What to look for in a medical curriculum

I exist again. As an update, I have now finished my clinical year and am in the process of studying for the USMLEs (the MCAT equivalent) and preparing to take a year off to continue my research in the specialty that I intend to apply into. I thought I would just take a quick break from my studies to give my thoughts on what is important in a medical school curriculum, looking back on it from this perspective.

1) Grades

Above all, know what you are getting into. Schools have a vast array of grading and ranking policies. Many schools have switched their pre-clinical years to a pass fail system, but a significant portion have retained an internal system of rankings (meaning they aren't really p/f it is just a farce). A select and growing group is unranked pass fail for the pre-clinicals. I personally am a fan of this, because of the fact that it takes the edge off of the learning experience. It gives you confidence to take advantage of the free time that you have rather than freaking out over random tables and appendices. The sad truth is pre-clinical grades don't mean much any more to residency programs. It is far more likely to hurt you than help you. If you do good, great how did this applicant do on their clincial courses and what were the USMLE scores? If you do bad, uh oh maybe this applicant isn't someone we want. Would being #1 in your pre-clinicals possibly be a distinguishing mark, absolutely. However, ONLY ONE PERSON WILL HAVE THAT DISTINCTION AND IT WON'T BE YOU.

Most programs continue to have clinical grades that have some form of ranking, or at the very least AOA (the phi beta kappa of medical school). Know what this entails. For some schools, it is just grades. Others look at grades, scores, research experience, etc, etc. Know what you are getting yourself into, even if it probably shouldn't be a determining factor.

2) When do you take USMLE Step 1

Step 1 is the most important exam of your medical school life. Know when you will take it, and just as importantly how long you get to study for it. Some schools get only a couple weeks off to study, whereas others get up to 10 weeks! That's a huge difference in stress level. A growing number of schools are starting to let students take the step 1 after their clinical training. I'm in favor of this approach. The clinical vignettes on the step 1 would definitely be easier with additional clinical knowledge, and stuff like genetic basis of diseases and pharmacology tend to come up a lot as well. You definitely forget a little more, but I think the net gain from more knowledge and more test taking experience (one major 3 hour exam per rotation) is worth while.

As an aside, don't listen to nonsense about teaching towards the step 1. Step 1 is an exam that, like the MCAT, requires copious review on your part. It is nice to know what resources are available to you (some schools host review classes, give you free books/question banks, etc).

3) Clinical Year Format

The clinical years are often ignored during the interview season, for the simple reason that they are further away and most of your interactions will be with first and second year students. Seek out people knowledgeable about the last two years,

Know exactly what the expectations are for you during clinical year. How many blocks during the third year are there and what rotations are mandatory vs electives (i.e. some schools do not require neurology, or surgical sub-specialties. It behooves you to get some electives in all specialties, so know if that is an option). Do you have any say in the order of your rotations? Are there breaks in between each block? How many vacation weeks? How long are each of the blocks (this is relevant for studying for the standardized exam at the end)? What is the general grading format (grades versus clinical evaluations. Which are more important. There is no right answer, but I prefer a combination of the two). How many fourth year electives do students get? How many students go abroad for electives? Do students get time to take the step 2 of the USMLE after clinical year, or do they have to make their own time.

You should also ask about how much time students get to interview. Two months is ideal.

4) Clinical Skills Prep

This is also very important. Know the institutionalized practices that help students improve as clinicians. Know how often students are educated on how to do interviews, physical exams, and presentations to attending physicians. Ideally, you want to have a solid understanding of each before starting the wards. You also want to know the general atmosphere of learning useful clinical skills. How often to students get to do blood draws, IVs, lumbar punctures, paracentesis, chest tubes, suturing, etc. Are there workshops given on these things? Are you taught how to do a rectal and genital exam prior to the clinical year? How much training are you given during the clinical year? For example, my school has one week rotations through the surgical subspecialties. As well as being an experience of itself, these rotations are expected to endow upon students certain skills. In anesthesia, we are allowed to intubate and place IVs, in urology we do genital exams and rectal exams, in optho we learn how to examine the eyes like a boss, etc. All of this stuff was taught to us prior to the clinical year, but getting it straight from the experts was far more useful.

As a warning, all students and schools will say that they get lots of hands on experience. This is why it is important to elicit the actual examples and programs.

5) Match list

This is not important. I only bring it up so that I can stress that it is not important. You can't read a match list, and I can barely read it (only in the specialty of my interest). So much has to do What is somewhat of interest, however, is the general geographic distribution of the class match. People often match close to the medical school for various reasons, which isn't really important to you. What is important, however, is students tend to benefit form programs that have had significant experience with a given medical school. If a schools match list doesn't have a single person sent to, say, Colorado, and Colorado is your dream residency location, then it may be worth taking note. You can still match in Colorado, but it may be a bit more of an uphill battle than if 32 kids in your class match there yearly. Likewise, one might think to do this within the specialty of your choice. I would discourage this only because specialty choice tends to fluctuate a lot from year to year (the year before me has 9 neurology applicants, the year before them had 1), where as locations tend to be pretty grounded.

I live

Hey readers,

For those who have asked, yes I do still read the site and I am still available to answer questions. I am in my clinical years now and I'm having a blast. This site was mostly meant as a repository for my views on a lot of important questions that get asked. If anyone has further questions I will be happy to write a response and post it here.

P=MD

Greetings to all of those who may or may not still be with me. I have returned once again to discuss a topic very dear to my heart. This week marks the passing of my very first exam (anatomy) in medical school. I did well (as most did), but what really made the experience different from undergrad was the fact that my medical school does not grade or rank students beyond the simple Pass or Fail policy. It was a far less stressful process than when I was neurotically protecting my 4.0 GPA and my dreams of ranking first in undergrad. As people discussed the exam, realizing a mistake did not send people into a panic. It was just a matter of a shrug and a lesson learned. And yet, we all still learned the material despite the need to only get a 66. As I stated above, everyone did well and this exam was by no means a walk in the park. The drive to learn and do well is embedded into us, but the stress of failure is far less. I have to say that I am enormously pleased at having made the right decision of going to a medical school that has a pass/fail AND an unranked policy for the first two years (a ranked pass/fail class is not truly pass fail. There is still an incentive to out do everyone else and thus the temptation of competition and cut-throat behavior). As far as some people worrying that not having grades the first two years hurts their students, do you really think schools like Harvard, Yale, and other top 10 schools would be doing it if this was the case?

In other news, I had a very unique experience with an applicant today. She has yet to get an interview and so showed up for the tour of the school that is given to applicants. I can only assume that she hoped to impress the adcom by her dedication and initiative. I must confess that it crossed my mind to do the same thing when I was applying. However, now that I am on this side of the fence I can not stress enough that it only makes you look silly, not impressive. Besides, the admissions office (which granted her request to join the tour) is NOT the admissions committee proper, nor are they likely to pass on the information of such a "daring" stunt. My advice to applicants, don't try this. At the very least you are going to garner the ill will of the other applicants, who might be your classmates someday.

I got to touch a lung today

By request, I have returned to tell you all of the wondrous world of medical school. After a summer of teaching and ant research, I am now holed up at this learned center of medicine. Let me just say that it has been awesome from the start. Orientation was last week, so I have just about completed my first real week of medical school. So far, my biochemistry degree has allowed me to float through the courses, but (amazingly) we are already reaching the boundaries of my knowledge. That's right, in 12 hours of lecture I am well on my way to being in the same boat as everyone else. I will say this though; there is a lot of material, but it is relatively basic. So while it may true that we have covered a half of a semester's worth of nutritional biochemistry in a week, it was a very cursory look. No mechanism drawing, no math, and minimal emphasis on being able to do theoretical biosythesis. We are skimming at the speed of light essentially, which is not easy regardless of the depth. I will also say that the speed isn't quite what some people make it out to be. We are moving fast, but 12 hours of lecture is a month of class time in undergrad. So we are maybe moving twice as fast as undergrad in terms of content overview. At my school, we only have three classes. One is essentially a time commitment with little in terms of memorization or examination that is mostly concerned with basic clinical skills and humanistic discussions. The other is the one that I have been mentioning. And finally, we have anatomy.

Ah, anatomy. As my title indicates, I got to touch a lung today. Stuck my finger right through the rib cage and gave it a rub. Pretty trippy. I really have to say though, this person that donated his body for my education is probably the best friend that I will ever have. No, I'm not talking to the cadaver, but I am serious. How many of your friends would be willing to donate their body for you to mangle in the name of education? It is a truly amazing gift that this person has given me, and he will cotninue to live in all of my group for our entire careers as physicians. He is the our first patient, in a way.

As far as anatomy goes, it is a blast to dissect. Our fellow is a bit on the portly side, but the benefit of that is that its a lot harder to accidently cut through something important when its an inch deep in fat. The unbelievable details of the human body are daunting. Thousands of bones, muscles, nerves, organs, and blood vessels. And then, pieces upon pieces within all of those categories. They aren't kidding when they say that medical school is a white rapids river of knowledge. I'm still on the lazy river at the moment, but I hear the rumbling in the distance.

Thanks to all that have and continue to read my blog. If anyone has any specific questions or comments, that might spur me to post more often in the future. Don't be shy, I always respond in one way or another!

I am on youtube now.

In an effort to further spread my advice, I've decided to start posting summaries of the info here on youtube. You can find the first video here:

http://www.youtube.com/watch?v=eBeaqRfjNuw

Dream Come True

It happened today, I was accepted to my top choice medical school! I won't say where exactly, though those who know me personally will know and I ask that you don't post it here. It's on the east coast in a large city, which is where I wanted to live. Ironically, I wasn't even going to apply there, but I did so that I could get a letter from the president of my University (who used to be Provost there). Turns out that I fell in love with it during my visit, and I've been enamoured ever since! I've learned two things from this experience:

1) Waitlist is not a deathlist!

I really thought that I was done for when I got waitlisted at all of my top choices, but here I am now getting ready to attend my dream school! Even more so, I was accepted before the May 15th deadline, which is normally when waitlist shifts begin in earnest. It makes me wonder if sometimes medical schools first accept who they need, rather than who they necessarily want... Who knows?

2) It pays to be persistent.

I wrote several times to the Dean of admissions at this and my other top schools. I found out last week that I was going to receive my University's closest equivalent to a Valedictorian award, so I decided to give each school a call. After reaffirming my desire to attend this particular school, the dean offered me an acceptance then and there. They want students that want them, as many schools told me on interview day. If they can secure a student that was high quality (meaning they interviewed you) without the hassle of you possibly withdrawing later on its a win win situation. Do not hesitate to write a letter of intent to matriculate at a school that you have decided was your top choice. Be serious about this though, integrity is all that we have at this point. If you say to a school that you will attend regardless of all other offers, there is no going back if you're accepted. Your word is everything, and is far more important than any scholarship or other offer you might later get.

Question 15: What can I do to improve my chances during this cycle?

Two words: Apply smartly. This in itself can be broken down to two rules. 1) Apply early 2) Apply broadly.

Let's tackle the second first. There is no such thing as a sure thing. No matter how many interviews at better schools you were offered, no matter how high your stats are, there is never a sure thing until you have the letter in hand. I have seen plenty of people get shot in the foot by not applying broadly. Never apply to only Top 20 schools. So much more than grades and your resume factors in at that level. You might get interviews at a dozen and only get accepted at one (I did), if any. That tends to be the biggest mistake for applicants with high MCAT scores. Just because you are in the 97th percentile of the MCAT doesn't mean diddly, because quite honestly there are at least 1000 applicants with as high or higher of a score than you! The schools have plenty of heavy hitters to consider, and at that point it all comes down to what they are looking for. The interview tends to be the make or break moment, but don't think that big pile of materials that you sent has been forgotten. It is never an even playing field, from start to finish.

I would personally recommend applying to about 15 schools. Try to break down your list so that 30% are reaches, 30% are about average (as best as you can see) for your stats and resume, and 40% which you deem less competitive. Quite frankly, the MSAR and other resources fail to really show the competitiveness, so don't underestimate those schools. Many of them pick up nontraditional or special circumstance applicants that often have low GPAs or MCAT scores. The traditional applicant tends to need a little more oomph. I'd shoot to be at least a point or two above the median for schools that you consider average at (0.2 GPA more would be nice as well). Consider applying to a few DO and MD schools, to really get a good range of schools (especially in state ones). If for whatever reason you choose to only apply to MD or DO, make sure to apply to all of the ones that are in state for you. Not only do they tend to be cheaper, they also often prioritize in state students during the cycle.

Now lets talk about applying early.

This quite honestly is probably the single most effective way to improve your competitiveness once the cycle has began, unless you are retaking the MCAT after a dismal score. You want to be the first application that is looked at, when every interview and every seat in the upcoming class is available to be offered to you. The longer you wait, the further down you fall in the pile, the more jaded the committee becomes, and the less opportunities for interview and acceptances are there. Most schools are what is known as rolling admissions, in which the school will offer seats to applicants during the cycle, rather than waiting until the end of the cycle. Some schools opt to be nonrolling, giving all of their seats at once at the end of the cycle. Theoretically, this means that every interviewee has the same shot. I am skeptical of this, as the committee is still meeting to discuss your application, and would still rather be the first than last to interview.

Ideally, you would want all of your secondary applications done by early August at the latest, well before interview season begins. Most schools don't offer the secondaries until about July 15th, so there is some wiggle room for those who might submit their AMCAS in mid or late June. If at all possible, devote as much time to essay writing and revisions as you can once they start to arrive, and don't hesitate to reuse essays. There is a trade of between revisions and time delay, so don't overly knit pick (which is of course difficult for pre-meds). The primary application essay is the most important (see one of the earlier questions to learn more about it), of course, so expect to put the most time into it. Whatever you do, don't put them off! I know people with 3.8+/35+ stats that bought the bullet on both interviews and acceptances by waiting until November or December to submit the secondaries. Try to interview early as well, if you are given multiple dates. You never get a second chance to make a first impression, but its also nice to be the first to make one!

The two biggest problems for future physicians (part 2)

So last time I rambled about the overuse of our health care system, now lets talk about the single biggest preventable drain on our healthcare system; obesity. The baby boomer generation has no choice but to be a big cost to our healthcare system, as they are old and we have made it so they can get older (unless we decided to "prevent old age" in a number of gruesome and dystopian ways). Obesity, however, is prevalent in all generations and ages, and is only becoming more common. It is really a fascinating problem, from an evolutionary point of view. We have done something that no species has ever accomplished, we have reached a level of dominance where our fitness literally does not matter. For the first time ever, people that once had disease and disorders that essentially prevented them from ever reproduced are now doing so. Bad recessive alleles are no longer being repressed as much. In the same way, we have also reached such a level of dominance and prevalence of food here in the Western world that we have the ability to gorge ourselves to obesity. Despite all of the wonderful mechanisms that our bodies have evolved to counter all sorts of problems, a mechanism to prevent obesity was not something that ever arose.

Why? Simply because it wasn't necessary. Abundances of food have occurred before, but ultimately if an animal got fat (assuming predators and omnivores here), they couldn't catch the food anymore. They would then starve until a point to which they were fit enough to catch food or die. Our obesity does not prevent us from obtaining food, due to the nature of being able to exchange food for money. Thus obesity can be a life long condition, rather than a temporary one.

So how does this effect the medical community? Cost. Obesity is an expensive chronic condition that costs lots of money to fix or mitigate its side effects. Heart disease, especially, goes hand in hand with obesity. Everyone knows about the health problems and thus healthcare related to obesity, but hospitals and our community have another problem. Just like our bodies weren't built to respond to rampant obesity, so is the current medical structure of our society not prepared for obese healthcare. Hospitals were not BUILT to handle the super-morbidly obese patients that are now rolling in (no pun intended). I've seen an obese person on a extra large rolling bed get stuck in an elevator and go into cardiac arrest. He was literally too fat for the hospital, and the doctors trying to get a crash cart into the elevator were more than happy to comment on it. I watched a surgery on an obese man recently. It was an intestinal surgery and the longest part of it involved simply getting through the fat to the target. After the fat clearing, the surgeon turned to me and said "I just go paid 700 dollars for cutting fat." Mark my words, smart hospitals will be soon instituting a midlevel specialist who's sole job is to clear fat out of the way for surgeons. I'm sure that this is just one of the many things that will need to change in order to make hospitals economically and physically viable for our obese future, and there are many people hard at work at the problem. Do you think its a coincidence that newer hospitals have much wider hallways and bigger elevators? I wouldn't be surprised if fellowships in Obese Medicine start popping up sometime soon.

The four year pathway: Doomed?

So my recent string of waitlists has gotten me to think about something that had popped into my mind during medical school interview season. It seemed to me that the really top schools that I interviewed at were predominantly filled with older interviewers. I know that at a few interviews that I was the youngest person there, and I'm 22. I checked up on this, and it turns out that almost half of all students accepted to the Top 10 medical schools were non-traditional, meaning that they took some significant time off. Whether this includes people who took a year off, I'm not entirely sure, but either way this is a very significant number. It basically says that in order to be truly competitive at the very best schools you have to have MORE than an undergraduate experience. This makes a great deal of sense to me. As much as we pre-meds like to think that we are all the best, most unique candidate, I acknowledge that I simply can't compete with some of these applicants at this time. I've got the grades and the scores, and I've managed to smash more interesting EC's into my four years than I thought possible, but ultimately my two years of part time work in research is no match for someone with a two year full-time fellowship at the NIH, and my teaching and tutoring experiences simply don't match up with someone who did a stint with Teach for America. There just isn't enough time in four years to fit things of that magnitude, though some people may come close. 

So the question that I ask and have asked is if this is a trend? Will this slowly trickle down to all schools until basically every applicant applies after a year of post-graduate work. Not likely, in my opinion, but it is clear to me by looking up the data that the barriers to the very top schools are growing higher for those who wish to make it there in four years. Everyone will tell you that medical school admissions is growing in competition, and the very top is definitely keeping ahead of pace. So, should I have considered waiting and done Teach for America like I wanted? Maybe knowing what I do now I would have, because I honestly didn't even think that I would be competitive at this level until the interviews starting coming in. At this point though, I wouldn't give up what I have to try again. Who knows, maybe in the coming months it will turn out that I did manage to jump those towering walls.

And so the dust settles

Well decisions are out, and I'm a tad disappointed. Mostly waitlists and a few rejections mixed in from some of the Ivy's that I interviewed at. Nonetheless, I'm still pretty happy with how I did. I got rejected from the school that I dreamt of when I was younger, but honestly I almost didn't even apply because I had fallen out of love with it (In fact, I applied to it three months after everywhere else because I had a change of heart). The school I am currently matriculating in is highly ranked in both research and clinical, and has the special programs for Medical History that I am very interested in. While it doesn't have the glamour of, say, Yale, it has more respect from the medical community than any other single school that I have talked to physicians about. In fact, my father ( a physician) regards this school more than a lot of the dozen or so schools ranked above it. It's also the only school that none have ever had negative comments about either. It wasn't my top choice, but I did really find myself liking it. Honestly, if it had more "bang" in terms of name brand prestige I would probably list it as my top choice. That sounds a tad superficial, and I'm sure in a few years I'll look back and laugh at myself, but in my experience it seems like getting into Academic Medicine has a lot to do with the being from a highly ranked medical school. That being said, the $20,000 merit scholarship, with room for more, "eases my pain". I sent a letter off to my top choice, but I'm already preparing myself for matriculation. Great city, though not New York like I hoped. Great facilities, great medical history department, great honor to be going.

Well that's all for now. I'm in the process of preparing my undergraduate "graduate level" thesis for defense. I'll keep you all updated when I hear yay or name from my 5ish waitlists that I care about on May 16th. I've also standardized my labels for easier searching through relevant posts.