At the end of your intern year, you will make another leap in responsibility. If your internship was separate from your residency, you may be moving to a new place and starting out with all new colleagues. But even if you’re in an integrated program, your second year will be one in which you take on a larger patient load and have more involvement in leading clinical teams and overseeing interns and medical students. Chances are, shortly after you start your residency, you will look into the wide eyes of one of your interns or med students and realize just how far you’ve come.
The number of years of residency training varies from specialty to specialty. At a minimum you will complete one year of internship and two years of residency. No matter how long your training program is, you will continue to progress in your clinical responsibilities and oversight levels from year to year. By the time you become a senior resident you may be elected to or designated a chief resident. As a chief, you will continue to fulfill your ordinary clinical duties but will also undertake a full slate of administrative duties and oversight responsibilities.
Once again, remember that this chapter is merely intended to provide an overview. We handle the specific details of residency and provide all the strategies for optimizing your residency experience in part six of this book.
MEDICAL LICENSING
You must obtain a U.S. Medical License in order to practice medicine in the United States. To do this you must pass all three steps of the United States Medical Licensing Exam (USMLE). Typically you will take Step 1 of the test after the first two preclinical years in medical school, Step 2 during your fourth year of medical school, and Step 3 after one year of postgraduate training (i.e., internship). After you’ve passed all three Step Exams, you will have completed national certification and can apply for a state license to practice medicine. Thankfully, this is just a matter of filing paperwork. You are not required to pass any additional tests to get licensed in different states.
During your residency training, you will probably work under a provisional license of the hospital and residency program, so you don’t need to complete your medical licensing application process until you actually complete your training. Getting all of your licensing credentials while still in training, however, will allow you to moonlight—that is, get paid for picking up extra shifts at facilities outside your training program. Some residencies restrict moonlighting, while others encourage it as a way to expand your clinical experience. Whatever the case, moonlighting can be an important source of additional income to the financially strapped resident.
Successfully completing each USMLE Step Exam is a major rite of passage on the long road through medical school. The USMLE Step Exams are intense, comprehensive experiences that require extensive study. Step 1 covers the full spectrum of medical knowledge and will truly test your ability to regurgitate and apply the preclinical material from the first two years of med school. Step 2 is based on clinical scenarios and will test your clinical decision making; it includes the Objective Structured Clinical Exam (OSCE)—a live demonstration of your clinical skills on actors trained as simulated patients. On this portion of the Step 2 Exam, you will be asked to demonstrate your interview skills, your physical-examination skills, and your clinical decision-making skills in a simulated clinical encounter. Finally, Step 3 attempts to test your more advanced clinical decision-making and medical-management skills. It also includes a computerized, case-based simulation component.
We’ll review each of the Step Exams as they come up chronologically in the chapters ahead.
FELLOWSHIP TRAINING
While in residency, you may decide you wish to continue your training to subspecialize within your discipline. To do this, you will have to complete a fellowship—typically an additional one to four years of focused, high-level training. Most fields offer some form of subspecialty training. For example, cardiology is a subspecialty fellowship of internal medicine. Similarly, cardiothoracic is a subspecialty of general surgery, and neonatology is a subspecialty of pediatrics. At the end of most fellowships you will be eligible for subspecialty board certification.
BOARD CERTIFICATION
The long road to physicianhood ends with the completion of your board certification. After graduating from your residency or fellowship you will be eligible to sit for your specialty or subspecialty boards. This is typically a two-day written examination created by a board of specialists in your field. Many specialties also require an oral board exam. In the oral exam, you will spend one or two days facing clinical case scenarios presented by a trained examiner, and you will be expected to verbally walk through the case, manage the patient, and reach a diagnosis. This is essentially a more basic version of the OSCE designed to test your reasoning skills on your feet.
CHAPTER 3
Surviving Premed
If you want the rainbow, you gotta put up with the rain.
—DOLLY PARTON
IT IS UNDENIABLE that a solid foundation in the fundamentals of science is imperative to your subsequent medical education. That said, the set of hurdles imposed by college premed programs is more a means to weed out those not fanatically dedicated to medicine than it is the wellspring of foundational knowledge required of physicians and clinical scientists. Thus, the goal in premed is simply to overcome this important first hurdle in your medical education and arrive on the other side with your enthusiasm intact. The best way to accomplish this is to arm yourself with an understanding of the process, keep your eye on your goals, and be creative wherever you can.
Let’s look at what classes are required and what you can do to excel in them, either as an undergraduate or as a postbaccalaureate student.
THE PREMED REQUIREMENTS
The Association of American Medical Colleges (AAMC) publishes a guide, Medical School Admission Requirements (MSAR), that is a worthwhile investment at the outset of your premed studies. This guide, available from the AAMC Web site (www.aamc.org/medicalschools.htm), details the basic course requirements, which include:
Physics 2 semesters
Biology 2 semesters
Chemistry—Inorganic 2 semesters
Chemistry—Organic 2 semesters
Calculus 1 semester
If you took Advanced Placement (AP) classes or International Baccalaureate (IB) classes in high school, you may be eligible to receive college-level credit and thus place out of some of these courses. If you have a solid, foundational understanding of biology, physics, inorganic chemistry, and calculus, we highly recommend placing out of as many of these requirements as possible, since the general premed curriculum will otherwise consume approximately onefourth of your college course load and require a very significant obligation of time, effort, and dedication.
PREMED AS AN UNDERGRADUATE
If you’re still an undergraduate and didn’t place out of any of these courses, you may find yourself staring at the above list of classes and wondering how you can possibly cram that list into four years already jam-packed with your other curricular requirements.
Relax. With a little bit of creative planning, you can prevent your premed requirements from eclipsing your liberal arts education and precluding the normal pleasures of college life.
Your primary task will be to avoid the myopic sense of drudgery that the premed curriculum instills and remember that college offers an astounding opportunity to delve deeply into a vast array of subjects. Focusing solely on the premed curriculum or choosing a major based on it at the expense of other interests may stultify and embitter you and deny you those nonscientific exposures and ideas that could well be the creative spark in your med-school application.
To strike the critical balance between courses you must take and the courses you want to take, you have several tools at your disposal. First, your college or university almost certainly employs a premed advisor. Get to know this person early in your life on campus. Not only will this person be able to offer important insight and guidance about the premed process, he or she will also b
e a critical source for a letter of recommendation someday. Ask about the typical sequence of classes, who the best professors are, when to take what, and which courses should not be taken concurrently. Find out what the most challenging classes are and how best to manage them. Write out a four-year master semester schedule and pencil in all the required classes. Now as you go about matching up your other nonpremed classes semester by semester, you’ll be able to sense what your premed workload will be and how best to fit the pieces of the puzzle together.
“I took all of my premed classes as a freshman and sophomore in college,” Adam recalls. “In a way I wish I had spread them out, as I probably would have been a bit more focused and done better in them.”
Surviving and thriving in the premed curriculum
Keep several key points in mind as you approach each of your premed classes. First, your performance in these classes will be closely scrutinized when you apply to medical school, so you should devote the necessary time, energy, and focus to them to ensure that you do your best. This does not mean that if you don’t maintain a 4.0 average in these classes you should order up a copy of Law School Confidential and reconsider your options. What it does mean is that these are classes that must be taken seriously.
And what does that mean?
Get organized early and stay organized. Stay on top of your problem sets, labs, and upcoming tests, and get extra help at the first sign of trouble. Most schools have built-in premed tutoring programs that can provide some additional one-on-one teaching time that can really make a difference, often at no additional cost to you. Second, remember that while these classes are billed as integral to your medical education, they are really just the primary training for your first big med-school hurdle—the MCAT. We strongly recommend buying an MCAT review book as you begin your journey through the premed curriculum and reading through the relevant material as you proceed through a given course. As you prepare for your exams in college, use a bank of MCAT-prep questions to hone your skills on a particular topic. This will help emphasize and reinforce the range and depth of topics typically covered on the MCAT and get you in the habit of using review books in conjunction with studying for classes—a tactic you will want to use again and again in medical school.
You must also strive to find personal relevance, interest, or realworld applicability in the premed curriculum. You’re learning stuff at a fundamental, often abstract level, but all of this stuff applies one way or another. Seek out examples of those applications. When reading about Pascal’s gas law, try to seek out some examples from pulmonary physiology; when grappling with the Henderson Hasselbach equation and acid-base chemistry, think about how these topics apply to buffering systems in the blood. Specific references to clinical medicine in your classroom lectures will, unfortunately, likely be few and far between, so focus and invigorate your studies by drumming up your own clinically oriented examples for projects and papers. Most professors will be happy to help you explore the clinical application of your basic science studies during office hours. Make the time to find these connections.
Finally, a last piece of advice: you’ll be studying medicine in one form or another for the rest of your life. The long road ahead features years of medical school, residency, and a lifetime of learning as a clinician to pursue the nuances of science in medicine. Take advantage of your four years as an undergraduate to become educated. Don’t succumb to the urge to follow the well-beaten path of the premed drones, blindly pursuing a biology major, volunteering at the university hospital, becoming an EMT, and surviving all of your other curriculum requirements with Cliffs Notes and canned outlines. Taking this approach will render you colorless and indistinguishable from thousands of other med-school applicants a few years down the road, and it will cheat you of one of the most formative experiences of your lifetime.
Take time to explore the curriculum and to find new horizons in areas you didn’t even know existed. Test your commitment to the medical profession. Yes, it will be a juggling act to seriously pursue other areas of interest while hammering away at the premed classes. In the end, though, it will pay off not only in making you a welleducated person but also in extending the scope of your medschool application into important nonmedical arenas that, as Dr. Friedman notes in the foreword to this book, are especially attractive to today’s admissions committees searching for well-rounded, “human” applicants.
Make sure your explorations extend beyond your courses as well. College is filled with unparalleled opportunities to get involved in all manner of activities, projects, travels, and groups. Find out if you can get involved in the local ski patrol. Scan the bulletin boards of various departments looking for assistants for far-flung trips to do research or offer humanitarian assistance. Remember that everyone’s med-school application will have the exact same premed classes, probably with similar grades. Look for ways to extend yourself with a different major or a different course load, and challenge yourself with a different array of experiences, and thus distinguish yourself as someone with the independent mind and the adventuresome, inquisitive spirit most sought after by med-school admissions committees.
I decided during the beginning of my senior year that I was going to take one year off after college before attending medical school. I found a nonprofit group based in Utah that ran Peace Corps-like programs in countries around the world. I ended up working for them in Bolivia, spending seven months living with the Aymara Indians.
—Adam
PREMED AS A POSTBAC
For those of you going back to satisfy your premed requirements after college, the road is a bit trickier. Chances are, you have ajob and a life, and as such you may be less able to simply drop everything and dedicate yourself solely to banging out these difficult classes in rapid succession. As someone already out in the working world, you may have less tolerance for busywork, and the idea of returning to entrylevel undergraduate classes will likely be considerably less appealing than it was your freshman year, especially without the keg parties.
“When you’ve been out a while, it seems bizarre to be back in an academic environment, and it was difficult for me to adjust,” Ben notes. “That being said, I think most of us who went back to complete premed requirements tended to have a broader perspective on what was important and what was not.”
“I served on my medical school’s admissions committee for two years,” Adam says, “and I can say with assurance that there is no disadvantage to taking time between college and medical school. An applicant can show sufficient interest in medicine regardless of his or her path to medical school.”
There are actually some important potential advantages to doing a postbac premed plan. First, you will be older and wiser than your classmates who come straight from college. You’ve likely worked or traveled a bit and subsequently decided to go back and pursue medicine after an assortment of real-life experiences. This means you now have a focused goal, and more advanced and varied skills to achieve it. You’re better able to prioritize and keep the forest in view while working among the trees. Since you’ve already completed college, your sole focus can be your premed studies and making sure you shine.
Second, and perhaps most important, you have maturity, experience, and perspective on your side. You’ve arrived at medicine’s doorstep on a path whose tried-and-tested alternatives led you to the conclusion that your passion and future lie in medicine. This informed decision making should provide an important source of staying power, passion, and focus as you grind through the premed classes.
“I think it is an enormous advantage to experience the world before plunging into the myopic existence of medicine,” Pete explains. “The perspectives you gain from working in the real world with real people are invaluable in providing understanding and compassionate care to whatever community you end up practicing medicine in. That appreciation of the people you work with is so important, as is the self-knowledge that comes from pursuing alternative paths before settling into medicine.
The flip sides to this, however, are multiple. First, it’s much more physically and emotionally draining to go through the rigors of residency as an older individual, particularly if you have children or a partner as part of your life at that point. Second, you realize how cushy a forty-hour workweek really is and can personally contrast that with the eighty-plus hours per week you work in the hospital as a resident and sometimes as an attending.”
I believe quite strongly that it is an advantage to take time off between undergrad and med school. Some will say it makes you a stronger applicant, mostly because you have something else to talk about during your interviews. More important, though, I think it makes med school and residency easier. When you are sitting in the library at midnight during the middle of your first year in medical school or on call for the tenth time in three weeks during your internship, you won’t be haunted by the what ifs that bother the kids who went straight through. You will have been out there in the real world. You will know firsthand how boring a staff meeting can be or how absolutely humiliating it can be to work in a cubical for a boss who is, at best, a moron. You know that you never want to have a regular nine-to-five job when being a doctor would be so much more fun.
—Chris
Where to complete your premed requirements
Where you take your premed classes is relatively unimportant. Some people return to their undergraduate institution, which has the advantage of producing a uniform academic record. Some people enroll in one of the many intensive postbac premed programs around the country. These programs, which are familiar to and typically wellregarded by med schools, are designed to be factories to crank you out through the premed process. Others simply take the classes at whatever institution is closest to their jobs and families, allowing them to continue working and living in the same area while completing the requirements. The Association of American Medical Colleges (AAMC) Web site (www.aamc.org) has a listing of every public and private premed program in the country to help you choose the program that works best for your situation.
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