Don’t Drown in the Suck

When talking to students considering medicine as a career, I talk about all of the advantages or taking care of patients. I also say to everyone –

“Remember, it is still a JOB.“

Physicians are stuck in the middle these days. The expectations are high, and rightfully so. Our patients’ lives and livelihoods are on the line.

So, where is the suck? We have many bosses: our patients, our physician leaders, and our administrative leaders, not to mention the insurers. The insurers want to do everything but pay medical bills. The first goal of every insurance company is to maximize their profit – the complete opposite of the first goal of every physician.

Primum non Nocere!

It’s easy to want to give up. “I don’t get paid enough to deal with this,” may be a tempting out. In many ways, that is fair. Fighting everyone around us against the stream to provide appropriate care is not what we ever agreed to. Physicians are taught to say “yes,” and “how can we help.” If you want to be a successful physician, you HAVE to be available, able, AND affable. No one likes a cranky doctor, but it’s so hard to put on a fake smile when you leave the patient room and run into roadblocks and brick walls.

First and foremost. Take care of yourself. Ensure you have a solid plan to take care of your mind, body, and family. Use your paid vacation days – EVERY SINGLE ONE OF THEM – throughout the course of a year. We don’t get paid to work 365 days a year. Read something that isn’t a textbook or a journal. Take some time out of every day for a workout or some meditation. Spend some time every day with your family and friends or your pets.

What can we do at work to prevent drowning in the suck?

Get right in the middle of it! Get involved in the decision-making. Join committees. Volunteer for strategic leadership opportunities. Notice, I said strategic. You can’t say yes to everyone and do everything. Be as picky as you can. Look for places where you can make a difference or where you have experience that will benefit you and your patients. At the beginning, start small. As you gain more experiences and the leadership get to know you better, you will be asked to do other things. Edit as you go. As you get overextended, pass along responsibilities to others that may be looking to get acquainted with your institution. It is expected that your interests and availability will change over time.

Go to the places where decisions are made so that you can be a part of the solution, not the problem. Engage with all of the bosses. When you spot a problem, point it out AND SUGGEST A SOLUTION. If the decision-makers see that you are thinking beyond the problem, they will ask you to participate.

At the end of the day, remind yourself why you show up at work every day. It isn’t to save the insurance company’s profit margin. You show up at work to take excellent care of patients, to change the lives of people in need.

Paralyzation or Triumph in Difficulty

We’ve all been there. We’ve been at the difficult junction in a case or found surgical progress stalled. We’ve planned for all possible paths a procedure might lead us down, but we operate on the human body, and not everything is predictable in every case. Perhaps something irreplaceable has fallen onto the floor or is broken. Maybe every step we take seems to lead to something worse.

When we find ourselves in this predicament, what is the most appropriate next step? How do we restart progress and complete the procedure? Do we find calm in chaos, or do we allow the difficulties to paralyze our decision-making abilities? In dire circumstances, when a life or limb is on the line, we can find ourselves in a fight or flight scenario, but with another human’s outcome on the line.

There are rare times when pausing for contemplating and conversation is not possible. Rapid hemorrhage, spreading infection, or hemodynamic instability are all examples where decisive action must occur instantly. However, in a lot of scenarios, finding some zen in confusion is essential.

We have to learn when trying less is the right move. In the field of orthopaedic surgery, hammering harder or choosing a larger screw is rarely what brings us to the finish line. Multiple brute force attempts to get a screw into the right place or the implant out at all costs may lead to an unsavory outcome.

My approach to these scenarios has been to take a second. Irrigate the wound. Step away from the table for a few minutes. Scrub out and walk out into the hallway for 5 minutes, if necessary. Take a second to review images and ensure there are not any unrecognized details missed during pre-operative planning.

If you are genuinely stuck, don’t forget that you are not there alone. Ask an assistant or trainee what they are thinking. Involve the entire team. Bring other personnel in the room into the conversation. If you have a partner next door, ask their thoughts.

Maybe you are operating alone and need another set of hands for better exposure. Perhaps the incision is too small. Inadequate exposure is often a cause for difficulties. Remember, incisions heal from side to side. A 3-inch incision will heal just as well as a 6-inch incision if that is required to complete the case safely; never hesitate to be more invasive. For example, in a hardware removal, extending the incision might make an otherwise 1-hour surgery a 10-minute procedure.

In fracture care, reduction and 3D visualization are a couple of pitfalls. In closed reduction attempts, it is never wrong to try. If closed reduction attempts aren’t successful, there is NOTHING wrong with using open techniques that respect soft tissues to get it right. For example, in intramedullary nailing, a small incision at the fracture site for manual assistance with the passage of the guidewire is a soft tissue friendly technique that can save a significant amount of time and facilitate appropriate length and alignment rotation and a successful procedure.

3D visualization is a complex skill to master for some. One of the things I discuss with learners is utilizing every surgical procedure to understand anatomy better. For example, visualize the starting point for an intramedullary tibia nail when doing a total knee arthroplasty. Pay attention to the cruciate ligaments for potential arthroscopy during the same procedure. There is something pertinent to your future surgical practice in every case you participate in for residents and fellows!

A part of planning is expecting things might go wrong. When preparing for surgery, understand how to respond when everything seems to be going wrong. Don’t let yourself get stuck in the quicksand. Slow and smooth are often the most appropriate way out of the worst situations.

What thoughts do you have? Fell free to continue the conversation at https://twitter.com/rkh_md.

The Patient, A Doctor and Their Shadow

The doctor-patient relationship is a truly remarkable bond.  On regular days, patients come into clinics and hospitals and tell a relative stranger about their life, sometimes details they do not tell their closest friends and family. On their worst days, patients are transported to emergency departments and trauma centers in extreme duress, with life and limb-threatening emergencies, expecting to arrive at a place where their injuries will get the full attention of the medical staff without prejudice.  

Unfortunately, the system is not setup to work equally for all.  We have been taught to be biased as physicians[1]. We were told (incorrectly) as students that physiology and pathology is different for people of different races[2, 3].  Our teachers have insisted that age and gender are important when many times they are not.  The books that have been written and updated for edition after edition have led us to believe that discriminating against our patients is practicing good medicine.

How can a physician start a new patient-physician relationship without bias?  This is where our “shadows” come into play.  As physicians, we need to train ourselves to evaluate encounters with patients from the bystander’s point of view – as our shadow might.  As we listen to patients and gather data, either in an effort to establish a diagnosis or to assess the success of our treatment course, we need to look for the clues that tell us the relationship is broken.  We need to be able to evaluate the phrases that our patients will use to tell us we are not having success.  When the patient says, “something is wrong,” or “I am concerned,” it is the physician’s duty to “seek out disease,” to search high and low for what is wrong and address the problem or reassure the patient that everything is OK.

Likewise, if these concerns are coming from the patient’s advocate, we must respect their relationship with the patient and their observations.  Assume the pure intentions of everyone involved and go above and beyond to make sure the fears of all concerned are alleviated.  This is hard work, to be certain.  It is not even work that may be compensated fairly when it comes to the time spent at the bedside.  It is, however, work that can potentially save lives.  We need to actively explore concerns.  We need to ask clarifying questions and address our patients’ concerns head-on.  

As physicians, remember we do not practice in a vacuum.  Medicine is a team sport.  In academic and teaching settings, it is important to seek out the observations of learners and other members of the team.  Talk to the least experienced people in the room.  Ask for their thoughts.  Ask what they observed about the encounter.  In all settings, listen to nursing and ancillary staff.  Seek out their opinions and respect their expertise.  Discuss what is said when you are not in the room.  Ask social workers, discharge planners and therapists to give you their opinions of the patient’s course.  Setup the environment so that they understand why the questions are being asked.  It is important to make sure everyone on the team understands that we are not looking for affirmation.  We are looking for problems and solutions before bad outcomes occur.

We, as a profession, need to rethink our practices.  We need to reprogram our brains to listen to our patients and not just attempt to recreate debunked statistical norms.  We need to listen to our colleagues that have sounded the alarm and pointed out the inaccuracies in our textbooks and teaching practices.  This should be especially true when we might not have the same life experiences as our patients or come from a different socioeconomic background.  If we truly listen to our patients, they will tell us what is wrong.  They might even present us with the solution.  

Disparities and systemic racism in healthcare are real[3, 4].  They lead to outcomes that, at their best, are disappointing and, at their worst, are deadly.  Not even the most knowledgeable people, our physician colleagues, are immune from these biases.  We do not have to look very far to find examples of these lapses in treatment.  They occur every day.  

1.         Amutah, C., et al., Misrepresenting Race – The Role of Medical Schools in Propagating Physician Bias.N Engl J Med, 2021.

2.         Inker, L.A., et al., Effects of Race and Sex on Measured GFR: The Multi-Ethnic Study of Atherosclerosis. Am J Kidney Dis, 2016. 68(5): p. 743-751.

3.         Hoffman, K.M., et al., Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A, 2016. 113(16): p. 4296-301.

4.         Ellis, L., et al., Racial and Ethnic Disparities in Cancer Survival: The Contribution of Tumor, Sociodemographic, Institutional, and Neighborhood Characteristics. J Clin Oncol, 2018. 36(1): p. 25-33.

Choosing Where to Go To Medical School

When it was time to choose where to go to medical school, I didn’t think all that hard. Indiana is unique. There is only one medical school in Indiana, at least there was when I was applying. (There is now IU, offering an MD degree and an osteopathic program affiliated with Marian University in Indianapolis.) Indianapolis serves as the hub, and there are eight satellite campuses spread throughout the state. The first two years can be done at any of the nine campuses. Some aspects of the third and fourth year can also be completed at satellite campuses, each with a different focus.

In-state tuition compared to going to an out-of-state or private school was a no-brainer. We’re talking double the price of tuition and fees, and I didn’t see the benefits as being worth the price.

Of course, we’re talking about getting into medical school here. You have to apply to more than one place. We’ll talk about this more when we get down the road to the residency match, but a large portion of this is a numbers game. Nothing is guaranteed in medical school admissions. There are more qualified applicants than there are spots. You have to position yourself to be within the pool of qualified people and hope something you do during the process sticks out enough to get you accepted.

The process isn’t simple, and it should begin as soon as possible. Check out this post for more on my thoughts regarding the application process.

Planning for and Navigating the Medical School Application

If you live in a state where more than one medical school is available to you, do some research. Different medical schools have different focuses. There may be small nuances in the curriculum that are preferable to your learning style or career goals. You may find a school focusing on primary care and a program that offers a fast-track to residency. Maybe the school has a focus in public health.

I wanted to go to one of the small IU campuses because I wanted more one-on-one time with professors and a focus on in-person classes. I wanted to be able to focus with a small group of people on my first two years. This was quite the opposite of my reasoning when it came to choosing an undergraduate school. Bloomington also had full-year classes for the first two years. More time in courses like anatomy and physiology allowed for more time to focus on details.

I’m not trying to say out-of-state or private schools are bad. You can earn the same medical degree at the end of the day. It’s also important to note that I’ve never been involved in a discussion regarding residency applicants where a degree from Harvard or Yale was considered more important than a degree from a state medical school. A medical degree and the appropriate requisite credentials are more than enough to get you into almost any residency, anywhere.

Excelling During an Orthopaedic Surgery Rotation

Trying to get a job in the middle of a pandemic is less than ideal. Given that, when you get an opportunity to work with residents and faculty one-on-one, it is crucial not to waste that time. Don’t get black-balled before you’ve ever even walked into the hospital!

It’s essential to understand who is usually on a residency selection committee. The committee is composed of representative faculty as well as residents. (If a program doesn’t have residents on their selection committee, you don’t want to go there.) It’s important to remember that you aren’t just doing an audition rotation to impress a faculty member and get a recommendation letter. The residents have a significant say in who they want to work with when a new class joins. A program may altogether remove a student from their rank list after resident feedback.

Don’t underestimate other people in the program. The residency program coordinator and the medical student coordinator (if a program has one) are essential. Same for PAs and NPs, nurses (in the office and on the floors), secretaries, and assistants. Be nice to the janitors! Treat everyone like they are your grandmother. If you are rude to them or don’t complete a task on time, that is likely to get communicated back to the program selection committee, and the result can be not being included on a rank list when the time comes. I know it seems like something that shouldn’t have to be said, but it happens way more than it should.

I’m not writing this to cause fear. You shouldn’t spend too much time walking around on pins and needles. Be a normal person, and things will go well. Here are some more thoughts that I have about excelling on an orthopaedic rotation.

  1. Show up to the operating room early. Introduce yourself to everyone in the room. Write your name on the board so the nurse can put you in the computer. Write your glove sizes on the board as well. Never assume someone will get your gloves. Grab gloves and a gown for the first case and ask the scrub if they want you to flip them onto the field or give them to someone else to put them on the field. Don’t be surprised if they don’t want you to put something on their sterile field until they trust you to do it correctly.
  2. When the patient gets into the room, help the team. Don’t stand in the corner and watch. Get in on the action. You may not be invited up to the table. The focus is on the patient at that point, not other people in the room. Go and grab a warm blanket for the patient. Help move the patient to the OR table (not the feet). Get in there and do the heavy lifting. Help turn the patient. Don’t throw stuff on the floor that one of the room staff is just going to have to come behind you and pick up later. If you show you have their back, they will get yours!
  3. When it’s time to prep the patient, ask if you can help. The person prepping the patient may or may not need it. Again, make yourself part of the team. Everyone in the room is focused on getting the case started and may not be looking around to invite people to help.
  4. Prepare for cases. Ask the resident or attending that you are working with to go over cases the day before. The resident may be able to prep you for questions. Read up on the anatomy. You aren’t expected by most people to know much more than that.
  5. When you are asked a question during a case or on rounds/in the office, don’t panic. The purpose of the question may not be to see whether or not you know the answer. It may be to evaluate your thought process. Can you work your way to the solution? I worked a lot with a faculty member as a student where I ended up doing my residency. He loved to ask me questions about musical artists. I almost never knew the answer. It became a fun game. No one was keeping score as to which answers I got right or wrong. Usually, by the way, no one is.
  6. Practice knot tying and suturing at home. Be able to tie one-handed and two-handed. Practicing using your dominant and non-dominant hand. Learn to use scissors and clamps with both hands. If you have practiced when someone asks you to do something and you can do it efficiently, you will be asked to help more and more. If you aren’t sure, ask the scrub to show you how to hold an instrument or use it correctly. They will show you.
  7. Have supplies with you that will be helpful. Keep a pen (that you don’t like too much) in your pocket. Have trauma sheers available. Help with dressing changes in the mornings. If you can work ahead of the resident or attending, you will be seen as a valuable team member.
  8. Be prepared to show up early and work late. This is the same thing a person would do if they got an entry-level job in the business world and wanted to work their way up the ladder.
  9. If you are on call and slept during the night, be prepared to stay and work the next day. You only get so long to work with the residents and faculty. Please take advantage of it. If you worked all night, that’s a different story. The team should be sending you home in that scenario.

At the end of the day, just like the residents and faculty are trying to decide whether you might be a good fit for their program, you should be doing the same thing. Try to talk to as many residents as you can. Get a sense of what their life is like. Are they miserable? Is it just that they are on a particularly busy and challenging rotation, or is every rotation at a program miserable and difficult? Get a sense from the faculty whether or not they enjoy their job. If the faculty are miserable, there’s a good chance the residents aren’t going to be much happier. Talk to PAs and NPs if you are helping them close. They can give you useful information about the program.

There are more applicants than spots. Except for a few people, almost everyone is mashed up pretty close together. Applications are surprisingly similar, with similar-sounding letters of recommendation and personal statements. Everyone has good clinical grades and an acceptable test score.

The best way to distinguish one applicant from another is to see their work-ethic in person.

I Don’t Understand Guns

This post is different from what I’ve been posting so far, but I want to share my thoughts. This post is my opinion. Some people may not agree. That’s ok. We don’t all have to agree.

“A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.”

Congress ratified the second amendment to the US Constitution in 1791, eight years after the American Revolutionary War. The state of the art weapons available were muskets. It took a well-trained soldier about 20 seconds to load their gun. Musket balls were lethal at close range, but are not very accurate from too far away.

Our country was new, and the Continental Army had been formed at the beginning of the war to allow for an organized defense against the British Army. Before that, the war was being fought by militias from each individual colony. We didn’t have grocery stores. People hunted for or grew their food. Guns were a necessary part of life.

Let’s fast-forward to 2020. Technology has advanced a million times over. We have electricity, refrigeration, the microwave, telephones, the internet, credit cards, grocery stores, etc., etc., etc. We have a more than sufficient military to protect us from potential threats. We don’t even need people in many circumstances to fight wars as unmanned drones can be dispatched to fire weapons that are infinitely superior to the musket.

And yet, we have automatic and semi-automatic weapons. These weapons serve one purpose – to kill people. A semi-automatic handgun can fire 40 rounds per minute. A fully automatic weapon can fire 600 or more rounds per minute. You can’t legally use an AR-15 or a 9mm handgun to shoot a deer or a turkey for food, nor would you want to. So, why are we so obsessed with having them. I’m no constitutional scholar, but I can’t imagine the framers could have ever even dreamed up the weaponry available to us today. They would not have ever considered this to be OK. We only promote violence from all sides with these weapons.

I’m not trying to say people shouldn’t be allowed to possess a firearm. I’m just asking, “Why do we need to allow such powerful weapons to exist?” The police argue that they need powerful weapons so that they aren’t out-gunned on the streets. So, instead of fighting fire with fire, why don’t we fight fire with water? Let’s de-escalate the situation instead of ramping up the wars that are being fought on our streets.

Again, I don’t want to collect and melt down all the guns out in the world. I do think, however, we should seriously consider getting rid of weapons whose only purpose is to kill or injure other humans. If no guns of this nature existed, we’d all be a whole lot safer than we are with them.

Academic Failure Is More Frightening

It’s one thing to fail at a goal to participate in a sports program. It’s quite another for a student interested in getting into medical school to experience academic failure. There’s no place where this is more likely to happen than in battle with every pre-medical student’s arch-nemesis: organic chemistry. I was a good general chemistry student. I enjoyed the classes, and my high school background in general chemistry was strong.

Organic chemistry was a different beast. It’s not just memorization and math. Organic chemistry requires an understanding of concepts so that they can be applied. I was able to get through the first Organic Chemistry class. I did OK. Then, I started Organic Chemistry II. Two course sections were offered that semester, and I didn’t do a good job of picking. The professor for that section had taught the honors course the year before. He had a reputation for being a tough professor. I didn’t know that.

Sitting through this man’s lectures were painful. He would use up all portions of the multiple chalkboards in the lecture hall. I would take 4-6 pages of notes during a 50-minute lecture. I tried to study. I went to the discussion sections and prepared for the first exam.

And then, I sat down in lecture one day, where he passed back the first exam.

12.

Out of 200.

6%.

The average for the exam was not high. But it wasn’t 6% either. The professor promised that our grades would stick. There wouldn’t be a curve. We had to earn the grades. He took his job as the head of a gateway course seriously. I sat through the rest of that lecture and took my pages of notes, but the decision wasn’t hard. I would need to cut bait and come back to play another day.

Lot’s of questions went through my mind. What would be the effect of a W on my transcript? In the end, however, I decided the W would look way better than an F. I would withdraw and then re-take the course during a summer session. It would allow me to focus solely on organic chemistry.

It’s pretty crazy how much fear comes with getting good grades for those who want to go to medical school. It’s important to know that good grades are important, but it’s OK to be human. Not every grade has to be an A to gain acceptance into medical school. Students are allowed to start slow, but you have to show progress along the way. We have to be learners to be competent physicians. Medicine is improving at breakneck speed, and the knowledge we gain during medical school is frequently defunct by the time we receive our diplomas.

I’m not trying to blame my first organic chemistry II professor on my lack of success in that course. I didn’t fully know how to study for organic chemistry at that point. I didn’t know how to apply the concepts, and I needed a new strategy. Luckily, the second time around, I did much better.

None the less, I made it to where I wanted to be, and I learned a valuable lesson along the way. You need the right strategy to be successful, and you need to be willing to course-correct along the way if you find yourself at risk of failure.

Success Doesn’t Come Without Some Failure

Not everything we try will be successful. I wasn’t necessarily used to failing in high school. The competition was stiff among many of my classmates, but hard work paid off. I graduated as the salutatorian of my class and won plenty of academic awards and scholarships.

Things change when the pool gets more substantial, and there is a significant chance that we will have to hear the word ‘no.’ I’m not exactly the world’s greatest athlete, not even close, but I enjoy sports. Like every good Hoosier, basketball is a great game, and involvement in athletics serves to teach many more lessons than how to dribble or shoot a basketball. Athletics provides lessons in loyalty and dedication and teaches us how to work as members of a team. There is something special about being a part of a team, and I enjoyed working with my high school basketball team as a manager. The work is hard and is not glamorous, but it’s worthwhile and necessary. No team can go without the folks who work behind the scenes.

I had a mentor in high school who had a connection with the IU basketball program. He introduced me to the IU basketball managers. The process is competitive and run by the senior-level managers. Each year, interested students show up for an introductory meeting to learn what it takes to be a manager, followed by an interview process. I went through two interviews and did not get the job during my freshman year. We had discussed my career plans after college, and the senior-level managers were concerned all the time required wouldn’t leave me enough time to study and get the necessary grades to get into medical school.

Failure doesn’t defeat me, however. I only became more resolved to be a member of that team. I worked hard in classes. I got a job – to help pay the bills – and show that I could do more than one thing and still be a successful student. I got all A’s my first year of school.

In my sophomore year, I came back and applied again. It took a great many conversations, but I was able to convince the senior level managers that I could do both, participate as a manager of the basketball program, and be a great member of their team, all while being a good student.

The moral of this story can be summed up by one of my favorite quotes—the words of Coach Jim Valvano as he accepted the Arthur Ashe Courage Award in 1993.

“Don’t Give Up. Don’t Ever Give Up.”

Navigating a Large University

Indiana University was absolutely the right place for me to go for my undergraduate education. I’ll never regret the experience, the knowledge I received, and the friends that I met there. I chose biology as a major, not because I felt that I needed that education to enter medical school, but because it was the subject I enjoyed learning the most. I find molecular biology fascinating. Learning the biologic transfer of information was a ton of fun. Although it isn’t a knowledge set that I use in my career, the basis of learning biology is still beneficial for understanding and practicing medicine.

In general, I see getting an undergraduate education as learning how to learn. It is also a significant transition from being dependent to being an adult. Aside from making sure to get medical school pre-requisites and test prep, my advice to any student would be to study whatever in college. Much like I mentioned in my post on the medical application, a unique undergraduate degree can make an application for medical school stick out – in a good way.

I mentioned this in an earlier post, but I see the most important thing one can do at a large University is make it smaller. Step one is to get engaged in courses. The 100 level courses at a place like IU are likely to be large, with multiple sections and a large teaching team. Engage in the small sections, but don’t forget to get to know the professors as well. Office hours are a great place to learn in a large class, and sometimes it’s good to go for the social interaction. It’s great to have questions, but it isn’t always about asking questions. Sometimes it’s just about getting to know the professor, where you can learn about the course material – or maybe just have a conversation about life.

I grew up in a small town. Introducing myself to diversity was an important part of going to a large university. I was fortunate to be able to make friends from all over the world. It was undoubtedly a new setting compared to a small town of 5,000 people in central Indiana.

I worked my way through college. I had two jobs during the year: teaching first aid/CPR/lifeguarding courses to the recreational sports employees and referring basketball for intramural sports. In the summer, I worked at the swimming pool.

I also had the opportunity to be involved in intercollegiate athletics. I worked as one of the managers for the IU Men’s Basketball Team. While not actually playing a sport, I had the opportunity to travel with the team and watch the team play for the NCAA Men’s Basketball Championship. This was close to a year-round job. We started practicing in the fall and played through March, with basketball camps and other activities in the summer. It was a challenging and rewarding experience that taught me how to manage my time and be a successful student. It also lengthened my undergraduate experience by a year – which is not necessarily a bad thing.

I applied to be a manager during my freshman year. I wasn’t successful – mostly because the team was worried I might ruin my chance to be a physician if I couldn’t focus on studying. I was able to convince them that I could manage both, and I’ll never forget the experiences that came from being a member of that team.

If you are looking for an experience, you’ll find it at a larger university. The full breadth and depth of opportunities are available, and I enjoyed that. At the same time, if you aren’t looking to be noticed, that’s possible, as well. Just remember, if you want to apply to medical school, getting noticed should be a goal. Finding mentors and advisors who know what they are talking about is key to making it to the next stop along the journey.

I don’t want to write this post to say you have to go to a large school to get into medical school. That is far from the truth. I know plenty of people who were successful at medical school admissions after attending a smaller college. It’s important to make your secondary education what you need out of it!

Planning for and Navigating the Medical School Application

I wanted to take a brief break from telling my story to discuss medical school admissions and the AMCAS – the standard medical school application. My hope would be someone in the pre-med years, or perhaps earlier, who is planning to apply to medical school would read this and start to think ahead. Applying and successfully matriculating into medical school is no small feat. It’s much more than just getting good grades and taking an exam. Medical schools are performing a more holistic review of students. They want to know that candidates have researched the profession and contemplated the reasoning for their decisions.

Disclaimer: I do sit on the admissions committee where I currently work. There are no trade secrets in this post. My goal is simply to point out some things every student should consider when they are applying to medical school.

The application can be daunting. Trying to distill oneself into a few pieces of paper can be a challenging task. It is not something that any student should do alone. Seek out advice. Ask questions of people who understand the process. Work to create an application that will differentiate you from the thousands of applications that every medical school has to sort through. Because the competition can be so stiff, simple things such as misspellings and bad grammar can lead to the quick rejection of an applicant. Check and double-check the accuracy of your application. Don’t let an overlooked fact or accidental misrepresentation screw up an application.

The personal statement is the first thing many people will read when reviewing an application. Try to write a story that doesn’t just recapitulate the rest of your application. At the very least, answer the question, “Why do you want to be a physician?” Talk about what led you to make that decision. Have something in your application that needs to be addressed? Address it in the personal statement. Write and re-write your statement. Give it to someone to read who will tear it apart and question everything you write. Continue this process until everything is perfect. Remember, it’s often the first thing that people read when reviewing an application, and first impressions are everything!

Don’t be passive about getting letters of recommendation. Talk with the people you ask to write letters. Ask them upfront if they are willing to be supportive and personal. Ask them if they can discuss what characteristics would make you an excellent medical student and, eventually, a competent physician. Where I work, grades are deleted for application reviewers and interviewers. A letter that just says you were ranked X out of X in a large chemistry class is not very helpful to you. If all the letters are like that, it will likely actually hurt the application, not help.

Find a longitudinal research experience and stick with it. A semester washing glasses in a lab doesn’t cut it these days. You don’t have to have publications to get credit for research, but you do need to prove that you have learned and applied the scientific method. Understanding research is fundamental to be able to judge the scientific evidence in the literature. Not everything that finds a way into a journal is good science.

Shadow physicians and get a sense of what the job entails. It’s vital to prove that you have explored the day to day life of a physician. Getting into medical school and then finding out midway that it’s not for you can be a costly mistake. Not sure where to start? Ask your pediatrician or family physician if you can spend a half-day with them. From there, they might be able to help you get in touch with other physicians to shadow. Have a specialty you want to see? Call a local physician’s office and ask to speak with the practice manager. Tell them who you are and what you want to do, and they will often help you out!

Get involved in community service. You can volunteer in the hospital or another medical setting, but you don’t have to. Again, try to make this a longitudinal experience. Four individual experiences that last a day or two are not looked upon as favorably as one experience where lots of time and energy were applied to help others. This is a place where an applicant can differentiate themselves from others. Having a unique experience on your application differentiates you when screeners are looking through a lot of applicants that look very similar or makes the interview memorable when an interviewer is preparing for a presentation to the admissions committee.

Be a leader. Show that you can lead others. Explicitly state where you have leadership experience. Is it a supervisor position at a job? Were you elected to be in charge of a volunteer experience or fraternity/sorority? Make sure to lay out exactly what your experience involved. This is the area where I see applicants struggle the most. It isn’t that most applicants haven’t been leaders. It is more that they just don’t highlight that in the application.

Consider working while in college. Learning how to be an employee, following instructions, and showing up on time are qualities that will make one an excellent medical student and eventually a good co-worker and responsible physician. Medical school is a lot more like a job than like previous educational experiences. Admissions committees (and residencies down the road) really look favorably on an applicant who has prior work experience.

Grades are not everything, but they are part of the holistic review. Don’t have a 4.0 GPA? That’s fine. If you have a lousy grade somewhere, make sure you address it. Maybe there is a reason why. Perhaps you start with a bad grade in a class. Consider dropping that class and re-take when you can focus primarily on that course. Some universities provide a tool that shows all sections of a given course and average grades for each professor. Don’t take the hardest section of organic chemistry if you have that sort of information available to you! Talk with an advisor about course timing. Again, perhaps it is a good idea to schedule a challenging course in the summer so that you can focus on that particular course and grade.

The MCAT, unfortunately, is required. Just like other standardized tests, one of the most important things one can do to be successful is to practice taking the MCAT. Get and utilize question banks. Do as many questions as possible. You probably won’t improve your score by just reading a book. Do the questions. Learn the right answers and read and study explanations. There are only so many concepts that they can test. Many studies show that the only thing that can successfully predict success on a standardized test is the number of practice questions completed.

Make sure to give yourself enough time to not do well on the MCAT. If you aren’t as successful as you would like to be, it can be important to re-take the test. I often see this question asked of applicants who have MCAT scores that don’t necessarily match the rest of their application. “Well, why do they only have one subpar MCAT score on their application?” It’s one thing to have an initial score in the 75th percentile and then improve on a second attempt. It’s quite another just to have one score.

Athlete, those who work or someone who devoted a lot of time to an extracurricular activity? Credit is given for these types of activities, but there are students out there who have competitive applicants, even with one of these activities. An applicant may not need to demonstrate thousands of hours of research if they play a varsity sport at a Division I school, but it is imperative that they still do research. The moral of the story is the holistic review. No one thing gets a person into medical school, but it is essential to present a complete application to be competitive.

It is important to embrace diversity and even a disadvantaged status. We can’t change where or how we grew up. In this setting, ensuring that it is part of the application story is very important. It seems that, at times, people attempt to downplay or leave this out of their application because they feel that they might be looked down upon. This is not the case. Medical schools are actively seeking to include individuals from a broad range of backgrounds into their classes. Just as our patients come from differing backgrounds, so too should our physicians! The comfort that a person might be able to provide their future patients will go a long way to providing them the healthcare they need and desire. In addition, the insight that students from different backgrounds can bring to their education will help their classmates who may not understand how to better care for everyone.

Gap years are important to be able to explain on an application. There is nothing wrong with not going straight from an undergraduate institution to medical school. On the other hand, if time is needed to strengthen an application or perhaps an applicant just has some goal they have set for themselves before entering medical school – waiting for a year or two is not a big problem. It is just important to be able to explain the purpose of that time. If it isn’t addressed in the application, one should be ready to discuss it in an interview. If it isn’t brought up in the interview and the time is not explicitly accounted for, bring it up in an interview. If an admissions committee understands the reasoning behind gap years, they are much more likely to accept them.

There is a lot to consider when preparing the medical school application. It takes years and planning to ensure that all of the experiences necessary are present and completed. In a lot of ways, a person interested in going to medical school needs to start planning as soon as, or very soon after, they start college – or sooner! Having mentors and advisors that understand the process is vital! Seeking out resources at a University is an excellent first step. Developing mentorships with physicians is an important step, as well. Those of us who have been successful in the process are more than happy to help the next generation along!