BigRedMed's journey through 4th year...

Pre-Med & Medical School Careers in Medicine
1

<p>So, I'm tired of studying for my Internal Medicine OSCE, and it seems like I do a lot to "enlighten" people about what med school is actually like, so I thought this might be of interest to some. This will be a sort of pseudo-blog about the upcoming year, with info about applying for residency, interviews and being a 4th year medical student in general.</p>

<p>So, as it stands, I've got 14 weeks left of my junior year - 2 left in internal medicine. I can honestly say that the last ten weeks of medicine have probably been the most educational portion of my life up to this point (I know that the first 6 weeks of being an intern will probably blow this away). I'm finding it somewhat difficult to separate how excited I am about what I've learned from whether or not I actually like medicine and adult patients. What I think I've realized is what I kind of suspected all along - I like inpatient medicine, I like having set end points for taking care of a patient, I don't like managing hypertension or diabetes. I'm not as cynical as I thought I was going to be in regards to adult patients, but outpatient clinic definitely confirmed many of my preconceived notions about how I would feel - I don't have a lot of sympathy for people who don't take their meds or smoke or refuse medical advice and then complain that they feel awful.</p>

<p>My schedule for next year is shaping up as follows (not finalized)</p>

<p>July: Inpatient medicine sub-internship at University Hospital</p>

<p>August: Away rotation in a western state for Pediatrics - either general inpatient sub-i or critical care month. One of my best friends is starting his anesthesia residency out there, so I'll be staying with him for the month, working hard and playing hard.</p>

<p>September: Radiology - fits as one of those months to acquire useful skills that will benefit me no matter what I end up doing.</p>

<p>October - boards prep course - done as small group cases, with extra teaching on EKG's and other generally useful topics. Runs from 8am to 1pm every day, will use the rest of the time to do boards prep.</p>

<p>November - month at the student run clinic - essentially a vay-kay month - but I did serve on the executive board of the clinic while an M2 so this is one way to give back. General medicine clinic meets once a week on tuesday night while STD clinic runs on wednesday night. Have to do 8 clinic sessions for the month and a small clinic improvement project as the direction of the exec board. Will use this month to take USMLE Step 2 CK and hopefully CS as well. </p>

<p>December - Pulmonary consult service - not an ICU month, but combines some clinic as well as inpatient, covers a lot of things like blood gas interpretation, pulmonary function tests and the like. Not too difficult to get off of for interviews</p>

<p>January - vacation month - using the month for interviews early on, and then for getting ready for February because...</p>

<p>February - AUSTRALIA - very excited to study abroad for a month. The hopeful plan is to get all my interviews done early in January, then head Down Under a week early to see some more sights on my own. From what I've heard, the clinic set up is pretty good for students so there's plenty of time to travel. Will be back in time for my brother's 21st birthday on the 28th of the month.</p>

<p>March - Pediatric Pulmonology - originally wanted Ped Cards, but I apparently lost out in the lottery for the spot. I'm definitely interested in Ped Pulm so it should be a good month regardless.</p>

<p>April - Teaching Assistant for the M1 History and Physical Exam class. This would essentially be a vacation month because the responsibilities of this selective are spread out throughout the year. Basically work with the M1's to help them learn how to do physical exam maneuvers, grade their H&P write-ups and evaluate their performance on OSCE's. I figure I'm going to have to teach while a resident so this is just one way to get started sooner. If I don't selected for this (find out early next week probably), then I'm going to have to look at changing my schedule around some, because this fills a very specific requirement for graduation.</p>

<p>April 30th - Hooding ceremony (and my 26th birthday!)
May 1st - Commencement</p>

<p>So that's where things stand right now. I'll answer questions, but try to minimize comments somewhat. I don't want this spiraling too far away from topic.</p>

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<p>Tag. =)</p>

3

<ol>
<li><p>What would an inpatient population include?</p></li>
<li><p>For away rotations, how do students go about looking for affordable housing? Pending they dont have friends in that area and the hospital does not having housing. I always wondered about this. </p></li>
<li><p>I see that you dont have an ICU month. Have you considered doing a NICU or PICU month? I heard it could be very informative, but I have no first hand experience with it.</p></li>
</ol>

4

<p>So inpatient means limited to actually being in the hospital. So these patients are sick or need to be in the hospital for workup and/or treatment. I like the fact that there is a minimal goal - get them out of the hospital. I actually do like peds well-child checks which I think its because they're more fun and they're usually healthy and you are doing something to make sure they continue to develop...whereas health care maintenance visits for adults is trying to prevent a time bomb from going off...At least thats how I justify it in my mind.</p>

<p>Away rotations, it seems like most places will help you find a place. The place I'm going has a list of physicans and people in the community who have hosted visiting students in the past. The other option is always to take out more loans - places like Extended StayAmerica aren't too expensive, certainly cheaper than a regular hotel.</p>

<p>3) Yeah, I know don't have an ICU month and they are very educational from everything I've ever heard. Part of my problem is that I'm possibly going med/peds for residency and so I need to have to do both med and peds rotations. If I was just one or another, I would for sure use that 2nd sub-i month for an ICU month of some sort. It's still possible that the peds month will be in the PICU, depending on what they place me in based on their fourth years. So...stay tuned. This schedule is still tenative at the moment I'm considering a few other things.</p>

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<p>When I said peds month, I meant the away rotation. Again, if I wasn't at least considering med/peds (i'm between that and just regular peds) I'd do the sub-i in peds in july, I'd probably take the board prep class in august, student run clinic in september (including taking boards), Radiology in october, PICU in November, and the rest of the year would have been roughly the same...</p>

6

<p>So today is Match Day for the 4th years - a VERY exciting time for those students. They found out on Monday whether or not they had matched, but today they find out where they're heading for the next 3-7 years of their training. </p>

<p>One interesting thing I learned in the past couple days. One fourth year I know is hoping to go into Anesthesia so he has to take a transitional year next year and then will start anesthesia in the following year. He only ranked 2 transitional year programs due to some certain special circumstances. He found out Monday that he didn't match his transitional year programs but did match in Anesthesia. So he had to scramble for a transitional year spot. What's interesting is that if you are in his situation you can call the NRMP to find out the city you matched in for your actual residency. So he knows he's going to Chicago and he knows he got his #1 choice because he only ranked one program in Chi-town. It's kind of interesting because with the exception of NYC, Chicago, Atlanta, Boston, and LA, there are very few places with multiple residency programs in one field...so in essence you can find out "early" where you're going.</p>

<p>Of course this only works in programs with transitional years, and you do have to go through the hassle of scrambling. But he seemed pretty happy with knowing his results in spite of the hassle.</p>

<p>As far as Match Day goes, most (if not all) schools usually have some big ceremony so that all the students can announce their match results. Just as the white coat cermony as an M1 was more exciting than college graduation, in a way Match Day is more satisfying than the commencement exercises that follow in 6-8 weeks. I think this is largely due to the uncertainty of Match Day. I know that Monday many friends were very nervous opening that email titled "Did you match?". The relief of knowing where you're headed I think is why students look forward to Match Day more.</p>

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<ol>
<li><p>What happens if you didn't match?</p></li>
<li><p>What is a transitional year? and what other specialities that have this year?</p></li>
<li><p>Do you only try to match in one field or you can try to match in many fields in different places?</p></li>
</ol>

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<p>If you don't match, you find out on Monday via e-mail. On Tuesday at noon, all the open spots and unmatched students are released online - so that everyone knows what's available - and the Scramble begins. From there, students and programs are free to make offers and deals - the goal being to figure it out before Thursday so you can announce with the rest of your class. </p>

<p>Transitional years are years spent either in general surgery, internal medicine, family medicine or specific transitional year programs which give exposure to a lot of different aspects of medicine. This is basically aimed at giving almost all first year house officers a lot of exposure to patient care. First year surgery residents even in the surgical sub-specialties (urology, ENT, Ortho, and neurosurg for example) have almost zero time in the OR. The point is to train them to be able to manage patients and handle the complications that arise. HO1's in Derm, Neuro, Anesthesia, Psych, ophtho, physiatry and radiology do the same thing, but can do any one of the one year programs while the surgical subspecialties will do General surgery years.</p>

<p>You're only going to be matched to one program in one field (with the exception of the transitional year...so at most 2 in 2). If you don't know what you want to do, then you can certainly apply to multiple fields, but it's a hassle as you often need letters of rec, and have to apply to a lot more places and such. And in general, you have some inkling that one field is the one you prefer, so by about half way through the process you start figuring that out and it becomes hard to go through with the process in the fields you're no longer interested.</p>

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<p>So if you wanted to do trauma surgery, you want to match with a 5 year general surgery program, with transitional as one of them, then do one or two years of trauma fellowship?</p>

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<p>That's one way. You can also go through ortho. But there are couple caveats, things that in general a pre-med (and even more so for a HS student) shouldn't really worry themselves about.</p>

<p>This discussion gets into the differences between prelim and categorical programs and spots within those programs. And this gets somewhat complicated.</p>

<p>There are three possible set-ups (to minimize the confusion, we'll focus just on a surgical sub-specialty. I'll use Ortho as my example).
1) Categorical positions - in these spots, you complete your general surg prelim year at the same institution as you will finish your Ortho residency. You apply for this spot directly.
2) You apply to the advanced position (the ortho residency) and separately apply to the general surgery prelim year spot at the same institution
3) You apply to the advanced positon, and a prelim spot at another institution.</p>

<p>Now whether a residency program even offers categorical positions varies. Some residency programs only offer advanced spots, and the student has to figure out prelim years on their own. Because they are obviously easier, as I understand it, categorical positions are highly sought after. Essentially if a program offers categorical spots, that's taking spots away that they could offer as prelim spots since there are only so many residents they can handle. Some schools on the other hand will ONLY offer categorical positions.</p>

<p>Now, for the most part, in GENERAL SURGERY, the positions are categorical. When you get into the subspecialties is where you begin to run into the advanced/prelim vs categorical issue. And of course, when you get into the subspecialties that don't require a surgical prelim year, then you get into issues on whether a categorical position means a surgical year, an internal medicine year, a family med year or a true transitional year, thus further complicating the process. There are a couple other unique scenarios I could discuss but I believe they are well beyond the scope of this discussion and have ZERO relevance for pre-meds and even most current medical students.</p>

<p>Fellowships are not done until you are actually in residency and they are usually applied for a full year in advance for most specialties. So for example, if I want to do peds pulm, and I end up doing a med/peds combined residency which is 4 years in length, I would apply for the fellowship during the 3rd year. However, the match days for fellowships vary GREATLY.</p>

<p>So to be a trauma surgeon you can go either:</p>

<p>General Surg prelim year --> ortho for 4 years --> Ortho trauma fellowship for one year </p>

<p>OR</p>

<p>Categorical General Surg for 5 years --> Surgical Critical Care fellowship for a year <a href="It%20should%20be%20noted%20that%20this%20fellowship%20is%20accessible%20from%20Gen%20Surg,%20Urology,%20OB/GYN%20or%20Neurosurg%20to%20complicate%20matters">i</a>*</p>

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<p>On a side note, I found out today that I was lucky enough to win the lottery drawing to be a TA to the M1's next year. So hello extra vacation month! I'm glad.</p>

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<p>Hm. How flexible are things in reverse? Could I do Ortho --> ID, with the intention of practicing mostly Ortho?</p>

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<p>@yg18, If you are interested, some medical schools broadcast match day over the internet. Some make it a formal dress event (UF), while others are relaxed and have it at a outdoor bar (USF). I like the way Vandy does it. Some links below:</p>

<p>Vanderbilt</a> University School of Medicine - Special Events
Match</a> Day reveals next stop on medical journeys
archive[/url</a>]
[url=<a href="http://www2.creighton.edu/publicrelations/newscenter/news/2007/march2007/march162007/031607_matchday/index.php%5D116">http://www2.creighton.edu/publicrelations/newscenter/news/2007/march2007/march162007/031607_matchday/index.php]116</a> Creighton Medical Students Participate in Match Day : PR Newscenter :: Creighton University</p>

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<p>Thanks ASMAJ</p>

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<p>Mike...ID as in infectious disease?</p>

<p>It doesn't work that way...</p>

<p>I found this paragraph in the ID program requirements posted on the ACGME website:<a href="http://www.acgme.org/acWebsite/downloads/RRC_progReq/146pr707_ims.pdf%5B/url%5D"&gt;http://www.acgme.org/acWebsite/downloads/RRC_progReq/146pr707_ims.pdf&lt;/a> </p>

<p>
[quote]
When averaged over any five-year period, a minimum of 75% of fellows in each subspecialty training program must be graduates of an ACGME accredited internal medicine training program. Non-ACGME internal medicine trained fellows must have at least three years of internal medicine training prior to starting fellowship. Prior to appointment, the program director must inform non-ACGME trained applicants in writing of the ABIM policies and procedures that may affect the fellow's eligibility for ABIM certification.</p>

<p>My emphasis added

[/quote]
</p>

<p>My assumption (without confirming) is that there are similar statements in other subspecialties' requirements.</p>

16

<p>Yeah, I was basically wondering whether a surgeon could do a medical fellowship, just for the extra expertise.</p>

17

<p>If you'd just asked me that question, I probably would have told you it doesn't happen, and with the ACGME wording, it's obvious it doesn't. Certainly, people are always able to pursue their interests, but as far as formal training...doesn't appear to be. I'm sure that at academic medical centers there are a lot more opportunities for this sort of cross pollination, and so you can get an orthopod interested in something like osteomyelitis working with the ID people on some sort of research and the like. But other than that...it looks like you'd have to be one of those odd balls who ends up switching residencies midway through or who just piles residencies on top of one another (I've heard stories of this happening where people end up having gone through a residency and fellowship only to decide that they need to complete another residency) in order to make that happen.</p>

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<p>A couple of my professors have multiple residencies and multiple fellowships. (One is Pediatrics, Neurology, and Genetics.) Was wondering how well the medicals stacked on top of the surgicals. Apparently not that well. Thanks for the reference.</p>

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<p>Brief update:</p>

<p>Applying for away rotations is a pain...a lot of meaningless paperwork to fill out and signatures to track down. I'm planning for that peds month out west and I had to get the signature of my HOME peds department education coordinator, the signature of my advisor, and the signature of my home College of Medicine program coordinator just to get permission from my school to apply for the spot. Then I had to get the program coordinator's signature again for the other University's paperwork, show a complete vaccination history, a negative PPD (and the one I had just done in January was NOT sufficiently current for them), do a HIPAA post test, and then send a non-refundable deposit, and there's still the chance that I may not get approved for the elective...</p>

<p>[/rant]</p>

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<p>So whats the process for applying for residencies if you match up?</p>