The Differential: Medscape Med Students Blogs

Dia dhuit From Baile Átha Cliath (or How To Succeed In An Audition Rotation)

Colin Son -- I’m writing this post from over in Ireland, which explains the Gaelic-English hybrid title.

I've got approximately two weeks free from my last third year rotation until my first rotation of fourth year, and I'm incredibly lucky to be getting to spend it in Europe. As much as I'm enjoying myself, it is difficult not to let my mind slip back to medical school on occasion. That little 'type A' that is a part of even the chillest of medical students' personalities is showing. I can almost promise I was the only sap in the pub with a neurosurgery review book open as the Spain-Russia Euro 2008 semifinal played out.

Excuse me for missing Guiza's beautiful second half goal but you see, I want to match into something pretty competitive. Towards matching in any residency you've got a number of measurements which are applied to you. Everyone is familiar on what you're judged -- your board scores, your GPA, your letters. In some of the more competitive specialties, especially the surgical ones, I think you can add another measurement -- your performance in audition rotations. I know that some don't but I actually like the title 'audition rotation'. Maybe you're auditioning for a better letter or for an actual interview at the program, but these rotations often do serve as weeks-long auditions.

I spend three of my first four months of fourth year doing neurosurgery sub-internships. That includes my first rotation, which starts in a week. Not to let any semblance of anxiety show (not me, ever, as a future surgeon) but that is a whole lot of neurosurgeons I'm hoping to impress. Such helps explain why I packed some review books in my backpack before I hopped on a plane.

I obviously haven't done a fourth year sub-i yet. Even so, I think I've gotten some good advice and a general idea of what I'll be facing. I thought it worth sharing as fourth year starts for so many medical students. Here are three (perhaps obvious) things I think fourth years should strive for during a sub-i:

First, and foremost, the distinction between your sub-internships and your third year rotations should be in you demonstrating more initiative and spontaneously taking on more responsibility. If the rotation is a specialty you're interested in, then you should take the name 'sub-internship' to heart and, without prompting, try to pick up the work load similar to what an intern would have on the service. To the extent that is possible of course without an M.D. after your name.

Second, use the time to learn to teach. This is a sometimes forgotten role of being a resident. Every third year medical student feels it when they've walked off a service with a resident with such a gift and when they've walked off a service with a resident who couldn't have cared less if they were there. Especially early in the year, fourth years can really be a guide to the incoming third years. I know I had an awesome fourth year doing an inpatient medicine sub-i early in my third year, and she made the rotation immensely better. Something as simple as going over hints for doing well on the rotation or over how to gown up in the operating room or over the intricacies of physical exam findings can help a lot.

Third, become more technically proficient. Whether you're going into a surgical specialty or not, there are technical skills it helps to be adapt at for the practice of medicine. I stumbled across interns during my third year who weren't sure they could draw blood or had never even seen a lumbar puncture done. True, this may not be required of them, depending on the ancillary services and their specialty, but isn't it at least a little embarrassing to be called Doctor and not possess some basic skills? With a surgical or procedure based specialty the demand to be able to demonstrate technical skills, even as a medical student, is even greater.

These goals are not exclusive of course, but hopefully they will provide a good foundation as I head off into fourth year.

I promise I'll keep you updated.

Choosing a Specialty

Ben Bryner -- If there's one thing I enjoy about medical school, it's talking to people about what specialty they're going into and why. Most students change their minds a few times during medical school. I was one of the lucky ones who knew exactly what I wanted to go into (surgery) after rotating there as a third-year, but for most people in my class it was not so obvious. It’s a hard decision; you’re making a choice that will affect almost every aspect of the rest of your life. At many schools, if you’re interested in a field that doesn’t have a required third-year rotation, it’s hard to get a lot of exposure to the field before your fourth year, when decision time comes up quickly. And if it turns out that you don’t like that one, it isn’t always easy to switch gears at a later stage in the game (but it’s certainly possible). To address this difficult situation, there have been a lot of different tools proposed to help you decide on a specialty beyond clerkship and elective experiences.

You might have already seen this graphic, which reflects the growing trend in medicine to reduce decision-making to following an algorithm. An even simpler method is the Goo Tolerance Index, which simply ranks the specialties by their exposure to “goo,” so all the student has to do is identify his or her desired level of goo exposure and pick from a short list. Both of these are pretty easy to use. Oddly, they both leave out OB/GYN (which would probably fit under the “crazy” and “high-goo” categories, respectively).

If you want to take a more comprehensive approach, you can take the Medical Specialty Aptitude Test online. It will ask you a series of questions (130!) and at the end will list the specialties you should consider. I didn’t get through all of them because it kept asking me the same questions over and over, but you might have better luck. Similar kinds of things are available at the AAMC’s Careers in Medicine site, but you need a password from your med school. And of course there are a few books on the subject.

But there’s no substitute for rotating on those services. Hearing about the field from others, shadowing, getting involved in interest groups, etc. are all somewhat helpful, but they can give you a very different picture of the field than your rotations. Of course, rotations are far from perfect tools for evaluating specialties. Since you’re mostly spending time with residents, you may get a pretty good idea of what the residents are doing, but not necessarily what it’s like to be a practicing physician in that specialty. And despite the fact that residency can be quite long and seems so imposing during medical school, it’s a lot shorter than your career. So it’s worthwhile to really try to get a feel for what the attendings’ workdays are like.

There are a lot of good choices out there, so good luck.

Seasons of Med

Thomas Robey -- June and July are the transition months for medical students, residents, and the entire medical community in the United States. Many schools and programs have a brief respite that allows trainees to recover from a busy year. Now is as good a time as any to wish you a:

Happy New Year!

525,600 minutes, 525,600 moments so dear.

525,600 minutes -- how do you measure, measure a year?

In call nights, in lectures, in complaints, in cups of coffee.

In write-ups, in IVs, in needles and thread.

In 525,600 minutes -- how do you measure a year in the med?

Congratulations to graduates and well wishes for moving to a new city and starting your residency. To all the medical students who got to step-up to the next level this week, well done! Good luck on USMLE Steps 1 and 2 if you haven't taken them yet. Applicants and first year students: keep up the hard work that will prepare you for a healing career.

My resolution for this coming medical year is to take more frequent pauses to consider those 525,600 moments so dear.

Credit and apologies to Jonathan Larson

Um... Hello?

Jeff Wonoprabowo -- Hello, everyone. My name is Jeff. I don’t think I’ve ever been great at introductions. I’ve always preferred meeting someone while doing something. It seems easier -– more casual. I always cringed when a teacher or group leader insisted that everyone in the room take turns to say hello, introduce themselves, and then say something interesting about themselves. It just felt kind of forced. I remember mentally scrambling for something to say before it was my turn. What can I tell them that is unique about me, but at the same time won’t make me sound like a total oddball?

But I’ll try my best; so here goes. I was born and raised in Southern California. In high school I enjoyed English, history, and Physics. I didn’t enjoy Biology (no interest in plants) or mathematics (didn’t see how it was applicable to my career). During high school, my mom also pulled me aside and told me she didn’t want me to go into medicine because she worried I wouldn’t have time for my family.

After high school, I attended Walla Walla College (now Walla Walla University) in Walla Walla, Washington. When I began college I was a computer engineering major, but I switched majors during my sophomore year. I ended up receiving a B.S. in Bioengineering with a minor in mathematics. I have just completed my first year at Loma Linda University School of Medicine, and I should be graduating from medical school in 2011. In the free time that I do have, I enjoy playing basketball, ping pong, tinkering with my computer, reading, watching movies, and practicing martial arts. I also write on my personal blog at JeffreyMD.com.

It would be foolish for me to think that my experiences in medical school are unique. So many students are currently going through the same things (and a few have been so eloquently writing about it here), and many, many more have gone through it before me. But maybe I can share with you my perspectives on my journey. And hopefully, somewhere in the words that I type, there will be something that will have made the post worth writing and your time worth spending here.

The Gift of Psych

Kendra Campbell -- Oh my goodness, I’m quite tuckered out. I started my psych rotation last week, and I just had a full day packed with all kinds of psych goodies. I promised to share my feelings about my first clinical rotation, so here goes. To sum up everything that I’ve seen in six days on the psych ward: I am soooo in love with psych!

As I’ve mentioned before, while just out of college I worked for three years at a state psychiatric hospital. My undergrad degree was in psychology and neurobiology, so I do have some decent experiences in psych. But since leaving the field years ago, I’ve really considered going into a different specialty. I’ve recently been leaning towards emergency medicine for various reasons. However, being a “green” third year medical student, I realize that I simply don’t have enough experience to make a definite specialty decision. And I have one of those personalities where I tend to enjoy just about anything I do, so I am always suspicious when I fall in love with anything.

All that being said, man I really do love psych. The hospital that I’m rotating at is in Washington, DC, and it’s a district (DC is not a state) facility. What this means is that the patient population consists of clients with very serious mental illnesses. The facility is not a place for persons with simple psychological problems. Everyone who finds their way into the halls is extremely ill.

This patient population is exactly where my experience lies. Having worked at a state hospital, I’m very familiar with schizophrenic patients who are refractory to treatment. I’ve worked with homeless folks, and while I’m no expert, I do have experience helping those who are less fortunate.

I know I still have many rotations to complete, and I’m sure that I’ll probably change my mind a few more times. But right now, psych is certainly starting to look like a very tempting field.

The population of very ill patients really grabs my attention. Those who end up in state facilities tend to have a lot in common. They are the poor, the neglected, and the ones that have very little hope left. Often times, their friends and family have abandoned them. In the past, society has overlooked many of these unfortunate souls.

I guess what I’m trying to say is that to be able to share with these folks, to be able to help them in any way, to be able to make even the smallest impact in their life -- in my opinion, that’s one of the greatest gifts I can imagine.

An Introduction Is Probably in Order

Colin Son -- It is a real pleasure to be writing for The Differential. Based on the example my fellow bloggers have set, I thought it proper to introduce myself with my first post.

I am a very recent fourth year medical student at the University of Texas Health Science Center in San Antonio.

I was born in east Texas and raised in San Antonio. I grew up in a family of physicians and, partly because of that, I actually had no interest in medicine as I hurried off to college. I loved screenwriting and making videos with my friends when I was in high school and so, like many who dream of being filmmakers, I headed off to film school in Los Angeles.

I imagine I’m one of the few current medical students the world over with a Bachelor's of Fine Arts, which I received from the University of Southern California. I loved film school but realized during my sophomore year that I wanted to do something more substantial with my life.

Searching for something meaningful to commit my life to, I was lucky enough to get to shadow several awesome surgeons. Granted, I had grown up around medicine but it was my shadowing experiences in the operating room that convinced me I wanted to go to medical school. Getting all the medical school pre-requisite classes and the MCAT completed during the last two years of film school was a bit of a challenge time wise. I made it though and now find myself a year from putting that M.D. after my name.

I’ve wanted to be a surgeon since the first day of medical school and now, with third year under my belt, I can say more specifically that I want to be a neurosurgeon.

Since getting to medical school I’ve been extremely involved in organized medicine and have held a whole bunch of leadership positions in my state medical society and at the national level. My major health policy interests lie in health care financing and access to care. If my school had offered a combined MD/MPH program when I entered, I have no doubt I would have been a part of it. Alas, formal policy study, while inevitable, will have to wait a bit.

Besides screenwriting, outside of medical school I am a big college football fan, I am a history buff (especially the American Civil War), I enjoy video games and I love to travel internationally.

Again, I am really excited to be here on The Differential and to be sharing my thoughts on medical school. I look forward to hearing back from all the readers and encourage y’all to drop comments frequently.

Skin Is In

Anna Burkhead -- Serpiginous. Violaceous. Herpetiform.

Who else gets to use words like this on a regular basis?

Dermatology is skin medicine. Dermatologists see patients with diseases they cannot hide. While the majority of skin conditions seen and treated by dermatologists are not life-threatening, they are damaging to self-esteem, relationships, and overall health status.

(Although, as a side note, I would like to reference the article “Psoriasis: the heart of the matter”, in the March 2008 issue of Journal of the American Academy of Dermatology, which describes the relationship between psoriasis and heart disease: “The degree of risk for myocardial infarction conferred by severe psoriasis was similar in magnitude to that of other major cardiovascular risk factors such as diabetes.”)

But besides being an important medical field in terms of prevalence of disease and patient-centered outcomes, dermatology is just plain awesome for many reasons.

1. You get to see people from newly out of the womb to nearly in the grave.

2. Teaching prevention is super important.

3. You get to practice medicine ranging from primary care to emergency to surgery.

4. Instead of boring color names, you say “violaceous”, “erythematous”, “honey-colored”, “dusky”.

5. You get to do biopsies and surgical excisions pretty much every day.

6. When you help people, they can see and feel the improvement.

7. Your eventual career path can range anywhere from private practice cosmetic procedures to caring for HIV and transplant immunosuppressed patients and their myriads of skin problems.

As you can tell, I am very much enjoying my elective in Dermatology. Skin is in, and I’m stuck on it!

Defining Yourself

Ben Bryner -- Most of the people who started medical school with me are doctors now and are starting their internships this week. (Although there are quite a few of us who took an extra year to do research or get an additional degree and will graduate next year.) I think most of them are excited, and probably a little terrified, too. It's kind of similar to the way a lot of us felt at the beginning of med school: a mix of excitement at taking another step toward becoming a doctor but uncertain about exactly what was in store for us.

Although my school's curriculum was based on class-wide lectures, we had weekly small-group meetings where a dozen or so of us students would meet with a faculty member. Usually we spent most of the time discussing a fictional patient case that got us into some interesting conversations. But one of the more important aspects of the group was that it gave us a fixed setting to get to know a group of people. When you're starting medical school, the pace and volume of material can make it hard to really know your classmates very well.

On the first day of these small groups, we had the typical introduction process, where we went around the room and said our names, where we were from, where we went to college, etc. By way of an icebreaker, the moderator asked us to name a song that described us. This is a fairly good question that lets you get a feel for what a person is like. But it's a difficult question to answer. It's certainly not the same as your favorite song, and it has to be one that most people know for it to mean anything to them. I ended up choosing the Theme from Shaft, Isaac Hayes' groundbreaking theme from the 1971 movie. I said it applied because I'm "the cat who won't cop out / When there's danger all about" (not because I am similar to the Shaft character in appearance, occupation, or awesomeness).

There was a kind of awkward silence for a second, and I worried that everyone thought I was crazy. But the faculty advisor laughed at least, and we moved on to somebody else. I'll admit the reference is a little dated, but what kind of song am I supposed to pick? It's not like there are hundreds of songs about first-year medical students that make you say, "Yep, that's me in that song."

It was the first time we had to classify ourselves in medical school, to distinguish ourselves from others. This process continued throughout our preclinical years; some students were inevitably identified as gunners and others as slackers.

Once our third year was underway (another time of great excitement and terror), people were still being classified as gunners (since gunners behave differently on the wards, and closet gunners are revealed). But far more significant was the way in which we started classifying ourselves by the specialties we planned to pursue. The more people began really settling into their specialties, the more that became the predominant classification. "What are you going into?" became the first question we asked a classmate who we hadn't seen for a long time. And since it was often the first question our residents would ask us on a new rotation, we got used to identifying ourselves as future surgeons, pediatricians, radiologists, or whatever, in almost all contexts. I think a lot of us started changing our personalities slightly to accommodate expectations; when you meet somebody new and all they know about you is your name and your specialty of choice, it's hard not to subconsciously start acting the way you think an obstetrician or a neurologist should act. (I'll resist the temptation to describe specifically what I think those stereotyped behaviors are.)

A few weeks ago a few of us from the small group had dinner with our group's faculty member. Since our last meeting had been during the third year, the first thing he wanted to hear was what specialty everyone from the group was going into. He also remarked on how interesting it was to watch our group go through the many transitions of medical school. We had all picked up new skills, new attitudes, and new classifications that described ourselves. I thought about that too; I've certainly changed a lot in medical school, and have fallen into categories now that I wouldn't have predicted when I started.

I also thought about the way I first classified myself to the others in my small group. Could I honestly say I'm "the cat who won't cop out / When there's danger all about?" By saying I am, I set a goal for myself. It's a lot like the way I classify myself as a future surgeon; claiming that label also shows me the work I have to do, and gives me a lot to live up to. I will certainly try to be a good surgeon, just like I will always try to be "the man / Who would risk [my] neck for [my] brother man."

The Constant Battle

Ben Ferguson -- It’s the most frustrating thing, really, to be in this position, to see it from their side for once. It’s a perspective they don’t explicitly offer in medical school within the bowels of biochemistry or pathophysiology or even the social context of medicine. I’ve had a few personal health issues come up recently -- not too serious, but serious enough that it definitely would have been mind-easing to have been seen by someone -- but because I’m poor, because I’d rather, if I must, spend large amounts of what money I do have on other things, and because my school’s insurance policy and inevitable red tape are so unbearable as to be less convenient to deal with than limping around all day, I’ve decided to largely opt for watchful waiting for pretty much everything that’s wrong with me.

And that is not good. That can never be a good thing.

I’ve never been in a position like this, but it really makes you empathize with patients you see on the wards who, at first glance, frustrate the hell out of you for seemingly having chosen to let their diseases go for as long as some of them have. My medical school happens to be in a pretty bad, pretty indigent part of town, which is bittersweet for us medical students. Sweet in that our clinical training is diverse, detailed, and not in any way cookie-cutter. Very bitter, though, in that such benefits come entirely at the expense of patients’ health. A huge reason our clinical training happens to be so good and varied is a direct result of the indigence of the surrounding population, simply because few around here can afford to pay for any of the procedures and medical attention they absolutely need, and so they make a difficult, conscious choice to opt out of medical care until it literally becomes a question of life or death.

While I’m not quite at that stage, I’ve caught a glimpse of this in my current scenario. It’s simply not worth it to me to spend several hundred -- if not several thousand -- dollars for referrals and physical exams and the briefest, most disengaged clinic appointment and imaging leading to a potential diagnosis of something I’m pretty sure I can diagnose myself, and something that would only present me with opportunities to spend even more money on treating the problem down the road, which itself may or may not be self-limited or all that detrimental to my overall health status in the end. It’s made me realize that patients I see -- patients everyone probably sees -- make value judgments like these all the time. Every time an appointment is made, you can be sure there was an internal conflict over whether the illness itself or the cost of attending to the illness would be more deleterious to their landlord’s quality of life.

Sometimes, things are just too expensive to fix, and so you live with them as long as you can.

Personal Statement or BUST!

Thomas Robey -- It’s that time of year again. The leaves are turning a deep shade of green, the mosquitoes are in full force, you’re on the lookout for a swimming hole, and the ERAS and AMCAS websites are opening for electronic applications. It must be summer.

That’s right, it’s been about a month since prospective medical students could submit applications, and the residency application site opens July 1. Applications are the boiled-down concentrated version of you. They’re an abstract, so to speak, of all the things you’ve done leading up to this point. When it comes down to it, applying to medical school and residency is like applying for a job. Most jobs require applicants to complete an application, submit a CV, and write a cover letter. Most employers do not, however, require new hires to pay them a salary or leave it up to a lottery to determine placement.

Maybe that’s why medical school and residency programs request personal statements.

In any case, the personal statement is often approached with trepidation or avoided until the last minute. This is a mistake. If you’re just now thinking about your medical school statement, get cracking! Medicine class of 2009? Hopefully you’ve already started drafting your residency pitch, too. Personal statements are the best way to individualize your application. It’s where you can be your very best. It’s the only thing in the whole bundle you have total control over. When the reviewer reads your essay, she should know the answer to the following question: “What is it about what you want to do that make you want to do it, and what is it about you that makes you the best person for the job?”

So, maybe you haven’t started writing your statement yet. Or you’ve thought about it, but it’s not coming together. What are some of the things you can do? There are a number of helpful tips and tools out there for fretting applicants. I won’t tell you to look no further than this entry, but if you need a jump-start or a fresh take on the mechanics of a personal statement, here are some basic suggestions centered on three main aspects of a personal essay: content, style and presentation.

CONTENT

1. Provide the information requested on the application. Programs are less likely to accept people who don’t read directions.

2. Convey both the seriousness of your intent and your individuality. If you are applying to residency, consider:

* How your skills match those valued by your specialty.

* Coursework that shaped your specialty decision.

* Interests and experiences outside of medicine that demonstrate your values and individuality.

* How the reasons for selecting the specialty align with your personal and professional goals.

* Vignettes that you want to be asked about in your interviews.

STYLE

1. Write to be understood, not to impress. Don’t pen words you wouldn’t use in everyday conversation.

2. Aim for a readable document that lets the content shine.

* Use simple, uncomplicated sentences of varied length in short, well-developed paragraphs that avoid the use of “I.”

* Examine each sentence for its purpose. What does it do to further your content?

PRESENTATION

1. Make sure the essay is the correct length (ie, read the directions).

2. Support your opinions with experiences.

3. Revise and rewrite as often as necessary. Most people work 4-5 drafts that are reviewed by professors, classmates and family.

4. Follow standard rules of grammar and punctuation. Don’t rely on spellchecker!

I’ve been told by many people, “This is not the time to get creative.” I agree. Except that my AMCAS essay (back in the day) consisted of original poetry and a brief discussion of it. Maybe that’s why I didn’t get an interview at that one school. My approach was honest, and my interviews were followed by offers from several prestigious schools. In the end, just make a decision about who you are and how you want to speak for yourself.

If you need more concrete help in getting your ideas on paper (I did), consider workshopping your statement using this guide. Remember, people won’t find out how great you are until you tell them.