The Differential: Medscape Med Students Blogs

The "Paperwork" of Applying to Residency

Colin Son -- It is coming up on crunch time if you are a fourth year medical student. For most, the residency application service, ERAS, has been open for a month for students to fill out. Come September 1st, students will be able to submit their application.

You fill out your personal information online. Your personal statements, letter of recommendations, and photo are uploaded. That means that you fill out all of your information only once. Such wasn’t always the case. There was a time, not so long ago, when there was no centralized electronic application.

I remember filling out my fair share of paper applications when applying to college. That was for nine schools. If you want to do something fairly competitive for residency, it isn’t atypical to apply to thirty or forty or more residency programs. Imagining filling out thirty applications by hand is a little depressing, even from our current, easier, time.

With the benefits of the current system recognized, there are some things which are annoying me about ERAS and the current way we apply to residencies. Largely, I feel the full potential of a centralized electronic application isn’t being realized; that ERAS remains too much work.

The majority of my criticisms revolve around the difficulty in designating the programs you want to send your application to.

Imagine a student applying to twenty internal medicine programs and he wants to stay in a specific geographic area. Currently he has to search for each individual program, either by knowing its ACGME ID number or by searching by state and specialty and then scrolling through a list of programs. He has to repeat the process for all twenty of the programs.

On top of that he has to specifically designate which letters and which personal statement he wants sent to each individual program.

There is some sense behind this. Requiring students to meticulously enunciate which programs they’re applying to and what they want to include in their application to each individual program limits errors. As well, the powers that be are distinctly against students casting their nets too wide. For instance, despite the fact the electronic processing and transmission of a student's application is essentially a flat fee (i.e. it costs the same for one program to download your application as fifty programs), ERAS dramatically raises the application fee the more programs a student applies to. Consider that for the first thirty programs a student applies to the cost is $290 but to apply to another ten programs on top of that, for a total of forty, would cost $540. The costs serve merely as a deterrent so that students don’t simply ‘pan-apply’ and clog up the system. In the same sense, making students individually look up each program may act as a barrier to applying to a huge number of programs.

I’m not completely sold on this reasoning however.

The way ERAS should work is that you should be able to add programs in batches based on criteria. For instance, in the example above, the student should be able, with only a few clicks of the mouse, to add every internal residency program in his home state and the states bordering his.

In a similar way, you should be able to batch edit your application to programs. If you only have a single personal statement uploaded to ERAS, having to individually designate that personal statement to be sent to every program is just fruitless work required on the part of the student.

I’m also not comfortable with the onerous restrictions placed on the number of programs students can afford to apply to. I’ll throw in my personal story here. I’m applying to a pretty competitive specialty and so I want to apply far and wide. There are currently forty-six programs on my ERAS list.

That isn’t excessive and it isn’t going to clog up the system. At least I don’t think so. But the rapid rise in the cost of the application when applying to more than thirty programs makes my ERAS application financially difficult.

I’m in a significantly better place than if I was trying to apply to forty programs on forty paper applications, but that doesn’t mean ERAS is without room for improvement. With any hope the next generation of fourth year medical students will have the entire residency application process even easier.

Advice for First-Year Students

Colin Son -- I’m getting to spend some time with the new first year medical students at my school, as I’m tutoring in the anatomy lab. It is a transcending experience for each class going into the anatomy lab and then taking a look at the incredible human body, up close for the first time. It is also an incredibly time consuming course for the first years. That only adds to the stress of starting medical school.

It is true, medical school is a rigorous, time consuming, sometimes difficult journey. I doubt many would hope anything less was required of future physicians. But the rigors of medical school have taken on a mystique of their own. Medical school attracts incredibly smart and driven people. Cramming together such Type A personalities only makes the situation worse.

The first year, specifically the first semester, can be filled with worry and just a touch of angst -- especially before the students grow comfortable with how they will be tested and evaluated. As I said, one of the most pressing courses your first year of medical school is the anatomy course, not because the grading is difficult but because with the lab thrown in with the course requires a major time commitment.

So, tutoring anatomy early in the year is half acting as therapist. I spend some of my time reassuring the first year students that medical school is a completely conquerable ordeal. I thought if such encouragement was so frequently required at my school, it should also be posted online for any first years who have stumbled across The Differential.

First, whatever the philosophy of your school (traditional lectures, problem based learning), in the end you learn the basic sciences the same way you did your undergraduate work. There is nothing mysterious about how students are educated, there just happens to be a bit more material in medical school. But for most students who have made it this far, the volume is completely shoulderable. Yes, medical school is tough, but don’t put it too high on a pedestal. Most students starting their first year have learned everything they need to know about study habits and time management.

Second, taking a test is taking a test. In the U.S., whether your school writes their own questions or uses the NBME shelf exams, the way medical students are evaluated on their knowledge is the same. I’m surprised by the number of new medical students who expect something dapper and mysterious in the way they are to be evaluated. But there is none of that.

Third, don’t get caught up and overwhelmed in experiences that are new. One of those is the anatomy lab. I know I had never been in a human anatomy lab before medical school, I had never seen a cadaver, I had never even had a formal dissection course. It seems to suck students in. Consider that the gross anatomy course during the first year is often worth about the same as the physiology course. You might not know that, especially during the first semester. As a result, many students seem to grow increasingly concerned about doing well in the anatomy lab, sometimes at the expense of studying for other things.

One thing we should realize is that, by and large, faculty educators realize experiences like the anatomy lab are new, and expectations are tailored accordingly. Yes, you need to know your anatomy backwards and forwards, which is a doable task I might add, but your dissections don’t need to look like you’re working for a Body Worlds exhibit.

Remember, medical school is a marathon. That is what I’ve taken to telling some of the first years in the anatomy lab. They all have the skills to muster the journey and they shouldn’t get so riled up and worried.

Easy for me to say, so far from my own "riled up and worried" year as a first year.

Google Your Future Doctor

Colin Son -- My school recently sent out an email to its students detailing the risks of publishing personal information online. We’re not talking about identity theft here. Instead, the email was prompted by a University of Florida study that looked at medical student use of the popular social networking website Facebook.

The study authors found what they considered a dangerous level of personal details which medical students made public online. For instance, more than half of all medical student profiles which the researchers looked at revealed the students’ political affiliation and sexual orientation. More than one in twenty students made their home address available.

A more in-depth look into several medical student profiles on Facebook found a plethora of examples of what the study lays out as “unprofessional.” Such included racist and sexist comments and pictures documenting excessive alcohol consumption.

The concern over online social networking is nothing new. I’m sure, like me, many have heard anecdotal stories of employers or schools "Googling" applicants or looking them up on websites like Facebook and MySpace. For future physicians in particular, the risk may be especially high because an elevated level of professionalism is expected of physicians.

This isn’t to denounce the rise of the social internet. This internet has bred a generation less concerned with privacy, and more willing to generate content for all to see based on their life experiences. That of course is for another intellectual discourse; the point is, though, that it has become the social norm. And I’m not even willing to bemoan that fact.

We should strive to find a balance where medical students (and others) can engage in online social activity and maintain a level of professionalism expected of them, even outside of the hospital.

One, you may want to give a little bit more thought to what you post online before you do so. As the University of Florida study points out, plenty in my generation are guilty of jumping before we think. I have pretty considerable exposure online between my participation in some social networking sites and my blogging, and I know at times I’ve been guilty of this myself.

Two, you may want to limit who can access what you publish online. One of the problems identified in the University of Florida’s study is that a majority of medical students made their Facebook profiles open to the public.

Generations past engaged in all the same "non-conformist" behavior that my generation has; just never was it so publicized. So, there will continue to be hiccups as the internet continues to reduce privacy. We need not be alarmist, though. What I think we are witnessing (and will witness) is generational friction, but social networking is too widespread to hold its use against all. We’ve entered a bit of transition in terms of defining privacy boundaries and, despite the truth in needing to have a little more discretion about what is revealed, in the end I don’t expect my generation to regret what they’ve published online about themselves nearly as much as others (say, the University of Florida study authors) imagine they will.

Don't Be a Jerk

Colin Son -- I’ll let you in on a little secret: providers in hospital settings can be really antagonistic towards each other at times. The same as any workplace, I suspect. Only in the hospital you’re sometimes dealing with life and death, not who ate your sandwich out of the break room refrigerator.

Here the surgery chief resident argues with the medicine attending whether this or that patient on the medicine service should get surgery. Here the ENT resident argues with the surgery critical care fellow whether the patient should be admitted on the ENT service or the trauma service. Here interventional radiology argues with medicine whether attempting a percutaneous mass biopsy is appropriate.

In the academic public hospital setting, the ones doing the arguing are often the residents since they’re the ones who essentially run the various services. As I get closer to residency, I’ve started to wonder how I’ll handle such situations.

Let me say that these heated debates over patient care aren’t necessarily a bad thing. You would hope that everyone involved would be advocating for what they truly believe is in the patient’s best interest. When that is the case, then arguing things out can be a good thing. The point is, there are truly times as a resident when you (or your staff) feels strongly about something and you need to hold your ground.

Such can be tough. I am not a Type A personality. I imagine myself a year from now, in a situation I’ve seen my residents in more than once:

I’m a month in and on call and some shunt kid who is cranky or not feeding well comes into the emergency room. Before the overworked and tired emergency medicine doc even gets the head CT he gives me a call. Down in the ER the conversation comes to a head with something like this from the EM attending, “You’re going to admit this patient.”

Well maybe, but it isn’t exactly his place to be saying something like that at this stage of the work up and it certainly isn’t his decision to make. No one in such a situation wants to be a pushover and nod their head, so that their chief has to call or come in and fight the battle.

At the same time, residency is a grueling ordeal and tends to "harden" more than a few people who journey through it. You don’t want to be a jerk and then suddenly the EM doc is waking up your attending at home.

I’ve got a chief right now that no matter where I end up I’d like to imitate in such encounters. I don’t think we’re merely talking about basic social skills here either. I’ve witnessed too many residents stumble when navigating antagonistic situations in the hospital. Playing the middle ground -– being an advocate for your patients and your service, while also not getting heated -– is a skill. Maybe being aware of that fact is the first step in mastering it.

Embarrassing Yourself

Colin Son -- Embarrassing yourself is part of life; part of medical school as well. Nowhere is this likely better demonstrated than the third year. Considering so many third years are within a month of starting their clinical lives on the wards and in the clinics, I thought I’d share one of my proudest moments.

It was my second month of third year. I was a week into a rotation on neurology, which wasn’t going too badly. I didn’t do a whole lot and the hours were good. This was kind of a blessing as I studied for the internal medicine shelf exam. And it is in this scenario that I got off one day at about four in the afternoon and made my way to my apartment. Apparently I fell asleep on the couch. Even in the grip of an "easy" rotation I guess I found myself a little pooped. At some point in the following two hours I managed to make it to my bedroom and the comfort of my bed, although I don’t particularly recall the journey.

When I woke up it was well past seven o’clock with light streaming through my bedroom window. It didn’t take much realization to prompt me out of bed and towards the bathroom and my toothbrush, in a flash. We started rounding at seven o’clock. The last thing I wanted was to impress my resident by being late, being a slacker on what was already a none-too-rigorous rotation. I’m sure I cursed myself, maybe even out loud, as I pulled out scrubs which I found littering my bedroom floor.

I raced down the street towards the hospital. At least I lived relatively close. It was two steps at a time up to the ninth floor; I didn’t really feel I could wait for the elevator. Up at the team work room I found no one and I figured they were already out seeing patients.

I gave the other student on my team a call. “Where are you guys?”

And she said, “Uh, I’m at home making dinner.” After a pause, “Why?”

I stood there dumbfounded and looked out the workroom window at the largely empty hospital parking lot below.

“No reason,” I said as it dawned on me what had just happened. “You have a good night,” and then I hung up.

Yeah, it was seven o’clock but not in the morning. I had slept a mere three hours before popping up and convincing myself, in my haste, that I was late for rounds.

Across town, standing over some boiling water and pasta no doubt, my fellow student was no doubt shaking her head as she put her phone down.

I walked to the elevators with a little slunk in my step and contemplated slapping myself upside my own head. I realized how empty the hospital was, how the sun must be in the west, that I didn’t really feel like I had slept more than twelve hours. It all made sense, except somehow it hadn’t for the whole twenty minutes it had taken me to race to the hospital.

The next day I had to explain to my partner on the team that strange call and I also let my resident in on my little screw up. Everyone got a good laugh.

Hey, I wasn’t late. I was dedicated enough to my rotation to come in extra early.

Nobody’s Favorite Exam

Colin Son -- I don’t know what your hospital is like, but the patient room we walk into is one of those unique ones crammed into an obscure corner. It is tucked away next to a utility closet and behind a team room. It screws up the numbering for every other patient room down the hall. An oddity of the multiple disorganized architectural revisions this hospital floor has no doubt gone through.

In one of those mysteries of modern life, the automatic door senses when we’re in front of it and slides open. I always expect it to do so with a hiss but that never seems to happen. Through the door I’m asked to practice that saturnine but all important final physical exam. I imagine, when it actually counts, there is nothing too unique about performing an exam to document brain death except in its requirement to be methodological and highly attentive. As I walk myself through the exam this day, in this room, I wonder if that is ever difficult; if bias ever hampers the whole thing. I mean, I had seen this gentleman’s CT scan. Maybe not. Certainly not during my first time through it, even if my exam doesn’t contribute anything to the outcome.

Brain death is something that deserves and has legal definitions. While the specifics of some of the laws vary by locale, in general the physical exam to document brain death is pretty standardized.

Foremost you need to rule out anything, other than permanent loss of function, which could be depressing the brainstem. Things to think about include:

- Intoxication or other depressants

- Hypoglycemia or other metabolic problems

- Hypothermia

- Paralytic agents

With those met, the physical exam can be performed. The standard of care through most places is an exam by two experienced physicians with each exam spaced by at least half an hour. In the U.S. some states require an EEG (or two separated by some time period). Some places even use radionuclide scans to document brainstem metabolism.

As for the physical exam itself, you’re testing brainstem function:

- Gag reflex

- Pupillary reaction to light

- Corneal reflex

- Oculocephalic reflex

- Vestibuloocular reflex

- Cranial nerve response to painful stimuli

- Apnea challenge

All of the above have to be negative.

The gag, pupillary light, and corneal reflexes are pretty typical. I’ll just clarify the others for completeness sake. The oculocephalic reflex is the doll’s eyes reflex. With an intact brainstem the eyes should fixate on a point. With their eyes open you take the patient’s head and turn it back and forth. If the eyes remain unchanging in their gaze then the reflex is absent. The vestibuloocular reflex is also known as the caloric test. For this test you typically use cold water. Inserted into the external auditory canal, the water should elicit eye movement if the reflex is present. The old mnemonic COWS (Cold Opposite, Warm Same), which refers to the direction of the primary movement based on the temperature of the water inserted into the canal, really isn’t important in a brain death exam. Any eye movement during caloric testing is enough to preclude a declaration of brain death. Finally, the apnea challenge just refers to disconnecting the patient from their ventilator and allowing the pCO2 to rise. If the hypercapnia will not evoke respiratory efforts in the patient, then the test is negative.

With all of those reflexes run through I follow my team out and up to the call room. I’d bet not the last time I’ll make that walk.

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.

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.