Importance of Building a Team

As a new resident physician, you are tasked with long days and the responsibility of learning how to analyze variances and subtle changes in lab tests, vital signs, diagnostics and much more. 

Developing a team approach can be a life-saver in your days as a resident. Each member of the team has special training in their area of expertise to help your learning curve.  

The interdisciplinary team can include:

·         Nurses

·         Pharmacists

·         Physical Therapists

·         Speech Therapists

·         Dietitians

·         Respiratory Therapists

·         Social Workers

 

How Can A Dietitian Help You In Your Practice?

A resident’s time is increasingly pressured to do more with less. Burnout is a real thing.  As a clinical dietitian (RD) for over 18 years, I have learned a thing or two about helping doctors develop the best plan of care, which ultimately can reduce demands on their time. 

Maybe even more importantly, a patient’s time spent with a dietitian may help speed a patient’s recovery and healing, saving the hospital money, improving the health of the patient, and making an ever-increasingly tight budget more manageable. 

Here are a few reasons to reach out to your hospital’s dietitians. This even extends well into the clinic setting. 

They know tube feedings and total parenteral nutrition inside and out

RD nutritionists are trained to assess a patient’s nutritional needs and can write tailored orders for nutrition support. They can make recommendations for when nutrition support is indicated. Some RD’s even have advanced practice training in nutrition support.

They know the vitamin and mineral formulary

I have had many discussions with resident doctors at my hospital and the bottom line: they don’t have time to investigate what supplements are available and when to use them, which kinds are most absorbable, etc. 

 

Your dietitians should be able to quickly share this with you or make recommendations. Even better, develop a rapport with the dietitian, and they will be able to obtain standing orders for these.

They can help increase Medicare reimbursements for malnutrition

How?  By helping with accurate diagnosis of malnutrition.  Patients who are malnourished are reimbursed at a higher rate through Medicare because they have higher morbidity and mortality.  However, the coding and wording of diagnoses needs to be done in a very specific way that RD’s know and are trained to do correctly.

Malnutrition Trivia:

Did you know that it is not only alcoholics risk the permanent damage of thiamine deficiency?  Malnutrition and gastric bypass often result in thiamine deficiency and that can cause Wernicke’s encephalopathy too.  Sugar addicts also run low on thiamine.

They are helping change the way perioperative feeding practices

At my facility, we have an amazing team of doctors and nutritionists.  Colleagues of mine have been integral along with the surgeons in starting a perioperative nutritional program.  Improved feeding practices in the perioperative period have resulted in reduced infections and dramatic reductions in length of stay http://www.espen.org/files/ESPEN-guideline_Clinical-nutrition-in-surgery.pdf .  In other words, evidence supports pre-operative nutrition assessment and feeding as well as post-operative early nutrition.  The RD is essential in helping these processes run well.

Nutrients may speed wound recovery and healing

A great nutritional plan at the time of admission for patients with trauma or wounds may speed healing and recovery time https://www.ncbi.nlm.nih.gov/pubmed/27574687

 https://www.ncbi.nlm.nih.gov/pubmed/16998143

https://www.ncbi.nlm.nih.gov/pubmed/17490965

Nutrients may improve functional recovery, especially in the elderly hospitalized patient

Many studies show that early intervention for supplements in elderly patients may reduce hospital costs and improve functional recovery. This may even reduce mortality https://www.ncbi.nlm.nih.gov/pubmed/1452950

https://www.ncbi.nlm.nih.gov/pubmed/19370584

https://www.ncbi.nlm.nih.gov/pubmed/28231616

Drug-nutrient interactions:

Many common drugs on the market today, if taken for long periods of time, rob the body of key nutrients for immunity and healing.  Corticosteroids, ARBs and ACE inhibitors, Methotrexate, chemotherapy drugs, and metformin are just a few of these. Your RD can help identify and make additions nutritionally to help the patient achieve the best chance of recovery. As a resident, make sure you inquire about drug-nutrient interactions.

Condition-related depletions

Conditions like Crohn’s, chronic diarrhea, heart failure, and even diabetes are notorious for causing nutrient-related complications. Ask your RD to help you ameliorate some of these issues.

 Education

Educating and motivating patients takes a lot of time; your RDs can help with this.  RDs are trained to motivate behavior change for diabetes, heart disease, depression, cancer treatment.  Some even specialize in depression, autoimmunity, integrative medicine and many more.

Cancer treatment side effects

Keeping patients well-nourished through cancer treatment will help keep them out of the hospital and will improve chances of survival and best outcomes. Your RD can help tackle malnutrition in this vulnerable population. 

Closing Thoughts

RDs are an important resource for resident physicians in the hospital; when working together, they can help improve your learning experience, patient recovery and save precious hours in the day.  A team-building approach will be beneficial to you in your career as a resident.  If you can develop a rapport with the therapy team, you will increase your understanding of the healing process.

 

 

Heidi Moretti, MS, RD has worked as a clinical nutritionist for 18 years and has conducted vitamin and protein research throughout her career. She is passionate about integrative and functional nutrition and is obtaining certification through the Integrative and Functional Nutrition Academy. She is a blogger and also has a private practice; you can find her on TwitterFacebookPinterest and her website: https://www.dietdetectiverd.com/

Roads to Residency

Did you catch that? The optimistic astute observer will be intrigued by the plural in the title, whereas the pessimist may presume it to be a typo. Rest assured, this is no typo as there are many roads (traditional and non-traditional) to reaching your residency destination. First let’s talk numbers. Numbers don’t lie. Numbers are not your best friend telling you that everything will be okay. In the 2016 match, there were 42,370 total registered applicants and 30,594 positions were filled1. Both of these figures were record highs. What happened to the remaining 11,776 unmatched applicants? Some will move on to other careers, some will reapply the following year with the same application. What will set you apart is how you use this time to boost your chances for the following year.

Traditional:
First let’s briefly outline what most students already know about applying for residency. Application is online through ERAS in September of the year before the intended match. Interviews occur between October to December, rank lists are due in February, and if your tale has a storybook ending like most NCAA teams hope for during March Madness, then March = Match!

Non-traditional:
So you didn’t match? What now? Is this the end? What are you going to do with $250,000 in student loans and this MD degree? Most unmatched applicants struggle with these difficult questions. Immediately post-match the SOAP (Supplemental Offer and Acceptance Program) is active online from Monday-Thursday of match week. In 2012, SOAP replaced the process formerly known as “the scramble”. To be eligible for SOAP and have access to the unfilled list of programs, an applicant must have applied to at least one program during the regular ERAS match cycle from September to December.  

Life after SOAP:
So SOAP didn’t work out? This is time to pause and take stock of your goals. Be honest with yourself. How can you improve your application to re-apply? Perhaps an alternative career may be better suited to your particular strengths. If your goal still includes residency, then there are a number of ways to turbocharge your application.

Application enrichment often includes an obervership to gain valuable clinical experience, updated recommendation letters, and a unique opportunity to audition at a hospital where you are likely to match. Working in medical education has the benefits of being in an academic setting, staying current with today’s medicine, and networking with academic faculty. Working in research is considered a scholarly activity and gives you something interesting to speak about on your interviews. Other scholarly activities include taking Step 3 or working towards advanced degrees such as an MBA or MHA which make you more dynamic in today’s modern healthcare world.

Networking is the single most important skill to cultivate during your year off. Be honest, would you hire yourself today? Why not? After addressing your weaknesses as detailed in the above paragraph, now it’s time to network. Promote yourself at the local and national level by attending conferences and professional society meetings. If you’ve been doing research, submit your abstracts to various conferences and strive for publication. Regularly pause and take stock of your progress. Each day should be getting you closer to residency.

What to do when all positions are “filled”?
The following resources are freely available. Some examples may apply to preliminary/transitional residents looking to secure advanced standing PGY2 positions.

AMA residency vacancies:
Bookmark and follow this website for postings for open PGY-1 as well as advanced PGY-2 positions.
http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/resident-fellow-section/rfs-resources/residency-vacancies-work-environment/find-residency-fellowship.page

ACGME listings:
Focus on programs with new/initial accreditation which need to fill their class. This list is particularly useful for residents who may have completed a preliminary year in Internal Medicine, General Surgery, or a Transitional Year and can apply for advanced PGY2 standing. As of 2016, there are 431 Internal Medicine programs and 498 Family Medicine programs. Among the advanced residencies which require an intern year, there are 139 Neurology programs, 189 Radiology programs, 137 Anesthesiology programs, and 81 Physical Medicine and Rehabilitation programs.
https://apps.acgme.org/ads/public/

Keys to success:
Instead of filling this paragraph with clichés like hard work always pays off (it does) or everything happens for a reason (sometimes), or you only live once (unless you’re a zombie!), let’s focus on staying motivated and driven for the long haul. This is a long and difficult road. Keep in mind the following excerpt from President Barack Obama’s commencement address at Rutgers University this spring2. “Gear yourself for the long haul...you're going to have some setbacks…You will be frustrated…You won’t always get everything you want -- at least not as fast as you want it. So you have to stick with it. You have to be persistent. And success, however small, however incomplete, success is still success…So don’t lose hope if sometimes you hit a roadblock. Don't lose hope in the face of naysayers. And certainly don’t let resistance make you cynical. Cynicism is so easy, and cynics don’t accomplish much…Don’t let that be you. Don’t waste your time waiting.”

References:
1) NRMP Match statistics:  http://www.nrmp.org/wp-content/uploads/2016/04/2016-MRM-infographic-post-SOAP.jpg

2) “Remarks by the President at Commencement Address at Rutgers, the State University of New Jersey”. The White House, Office of the Press Secretary. https://www.whitehouse.gov/the-press-office/2016/05/15/remarks-president-commencement-address-rutgers-state-university-new

3) Accreditation Council for Graduate Medical Education

4) American Medical Assosciation

5) The staff at MasterTheWards for their continued support and guidance. http://www.masterthewards.com/

 

Dr. Raman Sharma is a Physical Medicine and Rehabilitation resident in White Plains, NY where he has taken leadership roles in the program.  He completed his internship in Internal Medicine in Brooklyn, NY. He holds a faculty appointment of Adjunct Clinical Instructor for Touro College of Medicine for a clinical training site in Brooklyn, NY. Raman is also a Captain in the United States Air Force Reserve Medical Corps.

Comment

Raman Sharma, MD

Dr. Raman Sharma is a Physical Medicine and Rehabilitation resident in White Plains, NY where he has taken leadership roles in the program.  He completed his internship in Internal Medicine in Brooklyn, NY. He holds a faculty appointment of Adjunct Clinical Instructor for Touro College of Medicine for a clinical training site in Brooklyn, NY. Raman is also a Captain in the United States Air Force Reserve Medical Corps.

Medical School Loan Repayment

A medical degree is arguably the most expensive advanced degree. According to various resources, med school graduates carry an average debt of $180,000. If you take into account accumulating interest (at 6% add another ~ $60,000 in interest) the overall investment is far greater. Many have quipped it is equal to a mortgage without the home. Repaying medical school loans can be a long and arduous process, but with a bit of planning and being proactive, you can save thousands of dollars over the course of your repayment. Being smart about your debt ensures that it doesn’t run away from you.

Many assume repaying student loans will be something they will be able to handle with ease. But with ever increasing costs and contracting physician reimbursement, student loan repayment is something all physicians should take the time to plan. This includes calculating how the repayments will fit in your overall budget and how long it will take to pay all these loans. After all, you worked far too hard for too long to be saddled with debt. Here are some tips I gathered to help you save time and money.

First and foremost, a financial professional, such as an accountant or financial planner familiar with student loans can be an invaluable resource when designing a repayment plan. If you don’t already have one, I encourage you to seek one out. Besides, you will need an accountant for annual tax preparation. You can start by asking your medical school’s financial aid office for resources. Or, ask a close mentor or attending physicians, since almost all medical doctors are in the same boat.

To get through medical school you needed to be organized. Those skills will serve you well with a debt repayment plan. So make a spreadsheet or take out your highlighters or organizer and do the following:

  • Create a master document that includes the contact information for all loans, including amounts, issuing institutions or programs, and entities that service the loans.
  • Itemize interest rates, loan terms, and factors affecting repayment (including grace periods and deferment options).

Here are some repayment options to help guide you:

Pay Extra Towards Your Medical Student Loan Debt Each Month

This is common knowledge, but it warrants repeating: Even if you just pay a little bit extra on your medical student loan debt each month, you have the potential to shave years off the life of your loan. Also, while not my personal favorite, consider having the payments withdrawn automatically so you don’t have to think about them.

Income Based Repayment

Under the Affordable Care Act a new provision by the federal government, you are allowed to make loan payments based on your income level.  The new Income Based Repayment (IBR) for those with financial hardship (most post-graduate residents qualify), you can make payments of 10% (down from 15%) of your income. So even with a modest residency salary, you can still make some payments. Additionally, there is a cap on loan re-payment duration of 20 years (down from 25) before loan forgiveness.  That means if there is anything left on the loan after 20 years it is forgiven: WOW!

Public Service Loan Forgiveness

Only Direct Loans are eligible, but if you consolidate your loans into a Direct Consolidation Loan you may be eligible for Public Service Loan Forgiveness (PSLF). On the AAMC website (https://services.aamc.org/fed_loan_pub/index.cfm?fuseaction=public.welcome&CFID=1&CFTOKEN=B944240D-F2DC-1091-FC00983FB6B9423F) they have published a comprehensive list by state. In this scenario, you must be working for a qualified employer, such as:

  • Federal, state, and local government agencies
  • Nonprofit organizations (many hospitals are nonprofit)
  • Federally designated underserved area

Under these programs there are ways to receive federal loan forgiveness. For example, with PSLF, the terms state that if you make 120 qualifying payments, whatever debt you have left over is forgiven. You’ll need to check with your accountant or financial planner regarding tax implications here, but the overall savings could be huge. These payments are based on a percentage of your income, so for those looking at many years of training this could be a great option. For example, if a physician has 6 years of training (3 yrs. Internal Medicine & 3 yrs. Fellowship), he or she will have paid 72 of the 120 payments before their annual income increases significantly. Once income has increased, monthly payments increase as well: or as in the example above only the last 48 payment will be at the higher rate.

Refinance

Just like refinancing your mortgage, you can often find better rates on your medical school loans. The proven method of refinancing loans could also translate into substantial savings. This holds true especially if you had to take out private loans or if you’re already in practice and don’t qualify for IBR or PSLF. The best time to refinance depends mostly on interest rates. You can make a refinancing inquiry at any time to see if a better rate is available. For example, by dropping your interest rate from 8% to 5%, you can save thousands of dollars over the course of your repayment period. Keep in mind that you will typically need a good credit score to get the best rates. All things considered, refinancing is definitely a worthwhile strategy, but make sure it’s right for you before diving in.

Join the Military

You’ve heard of the military paying for college tuition, but did you know they will also pay you a large stipend and a grant while you’re in residency in exchange for service? Each branch of the military has a program and can amount to tens of thousands of extra stipend dollars to pay off most if not all of your debt. Another perk is that you get to enter the military as an officer. Here are some helpful links:

Navy:http://www.med.navy.mil/Accessions/Pages/Health-Professions-Loan-Repayment-Program-%28HPLRP%29.aspx

Army: http://www.goarmy.com/amedd/education.html

Air Force: https://www.airforce.com/careers/specialty-careers/healthcare/training-and-education

There are others. Of course, in return you owe service to the military, the duration of which can vary depending on your agreement with them and your specialty. Typically, you will owe 3–5 years of active duty or several more years of being a reservist. In most cases they offer about $40,000 annually that can be used for loan repayment. This is on top of whatever stipend they offer.

Deferment or Forbearance

During your ACGME accredited training (residency and fellowship), some loans have an option to defer payments until you graduate. This can be helpful for residents who are battling high costs of living, credit card debt or just other substantial expenses. However, if possible, make this your last option. While your salary is not where you would like it to be yet, allocating some funds to pay down debt makes sense. Why? Simple! Interest is still accruing and can add thousands of dollars to your overall debt burden. Look out for clauses like “capitalized interest.” This is bad.

Conclusion

Don’t get discouraged. Times have certainly changed in the last 50 years. In the 1960’s and ‘70s it was a rite of passage that when you became an attending you would purchase a fur coat for your wife. Now, many want an Audi or Mercedes and a large home. Most folks when they get discouraged are inclined to make an unnecessary luxury purchase or take a lavish vacation. This begins a bad trend and the start of a downward spiral.

No matter what your situation, it pays to look into your options for paying off medical school debt. Who knows? One of these tips might end up saving you tens of thousands of dollars. At the end of the day if all else fails, pay off high interest loans faster than lower interest loans.

Good luck!

 

As always, comments and suggestions are welcomed. If you have an idea for future topics please share and we can collaborate.

Michael Farca served as a residency program coordinator for the Department of Medicine at one of the largest training programs in the country.  He became the Department Administrator with continued oversight of the residency program, 2 primary site fellowships and 3 rotating fellowships.  Michael has dedicated over a decade to graduate medical education and is board certified in Teaching Administrators for Graduate Medical Education (C-TAGME).

Disclaimer: Michael Farca is an entrepreneur and is part owner and operator of Master the Wards, which provides Observership U.S. clinical experiences for IMGs, CV and personal statement development.

Acknowledgements: NEJM Career Center & AAMC

Decoding your Resume

Let’s first understand why a resume, also known as Curriculum Vitae (CV), is important.  In Latin, it means “course of my life.”  So by definition it is a brief account of a person’s education, qualifications and previous experiences.  Your CV is a marketing document (like a business card).  Creating a CV is like working backwards with a mathematical problem.  Start with end goal in mind: to get you an interview for a desired job.  There is no other purpose.  Some feel that the CV needs to:

  • Be showcase your every achievement since birth
  • Justification a job change
  • Mention promotions, awards, or special recognition
  • Be a forum for describing the size of an organization, team, or budget for which you had responsibility

With the average recruiter spending 8 seconds for the first pass on a CV the depth and fluff is not looked at.  So the goal of your resume is to get you the interview.  This is achieved by persuading the reviewer that time spent with you will be worth more than time spent with another candidate.  You'll persuade the reviewer by providing quantifiably proven results that you can do the job very well.

Resume length and structure

The first question people ask is how long should a resume be?  I have seen anywhere from ½ a page to 20+ pages.  The average resume should be no more than 2 pages. If you are a new graduate or recently entered the field: 1 page should suffice.  More is not necessarily better.  Specific to the medical field there are added elements depending on the stage you are in.  For example Medical school graduates might include a small section with USMLE score information or select research periodicals.  Whereas, if you are a graduating resident, the USMLE section is not necessary.

Your resume will be composed of several key sections: A heading with contact information; a professional summary; a chronological detail of your experiences; and your educational background.  There are some extras sections that you can consider depending on your field of application.  The most important element is to understand that your CV is a living and fluid document.

Your audience

Your resume is a marketing document that needs to get past certain pre-screeners to get you your interview.  Tailoring your CV to your audience is important.  Know that a large urban academic medical center will have different needs than a small rural hospital.  Understanding those needs and portraying that in your CV gives you a leg up to the competition.  You’ve heard it before: research the company or hospital to get a sense of what is important to them.

Section I: Professional Summary

This summarizes your professional ambitions, background, and talents.  This is 2-3 lines sales pitch.  This is not your biography.  You'll highlight your skills and successes.

Job titles: These can vary from company to company.  In medicine, junior attending, hospitalist, and nocturnist all mean something different.  Know the title and its related qualifications and custom tailor your CV to it.

Professional skills: list a handful of skills that you possess that are important to your success in the jobs you are seeking. This should be genuine and not made up.  Remember you might be tested on them.  A resume is a legal part of your application and dishonesty will only serve to hurt you.  Skills should also be "level appropriate".  Meaning, if you are a med student applying for residency, it is not expected that you are proficient in central line placements.  This is a skill developed during residency.

Descriptions of your past success: a few phrases that describe your demonstrated past success. Anything for which you have received recognition is appropriate (ex. For student graduates: Top-ranked student or dean recognition award).

Section II: Chronological detail of your professional success

This is singularly the biggest changed section in modern CV development.  You are detailing your success.  You are not listing your past titles or duties; not describing your staff composition or budget size; or administrative systems used; and certainly not mentioning how your medical school ranks in the world.  You will provide a chronological detail of your professional success, starting with your most recent job first.

After you list company name, employment dates, and your title for each role, you will include bullet points.  Each bullet point will detail your success that makes a persuasive argument (sales pitch) on your behalf.  Your most recent two jobs are most important and should not really exceed eight bullet points each (on average).  Your next two experiences can get half that.  If you have had anything else, even if they were your favorite, most nostalgic, most enjoyable times in your life only get one or two bullet points each. It is very important to note that nobody is hiring you today for the job you had a decade ago.  The basic structure of every bullet point in your success resume must include two things: A success verb and a number: Numbers are expressed in dollars, percentages, or a simple number.

I will include a list of verbs later but generally showing success means something got better.  You want to be seen as getting the job done.  Don’t waste time looking in your thesaurus for variations of any word.  It really doesn’t matter as much as looking like you accomplished something.  Of course if things didn’t work out well you’ll need some help and coaching.

Words to use:

  • Achieved / Contributed
  • Added / Improved
  • Awarded
  • Increased / Decreased
  • Exceeded / Expanded
  • Optimized / Introduced / Changed
  • Minimized / Maximized
  • Generated / Saved

Words to avoid:

  • Attempted to
  • Tried to
  • Used to
  • Wanted to
  • Prefers to
  • Managed
  • Part of
  • Handled
  • Responsibilities included

So a typical bullet point may look something like this:

  • Increased x by %
  • Improved x by $
  • Introduced new x that led to # more....

Other contributions are impressive and important but only the extent they are quantifiable. New methodologies, exhibiting leadership, or bringing innovation to a company are interesting only to the extent they measurable (ex. more referrals, increased revenue, faster turnaround or Length of Stay (LOS), increased pt. satisfaction).  When considering a performance improvement project or research area, see that it will contribute rather than just push paper.

If there is a professional skill that you highlighted in Section I and you want to include it as one of your bullet points that is appropriate.  For example if you want to showcase your ability to work in a “fast-paced-environment.”  You might want to bullet “executes multiple tasks at once without compromising quality or patient safety.”  If you’re a “team player” You may say “motivates others and accepts responsibility.”  You get the point.

Overall, the above outline is remarkably simple because the job search process, despite all the anxiety and confusion, is remarkably simple. You want to do work similar to the work you've done before but at a new place and a new level. To do so, you need to explain to new people what can give them confidence that you will be able to contribute to the new team. The easiest way to do that is to share numerical data that show you have contributed in the past and can, therefore, contribute in the future.  Unlike the stock market: past performance is a good predictor of future outcomes!

Section III: Education

Depending where you are in your career will determine where this section goes: beginning or end.  It is important to chronicle your education that is necessary for the job you seek.  If you’re applying for residency, your high school information is not necessary.  Start with college and then medical school.  You need not put any description about the size of the university or whether it is prestigious in your region of the world (you’d be surprised what folks write here).

Section IV (if applicable): Publications

Many folks have contributed to some original content or presented work.  It would be appropriate to add those accomplishments.  This includes: manuscripts, presentations, case reports, and chapters in books.  If you are a prolific author, you should include only works in the last 3 years.  If there are more than 10 (congrats to you) list only those which are appropriate for the position you are seeking and add your bibliography as a supplemental offering to your CV.  The only exception here is if you are applying for a research position and this is what needs to be showcased.

Section V (if applicable): Certifications and Licenses

Self-explanatory.  However, the format should include the title, region (national, state, etc...) and certification/license number, Year and any expiration dates.

 Supplemental sections can include:

  1. Honors & Awards
  2. Professional Societies
  3. Community Service

As far as your likes and interests on your resume, I’m on the fence.  Professionally it’s just filler on paper but to some it is the way to find common ground.  Perhaps focus on tangible things you do instead.  I generally, coach folks to use this section verbally during the ice breaking portion of any interview.

 Hope this has been helpful and good luck!

 

As always, comments and suggestions are welcomed.  If you have an idea for future topics please share and we can collaborate.

Michael Farca served as a residency program coordinator for the Department of Medicine at one of the largest training programs in the country.  He became the Department Administrator with continued oversight of the residency program, 2 primary site fellowships and 3 rotating fellowships.  Michael has dedicated over a decade to graduate medical education and is board certified in Teaching Administrators for Graduate Medical Education (C-TAGME).

Disclaimer: Michael Farca is an entrepreneur and is part owner and operator of Master the Wards, which provides Observership U.S. clinical experiences for IMGs, CV and personal statement development. For details on this service you can click here: http://www.masterthewards.com/cv-personal-statements/

 

Gap Year Post-Med School

According to the National Resident Matching Program (NRMP), 12,387 International Medical Graduates (IMGs) participated in the 2015 Match and only 6,302 successfully matched into a first-year position.  This sobering statistic shows that 50% of the IMGs that participated did not match this past March.

So what do you do during the gap period between this year’s match and when the program opens the following year on September 15th (about 7 months)?  If you’re an IMG how can you improve your application to better your chances for next year?

That’s where Master the Wards (MTW) can help. We focus on IMGs struggles by offering multiple services including:

  1. U.S. Clinical Experience - During the intervals between interviews and the match, WORK!  You need to keep in clinical mode so rust and barnacles don’t start to form.  Believe it or not it will also help you when responding to the medical questions during your interviews. If you’re talking medicine it will remain fresh.  Take time away and your acuity will dull.  Supplementing our hand-selected preceptors, MTW has added an element to keep you focused.  Lectures and conferences held at academic medical centers.  These are given by residents, fellows, residency leadership and Dr. Fischer.

  2. CV, personal statement, and profile development – We can review your past application, polish your personal statement and CV and recommend changes to stay fresh and focused.  We will provide an objective and critical look at your personal qualifications and determine if you have the right mix of volunteer experiences, research, and clinical experiences. 

    USMLE Step 3 – In most programs, residents in their PGY 1 year will be taking the Step 3 in order to get a contract for their PGY 2 year.  So to maintain competitiveness, your passing the Step 3 exam must be a priority.  MTW has all Dr. Fischer’s USMLE / COMLEX / Shelf exam, Board Review prep material available at a discount.  As the world’s most prolific medical education prep material author, this is to your advantage.  Scoring high on Step 3 is essential.

    Network – With your preceptor and hospital based lectures you will have the opportunity to meet many folks to talk and network with.  Do not under estimate the power of networking.  You have always heard the trite expression “it’s not what you know but who you know.”  While it is important to have a solid medical knowledge foundation, who you know is just as important.  Use this time wisely.

MTW is made up of physician and administrative leaders in the industry with over 50 years of combined graduate medical education experience.  So, if you didn’t match in the past, or even if this is your first time participating in the Match, you owe it to yourself to contact MTW and improve your chances of successfully competing in the next cycle.  Visit us at www.masterthewards.com to learn more about our services and who we are.

 

As always, comments and suggestions are welcomed.  If you have an idea for future topics please share and we can collaborate.

Michael Farca served as a residency program coordinator for the Department of Medicine at one of the largest training programs in the country.  He became the Department Administrator with continued oversight of the residency program, 2 primary site fellowships and 3 rotating fellowships.  As administrator he was responsible for all physician recruitment, contracting, and negotiations. Michael has dedicated over a decade to graduate medical education and is board certified in Teaching Administrators for Graduate Medical Education (C-TAGME).

Conrad Fischer, MD is the most prolific author for USMLE and the American Board of Internal Medicine examination including the best-selling “Master the Boards"  books. Dr. Fischer is Associate Professor of Medicine, Physiology and Pharmacology at Touro College of Medicine. Dr. Fischer has recently released “Master The Wards” as a pocket book that explains how to succeed the first time in your first clinical experience on an internal medicine rotation. He is the Program Director in Internal Medicine in Brooklyn NY at one of the largest training programs in the United States.

Vladimir Gotlieb, MD is boarded in Internal Medicine, Hematology and Oncology He began his career associate program director and medical director of ambulatory services, chair of performance improvement committee and a key member of the residency mentorship program. Dr. Gotlieb then served as Program Director and Chief of Hematology and Oncology at Nassau University Medical Center. Most recently Dr. Gotlieb became Vice Chair of Medicine in Education at one of the largest training programs in the United States located in Brooklyn, NY.

Disclaimer: Michael Farca, Conrad Fischer, and Vlad Gotlieb are entrepreneurs and part owner and operator of Master the Wards, which provides Observership U.S. clinical experiences for IMGs, CV and personal statement development.

What to know about The Supplemental Offer and Acceptance Program (SOAP)

Learning that you have not matched into your chosen specialty is one of the most stressful events of medical school. Students sometimes feel depressed, anxious, angry, frustrated, or that they are a failure. These are all normal feelings. However, there are multiple reasons for not matching including:

  • Some specialties are so competitive that even good students are routinely unable to obtain spots;

  • Geographic or familial limitations;

  • Inadequate number of applications to programs or gone on enough interviews; and

  • Some simply have unrealistic expectations of their capabilities.

The Supplemental Offer and Acceptance Program (SOAP) is a program that the NRMP developed and implemented in the 2012 Match.  Prior to that time, programs would be forced to “scramble” to fill unmatched slots:  Aptly named by Program Directors (PDs) and Graduate Medical Education (GME) offices.  As soon as the match results were posted, the fax machine would blow up and email inboxes would crash.  I’ve even seen candidates show up with their relatives to PD’s door steps in the hopes of gaining a coveted residency spot.  The SOAP takes place when students learn they have not matched into any residencies and must then seek out new opportunities among the unmatched residency slots that are still available.  The SOAP allows the opportunity for programs to electronically peruse applications and for candidates to cast applications on ERAS in a more organized fashion. Afterwards, both the program and candidate cast rank order lists, and hopefully make a match. Several rounds of these “matches” are made until all residency slots are filled. The numbers of unmatched slots are very small and the numbers of folks seeking them are ever increasing.  Picture the entire recruitment season that takes place over several months and includes planning and thoughtful decision making; the SOAP crams this into a few hours.

The Basics:

To be eligible to participate in the SOAP, you must be partially matched or fully unmatched on Monday of Match Week.

The SOAP begins on Monday of Match Week.  As you wait to find out whether your own fate has a happy ending, know these basics so you can have Plan B

  • SOAP is made up of a series of rounds in which participating programs seek to fill their unfilled residency positions.

  • SOAP begins at 11 a.m. EST on Monday of Match Week when applicants find out whether or not they’re matched

  • Plan to check unfilled programs on Match Day List of Unfilled Programs in the NRMP Registration, Ranking, and Results (R3) system starting at 12 p.m. EST on the Monday of Match Week.

  • You can begin submitting your applications through ERAS at 2 p.m. EST. You’ll be able to apply only for the categorical, preliminary, and/or advanced unfilled positions that you’re eligible for.

  • That same day, at 3 p.m. EST, programs can begin downloading applications through ERAS.

  • A series of rounds starts at 12 p.m. EST 2 days later on Wednesday, at which time the first SOAP offers go to the unmatched applicants listed at the top of programs’ preference lists.

  • Each SOAP round lasts two hours, during which applicants can accept or reject any offers they receive.

  • Offers are sent again at 3 p.m. Wednesday and on Thursday at 9 a.m., 12 p.m., and 3 p.m. SOAP ends at 5 p.m. EST on Thursday of Match Week.

Be ready if you’re contacted for an interview.  A program will contact you first by phone or email and conduct brief phone interviews.  Keep in mind that, as an applicant, you’re not allowed to initiate contact.  Some programs will want to have video interviews or, if you’re local, they may offer to have in-person interviews. No matter what the format, be ready during your residency interview to show that you’re the right candidate for the program.

Nothing is more anxiety provoking than learning you haven’t matched into your preferred specialty choice.  Below, I try to highlight some key points to know about the SOAP and hopefully increase your chances of matching into a program.

It has been my experience, the graduates who end up in SOAP or unmatched completely:

  • Had an overly optimistic assessment of their competitiveness.
  • Unwilling to consider any other specialty
  • Did not apply to enough programs.
  • Did not rank enough programs.
  • Did not apply to residencies where they had a realistic chance to match.
  • And most importantly, had no Plan B.

Know your competitiveness:

The National Resident Matching Program (NRMP) posts an annual report that will help you assess your relative competitiveness for a given specialty.  Dermatology, urology, neurosurgery and plastics remain near the top.

  • For U.S. seniors who preferred the highly competitive specialties USMLE Step 2 scores were significant, but USMLE Step 1 scores were a better predictor of match success;
  • Neither the number of research experiences nor the number of publications was a significant predictor of match success for U.S. seniors who preferred either a highly competitive or other specialty;
  • Having another type of graduate degree was not a significant predictor of match success for any U.S. Seniors;
  • According to recent data, MD graduates who re-enter the Match a year or more after graduation have less than a 50% chance of obtaining a position;
  • IMGs face even deeper challenges;

The Importance of a Plan B

As an Administrator we learn through experience that a plan B (and sometimes a plan C) is critical to systems and operational success.  As a student, your experience is limited to what you already know and hopefully what others have shared.  If you are applying in a highly competitive specialty, it’s important to develop a Plan B. Generally, having parallel plans and to dually apply in an alternative specialty can lower your chances of ending up in SOAP. This may be somewhat less necessary if your Step I score is at or above the average for your specialty and you are at the top of your class.  Although, this is not a guarantee it just allows you to say that you’re competitive.  Remember it’s not just your class you’re competing with but everyone else in the world.

Once you match, TAKE Step3 before starting residency.  That is when you have time to study! Putting it off until you begin residency will be detrimental.

Good luck!

As always, comments and suggestions are welcomed.  If you have an idea for future topics please share and we can collaborate.

Michael Farca served as a residency program coordinator for the Department of Medicine at one of the largest training programs in the country.  He became the Department Administrator with continued oversight of the residency program, 2 primary site fellowships and 3 rotating fellowships.  Michael has dedicated over a decade to graduate medical education and is board certified in Teaching Administrators for Graduate Medical Education (C-TAGME).

Disclaimer: Michael Farca is an entrepreneur and is part owner and operator of Master the Wards, which provides Observership U.S. clinical experiences for IMGs, CV and personal statement development.

Interviews: How to Stand Apart from the Herd

Medical school is grueling with the amount of material that needs to be absorbed.  The average med student learns approximately double the number of terminology than the average college student.  What they don’t teach is how to prepare for your residency and career interviews.  Yes, there are placement and guidance offices but mock interviewing is not formalized.  I hope to share some good information based on years of experience.

It is perfectly normal to be nervous during an interview as your entire career is focused on this moment.  That said there is no better way to present at an interview than being prepared.  You wouldn’t show up for an exam unprepared so, what’s the difference? 

First Impressions

  1. First impressions are essential.  The first things your interviewers will see are your application, credentials, CV and physical appearance. MAKE IT WORK!!!  So you made the cut and now its time to confirm that you can back up your success stories from your resume and apply them to the real world (and their problems).  Also, it’s an opportunity to see if you are a solid cultural fit for the organization.

  2. So how do you connect with your interviewer, and let them know that you are the right fit for the team?

  3. Non Verbal Cues – A firm handshake, good posture, eye contact, and a smile are critical. These will be your very first interactions with your interviewer, so make them count!

  4. Match Their Energy – Rather quickly you should be able to get a read of your interviewer’s energy.  Look for speech, speed, and gestures…matching them brings alignment.  But whatever you do – don’t overdo it!

  5. Ask Questions – No better way to demonstrate interest

  6. Find Common Ground – They searched your profile, look up theirs.  There is much that can be learned through social media so snoop around online before the interviewer.

  7. Tell a Story – One of the best ways to engage any listener is through stories.  This brings them in to your world

  8. Want to make the interviewer feel warm and fuzzy inside? Take a page out of Dale Carnegie’s book: “How to Win Friends and Influence People” – “talk to someone about themselves and they will listen for hours.” If you open them up they might just talk your ear off.  The more the interviewer reveals, the more you have to talk about.

What not to say

Knowing “what to say” is equally important as knowing “what not to say.”  Aside from things like mispronouncing your interviewers’ names or making a joke that bombs, there are some scenarios where you are more likely to plant your foot firmly in your mouth. Don’t ask a question that is easily “googled” like “how long has the hospital been around?”  Don’t ever say “I don’t have any questions right now.”  This is a big issue that can be interpreted as: you’re unprepared; you don’t care; you’re too self-confident; lack of enthusiasm; lack of respect for the interview and the person interviewing you.

When asked if you have any questions, this is the part of the interview to stand out.  Remember there are dozens or even hundreds of other candidates who have similar and competing experiences and qualifications.

Here are a few questions you may want to ask your interviewer(s) to get excited about you:

  1. What are your expectations of me as an employee?
  2. What is the supervision style?  Another opportunity to understand if this is a good fit.
  3. Can you describe what an ideal resident looks like?  Yes, this is basic! Understanding expectations beforehand will ensure it’s the right fit and it helps you understand what you need to succeed and strive towards.
  4. What does an average day look like for you?  This allows you not only to get a snapshot of how it really is on a typical day.  It also allows the interviewer to spend some time talking about themselves – and people like to talking about themselves.
  5. How does X get done around here?  Not so easy for someone to answer as they may not know.  But this shows interest in the administrative processes of the institution.  This can be very telling about the culture.

What to say

There are dozens of questions that will be asked during your interview ranging from ice breakers (tell me about yourself) to knowledge test (clinical vignettes) and the all-important one that will give you a key to what they are really looking for:

… it starts out something like: Do you have experience working in an environment doing … (insert whatever responsibility, duty, etc. that they are looking to find in someone). This usually tells you where their biggest “hurts” are.  If they need someone with special expertise or experience working under extreme stress, they’re going to make sure they ask you about that experience.  So how do you answer this all-important question in the best way possible?

Tell them about a time when …and of course the successful results.   But what do you do if you don’t have the experience they’re asking about?

Tell them you’re confident…just because you’ve never done something doesn’t mean you can’t do it.  An effective way to enhance this confidence is a response about a time when you did do something very similar—or something that could in some way relate to the experience they are asking you about.

Never, ever, say “No, I don’t know how to do that.”

 

As always, comments and suggestions are welcomed.  If you have an idea for future topics please share and we can collaborate.

Life After Residency & the Business of Medicine

If you’re like most 3rd year IM residents then you’re probably feeling a little less pressure than the preceding 2 years.  You are probably studying for your boards and thinking about your next step.  For some it might be a continuation of your training through fellowship.  For others it will be a career choice.  Either way, you will need to make a whole lot of decisions!  No longer will you be a doctor in the protected training environment but to you will be hired as an independent and real world physician.

Everything up to now has been pretty prescriptive: Apply to med school, take required classes, take your USMLEs, graduate, residency, and take your boards.  That’s it!  Now you are largely left to fend for yourselves.  The subsequent application and interview process is similar to everything else you have done with a twist.  There is no class offered to teach the next steps but there are some “must knows” before you begin your journey.

Your CV

The days of listing your name, education and contact information is a thing of the past and no longer applies in today’s fact paced and changing market.  The last CV you prepared was probably for application to residency.  Perhaps you updated it occasionally to include a recent publication but it is largely the same.  That version of your CV is a great starting point but not adequate for your job search.  It needs to be concise and specific to the job you are applying for.  For example – your CV for a hospitalist position will look very different then if you are applying to a private physician group.  Know the difference.  For example: hospital based appointments they want to focus on Length of Stay, Core competencies, Quality and Safety.  For Private groups they want to know what you will bring to the table to build the practice, ability to work safely with efficiency and grace. 

Organization is also very important as structure and content must be appealing to the reader.  The average recruiter scans a CV in less than 7 seconds before making a preliminary decision.  Some basics to include are:

  • Opening summary paragraph – This is your 30 second bio.  Think patient “sign outs.”  Only hit relevant items that tell the reader who you are.
  • Bulleted highlights of strength areas – these are one or two word phrases (a.k.a. buzz words) from the industry.
  • Use relevant key terms throughout – more buzz words. Particularly if there is an online version as recruiters can scan a document looking for particular buzz words.
  • Education – Just list the school, its location and the years you attended.  Graduating with honors is acceptable but please do not add “prestige fluff” about your school.  Remember the CV is about you.
  • Publications – Keep it to recent publications.  Most academic centers want a 5 year history because it can be used for ACGMEs “scholarly activity.”  If your applying to a private facility this becomes less important.

You do not need to include every club and interest group you’ve ever participated in.  It is resume filler and does not add value.

Interviews

Much like your residency interview, you will be competing against other candidates.  As such you need to look and present your best (See previous post for interview tips).  You will want to ensure you have your letters of recommendation.  You will want to have done some research on the facility you will be applying to as well as the folks who will be interviewing you.  In all likelihood your social media profile was reviewed prior to your interview so why not search whose interviewing you.  You will be surprised what you can find.  Common ground is a key element to establishing rapport.

Contracts Negotiations

Congratulations! If you made it thus far you have been preliminarily offered a position.  Here is where you have the opportunity to excel or fall flat on your face.  There are many elements to a contract that you have never heard of so before throwing money at a lawyer you don’t have here are the main points to be cognizant of that exist in all worthwhile contracts:

1.    Compensation – Probably most folks will understand the bottom number: your total compensation.  But how they arrive at that is sometimes not as straight forward.  For example, few if any employers are paying physicians’ straight salaries.  Today there are “models.”  Understand the model being offered.  Each employer sticks to a particular model so chances of changing it are slim-to-none.  However, altering the elements in the model is fair game.  Let’s run through a basic split RVU comp package: You are being offered total comp of $200,000.  You will have a $125,000 guarantee and have to earn the balance of $75,000 through RVUs.  RVUs are tied to volume, procedures, and if you’re in an academic setting there is a small percentage for teaching and administration.  There are literally dozens of combinations with these models so understand if the goals are achievable or are you being set up for a short fall salary.  Don’t find out at the end of the year.  Know before you sign.

2.    Restrictive Covenants (a.k.a. non-compete clause) – While no one thinks of this as a major issue it does present a problem should you decide to change jobs.  Don’t think if you decide to move on you can open up-shop next door and have all your patients follow you.  Know what’s restricted with regards to “distance to practice” from the employer and “who has rights” to the patients. Ultimately this will restrict you from practicing in a particular geographic area for a specified period of time.  Geography is relative so consider where you are working.  I recall working with a physician who showed me a 10 mile restrictive clause.  I told him to understand that will bar him from practicing pretty much anywhere in the 5 boroughs of NYC.  This was successfully negotiated to 3 miles after some discussion.

3.    Malpractice – Generally covered and not much of an issue.  However, you will need to understand what “tail” liability coverage means and if possible ensure that it is part of the coverage.  Essentially the tail refers to the period of time when the policy ends and when a claim is filed.  If there is no tail liability coverage the physician will be left “bare.”  You can purchase this separately but will cost you substantially after the fact.  If it’s not included negotiate for it.

Credentialing

Not much to say here other than every piece of official paper you ever accumulated will be needed.  Have it ready or you will be scurrying when asked.  The number 1 cause for credentialing delays is missing documents.  Keep things organized and you will be prepared.  The biggest drag on credentialing is the insurance piece which can take up to 6 months for certain carriers.

Wealth Management and Insurance

I know you are in serious debt from medical school and got paid very little during residency, “why would I ever need to know about wealth management,” you ask.  As a physician you will be exposed to potentially making more money than the average person.  Up until now you have not known about having any surplus.  You will need to learn how to budget to pay off any loans, apply for a mortgage, and take into account supplemental disability and life insurance.  I know you are just starting out your career why do you need to think about its end?  In the unfortunate circumstance that you find yourself unable to work because of disability, you will want to still manage your expenses without too much compromise.  Life insurance is just a necessary evil to protect your family at least until the kids are out of college and your house is paid for.

So good luck and remember my motto: EVERYTHING is negotiable!

 

As always, comments and suggestions are welcomed.  If you have an idea for future topics please share and we can collaborate.

Michael Farca served as a residency program coordinator for the Department of Medicine at one of the largest training programs in the country.  He became the Department Administrator with continued oversight of the residency program, 2 primary site fellowships and 3 rotating fellowships.  As administrator he was responsible for all physician recruitment, contracting, and negotiations. Michael has dedicated over a decade to graduate medical education and is board certified in Teaching Administrators for Graduate Medical Education (C-TAGME).

Disclaimer: Michael Farca is an entrepreneur and is part owner and operator of Master the Wards, which provides Observership U.S. clinical experiences for IMGs, CV and personal statement development.

This article is based on personal experiences but acknowledge Journal of Graduate Medical Education, September 2015 for inspiring to write.

The Night Watchman

I’ve been asked many times about hospital administration and the notion of needing to scale up amid crisis and policy change.  I am then reminded of the story of the night watchman.

Some time ago in an urban community there was a used car dealership that was bearing the brunt of local crime. After trying several remedial approaches (locks on the gates, surveillance cameras and signage) the board of directors became frustrated that nothing worked.   The hindsight committee quipped that the thieves didn’t read the signage nor gave any credence to the camera systems.  After further discussion they unanimously voted to hire a night watchman. 

Crime had stopped immediately.  However, after several weeks the vandalism and stolen property started again.  With an unannounced night visit, the night watchman was found sleeping.  He was so apologetic and pleaded his case of working 2 jobs to support his family. He vowed it would never happen again.  The board met once again and voted unanimously to hire a supervisor to be responsible for the night watchman.  This worked well for a few weeks and when unfortunately the night watchman took ill and the supervisor asked the board to consider a part-time employee to fill in as needed.  The board unanimously voted to approve a part-time employee.

Now with several employees they found the need to create a sick and vacation policy.  The board agreed that a human resources person was needed to create policies and procedures, as well as, address any other issues that arise including payroll.  After several weeks the board met yet again to hear a report from the supervisor that crime in the parking lot was almost non-existent but reluctantly shared that they were now over budget.  After careful deliberation the board unanimously voted to fire the night watchman.

Medical Students’ Clinical Rotation Pitfalls

You have invested extraordinary sums of money for med school.  Now, as you enter the realm of your clinical rotations there is a sense of excitement, desire, and fear.  Each year med students flock to hospitals to achieve their long awaited clinical rotations.  I have seen many such students over time and have found, and agree with much of what is written, there are many mistakes that are made.  The issue is not that a mistake is made; it’s that year after year the same mistakes are being made.  Perhaps a class should be offered or as part of orientation that these items are reviewed.

The most important thing is to be clinically prepared!  Everything else is rudimentary.  That said let’s review some preparatory points.  You only have one chance at first impressions, so get it right.  The way to do this is to be prepared. Preparation, like the first two years of med school requires hard work and dedication.  Your biggest ally is your ability to read.

So what not to do…

  1. Arguing - Probably can be broken down into arguing with your fellow student, residents, attending, or the patient.  Let’s be clear – none of these is acceptable and is grossly unprofessional.  Aside from learning how to care for your patient clinically, there is an un-taught requirement that physicians help patients through empowerment and shared decision making.  If you argue with them you violate this principal.  If you have a difference of opinion, there are ways to express it without being hostile or arguing.  And if you are permitted to write in a patients chart, this is definitely not the place to air your dirty laundry.  It is passive aggressive and unprofessional.
  2. Reporting falsely – As in the 10 commandments, ‘Thou shalt not lie.’  Whether reporting this on rounds or documenting it in a chart (when no one is watching).  This is a cardinal sin.  Physicians are held to a higher moral standard and if you can’t handle that then it’s not the right profession for you.
  3. Forgetting the chain of command – Hospitals are high octane high stress environments.  You need to know your department structure.  Generally, Chairman and directors are at the helm; followed by attendings, fellows, chief residents, residents and finally you.  The pecking order is real and follows the laws of gravity: It goes one way.  Best piece of advice hear is don’t take anything personal (except constructive feedback).  Don’t skip a level.  No one likes that anyone went over their heads.  It’s a show of disrespect and will land you in the hot seat.  Remember if you look good then those above you look good and everyone wins!
  4. Disrespecting nurses - If you want to make your life miserable, make the nurses hate you. They are the gatekeepers to your happiness and the grease to your wheel.
  5. Dressing inappropriately – Would you show up to a job interview wearing jeans and a crumpled shirt?  Don’t think your short white coat will hide anything.  Dress not necessarily to impress but for the job you want.  Patients, their families, and hospital personnel remember (and talk behind your back) on your choice of clothing.   Always look clean and presentable in business attire.  That means ties for men and nothing provocative for women.  Grooming should be maintained and funky hair styles and colors have no place in a hospital environment.
  6. Keeping important findings to yourself – Your resident and certainly your attending will be rabid if they learned of a finding in the chart first.  It is your responsibility to inform verbally and then document accordingly.  This has led to more negative evaluations than I care to remember.  I’ll also add in hiding possible errors.  If you make a mistake tell someone.  Your patient’s life may be at stake.
  7. Tardiness – Thinking that it’s only a few minutes and it’s not significant, is flawed.  Your team will notice when you're late. It's unprofessional and disrespectful and tells the team that your time is more important than theirs. Traffic, weather, children, pets are excuses.  Everyone has a life and everyone else makes it on time.  On that note, don’t leave early it gets noticed just the same and is even more irritating to the team.
  8. Uncredentialed procedure – Some hospitals don’t allow med students to “touch” patients.  That said, it’s difficult to learn how to percuss an abdomen if you’ve never experienced it on a live patient. Blood drawing and other routine items are in the same category.  Know your boundaries and do not do a procedure that is above your pay grade (i.e. central line placement).  Watch and learn, you will get your chance.  Any emergency that may arise should be handled by your seniors.
  9. Striving for average – Don’t be a minimalist or the overachiever.  You’re in med school, your pretty bright so strive for excellence: ALWAYS!  Don’t be invisible.  There is a wealth of information available to you; you just need to figure out how to absorb it.  Juggling all your responsibilities can be overwhelming.  You are not “less than” to seek help.  It is OK.  Everyone feels overwhelmed at times.  It is a feeling and it is normal.  Time management is the key.  Daily and weekly planners are essential.  You do not need to be a slacker to fall behind so stay fresh and take a few minutes a day to exercise.  Remember how you perform will be the basis for your evaluations.  If you are invisible then evaluation will reflect that.
  10. Being a ‘know it all’ – You’re still in school.  Some things only experience can teach.  I always felt that raising your hand and blurting out answers and correcting others publicly was a show of intelligence.  Well, it is a show, but of arrogance.  Your brilliance will be noticed without being the overachiever.  Gunning,” “Upstaging,” or “sandbagging” is not the way to make friends.  Remember there is a lot of stress on the wards so try to make it as amicable as possible.  You will also soon realize you have a lot to learn.  Medicine is dynamic, fluid and ever changing.  If you think you know everything, you will get into trouble.
  11. Forgetting to read – This has been drilled into to you since elementary and prep school.  It’s super important to keep up with all the information. The easiest way to look foolish is to not know your patients.  If your new patient has CHF, read up on it overnight.  Know the treatment, medication, dosages.  Being prepared is the only way to impress your attending.  If you neglect reading it will become quickly apparent how little you know. You cannot afford this. As mentioned earlier, you have only one chance to make a first impression so get it right on your first case (excerpt from Dr. Fischer’s MTW – IM Clerkship).
  12. “Pimping” – This nomenclature means to berate someone.  It is never condoned or acceptable and should be abolished.  Until that time, I feel a duty to warn. Therefore, like hazing on a college campus, there is a certain element of this happening.  Like any other hierarchy pimping up the totem pole is a no-no.  It generally ends when you advance levels of training.
  13. Not all seniors are created equal – Just like your fellow students there are those who are truly exceptional and those who are average.  Attendings are the same.  Not all are teachers or know how to teach.  Attendings are more and more being pressured into “doing more with less.”  This added pressure affects their ability to teach.  They are all your attendings and your senior so be grateful and respectful.  Some of your seniors residents and attendings alike have developed less favorable habits over time.  Be careful who you choose to emulate.
  14. While there is no dumb question but there are “simple” ones – Don’t ask simple questions.  It wastes time.  Instead make a note of it and look it up later.  This is difficult to navigate and will come by experience very quickly.  Besides, your attending, if not scoffing at the question, will say go “look it up.”  Gain the confidence you need, because it’s not your ability to remember facts from a book and regurgitate them on an exam but how well you can decipher and apply the material into real patient care.  The flip side is true also, asking appropriate questions demonstrate interest and engagement.  This means you are part of the team.
  15. Pride – Some students find themselves in hot water because they cannot accept constructive feedback or challenge others and cannot accept being wrong.  Two very poor traits.  Humble yourself and you’ll have a better chance for success and learning.  You may be brilliant for your class level but you have not earned your attending stripes yet.  Listening to your senior just might help.  Self-confidence is good so believe in yourself. Do not be ashamed of being wrong! You have earned your spot.

There are many competing things that require your attention:

  • Patient care
  • Shelf exam preparation
  • CV strengthening
  • Application strengthening
  • Letters of recommendation

So keep your eye on the prize and reach out for help where needed or just to decompress.

If you have any uncertainty, drop me a note for objective non-judgmental support.

As always, comments and suggestions are welcomed.  If you have an idea for future topics please share and we can collaborate.

A Physician Friendly Administrator Speaks

Administrators find themselves involved in every aspect of the hospital operation: clinical and non-clinical alike.  It seems elementary but hospital administration is one of the most complex beasts to overcome for most employees particularly physicians: Largely because they speak a different language.

As a former administrator for over a dozen years, I spent most of that time trying to break the dichotomy between MDs and Admin, but I found myself smack in the middle on most days.  It is often said that "never the 'twain shall meet."  Let's face it, competing views and strategies on the delivery of health care has pitted the two against each other more times than not.  For starters: administrators see physicians as another “cog in the wheel” in the overall healthcare operation while physicians see administrators as the “enemy.”

Statistics indicate that for every hospital based MD there are 16 staffers.  Six may be involved in clinical care and the remaining 10 are purely administrative.  Why?  Regulatory agencies, insurance company demands and the ever changing landscape of the industry has increased the layers of “stuff” that hospitals and physicians' offices must comply with. Let’s be clear, these added demands go uncompensated as hospitals and physician offices are vying for the same pool of limited dollars.  Volume has largely remained flat and reimbursement rates have dropped; not a good recipe for financial success.  Even in rural areas, hospitals are closing.

Administration is charged with carrying out the operations and establishing the rules and regulations that are bestowed upon them by the payers (3rd party) and regulators (JC, DOH, ACGME, and don’t forget the HR and federal labor laws, to name a few).  Department Administrators have responsibility for all the human resources, budgets, schedules, procurement, and contracts.  Behind every patient encounter there is a labyrinth of requirements to ensure payment.  Assuming the planets are aligned the hospital will get paid.

Talking to your administrator is often frustrating.  So what is the language that one needs to know to effectively manage those encounters?  Here are my top favorite lines:

  1.  “I’m working on it” – An all-encompassing phrase that is used most frequently to tell the receiver that I either forgot or got tied down with useless meetings or busy work and haven’t gotten around to it yet.
  2. “It’s not in the budget” – A classic line to tell the receiver that I like your idea but we are spending money on other things important to administration.

  3. “I’ll get back to you” – The usual response for being too busy to even think about your request.  This is a trap because you’ll have to remind me.  And when you finally remind me it would be the first time I thought about it since the last time you asked.

  4. “I’m on your side” – This means I want you to feel good about the bad news I’m about to bestow upon you; also, commonly used when I want you to do something that you don’t want to do.  Shallow attempt at showing feelings/compassion.

  5. “Let me check the contract” – Most of the time there is no contract but that’s not the point.  This is the way of saying no while passing the blame to some 3rd party piece of paper (see also #4 above as they can be used in sequence).

  6. “Your FTE count is maxed out” – FTE is Full Time Equivalency (employees).  Similar to #2 this is a mathematical calculation to sound important but since the formula is robotic, it does not account for people.  Therefore you always feel short staffed.  That said this line means - I know you’re short staffed but the numbers speak for themselves.

  7. “They are not patients they are customers” – this is a psychological attempt to level the playing field.  Meaning I, Mr. Admin, cannot take care of a patient but I can take care of a customer.   Since we want repeat customers I expect you handle it like I tell you and definitely prevents throwing the MD degree at me.

  8. “Providers” – These are all the folks who provide care to patients that hospitals can bill for including: MDs, PAs, NPs, and Midwives.  Intentionally lumping MDs into this mix is another attempt to level the playing field.  Yes, it is demeaning.

  9. “Senior admin wants us to do ( XY&Z )” – This is an attempt to speak in the 3rd person and take the onus off of me and deflect any personal criticism.  May also be followed by: “I know it’s not fair” or #4 above.

  10. “I feel the same way” – an attempt to show emotion despite our inability to feel anything. (see also #4 above).

  11. “We are not in a position to do that right now” – A clandestine response that combines #1 and #2 above.  It implies that I know something you don’t thereby giving me the upper hand and perception of power.

  12. “Patient satisfaction scores” – The ace in the hole when we need something accomplished.  We indicate that this will adversely affect physician and hospital satisfaction scores.  There is truth to this as patients are choosing where they get their care more and more.  This is not our doing and unfortunately it is tied to reimbursement

  13. “Core Measures & Best Practices” – This is ‘regulatory speak’ for initiatives that they want to ram down your throat and have no leverage other than to say “do it or I won’t pay you.  Obviously this cookie cutter approach to medicine then roles downhill to, you guessed it, the providers.  Now don’t get me wrong, there are many good things coming out of core measures but as we all know every patient is different.  Particularly in populations with high frequency of co-morbidities and complications.  This approach ignores that and levels the providers approach to patient care.

Hopefully this helps to translate some of our basic language.  Let’s be clear though, much of this is done because of the gauntlet of requirements that need to be negotiated just to get paid.  Many of my colleagues are genuinely good people with families and feelings and yes, we wear jeans and t-shirts and no we do not sleep in a suit.  For all the complications in the hospital the real enemy is not each other but those that mandate and dictate practice including insurance companies, government, or regulators that add layers of administrative crap to a point where we lose the simple notion of taking care of patients.

If you have a line that you are uncertain of, drop me a note for interpretation.

USMLE Tips Consolidated

People often overlook the necessity of planning. Planning is an essential element of success, whether you are planning a trip or planning a career path you would never get out there and just “wing” it. If you do “wing” it for the USMLEs you will surely be disappointed. There are many tips all over the internet about the right model for studying for the USMLEs (a.k.a. the Boards). Here I will consolidate suggestions, add my perspectives with a little help from my friends, to help better prepare you. Understanding what’s on the test and how to prepare for it is a key first step to your success.

 This article is being sectioned as follows:

  • Components of the Exams
  • Study Habits
  • Study Material

Components of the Exams

The USMLEs are 3 separate exams in 4 parts:

  • Step 1
  • Step 2 CK (Clinical Knowledge)
  • Step 2 CS (Clinical Skills)
  • Step 3

 Here is a brief summary of each exam.

Step 1

Arguably the most difficult of the exams this test is comprised of 325 multiple choice questions; this computer based exam takes a full day (8 hrs.). This exam is generally taken after the 2nd year of medical school when you have completed your basic science courses. The content covered on this exam includes all of your basic sciences in an integrated fashion:

  • Anatomy
  • Biochemistry
  • Microbiology
  • Pathology
  • Pharmacology
  • Physiology
  • Immunology
  • Genetics
  • Aging
  • Behavioral sciences
  • Biostatistics and epidemiology
  • Nutrition
  • Molecular and cell biology

Step 2 CK

Taken generally in your 3rd or 4th year of medical school, this exam focuses on your ability to apply clinical knowledge. This exam is also a computer-based one day exam comprised of 350 multiple choice questions.

Step 2 CS

Already out for several years, this exam is vastly different than any other. This exam tests your ability to apply your clinical skills in mock scenarios with “standardized patients.” This is also a one day exam and is regimented. You will have 12 patient cases (encounters) each allotted 25 minutes (15 minutes for patient interaction and 10 minutes for documentation). You will be scored on the following 3 metrics:

  • Communication and Interpersonal Skills (CIS)
  • Spoken English Proficiency (SEP)
  • Integrated Clinical Encounter (ICE)

Step 3

This exam is given over 2 days and is generally taken after graduation. The exam is a multiple choice and tests your ability to apply clinical science to patient care.

Study Habits

As mentioned earlier, a little advanced planning for your study schedule each day will keep you focused and save you valuable study time. You need to treat studying like your job: regiment it and you will succeed. Don’t wake up each morning and then decide what your game plan will be for that day, as this indecision will just waste precious time. Knowing in advance what activities you will engage in and when (i.e. reading, QBank, making flash cards, practice tests), will help minimize lost time during transitions.

I don’t care what anyone else tells you, preparation for your exams (particularly Step 1) begins the moment you set foot into medical school. How you ask? Simple: when reviewing your coursework in any of the basic sciences you can add targeted QBank into the mix.

However, for most folks that can be a little overwhelming. So, make a 6-8 week schedule that includes meals and socializing and time to take care of yourself. Let’s face it…you can only isolate yourself for so long before going a little crazy. You will need to account for breaks, meals and full practice exams. As you go along, and you see something is not working, modify the global schedule not just the day’s events. This is now your daily “work schedule.”

The best way to overcome anxiety is preparation. Preparation means familiarity with a particular subject. So, in preparing for an MCQ exam, it makes sense to familiarize yourself with MCQs.

  • Take a practice test early to see your strengths and weaknesses. We recommend at least 1per week over the course of 8 weeks. Chart your progress. It’s important to make these practice tests timed and equally regimented to the actual test as it prepares your body for the real thing.
  • As you master a subject…move on. Spending time focusing on areas in which you are struggling will only improve your results.
  • Find a partner(s) to study with. Motivate each other.
  • Breaks in your study day are a must so aside from meals make sure you include at least 30 minutes of exercise. Your body will thank you. Every hour or so get up and shake “it” off. When you get the crick in your neck or other bad sensations your body is telling you to MOVE!
  • Create a study space – the best space is a table or desk. This is best found in the library or study hall. If you room is your option, make sure you stay clear of distractions and the bed.
  • Set boundaries – Keep family and friends away during your study time. You wouldn’t bother your friend while at work would you? Probably not, so if you consider this your work, setting boundaries will be easy. Leave your phone away from your study space. This is a bad distraction. If there is a global calamity I’m certain you will find out.
  • Be true to yourself – Only you can tell how much effort you need. Are you memorizing facts or do you understand the matter? Understanding = long-term memory. Passively reading a book is not effective. Repetition is the key to understanding.
  • Block studying – I have never been an advocate of this as the real world does no present itself in a block format. However, for test preparation all bets are off. Consider a portion of your week studying in a block format, meaning take a subject and watch videos, read and do sample MCQs on that subject only. Beware, Step 1 requires an integrated approach and so you will also have to know how each basic science subject connects.

The USMLEs are difficult exams so don’t beat yourself up if your struggling. Test anxiety might get in the way but it is best to ensure a good night’s sleep the night before the exam. Wake up earlier, fresh and energized to ace that exam. With proper preparation and focus, you will be prepared and confident when you walk in on test day.

Study Material

It is important to say that no one method is sanctimonious. The best approach is to view each venue as a supplement to another. While your budget has much to say about what you choose, don’t settle for the commercial courses because of the “name,” choose one based on their outcomes. This will make your studying whole. The major venues include:

  1. Prep Courses - They offer structured lectures and preparation materials. For those who learn best through this classroom style learning this is a good supplement. You may also want to consider saving a few bucks and enroll in a live-online course. Some medical schools offer prep courses as part of the curriculum. Avail yourself of the opportunity to take them. Some courses are offered by well-known companies like Kaplan, Medquestreviews, and Doctors-In-Training.
  2. QBanks – These are essential for USMLE prep. They offer hundreds of MCQs in varying formats with explanations. There are some freebees that can get you started as well as inexpensive starter options from USMLE and NBME. But do NOT rely on them. Comprehensive proprietary QBanks will need to be purchased as a subscription.
  3. Study Guides – “First Aid” is known as the Step 1 bible. Use it!

Final pearls:

  1. Create a study plan – Stick to it. Don’t get distracted.
  2. Make time for yourself – Exercise daily.       Also, like residency you need 1 in 7 days free from patient care; here you will need 1 day off from studying. If you don’t take care of yourself you will burn-out quickly. Pick a day and make it part of your schedule.       This will help you mentally stay the course.
  3. Proper planning, focus and preparation – Remember: Knowledge x Effort = Results.

 Good luck!

 

As always, comments and suggestions are welcomed.  If you have an idea for future topics please share and we can collaborate.

Michael Farca served as a residency program coordinator for the Department of Medicine at one of the largest training programs in the country.  He became the Department Administrator with continued oversight of the residency program, 2 primary site fellowships and 3 rotating fellowships.  Michael has dedicated over a decade to graduate medical education and is board certified in Teaching Administrators for Graduate Medical Education (C-TAGME).

*Disclaimer - Michael is an entrepreneur and operates an observership program and offers USMLE and Internal Medicine Board review materials.

Tips for Your Interview & Residency Match

August is that time of year when the new medical interns are acclimating to their programs. The summer is winding down and IM programs are starting to plan their interview season. ERAS opens in September and most programs don’t start interviewing until October or even November. Depending on program size, they will have, on average, screened thousands of applications after filters are applied and interview about 10% or less. I wrote another post on FAQs where I covered timing of ERAS see:  Consolidated FAQs for IM Residency Applicants

Here are some tips to focus you during Interviewing and Residency Match season:

Networking

You’ve all heard the trite expression: “It’s not what you know but who you know.” Residency is no exception. If you read nothing else below, networking is the single biggest advantage you can achieve when all else is “similar.” However, this is particularly difficult for IMGs because of the limited time spent in the US. There are opportunities to meet people you just need to be willing to do the leg work. Observerships, volunteering, research and other electives allow you to meet people. This is your opportunity to connect and network, show your abilities and perhaps earn a recommendation (LOR). By being in front of those whom you will eventually interview with allows you more than the 5-10 minutes to show your stuff on interview day.   You can become known as a solid worker who would fit the respective corporate culture. This is only achieved through “face time” (and no, not on your iPhone).

The USMLE score

There is more to a person than scores. If you have already made the interview then you’ve passed the score filter. However, if a decision needs to be made between two applicants and all else being equal, scores generally prevail. There are exceptions to everything so it’s best to put all efforts into it rather than regrettably saying later “why didn’t I say or do ----?” Also refer to my FAQs on scores: Consolidated FAQs for IM Residency Applicants

How important is your visa?

Visas are a concern for many programs and some have outright done away with accepting them. This was done largely because issues arise later on that necessitates a delayed start or worse, a break somewhere in the training. These programs don’t want that drama of uncertainty. However, good people don’t necessarily carry green cards nor are citizens of the US. It is important to have all visa issues resolved prior to the match. This gives programs some degree of comfort. I realize this is very challenging because you don’t know where you will end up. In my experience J-1 is better than H-1 but best to use an immigration lawyer to lay this out for you.

Do your Homework

Like any other industry, when interviewing, research the programs ahead of time. It demonstrates your interest and allows you to have dialogue during interview beyond the standard “I am a graduate and want to be a resident here.” A program’s minimum requirements are sometimes bypassed based on circumstances. So, don’t be discouraged if you’re on the cusp: There is still hope and opportunity particularly if you’ve networked.

Keep working

During the intervals prior to and between interviews and the match, WORK! You need to keep in clinical mode so rust and barnacles don’t start to form. Believe it or not it will also help you when responding to the medical questions during your interviews. Program Directors want to know that you are working in the field during these down times. Observerships, electives and volunteer opportunities are good avenues.

Follow-up

Your interview was one of hundreds and it might be months before the match list is prepared. You’ve heard that thank you letters are standard but the timing of the thank you letter is equally important. In this case, if you were an early interview I would send a letter just after your interview and then a second letter at least to arrive a couple of weeks prior to the match lists being submitted. This ensures the arrival of the letter and that you are fresh on the Program Directors mind. So, show your appreciation with writing thank you letters. Be courteous but not overbearing. You want to stay in touch with the program but not to the point of being a nuisance.

Personal Statement

While the personal statement is not the primary component of your application it is important to have a one page well-constructed document. This is different from your medical school statement, so change it. And please stay away from “I always wanted to be a doctor since I was…born”. This is trite and doesn’t speak to who you are. There is a journey you’ve taken to get to this point and I would share relevant pieces of it. Remember, people are collections of their experiences so share your story. Also, some programs focus on different things and therefore you can custom tailor your personal statement to suit.

Pitch

You have learned or will become experts in how to present a patient’s case in 30 seconds. When it comes to “you” most folks can’t present themselves. I call this the 3 minute elevator pitch. Think of a seamless presentation of who you are and what you will be able to contribute to the respective program. Once you’ve done that practice it until it feels good and natural. You will be viewed as a person who presents well and with confidence, not chirpy or arrogant. Everyone you meet that day is involved in some respect with your interview and ultimately the rank order list. This means that everyone has influence in this process. A negative impression somewhere during the day can cause your ranking to suffer or be bumped entirely. There is a lot of pressure here so try and prepare and hopefully this will be alleviated to some extent.

NRMP has tips on their website. Please read them. A few key ones are being shared here.

  1. Rank programs in order of your TRUE PREFERENCE, not where you think you will match.  Also, rank only those programs where you would be happy to train.  Remember, the Match commitment is binding.
  2. Be realistic about your competitiveness and the competitiveness of your preferred specialty
  3. Go for your “reach” program but also include at least one “safety” program.
  4. Review the data. Make sure everything is entered correctly.
  5. Do not wait until the last minute to enter your rank order list.

For a complete list you can visit their website at NRMP.

IMGs Specific

You will be overwhelmed! This is to be expected. This is so because of the interview process and doing it in a foreign place. I am not certain about the rest of the country but NYC is a melting pot and regardless from where you are from you can find familiar things. 

If you’ve taken your USMLE Step2 CS then you know the English language. However, be mindful of your accent as that can be offsetting to those you will interview with (and ultimately your patients). Different parts of the country also speak differently. I’m from NY and it will never be mistaken that I’m from NY, regardless of where I travel, because of my accent. Take a class or practice if you think it will help.

Chances are that you will also be meeting a lot of folks from other parts of the world coming for the same reason. Say hello and make friends. When time permits look around a bit. This country has many beautiful things to see in every State. This might come in handy on interview as you will have common ground with those who are interviewing you.

Parting Thoughts

  1. Most of all – Be interesting!
  2. Murphy’s Law – What can go wrong will go wrong! So prepare and don’t underestimate anything!

Good luck!

 

As always, comments and suggestions are welcomed.  If you have an idea for future topics please share and we can collaborate.

Michael Farca served as a residency program coordinator for the Department of Medicine at one of the largest training programs in the country.  He became the Department Administrator with continued oversight of the residency program, 2 primary site fellowships and 3 rotating fellowships.  Michael has dedicated over a decade to graduate medical education and is board certified in Teaching Administrators for Graduate Medical Education (C-TAGME).

Disclaimer: Michael Farca is an entrepreneur and is part owner and operator of Master the Wards, which provides Observership experiences for IMGs .

My Road to Conquering Public Speaking

As a medical student and resident you will most certainly be required to present cases, morning reports, journal clubs, and other academic conferences. If you are an average guy like me (or woman) the thought of public speaking is anxiety provoking. Well, it used to be for me. Here’s how I overcame that paralyzing fear, diaphoretic, clammy hands, blinders on the eyes, and a shaky voice (borderline vasovagal / syncopal).

One of my first jobs out of grad school was for a small not-for-profit organization in NYC. I was responsible for building a program for youth who were one step away from incarceration. It was a tough crowd but, frankly, that was the easy part. At my first job performance review my supervisor was very pleased with the infrastructure that I built and the relationships that I had developed throughout the company, including the Depts. of Probation, Education, and the Juvenile Courts. She then asked a question I was not prepared for: “How many group speaking engagements have you completed to educate the community and my new contacts about the services?” I was floored! I could recall everyone I spoke to, all the policy and procedures I created, the staff I began hiring and training. I built a team that was mobilized in less than 90 days. I did not remember that public presentations were part of my review (at least I thought I could hide it with all the other wonderful things I accomplished).

While overall my performance was impressive there was a need to have public speaking engagements. It was not enough to meet with the heads of each departments and judges but there was a need to educate their people. WOW! I had a great evaluation with one major area in need of improvement: Public Speaking.

In the coming days I spoke with my supervisor and expressed my fears in the hopes of getting some guidance (or an exemption was more like it). No such luck and it was now my responsibility to figure it out. After a little research I found a program that was pretty well known. A week later I was registered for a 4 - hour workshop on public speaking.

I made it to the seminar. So here was my choice: Take my normal spot in the back of this enormous room or get engaged by taking this one head on in the front of the room. Well, I decided to sit up front not to mention the back of the room was already full. The room was packed with about 200 people and I really wanted to hear this guy. Plus, I wasn’t sure what was on the agenda.

As the seminar progressed we were divided into small groups of 10-15 people. A spokesperson was needed for each group. I ended up raising my hand partly because everyone at the table was looking for someone other than themselves and partly because I had to figure this thing out. So I volunteered to lead a group at a table exercise. Besides, group activities and table top exercises were no big deal. Much to my surprise, I quickly learned that the group leaders responsibility included a very public and “really” videotaped (yes this was some time ago with VHS) presentation. Well, I survived, barely. But what was amazing was we were given an added benefit of reviewing our recordings with one of the trainers, in private, and came away with some really amazing tips. I’ll share some of my favorites:

  • Lead in Statement – This is the attention grabber. Should be a fact, statistic, or a joke. Whichever it is make it yours and sound natural.
  • Hold something – in the beginning I used to hold a pen and pretended it was like a pointer. As I became more comfortable I used my hands in an expressive manner. This helped control the nervous energy that I had. By channeling it to the pen and then my hands I was no longer rocking back and forth
  • If you are wearing a suit keep your jacket buttoned. Essentially it conveys an image of professionalism and authority. Since you’re in charge of the presentation you have control of the room.
  • Body movement – it’s OK to walk around but do not rock back and forth. That’s a sure sign of nerves and usually indicative of a psychiatric patients’ self-stimulating. See my comment about holding a pen until you orient yourself to the stage.
  • Eye contact – look around take it all in because the room is actually listening to you. This lets you connect with people and you will begin to see them nod in agreement.
  • Rehearse – yes you should review your presentation until it feels right. But I have found that also preparing answers to a few anticipated questions will help you gain some confidence. There is nothing more anxiety provoking when a member of the audience asks a question and you stare at them like a “deer in headlights.” Questions are good because it shows people were actually listening. Give your presentation a trial run (or 2 or 3 times) to a colleague. This will help with any holes in the presentation, get comfortable with the information and understand what some questions might arise. Obviously, it helps to know what you’re talking about. Very few talented/gifted folks can get up in front of a room “cold” and start speaking.
  • Video – OK this is a little corny. But truthfully if you want to see what you look like before getting in front of an audience record yourself practicing. This is the best way to see your non-verbal movements (in some folk’s manic gesticulations) and the sound of your voice. Pay attention to these tips when you review it. It wasn’t until I saw myself on video that I really appreciated how I appeared. You don’t need any fancy equipment. Use your phone to record. The video doesn’t lie but your friends, family, and colleagues might to spare your feelings. Once you see it, then can you correct it.

Remember nerves are normal and everyone gets anxious. Public speaking is one of the tougher ones to overcome because of “performance anxiety.” The fear of public embarrassment and that you may not know what you’re talking about or that the group is smarter than you. True you might be challenged, but your audience is there because they want the information in your head. Just have a conversation with them and it will start to flow.

Over the years I was expected to lecture and present in front of groups of 100s. Many of these groups were physicians and for me that was intimidating. But at the end of the day they are in the audience to hear you and learn something. It was these tips that helped me overcome this fear. Although I must admit that I still get a little nervous energy: Except now I use it to feed my performance.

So whether you’re a medical student, medical resident, business person or seasoned veteran of your field, I hope that this helps you be better prepared for that next presentation. Remember, a little work upfront pays dividends in return. So get out and present. I’d love to have feedback. Please share your story.

 

As always, comments and suggestions are welcomed.  If you have an idea for future topics please share and we can collaborate.

Michael Farca served as a residency program coordinator for the Department of Medicine at one of the largest training programs in the country.  He became the Department Administrator with continued oversight of the residency program, 2 primary site fellowships and 3 rotating fellowships.  Michael has dedicated over a decade to graduate medical education and is board certified in Teaching Administrators for Graduate Medical Education (C-TAGME).

LinkedIn Profile Tips

Let’s get something straight from the outset: LinkedIn is not Facebook/Instagram/Twitter or any other social media network. While they each have their respective value, LinkedIn should remain what it was designed for: A professional network. Let’s also leave politics and religion out of it.

I’ve read through several articles and posts trying to guide folks to make a professional profile and found that despite much information available, all too many people have not taken any advice. So, for my network, I write this post for you. I will also make certain assumptions and they are: you will always maintain truthfulness, honesty and integrity throughout. Here are a handful of strategies to enhance your LinkedIn profile.

1. Temporarily Turn Off Activity Broadcast

If you’ve already connected with folks and are looking to re-build or modifying your profile, temporarily turn off your update broadcasts. Forgetting to do this will fill your connections ‘Wall’ with all your update notices. There is nothing more frustrating to connections seeing every little detail about you being modified/updated/edited however many times. For illustrative purposes let’s assume you are preparing your personal statement to send to your 100 connections and prospective employers. Turning this function off is equivalent to editing your personal statement privately. By leaving it on, it sends every sentence to your group in real time. Get the picture? Good, turn it off.

To do this, go to ‘Profile’, => ‘Edit Profile’ and right hand bar you will see the disable button Turn on/off ‘Notify your Network’. There is another way through settings and they do the same thing. You can choose to leave it off or turn it on after you’re done editing. I would turn it ‘On’

2. It's All in the Details

Take advantage of the LinkedIn guide as it step by step asks you to add/plug in information. Each section tells a more complete story about you. Let’s face it when you see your life as a proverbial book, it’s less inviting and somewhat frustrating when you’re missing some chapters. Your profile is similar to your CV/resume, where you display your past education information, work experience, skills, current work position and profile picture. Just like you would put on your CV an Objective/headline be sure to add one on your LinkedIn profile. Newspapers have perfected this since “yellow journalism” was founded in the 1800’s: learn from it and you’ll make an impression. Where this differs from your CV, LinkedIn can be your digital brand. Use what you like to stand out. Be creative and have fun with it. Don’t be afraid to be a little personal. Your profile is like a sales ticket, nobody is interested unless you stand out. Be truthful and it will all come together.

In the age of internet searching keywords has become the new Index to look things up. Throughout your profile, headline, summary and the body, use key words. Think about the last time you wanted to “Google” something, you use keywords to search.  This is no different. Advanced searches allow for prospective employers to search using keywords.

Quick Tip: Go to “Google” and start entering your keywords. Google will auto-populate suggestions for searches. These suggestions are top searches performed on Google by other people.  You get the picture

3. Proofread

Would you ever submit anything to a professor or employer without proofreading? I hope not. You’re CV and your LinkedIn profiles are no different. Grammar and spelling are important. If English is your 2nd language, get help! When telling a story, tell it so it is coherent and well structured. A fragmented thought conveys confusion. Your story is important so make people want to read it without struggling. This also means check your name: is it clean, did you accidently put your last name first? If you are a doctor is Dr. capitalized properly? Proofread!

4. Profile Picture

This is not an option. If you do not use a picture you’re foolish. The default avatar is for idiots and folks who are disinterested in their profile. People like to know who they are connecting with and makes it more personal when there is a photo rather than a blank space. You’ve been looking at yourself in the mirror for years; let others see you as well.  Be proud!

Again, this is not Facebook, Instagram or Snapchat or anything else. Professional photos are not necessary but you want to look professional. You should be alone in the picture and not some cropped photo you took when you were out with your friends. Take the time to get it right. Also, I can’t believe this needs to be said but if you upload your photo, make sure it is not upside-down or sideways. Also, pictures of you as a baby or your pets or the beach are nice but not on LinkedIn. A Good quality and recent profile picture of you is the safest bet.

5. Stay Active & Be Opinionated

If you ever went to a school dance or a dance club there are those who are dancing and having fun and there are those who are looking at those who are dancing (wishing that someone would dance with them). They are the ones usually looking on from the perimeter. The only way to join the party is to get involved. Staying active on LinkedIn either through group discussions, writing posts, and/or sending relevant updates can make all the difference. Don’t play devil’s advocate but share your thoughts. This is sure to bolster discussions.

Bonus Tips:

  1. Add your linked in profile as part of your auto signature on your email. This is an indirect way of exposing your profile.
  2. If you have a twitter account that is personal, DO NOT connect it to your professional LinkedIn account. Remember the two are not the same. If you maintain them professionally then connect, you can selectively share posts from LinkedIn to Twitter. This connection is easily done under ‘setting’ => ‘Manage Your Twitter Settings’.
  3. Get recommendations. Don’t be shy: ask for them.

Now that you have the perfect profile start reaching out to folks. In 2014 LinkedIn reported that they have nearly 300 million users worldwide: Get Connected!  I'll be waiting.

 

As always, comments and suggestions are welcomed.  If you have an idea for future topics please share and we can collaborate.

Michael Farca served as a residency program coordinator for the Department of Medicine at one of the largest training programs in the country.  He became the Department Administrator with continued oversight of the residency program, 2 primary site fellowships and 3 rotating fellowships.  Michael has dedicated over a decade to graduate medical education and is board certified in Teaching Administrators for Graduate Medical Education (C-TAGME).

Clerkships, Externships & Observerships Explained

This post is intended to help IMGs understand the difference between clerkships, externships and observerships.  Often times these terms are used interchangeably by students and graduates which can lead to confusion for those seeking opportunities in US clinical experience.

Clerkships:

Typically, the structure of medical education is as follows:  Medical students spend the first 2 years of medical school in the classroom gaining the basic science knowledge.  Here, they study Anatomy, Physiology, Biochemistry, and Pharmacology among other things.  The 3rd and 4th years of medical school are spent off campus gaining clinical experience in hospital settings.  This is commonly referred to as clerkships or “rotations.”  Clerkships are a part of the school’s curriculum and required to graduate. These typically have direct patient care or “hands on” experiences.

Externships:

Refer to clinical experiences not directly provided by the medical school’s curriculum. These types of rotations can be done by undergraduates as extra-curricular or as graduates seeking additional exposure or clinical edge to the competing environment.  These typically have direct patient care or “hands on” experiences.

Observerships:

Refers to a clinical experience that does not involve direct patient care. This experience is generally sought by undergraduates and graduates alike.  It is not part of the course work and serves to strengthen individuals’ application by learning US clinical practice.  As 1/3 of Internal Medicine residency is spent in the ambulatory setting, it is important to gain this appreciation.  This is also the opportunity to gain greater exposure and experience with a particular specialty, obtain letters of recommendation for applications and improve their clinical skills and cultural competency. The restriction on patient care is largely for malpractice insurance issues.

Like any other field of study, when applying for a residency position, gaps in clinical education raises questions.  This becomes an increasing concern the longer one graduates from medical school.  For example, a person who graduated this past year should naturally flow into residency.  In contrast, someone who graduated one or two years earlier raises the question “what have you been doing for the past ___ years to keep abreast of medicine?  Will the applicant be ready to provide direct patient care?  Observerships provide continuity and, when earned, they provide letters of recommendation (LOR) from physicians within the field.

One question I do get is: "Does my observership need to be in a hospital?"  The answer is no.  Again 1/3 of residency training is ambulatory and there is a strong push to reduce hospital care to the less expensive alternative.  That said, the importance of observership training is to remain clinically oriented, earn an LOR and network with folks that can help in your ultimate goal of a successful match.

Hope this helps and as always I'm open to comments and suggestions.  You can visit me at www.masterthewards.com and always follow me on twitter @mfarca. #meded, #medstudents, #observerships, #MTW, #Masterthewards.

Consolidated FAQs for Internal Medicine Residency Applicants

I've had the pleasure of working in graduate medical education affiliated with large teaching hospitals for years. There have been many blogs, posts, books, videos, lectures, and every other form of media coverage on how to prepare for residency.  What I have found, over the years, is that despite the changing faces (and yes they are looking younger) many of the questions have remained the same.   Here I am listing the some of the most frequently asked questions (FAQs):

Do USMLE scores count?  Simply stated YES.  USMLE scores are the only objective  measure that allow Program Directors (PDs) to measure the academic aptitude of applicants.  Some critics have said that it only demonstrates people who are good test takers.  This type of criticism is near sighted at best and usually authored by those who did not score well.  Let's put this into perspective:  While I point to a fictitious scenario, it is just one of many real applicants.  An applicant presents with a 204 (2 attempts on step1) and a 235 (1 attempt on step2).  As the interview progresses the eventual question comes "so what happened on Step1?"  To which the applicant responds (pick the excuse), "I was faced with illness in the family/my wife left me/my husband left me/I have a personal tragedy."  This answer shoots the applicant in the foot.  He does not take ownership for his circumstances and clearly can not handle important matters under stress.  Picture an ICU rotation with 2 crashing patients and 2 admissions: talk about stressful.  Think about providing care to patients, if you screw up are you going to say "oh it was a bad day, I had gastritis or what ever).

Literature shows that USMLE scores are a good predictor of Board passing.  PDs will generally not say this but they are under the gun to keep their pass rate up.  One of the major indicators ACGME monitors programs for is their board pass rate, which for IM is 80% of first time test takers.  When you fall below this threshold PDs jobs are threatened.  So there is a balance between finding residents with good scores and the right personality fit for their respective institutions.

Can I overcome poor USMLE scores? This is difficult to answer.  However, the best course of action when faced with the question during your interview is own up to it.  "Yes, I did poorly and it really upset me as it does not really reflect my knowledge base as well as my ability to perform during highly stressed circumstances."  Beware, you will be challenged so if you answer like this you may get hit with a STEP or board review type question that you better be able to answer.

Which USMLE Step exam is more important? Simply put Step 1, 2, and 3.  Let's qualify.  We already answered that step scores matter.  But what if you didn't do well on Step1 and did very well on Step2?  The thinking from several PDs is "redemption" and "You are capable."  This is important.  Pass big on the Step2.

Should I take Step3 before applying?  It depends.  PDs philosophy is that they need to see that you are capable.  If you did not perform well on Steps 1 & 2, you should take Step 3.  But better prepare yourself to score BIG!  Having said that, if you are satisfied with your results and they will meet the PDs criteria for interview (usually above 230) then don't take it until afterwards as you have nothing to gain.

What's the issue with Visas?  Many programs do not take visas.  The issue for PDs is that residents don't always show up on time for various reasons.  This creates scheduling problems and stresses the program on day one.  However, some PDs open their programs to visas to give opportunity and broaden the quality pool of applicants.

When should I submit my application?  Opening day for applications is September 15th.  Do not be fooled that this is the day you MUST have your application in by.  Applications are filtered and reviewed for weeks prior to interviewing.  Some programs don't start interviewing until October and some not until November.  Better to have a more complete and inclusive application rather than getting it in on opening day.

Do Letters of Recommendation (LORs) matter?  LORs are not as important as the content of that letter.  It is very important when seeking an LOR from someone that it contains something personal.  Form letters and neutral letters are not helpful as they all sound the same.  PDs hate reading them.  A personal letter distinguishes your performance and contribution.  Not all preceptors should be writing a letter.  Choose your author carefully and remember if you want it to say something special, you have to do something special.

Any application red flags?  Gaps in training or changing medical schools are red flags.  They lead to questioning in an interview that generally does not work favorably for the applicant.  Years post grad is also a red flag unless it is filled with something appropriate like finishing a PhD or some other advanced training

How can I write a killer Personal Statement and does it matter?  This seems to be the most difficult part of the application for folks.  Know that a poorly written and grammatically incorrect letter will hurt you.  Personal statements should be just that...personal.  Personal statements should be like an LOR and your 60 second commercial distinguishing you.  Say something about an issue you encountered and how you overcame it.  Do not write I always wanted to be a doctor since I was a zygote.  But give some indicator as to why you chose medicine.  Check it and have someone else check it.  A basic rule of thumb is that it cannot be checked enough and keep it to one page.

Do publications help?  This is one of those questions that always comes up.  Publications are never looked at to determine eligibility for interview.  However when PDs are faced with a choice between 2 persons for one remaining slot, the one who has distinguished themselves more will likely get the slot.  This means publications help distinguish your overall application.

How are candidates selected for interviews?  Simple.  ERAS is a system that is used to sort by scores, schools and any other criteria that PDs want to filter out.  Generally this is done by someone other than the PD, generally the coordinator or administrator.  Only after those filters are applied are other elements looked at to invite for an interview.

What are other interview tips are there?  Understand that there are certain things that you can not change: where you went to medical school, where you were born, etc... Work hard, sacrifice, and prepare.  But you can change your USMLE scores by preparing for them.  This requires a high degree of honesty with yourself and following this formula:  Knowledge x Effort = Results.  If you are smart you will not have to prepare as much as the guy who is not as smart.

Interview tips:

  • Show up on time;
  • Make eye contact;
  • Sit up straight;
  • Look professional (this does not mean wearing a black or navy colored suit as almost all applicants do);
  • Distinguish yourself from the pack by highlighting what you have done and your knowledge/skill set;
  • Know as much about the program you are going to interview with;
  • Do not criticize the program (it's insulting);
  • Be prepared with open ended follow-up questions;
  • Prepare a 60 second commercial about who you are.  This is your opening line to introduce yourself.  Practice this over and over until you feel right with it.
  • Send a hand written thank you note.  It doesn't hurt and shows interest.

Well, that rounds out the top 12 questions from students and graduates who are applying for residency.  If anyone has any additional questions that were not listed here please let me know and if I don't already have an answer for you I'll get it. 

New Academic Year: New Interns

Every year, nearly 8,000 (according to ABIM) Internal Medicine interns will join the ranks in residency programs across America. This possesses challenges for the residency program and the new intern. Well, July 1 marks that transition: The new interns are here!  What everyone should expect:

Programs:

Having interviewed many candidates months earlier, rank listing, and awaiting the match results this is the moment where programs figure out if they got it right with resident selection. Most programs stick to certain algorithms so it takes much of the guess work out. But with the average tenure of program director being only 5 years, programs are in perpetual periods of change.

Starting at least a month before (June), there are many behind the scenes challenges: vacations, release of PGY 3s for board review courses, outgoing residents moving, and interviews always made the schedule tight.   So, preparation has been at a feverish level for nearly a month with residency program coordinators contacting all incoming interns, scheduling orientation, and with any luck getting everyone where they need to be on July 1st. Yes, programs got used to everyone being where they are supposed to, like a big game of musical chairs everyone gets up and shifts to new roles and responsibilities.

 Graduating PGY 3s:

That time has come. You’ve been reading extra to prepare for your IM Boards and trying to find your next move in your career: begin your career as a physician (hospitalist/private practice) or continue learning in Fellowship, maybe move to a new city and all the challenges that go along with it. Either way, senioritis is in full swing and you are already moving to the next phase of your life. You worked hard so at graduation, take pause, enjoy the moment and take it all in.

 PGY2s => PGY 3s:

You are finally considered the veterans of the group that everyone looks up to. Some of you achieved the coveted spot as chief resident, which has its own unique set of challenges. Time to get all those extra electives you’ve been craving for the past 2 years.  Time to teach your junior and increase your reading to prepare for your Board exam

 PGY1s => PGY2s:

I guess you are mostly just relieved that you’re no longer an intern. The transition seems to quickly happen from mentee to mentor, but believe that all your experiences during this past year has groomed you to be a supervising resident. Pretty cool!

Incoming Interns:

Well, with your new, starched and very white coats, you will be hit with more information than you can absorb. (Note: when you screw up someone will say “don’t you remember we covered that in orientation”). Well statistically, you only remember about 30% of what’s covered in orientation so it’s important to know what your alternatives are. Here are a few tips from the field:

  1. What’s really covered in orientation – All hospital and departmental systems including policies and procedures, EMR, new email new passwords, HR, schedules, hospital layout, daily routine. Grab the important stuff, take a few notes and move on. Better to spend the time getting to know your routine and your colleagues. There are countless leaders giving inspirational talks and encouragement on how “it’s going to be a great year.”
  2. Who can I turn to with a question? – The beauty of residency structure is that you’re never alone. If your senior resident is not available then you can call your chief resident. If they are unavailable then always call the attending (yes, even at 2:00am). Better to get it right then to make an error. If the attending is for some reason unavailable, other program leadership like the APD or PD will always give you direction (Make sure it’s important and you have all the facts). In all cases, it will frustrate the person you are calling if you first have to start checking things. Know the labs, the meds, and the significant change in condition prior to the call.
  3. Who else? – Well believe it or not RNs can be extremely helpful. Particularly when it comes to systems and processes. Remember they have been there for years. Medication issue, consult with the pharmacist but remember you have the ultimate scrip writing power.
  4. Typical day - Check in rounds, round your patients, morning report, teaching rounds, lunch/conference, more rounds, check out rounds, try and go home.

For many programs the legacy residents are leaving meaning that the remaining ones and the incoming ones will only know EMRs. This technology revolutionized the way we:

  • document our encounters,
  • charge capture (bill)
  • best practice modeling
  • performance / quality improvement
  • report / metrics / meaningful use
  • research
  • communicate and care coordination

These interns are going to have to learn a new type of medicine, to practice in ways that are far different from their predecessors, even just 5 years ago.  There is a new set of Alphabets that they need to know and understand.  To name a few:

  • PCMH - patient-centered medical home
  • ACO – Accountable care organizations
  • PFP – Pay for Performance
  • JC – Joint Commission (Formerly known as JCAHO)
  • EMR – Electronic Medical Record
  • CC – Corporate Compliance
  • MU - Meaningful Use
  • RVUs – Relative Value Units
  • ACGME - Accreditation Council of Graduate Medical Education
  • DOH - Department of Health

And yes, if not understood can cost you money.

I have always said that access to healthcare has non-traditional barriers as well (More on this on my next post). It seems as though the more we try to fix it the more we box ourselves in by adding more regulation. The planets really need to be aligned to make access smooth.  All that said let’s inspire the new interns and role with the times!