In general people from U.S. medical schools do quite well on the exam, even the first time around. The first Step 2 CS Examination was in June 2004. As of March 2005, there had been approximately 17,700 examinees. About half of these examinees were students from U.S. and Canadian medical schools, and about half were students or graduates of international medical schools. The overall pass rate for these U.S. and Canadian students was 96 percent and the overall pass rate for international students and graduates was 83 percent. These numbers will probably evolve as the exam matures and the examinee group grows. One of the bigger challenges of taking the exam has been the limited number of national testing sites, making expensive travel an added burden on the already financially strapped and stressed-out third-year student. Financial-aid packages now try to take this into account with additional loan monies made available, and more testing centers continue to open.
FOR D.O. STUDENTS IT’S THE COMLEX LEVEL 2
At this point in their med-school careers, D.O. students will take the next step of the COMLEX exam. Many D.O.s elect to take both the USMLE and COMLEX series in order to keep their options open. The tests are very similar and cover essentially the same scope of information. If you’re taking both, by all means schedule them close together so that you have to make the study push only once. For more information on the COMLEX exam, check out the National Board of Osteopathic Medical Examiners Web site at www.nbome.org/examinations.htm.
CHAPTER 20
Elective Rotations
An investment in knowledge always pays the best interest.
—BENJAMIN FRANKLIN
ONE OF THE most astounding things about medical training is that after you achieve a foundation of knowledge, the world is literally your oyster. You are not merely encouraged but required to try on a wide range of fields and determine which one suits you best. Once you’ve completed your core rotations, you will realize how astoundingly broad the field of medicine is, and being forced to choose a single field for a career becomes both a blessing and a curse. The remainder of your third and fourth years will be dedicated to doing this through elective rotations in various fields and to building your application for residency.
Your med-school course catalog will provide an exhaustive list of available electives. There is no magic formula for which electives to choose, but the time has come to start homing in on a career choice. Be aggressive about gaining experiences in your fields of interest so that you can narrow your choices, finalize your decision, and begin to develop your residency application (see the next chapter). Talk to upperclassmen who are going into these fields and discuss with them the best elective options and best sequence of rotations. Ask them about what other fields they were considering and how they made their choices.
You need to make sure you fulfill all your curricular requirements and address any experiential requirements for your residency application, but beyond that you should have some fun and see where this senior medical student thing can take you. You may wish to do electives in related fields to gain additional exposure that will be useful when you start your internship (e.g., radiology or infectious disease). You may also want to seek out some unique experiences you’ll never get a chance to try again. Ever wonder what radiation oncology is all about? Curious about forensic pathology and the medical examiner’s world? How about the numerous international electives that will provide wide-ranging experience in countries all across the world? Since some of these opportunities occur outside the confines of the U.S. medico-legal system, these rotations can give you tremendous latitude and authority as a student.
Another popular elective is the research month. If you’ve encountered someone along the way who is doing active research that you’re interested in, see if you can set up a month to learn some hands-on clinical-research skills. Try to make sure that you define an achievable scope so that you come away with a definitive product you can use for your applications and resume (such as authorship on a paper or presentation, and so on).
The sky is truly the limit here, and most schools will give their graduating seniors considerable latitude in defining their own electives, so while you’re homing in on a final selection think creatively and have fun!
PART FIVE
Applying for Residency and Surviving the Match
CHAPTER 21
Thinking About Residency
A ship in the harbor is safe, but that is not what ships were built for.
—DONALD KENDALL
THE FOURTH YEAR sneaks up on most students. You’re so deeply embroiled in moving from one intense rotation to another that the time just seems to slip by. Before you know it, your third year is drawing to a close and it’s time to start contemplating the road ahead again. It’s time for more soul-searching to determine your specialty of choice, time to dust off your promotional skills for another round of apps, interviews, and choices.
For a minority of you, the selection of a specialty may prove an easy choice. You either remain dedicated to the direction you arrived with, or you have discovered the field along the way about which you are now utterly passionate.
More power to you if your choice is that clear.
The reality for most, however, is that there are a number of fields that seem both attractive and a good fit. This chapter will help you work through that decision-making process. It will also lay the foundation for a winning run at the residency of your choice.
MAKING THE CHOICE: WHAT DO YOU WANT TO DO WITH YOUR LIFE?
It probably seems not that long ago that you made the decision to go to medical school. So how can you already be facing the choice of what kind of medicine to practice? And, more to the point, how can you base such an important decision on a few piddling weeks rotating on a service?
Oh, and what if you liked every rotation you did? How are you supposed to choose then?
“Much like going to medical school for the wrong reasons, if you go into a specialty you don’t really enjoy, it will make you miserable,” Chris notes. “Do not just look at the economic possibilities or the lifestyle or the prestige associated with certain specialties. If you do not absolutely love what you’re doing, it is likely you will regret it later.”
Just like applying to med school, there’s no magic formula for making a decision about residency. Review your rotations and think back to the time you felt most inspired. A great place to start to gather information is the American Medical Association’s fantastic Fellowship and Residency Electronic Interactive Database (FREIDA Online) Web site (www.ama-assn.org/ama/pub/category/2997.html). This Web site details every imaginable specialty, the nature of the field, the lifestyle, the compensation, and every accredited residency in the United States where it is offered. As you peruse your options, you might want to consider some criteria you should use while evaluating a specialty. We’ll call them the five Ls of choosing your field.
Learning opportunities
The first question you should ask yourself is “Will I remain challenged by this field years from now?” You’re about to dedicate a long career to a particular field of study. It’s worth making sure you are engaged by the subject matter. This doesn’t mean you have to be fascinated by every aspect of the field. It should mean, however, that you find yourself almost inexplicably drawn to the subject matter.
It should also mean that when relevance to this specialty comes up on other rotations, you find yourself a little more excited, paying a little more attention, or having a little more to offer your team in the way of expertise. The signs may be subtle at first, but you should gradually awaken to a gut feeling that this subject field resonates with you.
Think carefully about this, and figure out which field has given you the strongest positive attraction.
Long-term camaraderie
Another important part of finding your specialty is finding the right fit with the people drawn to that specialty. You’ll be spending many years and many late nights with these folks, so finding a group that you seem to na
turally connect with will make your life easier and more enjoyable. Even more than that, sensing that you fit well with the predominant culture of the specialty will mean your work ethic and attitudes will be more closely aligned with those of your colleagues, making your chances of success and reward that much higher.
“Sometimes you just know it’s not going to work out,” Pete notes. “One of my funnier experiences from residency interviews came when I asked a program about abortion training in a rural town in northern California. The interviewer stated somewhat defiantly that just last week the Planned Parenthood clinic had burned down for the third time in five years. Needless to say, I withdrew my application from the program.”
Lifestyle
This may be the most crucial measure in selecting your specialty, but not just because of what it says about how well you’ll succeed in that field. You must find a field that suits your sense of balance between work and personal life. To violate this rule is to doom yourself to an unhappy and ultimately unsuccessful career.
There are lots of great fields in medicine, and many outstanding physicians who accomplish incredible things on a regular basis. But if your heart is set on an intense field like trauma surgery, you must be very realistic about the impact the decision will have on your life. Consider carefully how many years of training it will take and how old you will be when you graduate. Look at the attendings around you and ask yourself if you can be happy in their job. Are they happy in their job? What is their family life like? Do they have families at all? The people who are most satisfied and successful in these highintensity fields are the ones who scrutinized the lifestyle before they joined it and recognized and accepted the choices they would have to make.
On the other hand, you also should not select a particular specialty solely because it offers an easier lifestyle or exceptional compensation. Again, you have to be careful what you wish for. If you are entering the specialty solely because of its rewards but without a real passion for the subject matter and the patients, you will ultimately be missing out on the most important reward of all—the immense satisfaction that comes from being excited to go to work every day. Worse still, you may find yourself married to the financial gains of a field you no longer have an interest in practicing. This is a disservice to your patients, not to mention to your own life and potential.
“Don’t sell yourself short in terms of personal happiness,” Deb advises. “We are all so gung-ho and willing to work ourselves into the ground to prove we are dedicated. Don’t underestimate the need for personal time.”
Likelihood of success
Medicine is an ever-evolving field, and with each passing day the business of medicine becomes a little more complicated and a little riskier. If you’re passionate about a field, you should never be dissuaded by lower salaries or fewer opportunities. On the other hand, you need to be realistic about what the prospects in your field look like both in the near-term (i.e., when you graduate) as well as twenty or thirty years down the road.
Consider the impact loan repayment will have on your monthly income and, thus, what impact it should have on your choice of career and location. Most specialties have undertaken extensive studies to determine the projected workforce needs and future job markets for their field. These studies can be a useful guide when making your decision. Try to ensure that the life you imagine building for yourself more or less matches the opportunities to succeed in the field.
“Ask a lot of questions and spend ample time within your specialty of choice,” Adam suggests. “Make sure the lifestyle of the attendings and residents is in accordance with what you expect. I would advise against choosing a specialty solely on financial grounds. These things tend to change rapidly, and you risk getting bored with your choice.”
Love of the particular field
This is the most nebulous of the criteria, but the list would be incomplete if it did not include a real evaluation of your sincere and reliable interest in the particular field. In choosing to go to medical school, you dedicated yourself to serving the needs of your patients. One would hope you will always bring to their bedside a passion for your work. This is a difficult thing to measure, particularly so early in your career and with such a limited exposure to the specialties you’re considering. Furthermore, passion is something that grows and deepens over time as you develop experience and a broader perspective on your field. Nonetheless, if you have doubts, you’d do well to keep looking.
Even after applying these five Ls to your list of prospective specialties, you may still find yourself struggling to make a choice. Keep working at it, and keep looking for ways to eliminate some of the options. For a few people, applying to multiple specialties might be an answer. You might, for example, be tied to a specific geographic location by family. In this case, your only options in that state in your top-choice specialty may be a few extremely competitive programs. You could, therefore, apply to these programs and then broaden your list to programs in another, less competitive specialty or even a generic internship in hopes of still securing a spot within that same state.
Whatever the case, the choice must ultimately be yours, made on your own terms, and according to your own personal criteria. Do your homework, talk to mentors, talk to residents, and make your lists of pros and cons. Then, informed by all the facts, make a decision with your gut. As with most major choices in life that require a serious commitment, the decision will ultimately be at least a partial leap of faith from something you know to something you can only imagine.
In my opinion, the top five criteria that should factor into your decision are (in no particular order):
Lifestyle in the field (hours, call schedule, length of training, and so on)
Compensation
The needs of the community you intend to practice in
Academic stimulation and reward
Respect for and positive interactions with your peers Look closely at the bread and butter of each specialty—as a dermatologist there are lots of rare and exotic skin conditions, but much of your day will be acne.
—Pete
DESIGNING YOUR APPLICATION SCHEDULE TO MEET YOUR GOALS
Now that you’ve chosen a direction, the next question is how to get there. Applications for residency are due in October of your senior year. That means that by the spring of your third year you need to be gearing up to apply. That also means you have a precious few months in the beginning of your fourth year to do some critical clinical rotations that will weigh heavily on your application.
All schools require that you complete a subinternship as a prerequisite to graduation. In your subinternship (also known as a “sub-I,” or “AI” for “acting internship”), you will take on the role of an intern. You will be expected to cover more patients, to work more independently, and to bring a more experienced perspective to bear. The thrust of your evaluations of your sub-I will be an assessment of your fitness as a future intern and resident. Obviously residencies look to these evaluations for insight into what kind of resident you’ll be. Therefore, it is essential that you pick a good sub-I for your field and work hard to excel in it. It is also critical to schedule this sub-I during the summer before your fourth year so that you’ll have your sub-I evaluation in time for residency application season.
Many students also do an away rotation in their field of choice at residencies they are particularly interested in applying to. You definitely aren’t required to do an away rotation, especially if you plan on trying to stay local for residency. However, it can offer not only serious insight into a program you’re interested in but also what amounts to a month-long, in-depth interview that will have substantial bearing on your application to that residency program. Furthermore, you will develop a broader perspective on the specialty by traveling to a new site with a different faculty and a fresh perspective.
Most programs reserve a limited number of slots for medical students from other institutions, so these slots are generally hotly contested. Ther
efore, you should work early to identify programs you may be interested in and try to set up an away rotation early on.
When I was applying to programs I targeted my top-choice program early. I had heard it had an excellent and growing reputation, and the more research I did on the program the more intrigued I became. In April, I arranged an away rotation, filling one of the last available slots for October of that year. I had a fantastic month that confirmed everything I had heard, and I solidified my choice. I arranged to rent a spectacular seaside cottage for an end-of-season price, and I brought my wife and daughter along with me at the last moment. It worked! They too fell in love with the region, and our top choice was made.
I expressed my enthusiasm for that program both in my interview and in discussions with the residents that month. The research director ended up inviting me to stay on an extra month to help out on a last-minute research project. I was able to rearrange my school schedule and break out another elective. The second month only deepened my interest, and it offered a unique chance to hang out with residents and faculty and develop some personal friendships. Come January my decision was an easy one, and on Match Day we were thrilled to get our first choice.
Med School Confidential Page 24