a matter of hours with highly qualified candidates.

In a non-competitive specialty like Family Medicine there are usually plenty of open spots, often several in every single Family Medicine program so if you were lazy, didn’t want to interview, and didn’t really care where you went you could easily get a spot somewhere.

I know all about the scramble because I failed to match last year and as I had no chance of getting one of the only 11 (out of around 1200) open Emergency Medicine spots I threw in the towel and scrambled into family medicine. This turned out to be a costly mistake as I will describe later by telling you what I should have done.

So those are the basics. In the next posts I will describe the actual process of applying to programs and to the match. I’ll also give you some pointers on scrambling…well, not pointers so much as bone-headed things that I did from which you may draw you own conclusions.

The Residency Match Part 1

USMLE Step 2 Clinical Skills

Highway Robbery

Might as well come out and say it. The Step 2 Clinical Skills test is a swindle foisted on medical students by bureaucrats with too much time on their hands and not enough to keep them occupied. It had its origin in the the clinical skills test administered to foreign medical graduates to ascertain their level of English proficiency and their comfort level with Western clinical skills under the theory that advocating consulting the entrails of a lizard in broken English would preclude you from practicing in the United States.

Since money could be made by making American medical graduates take the test, beauracrats hired other beauracrats to prove that we were not being taught how to interact with patients during our four years of medical school. Despite strong resistance from the medical community and medical students, money was spread around and the result was an expensive solution to a non-existent problem.

Step 2 CS is a day-long standardized patient exercise which tests your ability to take a history, do a physical exam, and write a note with an assessment and a plan. Nothing to it, right?

Right. The first time pass rate is in the mid 90 percent for American medical school graduates and very people study for it at all. So you see, and try to follow me here, if there really is a problem then people would be failing this thing left and right leading to the kind of studying we normally only see for the clinical knowledge portion of Step 2. Which does not happen. Medical schools do a good job of teaching you clinical skills. There is no problem.

Not to mention that Step 2 CS is pass/fail so it can’t even be used as a measure of anything other than your having at least the same skills as some guy from Bolivia who’s father paid the Minister of Health to get him into medical school.

But I digress. Step 2 CS is a done deal so you are going to have to take it. It was about a thousand bucks in 2005 not counting transportation and accommodation at one of the only twelve testing centers in the United States. (I took the test in Houston.)

As I mentioned, Step 2 CS is a day-long standardized patient exercise. For those of you who are not familiar with them, “standardized patients” are actors trained to pretend that they have various clinical conditions. Many medical schools use them to introduce students to the history and physical exam.

The Step 2 CS site is set up ostensibly like a real outpatient clinic. During the day you will see approximatley 12 standardized patients in a round-robin fashion moving from room to room rotating patients with your fellow examinees. Each clinical encounter consists of up to 15 minutes for a history and physical examination and then up to ten minutes to write your note. You can leave the patient’s room before your history and physical exam time is up and use this extra time for writing your note. Once you leave the room however you may not reenter.

Posted on the door of each room is a board with the chief complaint (as would be elicited by a nurse) the patient’s demographic information, and his vital signs. At a signal from the proctors, you knock on the door, enter, and begin the song and dance.

I will explain the history and physical exam in a later post (for those of you who are not in medical school yet, of course) but suffice to say that one enters the room, exchanges the usual pleasantries, elicits the Chief Complaint (CC), gets the History of Present Illness (HPI), and performs a physical exam.

To assist you the actor playing your patient may have moulage (makeup simulating an injury) as well as cards telling you the result of invasive exams like the digital rectal exam which you will not do on standardized patients.

(Some view the Step 2 CS as a digital rectal exam done on medical students.)

Now, here is the key to this portion of the test. Since this is a simulated real world clinic, you should do a focused HPI and physical exam. The patients will all have classic presentations of common clinical problems. I don’t think I will be violating the NBME’s non-disclosure agreement if I tell you that you might get a patient who’s chief complaint is chest pain and shortness of breath with exertion. In this case a complete neurological exam is not necessary, will gain you no extra points, and will eat into your time. There are no zebras on Step 2 CS.

Once you are done you exit the room and start writing your note which is essentially a SOAP note. You can write this on a form that is provided or enter it in a computer. The form has a space for the history, the results of the physical exam, your assessment and your plan. In the case of Step 2 CS your assessment is a differential diagnosis ( a list of the most likely causes for the patient’s symptoms) and your plan is the next step in the diagnostic work up.

Note that unlike on a real SOAP note your plan will not specify a treatment but only your next proposed steps in the diagnostic work-up.

In the case of chest pain with shortness of breath, your differential diagnosis might include Acute MI, Pulmonary embolus, GERD (heartburn), or PUD (peptic ulcer disease). Your plan for diagnostic work-up could be to draw cardiac enzymes, get an EKG, obtain a spiral CT scan, do a heart cath, or anything else you feel would be appropriate. You will not get any credit for suggesting treatment so save yourself the effort.

How long should your note be? Well, go look here: http://www.usmle.org/step2/Step2CS/Step2CS2005GI/appendixC.asp

Does that look like a long note? Of course not. It is not necessary to write the great American novel. I usually only needed ten minutes with the patient and five minutes for the note leaving me with ten minutes of thumb-twiddling time. Yet I saw most people leaving the room on the fifteen minute mark and scribbling furiously for the entire documentation time. They were obviously over-thinking it.

Focused history and physical. Concise note. That’s all there is too it.

The Step 2 CS exam is scored in three separate components each of which his pass/fail and all three of which must be passed. The first part is called the ICE or integrated Clinical Encounter which includes your history and physical exam skills as well as your documentation and assessment.

Communication and Interpersonal Skills (CIS) assesses your demeanor, your bearing, your use of empathy, your sensitivity, and even your appearance. Wear conservative clothes and a clean white coat.

The third tested area is English Proficiency.

All you will need for the test is your white coat and your Stethoscope. Every other piece of diagnostic equipment you need wll be in the room. PDAs and reference books are not allowed.

Do you need to study for the Clinical Skills test? I say no. I know there is a mini-industry of test prep material but your four years of medical school should be enough. Just act natural, do what you have been doing for your entire third and fourth year and don’t worry about it.

USMLE Step 2 Clinical Skills

USMLE

Your First Big Hurdle in Medical School

I got a fairly decent but not spectacular score on both Step 1 and Step 2 of the USMLE (United State Medical Licensing Exam) so I am not claiming any revealed wisdom or special insight into the tests. You must take what follows as my opinion alone and I caution you to study for the test in a manner which feels right for you.

OK?

For the uninitiated, the USMLE is a three part test which you will take at various times in your medical education. Step 1 is typically taken at the end of your second year of medical school and covers what you should have learned during that time. Step 2 is typically taken during fourth year and emphasizes the clinical aspect of medicine. Step 2 includes the “Clinical Skills” test which is a day-long standardized patient exercise that will cost you a thousand bucks. The only difference between paying a thousand bucks for the clinical skills test and being mugged is that you can’t file a police report after the test. (But more on that in a future post.)

Step 3 is usually taken early in your second year of residency and is your last hurdle to becoming a licensed physician.

Let’s talk about Step 1. Although you have spent the previous two years in the intense study of medical knowledge you will have to study for this test. I am sure that the average medical student can take the exam “cold” and probably pass it three times out of four with a grade close to the minimum passing score. A pass is a pass of course but a low Step 1 score will adversely impact your ability to match into a competitive specialty or a generally non-competitive specialty at a competitive program. In fact, many residency programs screen applicants by Step 1 scores so a low score will automatically close many doors for you.

Additionally, at all American medical schools Step 1 is a “must pass” test and you cannot advance through third and fourth year until you do so. At most schools you will get three chances to pass it. Upon failing the first time you will probably be pulled out of the third year rotation schedule and during the block you sit out you will be expected to study for and pass the test (this time comes out of your vacation). If you fail it for a second time you will be dropped back a year. Fail it a third time and they stick the fork in you as you are done.

At most schools you must attempt Step 2 before graduation but passing or even having the scores back is not required to graduate.

The question then becomes how long and what should study?

The answer depends on your school. My medical school had an eight-week break between the end of second year and the first day of third year. Most of my classmates elected to take Step 1 during this time either earlier or later depending on their comfort level and study habits. I believe that eight week is too long as you will invariably both lose your edge and also start to forget what you studied ealier. Three weeks is not enough time as you do have a lot of information to cover. Five to six weeks seemed to be the average in my class.

If your school doesn’t give you this kind of time then you need to make the best of it.

To study effectively you need to understand the format of the test. Step 1 and Step 2 are day long, computer-based, multiple choice tests. They are broken into hour long blocks of fifty questions selected more or less randomly from various subject areas of medicine. No two tests are exactly alike but an effort is made to keep the relative level of difficulty and mix of subjects more-or-less constant.

The tests are multiple choice but are not like the multiple choice tests which are probably the norm at your medical school. First of all, many of the questions have choices “a” through “k” rather then the standard “a,b,c,d.” You are consequently going to work a lot harder at eliminating wrong answers.

Additionally, the tests are concept-based, not fact-based, and feature many of what I like to call “double pump” questions. Rather than presenting you with a set of information and asking you to name the disease, for example, the typical Step question presents you with a brief case summary after which rather than asking you to name the disease the question might be, “What is the next step in the management of this patient?” Your excitement over knowing the disease was premature as this is not the answer they are looking for.

Heck, in many questions they tell you what is wrong with the patient. Consequently it pays to read the question at the end of a long paragraph first as the presentation is irrelevant once you know the diagnosis.

Another popular question style is to present you with a case followed by a selection of different lab results, your task being to pick the one which fits the presentation. You can usually eliminate most of the possible answers as obviously wrong (high pH in a set of lab values that you know should describe acidosis, for example) but invariably you will be left with a handful of reasonable looking results.

A variation on this is to present you with various simplified graphs and ask you to select the one which correctly represents the case.

Then there are the deceptively simple Behavioral Science questions which present you with a scenario and give you a list of choices only a few of which you can obviously rule out. The rule of thumb here is when in doubt go with the politically correct answer. Spanking is always wrong and it is never correct to advise a patient take responsibility for their actions.

I would say that of all the questions on Step 1 and Step 2, only a handful had a discrete, definite answer like “Sickle Cell” or “Guillan Barre Syndrome.”

So how should you study?

First, do not attempt to go back and review two years worth of class notes. The typical lecture curriculum probably has close to 4000 lectures in two years and you simply do not have the time. Not to mention that since the Step tests are standardized and your curriculum is not (despite the best efforts of your faculty) you might waste your time studying something taught at your school which is not emphasized at another and not likely to be included on the test.

Second, do not read text books because if your lecture notes are full of trivia the text is even more so. Again, you do not have time. This also goes for review books and I confess that I had a change of heart on this between Step 1 and Step 2. You simply do not have the time to review two years worth of material. The four weeks or so you will devote to study will dwindle quickly and your studying will bog down in a quagmire of detail.

Frankly, the best way to study for Step 1 is to do well and study hard during first and second year. You will retain more than you imagine and this is the best base for the most effective Step test study method which is to do practice questions and little or nothing else for your alloted preparation time.

The best practice questions, in my opinion, are those sold on-line by Kaplan or USMLEworld qbank. These are subscriptions to about 2000 questions each which are formatted exactly like the real questions, cover the same mix of subjects, and can be taken in Step-like blocks of questions exactly like the real test. The best part about the service is that you can read the explanations to the correct answer as well as to the wrong answers which in my book is just as important.

As I did the questions I made a point of reading or at least skimming all of the explanations to the right and wrong answers on all of the questions about which I had any doubts at all.

The advantage of these (and similar) on-line question banks are many. First, they are the exact same format and feel of the real test and will get you used to the “physics” of the computer test. That way there will be no nasty suprises on test day when you suddenly run out of time on several blocks or wrestle with the interface.

Second the questions focus on subjects which are actually tested. This means that you are going to get the typical standard presentations and basic medical knowledge with nothing coming out of left field. It was my sense that the questions are not written to trick you and it is only your lack of knowledge which can confuse you. The hoofbeats are always horses, never zebras.

Another advantage is that the questions are phrased and presented in a similar manner to the real test with the important distinction that the practice questions from Kaplan and USMLEworld seemed harder than the real questions. In fact, I scored considerably lower on the practice tests than on the real thing. The practice questions distributed by the USMLE are almost exactly like the real questions in difficulty.

Finally, doing practice questions will put you in the test-taking mode. If all you do is read review books you will have a store of rapidly disintegrating facts jumbled in your head. Doing practice questions narrows your focus to answering questions based on patterns which you have seen before.

Each of these services costs about 100 bucks for a one month subscription . A couple or three thousand quesitons should keep you busy for a month.

A word about “First Aid,” a popular USMLE review book which has an almost cult-like following.

Save your money. First Aid is a collection of “buzzwords” and supposedly high yield facts which are touted by some as all you need to study for the Step tests. I understand that in the old days the Step tests were twice as long but had shorter questions with discrete answers. First Aid might have been useful for a test like that but the nature of the test has changed making First Aid less useful.

Like I said, some people swear by it and claim to to make fantastic scores by studying nothing else. I am skeptical. I hit First Aid pretty hard for Step 1 (before I got smart and started doing practice questions) but I could remember only a few questions on the test where I thought First Aid had even remotely helped me.

Just a few random thoughts:

1. Avoid the temptation to cram the night before a Step test. How much are you really going to retain and more importantly, of the two years of knowledge required to take the test, how much of it can you cram into one sleepless night? Relax. I stopped studying a week before I took Step 1 because I literally could not stand doing another question or reading another page of review material. Remember what I said about peaking early. You just have to know when to say “no mas.” Let your conscience be your guide but it is better to go into the test relaxed (but alert and ready) than to panic and lose sleep over it.

2. It will be a long day. Bring a lunch, of course, and wear comfortable clothes. Paradoxically the day will seem to fly by once you get into the test. You are given plenty of break time but most people just plow through most of their breaks to just get the test over with.

3. I thought I had failed Step 1. I mean, looking back it seemed that every question was renal physiology and that there were only a handful of the 350 question on the test of which I was sure of the answer. It seemed that I could get most of the questions down to two or three choices but I was never really sure on most of my answers.

So I dreaded getting my score and anticipated failing even though the first time pass rate for American medical students is something like 93 percent, I am not stupid, and I studied pretty hard. I asked around and this seems to be a common perception after finishing the test. Almost everybody thinks they bomb it but most people don’t. Move on. Enjoy the rest of your vacation. Unfortunately it will take six weeks to get your results so you have a long wait.

4. Step one is divided into seven one hour blocks of fifty questions. I am a very fast reader so my strategy was to read the question, quickly select an answer, and if I wasn’t sure mark it for later and move on. (The software allows you to select questions within the block for review.) I found that I was able to get through the block in about half and hour leaving me with half an hour for review. Typically I had about half of the questions marked and spent the time wrestling with them. There were always a handful of questions for which I didn’t have a clue and these I marked “C” without wasting any more time trying to figure them out.

The key is to have a system that works for you and not to get hung up on one question. If you don’t know the answer mark it for review and move on. Don’t win the skirmish but lose the war.

I repeat: Take my advice as free advice and thus worth what you paid for it. I welcome your comments but please don’t flame me because we disagree. I am perfectly willing to be corrected, proven wrong, or convinced of your point of view.

USMLE