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.thehealthyrd.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.

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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.

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/