VOL. 25 NO. 1 â€˘ $5.00
The Residency Match Guide
together we build a brighter future. Our vision is an ambitious one… to end disparities, help everyone get the care they need, and make better health a reality for all.
Kaiser Permanente Residency Programs INTERNAL MEDICINE, INTERNAL MEDICINE/MPH, INTERNAL MEDICINE/PREVENTATIVE MEDICINE, OB/GYN, OTOLARYNGOLOGY, PEDIATRICS, PODIATRY, FAMILY MEDICINE, EMERGENCY MEDICINE, GLOBAL HEALTH PROGRAM, FELLOWSHIPS, CLERKSHIPS
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Michigan State University Kalamazoo Center for Medical Studies
These special friends of the Journal for Minority Medical Students have demonstrated their commitment to reach out to minority medical students by placing their recruitment messages in each quarterly issue. We salute them and encourage our readers to consider these programs as they continue their medical education.
Hofstra North Shore-LIJ School of Medicine Graduate Medical Education Programs Dedicated to Patient Care, Teaching and Research in the New York Metro Area ■
Third largest secular, non-proft health system in the United States. 16 hospitals with 10 teaching facilities. The Feinstein Institute for Medical Research is among the top six percent of research institutions receiving National Institutes of Health funding. Over 100 graduate education programs responsible for more than 1,400 residents and fellows.
State-of-the-art simulation and bioskills education center. Home to Hofstra North Shore-LIJ School of Medicine and its innovative internationally recognized curriculum. Affiliated with Albert Einstein College of Medicine, NYU School of Medicine, SUNY Downstate Medical Center, New York Medical College.
Residency Programs • Diagnostic Radiology • Emergency Medicine • Emergency Medicine/ • • • • •
Internal Medicine Family Practice Medicine General Surgery Internal Medicine Neurology Neurosurgery
• • • • • • • •
Obstetrics & Gynecology Opthalmology Orthopeadic Surgery Pathology Pediatrics Plastic Surgery Psychiatry Physical Medicine & Rehabilitation
• Radiation Oncology • Urology
Dental General Practice Dentistry Oral Maxillofacial Surgery Oral Pathology Pediatric Dental Medicine Podiatry • Podiatric Medicine & Surgery • • • •
Fellowship Programs Cardiology • Cardiothoracic Surgery
Emergency Medicine • EM/IM/Critical Care • Toxicology • Sports Medicine
Internal Medicine Cardiovascular Diseases Gastroenterology Geriatric Medicine Endocrinology Hematology/Oncology Infectious Diseases Interventional Cardiology Nephrology Palliative Care Pulmonary/Critical Care Rheumatology Sleep Medicine Neurology • Clinical Neurophysiology • Movement Disorders • Vascular Neurology • • • • • • • • • • • •
Obstetrics & Gynecology • Maternal Fetal Medicine • Female Pelvic Medicine & Reconstructive Surgery Pathology • Cytopathology • Hematology Pediatrics • Adolescent Medicine • Allergy & Immunology • Cardiology • Child Neurology • Critical Care • Developmental Behavioral • Emergency Medicine • Endocrinology • Gastroenterology • Hematology/Oncology • Infectious Disease • Neonatal/Perinatal • Rheumatology
Psychiatry • Addiction • Child & Adolescent • Geriatric • Psychosomatic Medicine Radiology • Body Imaging • Neuroradiology • Pediatric • Vascular/Interventional Urology • Endourology • Pediatric Urology • Neurourology • Urologic Oncology Surgery • Colon & Rectal • Critical Care • Laproscopy • Pediatric • Vascular
For additional information visit us at northshorelij.com or call the North Shore-LIJ Office of Academic Affairs (516) 465-3192.
THE RESIDENCY MATCH GUIDE Vol. 25, No. 1 VOL. 25 NO. 1 • $5.00
Features 27 The Match Guide Intro 28 Match 2013: Highlights from a record-setting year 30 Match 2013 Profile: Evelinda Gonzales, MD 32 Timeline and Tips for Residency Applications 35 Be Prepared: Questions You Might Encounter on the Residency Interview 37 Former Georgetown Students Give their Advice on How to Ace the Residency Interview The Residency Match Guide
on the cover: Match Day 2013! Sophia Malary of University of Rochester School of Medicine & Dentistry, holding her match letter, will be heading to the University of New Mexico for a family medicine residency. photo by J. Adam Fenster, University of Rochester
40 Match 2013 Profile: Toni Ramirez 41 Residency Director Interview: Salahuddin Kazi, MD, UT Southwestern Medical Center, Internal Medicine 43 Residency Director Interview: Michael Leitman, MD, FACS, Beth Israel Medical Center, Surgical Residency 44 Match 2013 Profile: Obinna Ndum, MD, MBA 45 Residency Director Interview: Thomas K. Swoboda, MD, MS, Louisiana State University Health Sciences Center, Emergency Medicine 47 Rocking the USMLE Step 1 by Cam Medlin, MD 49 Match 2013 Profile: Tosha Vann, MD 50 Match 2013 Profile: Sungjin Song, MD
Perspectives 8 Publisher’s Page 11 AAMC Perspective 15 AMA Perspective 19 NMA Perspective 23 SHMA Perspective 25 The Surgeon General’s Report 51 A Second Opinion, Please
PASSION: global health
family medicin e
My family medicine training gave me the skills I need to create sustainable solutions where they are needed most.
BE THE DOCTOR
you always wanted to be.
MENTORSHIP INTERNSHIP FELLOWSHIP jOURNAL FOR MINORITY MEDICAL STUDENTS PUBLISHER Bill Bowers EDITOR-in-chief Laura L. Scholes email@example.com SENIOR ACCOUNT EXECUTIVE Gail Davis Campus Rep Liaison Nisha Branch, Howard University College of Medicine ART Director Jeff Garrett CONTRIBUTING WRITER Benjamin Van Loon copy editor Robert Wilder Blue
Choose a career in Orthopaedics. Our mentoring and internship programs can help prepare you for success.
PUBLISHER’S ADVISOR Michelle Perkins, MD
For medical students aspiring to become orthopaedic surgeons, our mentoring program and summer internship program are invaluable. You’ll get the opportunity to expand your knowledge and gain practical experience that may lead to orthopaedic electives, clerkships and even resident scholarships. Visit our website today and see it all—including insight, information and inspiration from fellow surgeons who have succeeded with our programs.
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Diversity Advisory Board The AAOS extends sincere appreciation to Lilly and Zimmer for their charitable contributions in support of our programs. www.spectrumpublishers.com www.spectrumunlimited.com
While Keeping the Doctor Shortage in Mind By Bill Bowers, Publisher, Journal for Minority Medical Students
Albany Medical School
atch Day is one of the most exciting days in the life of any medical student. After years and years of blood, sweat, and tears (literally!), soon-tobe doctors discover where they will do their residencies, a decision that will have a dramatic impact on their careers. And though it’s exciting that medical schools are graduating more bright, energetic med students than ever, we’re frustrated that residency programs are being “handcuffed” by Congress, which will not lift the cap it imposed 15 years ago on federal support for residency positions. Why is this bottleneck so critical? Without residency positions, those eager doctors won’t be able to get the training they need to actually care for an aging population. The Association of American Medical Colleges (AAMC) has been warning us about this for some time. They’ve told Congress and other policymakers that by 2020, the doctor shortage is estimated to reach 91,500 physicians— about half of which are primary care
docs—right as Baby Boomers start to need more medical care. AAMC notes that there is hope on the horizon (and not a minute too soon) with “Training Tomorrow’s Doctors Today Act” (H.R. 1201), a bipartisan bill introduced by Representatives Aaron Schock (R-Ill.) and Allyson Schwartz (D-Pa.), which would increase the number of residency positions by 3,000 annually for the next five years. Over in the Senate, a trio of Democrats—Bill Nelson (D-Fla.), Charles Schumer (D-N.Y.) and Senate Majority Leader Harry Reid (D-Nev.)—have introduced their own version of the legislation, the “Resident Physician Shortage Reduction Act of 2013” (S. 577). We know our country has endured rough economic times over the past five years, but we believe that taking care of the health of our citizens is a priority that should not and cannot be “kicked down the road.” We hope that in the coming years, our country will fund these residency programs, so there will continue to be lots to smile about on Match Day.
Stony Brook University
Medical Student Programs at Harvard Medical School Boston, Massachusetts
VISITING RESEARCH INTERNSHIP PROGRAM (VRIP)
VISITING CLERKSHIP PROGRAM (VCP)
Sponsored by the Harvard Catalyst Program for Faculty Development and Diversity, VRIP is an 8-week mentored summer research program open to 1st and 2nd year U.S. medical students, particularly underrepresented minority and/or disadvantaged individuals from accredited U.S. medical schools. VRIP is designed to enrich medical studentsâ€™ interest in research and health-related careers, particularly clinical/translational research careers. VRIP offers students housing as well as a salary and transportation reimbursement for travel to and from Boston. Applicants must be U.S. Citizens or U.S. Noncitizen Nationals or Permanent Residents of U.S.
Sponsored by the Harvard Medical School Minority Faculty Development Program, VCP is open to 4th-year and last quarter 3rd-year minority medical students in good standing at U.S. accredited medical schools who wish to participate in a clerkship in any discipline at Harvard Medical School (HMS) affiliated hospitals. Housing and financial assistance towards transportation expenses to and from Boston are available. Students are assigned a faculty advisor, provided the potential to network with HMS residency training programs and have access to the medical school library, seminars and workshops. Clerkships are offered year-round. Applications must be submitted 3-6 months in advance of the desired rotation.
For more information on Harvard Catalyst programs please contact: Rachel Milliron, Project Coordinator Phone: 617-432-1892 E-mail: email@example.com Web Site: www.mfdp.med.harvard.edu/catalyst
For more information please contact: Jo Cole, Program Coordinator Phone: 617-432-4422 E-mail: firstname.lastname@example.org Web Site: www.mfdp.med.harvard.edu
Program Director: Joan Y. Reede, MD, MPH, MBA Dean for Diversity and Community Partnership Associate Professor of Medicine Harvard Medical School
Medical Students: A Career In Pediatrics Can Open Up New Doors The American Academy of Pediatrics (AAP) has a membership opportunity for medical students. The AAP offers many benefits, both general and specific to medical students, including: Affiliate membership in the Section on Medical Students, Residents and Fellowship Trainees FREE admission to the AAP National Conference & Exhibition (NCE) Discounts on all AAP products and services Pediatrics 101—a resource guide from the AAP Online Resources - An e-newsletter for medical students, - Medical Student Listserv®, - Access to the YoungPeds Network AND the new networking site YPConnection!!! And much, much more!
For information please contact us at: email@example.com or call Julie Raymond at (800) 433-9016 ext. 7137 or visit www.aap.org/ypn
Match Day Traditions Jeanette L. Calli, Careers in Medicine
s any fourth-year medical student will tell you, the third week of March is momentous. It’s Match Week, and at noon ET on Friday, March 15, 2013, this year’s crop of seniors learned where they matched. Few other occasions in medical school inspire as much anxiety, joy, tears, and anticipation as Match Day. And traditions have developed to help students enjoy and share this important event with their classmates, families, and friends. At the University of Missouri School of Medicine in Columbia, MO, the day is a family affair, including a visit from the hospital mascot, T.J., and a breakfast reception in the school atrium. Just before noon, the student programs dean enters the atrium followed by several staff, holding Match envelopes high. The dean of student programs calls the class president forward to present him or her with the first Match envelope, signaling the rest of the class to retrieve their envelopes from staff holding the alphabetically grouped envelopes around the room. The students rejoin their groups of friends and family. Excitement and cheers fill the atrium as the envelopes are opened and the students discover their residency programs. The party doesn’t stop there though. The seniors gather again in the evening to announce their match to classmates, place pins in their residency location on a large U.S. map, and hear their senior superlative—a “most likely to…” that aptly describes their personality. The University of South Florida, Morsani College of Medicine in Tampa, FL heightens the anticipation by calling students randomly to receive their Match envelopes. As the students take the stage at Skipper’s Smokehouse (the venue for the last 20 years), they deposit $1 into a money box, then open the envelope and announce their results. As a reward for enduring an agonizing wait, the student receiving his or her results
Jeanette L. Calli
last receives the collected money. Students who prefer to receive results privately but still wish to attend the ceremony can receive their results delivered personally at noon. If they decide to announce their results, the envelope is randomly mixed among the others. Noshing on fried alligator bites and alligator black bean chili, more than 400 friends, family, faculty, staff, and other students attend in person, but with Web streaming and a YouTube video, families, friends, and others unable to attend in person are thrilled to watch remotely. Eastern Virginia Medical School (EVMS) in Norfolk, VA, kicks the festivity up a few notches for its Match ceremony. In February, graduating seniors select a theme for Match Day, such as cartoon characters, singers, or movies, then decorate the auditorium where the Match ceremony is held in that theme. Initially, students simply wore masks to the ceremony, but now, it’s a huge, costumed event. In some cases, even spouses and children of fourth-year students don costumes.
Match Guide 2013 | 11
Major strength lies in the quality of our faculty, residents and students
OFFiCE FOR DiVERSiTy HOUSE STAFF AND FACUlTy AFFAiRS
Vanderbilt School of Medicine is seeking to bring the best residents, fellows and faculty from all ethnic, racial and gender groups into this great Medical Center. As we broaden our reach, you will enrich our environment and make Vanderbilt a leader in promoting people of diverse backgrounds. We invite you to visit Vanderbilt and learn more regarding our training programs or visit our website at www.mc.vanderbilt.edu/gmediversity. U.S. News & World Report listed Vanderbilt Medical Center 16th on its 2009 “Honor Roll” of hospitals, a tribute reserved for a select group of institutions labeled the “best of the best.” Vanderbilt is the third fastest growing health sciences center in the country in research funding
The Monroe Carell Jr. Children’s Hospital at Vanderbilt has been ranked No. 15 on a listing of best children’s hospitals in the U.S. by Parents magazine, the third national accolade earned by the hospital this year. Our office supports the Minority House Staff for Academic and Medical Advancement (MHAMA), an organization of Vanderbilt house staff and advisors www.mc.vanderbilt.edu/mhama. Contact us by e-mail at lashonda.m.moore@Vanderbilt.Edu firstname.lastname@example.org. or call 615-343-7958 André L. Churchwell, MD Associate Professor of Medicine (Cardiology) Associate Dean for Diversity in Graduate Medical Education and Faculty Affairs Vanderbilt University School of Medicine
AAMC perspective What’s more, many students perform prepared skits, songs, or dances as they climb on stage in random order to receive their envelope. “The event has become well-known on campus”, says Janet Winner, PhD, Director of Careers in Medicine at EVMS. “And it’s wonderful to see all the families of students participate in the agony, ecstasy, zaniness, and drama that surrounds this momentous day. Check out all the fun in this YouTube video of highlights from the EVMS event. Once all students have their moment on stage, they open their envelopes en masse at 1 p.m. “Watching the looks on students’ face as they learn their destiny is fun, but the emotional support and physical presence of the larger community are truly uplifting,” says Dr. Winner, “It feels like a lot of people participated in helping each student reach this day.” Thanks to Jennifer Rachow, Program Coordinator at the University of Missouri-School of Medicine, Danielle Schutz, MA, Director of Student Affairs at the University of South Florida Morsani College of Medicine, and Janet Winner, PhD, Director of Careers in Medicine at the Eastern Virginia Medical School for contributing to this story.
Texas Tech University
A modified version of this article originally appeared in the Winter 2012 issue of the Choices newsletter.
Match Guide 2013 | 13
Uvst f MssU surgical eidency Program
Alongside surgeons at University Hospital and Clinics, Women's and Children's Hospital, and Ellis Fischel Cancer Center, surgery residents are trained by providing the full range of surgical care for more than 68,000 people every year. They participate in approximately 13,400 procedures annually on patients ranging from the newly born to octogenarians. Residents manage the severely injured and sick at our level I trauma and tertiary referral center to performing same day procedures at our newly acquired Missouri Center for Outpatient Surgery. Our patients come from all walks of life to experience a broad range of care from our diverse staff. Join a diverse and dynamic team at the University of Missouri School of Medicine and University of Missouri Hospital and Clinics. For more information, please visit: www.medicine.missouri.edu/surgery The University of Missouri-Columbia is an Equal Opportunity/Affirmative Action employer.
Matching Efficiently and Ethically Stephanie Auditore, JD Policy Analyst, AMA Resident and Fellow Section
s you’re surely now aware, the National Resident Matching Program (NRMP) pairs freshly graduated doctors with a residency program where they’ll complete the years of training requisite to become a fully licensed physician. But the match isn’t a blind one based solely on test scores and performance reviews. Students attend interviews with prospective programs around the country, after which both the program and the resident will rank each other by preference. There is a written etiquette to these pre-match meetings. For example, while interviewers are not supposed to ask about your rank-list priorities, you are free to share this information. This means medical students must achieve a delicate balance between ethical considerations and obtaining the desired ranking by programs. The match provides the benefit of allowing medical students to interview at multiple programs, without requiring a commitment before weighing all the options. In fact, even though the two parties may express their interest in each other, expressions of commitment are strictly forbidden by the NRMP. Violating the NRMP standards can have severe consequences, including exclusion from the matching process. In reality, studies indicate a high degree of non-compliance with the standards. Despite the potential consequences, some programs and students proceed to lead each other on and make commitments contrary to their actual intentions and in opposition to the standards. Students are in an understandably tricky situation, they want to leave each program with as favorable an impression as possible while maintaining their professionalism along the way. As long as the amount of residency positions remains capped, the number of
Stephanie Auditore, JD
resident applicants will continue to exceed the available positions. This adds to the pressure students face when asked where they’ll be ranking prospective programs. Residents Jennifer Sbicca and Katherine Gordon, and program director Stefani Takahashi discuss ways of handling pressure from programs in a recent article featured in Virtual Mentor, the AMAs Journal of Ethics. Ultimately, we need more structured requirements for resident-program interactions, they write. Meanwhile, residents must “weigh the pros and cons of their communications with programs, faculty members, and their future colleagues while trying to maintain the utmost integrity.” While the NRMP promises anonymity for students reporting a program for violations, in reality that can be harder to accomplish. In the end, residents shouldn’t yield under pressure, and instead rank programs based on their true interest, Sbicca, Gordon, and Takahashi recommend. Match Guide 2013 | 15
AMA perspective Luckily, program visits are the perfect place to determine where your true interests lie. Interviews are your best opportunity to discover the information you need to properly rank the program. You will be spending a significant amount of time at these institutions over the next several years, so this isn’t a decision to be taken lightly. When visiting programs, you’ll want to find out the types of required rotations, the amount and type of elective rotations, the balance of inpatient and outpatient responsibilities, leave policies for things such as vacation and maternity/paternity leave, and other work/life issues important to you. Does the program support international opportunities or electives at sites other than the base institution? How do they support residents interested in participating in professional societies? What’s the morale among employees like? You can answer this last question by spending some time interacting with current residents in the program and obtaining their perspectives. Program visits highlight another important issue medical students can sometimes forget while bogged down perfecting their applications. No matter how
University of Michigan 16 | Match Guide 2013
outstanding a candidate is on paper, personality and communication skills can go a long way in landing the right position. Program directors list interpersonal skills as a top factor contributing to their ranking. Your visit is your opportunity to showcase your personality and why you’re a right fit for the program. The director is looking for residents who are eager to learn and with whom they would enjoy working. Remember that hospitals and medical centers work as a team, and you need to be patient and respectful to every staff member that you encounter. This includes everyone from professors and program directors to the receptionist who greets you when you first arrive. Go into the interview energetic and prepared with information about the program, ready to ask institution-specific questions. In the end, a perfect match is one that works for both parties on a personality and an educational level. Interviews are the perfect time to learn more about each other, while maintaining the professionalism necessary for the Match to function.
U C D AV I S S C H O O L O F M E D I C I N E
Visiting Clerkship Program The Visiting Clerkship Program provides support for fourth-year students from socially and economically disadvantaged backgrounds who have historically been underrepresented in medicine. This program is sponsored by the UC Davis School of Medicineâ€™s Office of Student and Resident Diversity, in collaboration with the departments of Family and Community Medicine, Internal Medicine and Pediatrics. The program is designed to: n
Expose students to both the academic medicine and community service opportunities offered through the above UC Davis Residency Programs
Allow students to care for a racially and ethnically diverse patient population from both rural and urban communities
Encourage students from diverse backgrounds to apply to the UC Davis Residency Programs
Eligible participants are: full-time, fourthyear medical students in good standing at accredited U.S. medical schools. Students remain registered at their own schools while participating in the externship at UC Davis; however, student must complete an application form through American Association of Medical Collegesâ€™ Visiting Student Application Service (VSAS): www.aamc.org/programs/vsas/start.htm. Length: Rotations are four weeks in duration and are subject to space availability. Mentoring and Networking opportunities: The students will meet Darin Latimore, assistant dean of the Office of Student and Resident Diversity. Students also will be introduced to members of the Latino Medical Student Association, the Student National Medical Association and the LGBT Students in Medicine group, if interested.
Office of Student and Resident Diversity
Acting Internship and Externships in Family and Community Medicine, Internal Medicine and Pediatrics. Visit www.ucdmc.ucdavis.edu/mdprogram/ registrar/visiting.html for more information.
Financial assistance: n
Reimburse up to $500 toward travel costs
Provide a $500 food allowance
Waive the application processing fee ($150)
Housing: The Visiting Clerkship Program provides housing for participating students at the Courtyard by Marriott, which is on the Sacramento campus of UC Davis, where the School of Medicine is located. Applications: Please submit both the VSAS application, which has a link located on this page, and a UC Davis Office of Student and Resident Diversity Visiting Clerkship Program application, which can be found in the Quick Links section on this webpage: www.
For information about the Visiting Clerkship Program, please contact email@example.com. 11-0601 (3/12)
Intercampus Medical Genetics Residency Programs Understanding the role genetics plays in both health and disease provides a path to integrating scientific discoveries into diagnosis, prevention, and treatment of many diseases, both rare and common, as well as overall improvement in the health of society.
Cedars-Sinai Medical Center
UCLA Medical Center
UCLA is widely recognized for its excellence in Pediatric training and the UCLA Intercampus Medical Genetics Training program is one of the leading Medical Genetics programs in the U.S. The goal of this five-year combined program is to train physicians who truly want a joint career in Pediatrics and Medical Genetics. Residents of our five-year combined Pediatric-Medical Genetics program receive a well-rounded, academically oriented training experience, including intensive training in all aspects of medical genetics and pediatrics. For individuals who have completed training in one of the primary residencies and are interested in Medical Genetics, the UCLA Intercampus Medical Genetics Training Program would like to invite you to apply to our two-year Medical Genetics Fellowship Program.
Harbor-UCLA Medical Center
The UCLA Intercampus Medical Genetics Training Program utilizes the clinical and research resources of its affiliated campuses and teaching hospitals, Cedars-Sinai Medical Center, UCLA Center for Health Sciences, Harbor-UCLA Medical Center and CHOC Childrenâ€™s Hospital.
We are proud of our diverse group of residents and faculty and invite you to apply our program. CHOC Childrenâ€™s Hospital
Combined Applications are accepted through the ERAS Main Residency Cycle: Pediatrics-Genetics Residency, Cedars-Sinai Medical Center/Harbor/UCLA Program
Two-Year Fellowship Applications are accepted through the ERAS July Fellowship Cycle: Cedars-Sinai Medical Center Program.
For more information please contact: firstname.lastname@example.org
NMA perspective Healthcare Reform:
A Landmark Achievement for the Future Rahn K. Bailey, MD, FAPA President National Medical Association
t was the late Reverend Martin Luther King, Jr. who in a 1966 speech to the Medical Committee for Human Rights said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” I have identified three priorities for my term as NMA President—health care reform, disparities, and stigma—and in this column, I want to focus on health care reform. What is health care reform, and why does the NMA support it? The mission of the NMA is to advance the art and science of medicine for people of African descent through education, advocacy, and health policy to promote health and wellness, eliminate health disparities, and sustain physician viability. Although the NMA has focused primarily on health issues related to African Americans and medically underserved populations, its principles, goals, initiatives, and philosophy encompass all ethnic groups. As a result, the NMA promotes health care for all Americans. Personally, as a physician who has cared for the poor and underserved for over 22 years, I believe that health care should be a right for every American irrespective of race, ethnicity, gender, age, or socioeconomic status. On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), also known as the Affordable Care Act (ACA). It is the landmark health care reform legislation of our generation. As an association, the NMA emphatically supports the Affordable Care Act. It was imperative that the government overhaul the current American health system, because what we had in place was inefficient, ineffective, and inequitable, to say the least.
Rahn K. Bailey, MD, FAPA
For example, when I started my private practice in 1997, if a patient, such as an African-American woman, walked into my office with a son, I knew there would be a one-in-five chance she wouldn’t have health insurance. Looking at her, I knew as a physician, there was a strong possibility she would be employed, but by our standards, she would be considered indigent and would have lived below the poverty line. I knew going in, that once I agreed to accept her as a patient, and if she had a major form of cancer, there would be no guarantee I could present a better outcome to her than ten years before, even though the cost of that care would have been twice more than what it was then. If she did have cancer, all I could do is hope and pray that she had gone against the trend and come in early, instead of delaying her visit due to the lack of health insurance. As a physician, I would examine her son, hoping I would not find that he had a pre-existing condition, Match Guide 2013 | 19
NMA perspective such as sickle cell anemia or asthma. If he did, I knew he would never be able to acquire health insurance. Can you imagine the pain and heartache this mother and son had to endure knowing that they had no health coverage? That mother could have been yours, your sister, aunt, cousin, best friend, niece, grandmother, etc. and that young man could have bright future, and could be a future Morehouse student. The health care system was too expensive and did not assist enough people. Something had to change. What was wrong with the old system? Here are some statistics for you to ponder: 1. 18,000 people die each year because they are uninsured. 2. One-out-of-five Black Americans have no health insurance. 3. One-out-of-three (36%) families living below the poverty line are uninsured. 4. The infant mortality rate for the U.S. is now higher than for many other industrialized countries. The rate is especially high for African Americans.
results guiding research and other benefits built in, she will get the best care possible. I know that her child will be covered even if he has a pre-existing condition. I know that the costs of their prescriptions will be lower. In a nutshell, I know that this hardworking African American woman who has made a lot of sacrifices and good choices in her life will not be victimized by our American health care system; that her good choices will translate into even greater health care for her and her child.
What are the consequences of being uninsured?
Providing basic affordable health care for all Americans is the right thing to do, because it levels the playing field and provides opportunities for all Americans to be productive citizens. In 1965, the National Medical Association supported the Medicare Law, and today we support the Affordable Care Act, because we believe in advocating for our patients. We are and will continue to be the people that stay on the right side of history, and we look forward to the day when the Affordable Care Act will fulfill its ultimate purpose to provide access to basic, affordable health care to every man, woman and child in the United States of America.
1. The uninsured are more likely to miss preventive and routine care for chronic and preventable illnesses. 2. The uninsured are the most frequently hospitalized for conditions that are potentially avoidable. 3. Communities pay a price for their uninsured residents. 4. The uninsured have more health expenses due to untreated health conditions.
What is the impact of the ACA on NMA Doctors? 1. More patients have insurance coverage. 2. Medicaid payments are approaching parity with Medicare payments, eliminating the two-tiered system, one for haves, one for have-nots. 3. Gives small business tax breaksâ€”most NMA doctors are small businesses. 4. Provides training. 5. Emphasizes prevention.
ACA: A vision of a healthier future
How the Affordable Care Act will make a difference Let us go back to the mother and child I spoke about earlier. If she came into my office today, my worries about her would be fewer because I know she has a safety net. Now, she will have health insurance, with the flexibility and control to take her insurance with her anywhere she goes. I know that she can get screened for many of the most common illnesses for free. I know that with the emphasis on outcomes, on Match Guide 2013 | 21
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Medicine and Leadership Go Hand-In-Hand By Nisha Branch, MD SNMA National President
here are some who believe that leaders are born, while others believe that leader can be made. Within the world of medicine it can be said that by virtue of being in this field, you must be or will be a leader of some sort. However, what happens when someone emerges as a leader among leaders. I had not previously thought about this concept until a similar question was posed to me on the interview trail. My work within the Student National Medical Association (SNMA) was mentioned by interviewees and interviewers alike. However, I did not see myself as anyone particularly special, noting that plenty of people have served in this position before me and certainly many more will come after me. Even within the group of SNMA national officers, many have dual roles as class presidents, chapter presidents, and officers in school-based organizations, all of whom are significant leaders in their own right. The main difference I noted, however, between students discussing my position and the faculty interviewers was that the students were amazed at the notion that I was in this position as a senior medical student. I knew going into the position of national president it would be time-consuming, demanding, and stressful. However, when you add applications, interviews, and acting internships on top of that, at times it felt like my full-time job was SNMA, and being a student became my hobby. How does one manage to juggle so many moving parts at one time. For me, it was aided by years of having had multiple jobs while being a student. While at the time, these positions seemed somewhat random (makeup artistry, bartending, IT professional, clinical research, public health), they provided invaluable time management, people, and prioritization skills, which afforded me the ability to complete both endeavors virtually unscathed.
Nisha Branch, MD
Looking back, though, I wonder: was it the combination of my experiences that brought me to this position or was there something innate I initially overlooked and perhaps it took someone else to see my potential. I do not know the answer, but I do believe that I would not have been prepared to handle the challenges without the support of the student and physician mentors Iâ€™ve encountered along the way. In medicine we know we must be(come) lifelong learners. As such, I encourage all students and premedical students to find the lessons from lifeâ€™s situations. Take the time to learn from your patients, classmates, professors, and mentors. In the past year, Iâ€™ve learned that there are so many types of leaders and leadership styles. Most of us will not end up on a national stage, but we can all find ways to be leaders in more intimate settings with colleagues and students. It is the everyday leaders who take time to teach those around them, lead by example, or, when necessary, take on additional Match Guide 2013 | 23
SNMA perspective responsibilities, and who also play pivotal roles in medicine. It will take time to learn oneâ€™s own leadership style, whether it be a micromanager, a hands-off approach, dictator or delegator. In the end, many will find that over time and given the situation, all styles may be useful in achieving the ultimate goal. What each of us must do is learn what styles we have mastered, which we need to acquire or develop, and most importantly, when and where to employ them. We will all be faced with many opportunities to lead those around us and to be led by others. The key to success is knowing when to lead and when to follow. This extends beyond the traditional hierarchy of medicine, as there may be a time when you least expect it that someone expects you to take charge.
University of Hawaii 24 | Match Guide 2013
As we look forward to celebrating SNMAâ€™s 50th anniversary, we want to also take time to celebrate the everyday leaders who helped create and sustain our organization. And we look forward to SNMA continuing to play an important role in leadership and medicine.
The Surgeon General’s
The Health Care Law Turns Two By Regina M. Benjamin, MD, MA VADM, USPHS Surgeon General Regina Benjamin
e recently celebrated the two-year anniversary of the Affordable Care Act. Since the healthcare law took effect, people all across the country have been directly benefiting from the law. And many aspects of this law aim to reduce health disparities. The healthcare law uses common sense rules to ensure that an individual’s or a family’s insurance coverage will be there for them when they need it. It also ensures that they have the freedom to choose their physician and to take charge of their own health care. The Affordable Care Act gives patients the peace of mind that, soon, they will not be denied coverage due to a pre-existing condition, and that you will not be dropped from your insurance if you get sick. This means that people with chronic diseases and pre-existing conditions will no longer be at the mercy of insurance companies. Starting in 2014, insurance companies will no longer be able to deny coverage due to a pre-existing condition or gender. This is a key aspect of the law, and especially important for women. In the past, insurance companies have denied coverage to women because they were victims of domestic violence or had a C-section. They have also charged women up to 1.5 times higher premiums than men for the
same coverage. Soon, they will no longer be able to do either. I am particularly excited about the prevention benefits of the law. Most insurance plans are now required to cover recommended preventive services without a co pay or deductible such as: • Blood pressure, diabetes, and cholesterol tests • Cancer screenings, such as mammograms and colonoscopies • Counseling for quitting smoking, losing weight, and reducing alcohol use • Routine vaccinations, such as the flu shot • Well-child visits As a family doctor, too often have I seen patients put off preventive care even if they have insurance—simply because they could not afford the co pay. Finally, starting in 2014, over 30 million uninsured Americans will gain health insurance—a historic step in prevention and in the elimination of health disparities to ensure America’s future as a healthy and fit nation. For more information Affordable Care Act, go to: Healthcare.gov.
Match Guide 2013 | 25
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University of Michigan Medical School
University of Massachusetts Medical School
The Match Issue
This year’s Match was the biggest on record, and for thousands of med students across the country, the happiest. If you’re already thinking about getting ready for next year’s Match, this issue of the Journal will act as inspiration—and information. Enjoy!
University of Nevada
University of Louisville
Match Guide 2013 | 27
Match 2013: Highlights from a record-setting year
ccording to National Resident Matching Program (NRMP) Executive Director Mona M. Signer, for the first time ever the total number of Match registrants topped 40,000, including almost 1,000 more U.S. seniors. “We attribute the rising number of U.S. students to three new medical schools graduating their first classes as well as enrollment expansions in existing medical schools,” Signer said. These individuals are among the 17,487 graduating seniors who participated in the Match. NRMP reported that in addition to students from U.S. medical schools, the 2013 Match included: • 2,677 students and graduates of osteopathic (D.O. degreegranting) schools—an increase of 317 over 2012 and up more than 600 over five years. • 5,095 U.S. citizen students/graduates from international medical schools(IMGs)—816 more than in 2012 and up more than 1,700 over five years. • 7,568 non-U.S. citizen students/graduates of international medical schools(IMGs)—740 more individuals over 2012.
Chicago Medical School 28 | Match Guide 2013
U.S. medical school seniors made up 16,390 of the 25,463 applicants who successfully matched to first-year residency positions. With a match rate that always exceeds 90 percent, they are the most successful applicants in The Match. Notable this year, however, are the results for U.S. citizen IMGs and foreign national IMGs, whose match rates increased by four and seven percentage points, respectively. The overal. match rate for applicants to first-year positions rose by one percentage point to 74.1 percent. Of the applicants who matched, 78.8 percent of U.S. seniors and 78.8 percent of independent applicants matched to one of their top three choice programs. More than half of U.S. seniors and almost half of independent applicants matched to their first choice. Applicants who did not match to a residency position tried to obtain one of the 1,041 unfilled positions, most of which are in the NRMP Supplemental Offer and Acceptance Program (SOAP). During SOAP, the NRMP makes available the locations of unfilled positions so that unmatched applicants can apply for them using the AAMC Electronic Residency Application Service® (ERAS).
The total number of positions offered in The Match was 29,171, an increase of 2,399 over last year and an all-time high Primary care is a winner After a slight dip in the 2012 Match, the number students choosing residencies in primary care specialties rose again in 2013. The number of U.S. students choosing primary care—internal medicine, family medicine, and pediatrics—rose by almost 400 over 2012. Despite rising interest in primary care among U.S. medical students, The Association of American Medical Colleges (AAMC) still forecasts a shortage of 46,100 primary doctors by 2020. The AAMC sees a shortage of 45,400 doctors from other specialties by 2020. That is unlikely to change if the cap on Medicarefunded residency slots is not lifted, according to the AAMC, the American Medical Association and others.
Specialty trends The total number of positions offered in the Match was 29,171, an increase of 2,399 over last year and an all-time high. “The significant increase in positions was due to a change in NRMP policy that requires Match participating programs to register and attempt to fill all positions in the Match,” said Signer. This year 1,000 more internal medicine positions were placed in the Match, along with 297 more in family medicine and 141 more in pediatrics. Match results can be an indicator of career interests among U.S. medical school seniors. Among the notable trends this year: • 3,135 U.S. seniors matched to internal medicine, an increase of 194 over last year. • 1,837 U.S. seniors matched to pediatrics, an increase of 105 over last year. • Family medicine matched 1,355 U.S. seniors, 33 more than last year. More than 95 percent of family medicine positions were filled. • Emergency medicine programs offered 1,744 positions, 76 more than last year, and filled all but three of them. • Anesthesiology programs offered 1,653 positions, 177 more than last year, and filled all but 62 of them. • Specialties with at least 50 positions in the Match that filled at least 80 percent of positions with U.S. seniors were dermatology, emergency medicine, medicine-pediatrics, neurological surgery, orthopedic surgery, otolaryngology, radiation oncology, general surgery, and plastic surgery.
University of California, Davis
Couples in the Match This year, The Match included 935 couples, an all-time high. Participants who enter the Match as a couple agree to have their rank order lists of preferred residency programs linked so they can try to match to programs suited to their preferences, such as within the same geographic area. This year, 868 couples matched to their residency program preferences.
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Match 2013 Profile Evelinda Gonzales, MD
Graduated: University of Arizona (MD/MPH program) Matched: Family Medicine, University of New Mexico School of Medicine, Albuquerque In her third year of medical school, Evelinda Gonzales, 28, realized that she loved working in pediatrics, obstetrics and gynecology, and adult and geriatric medicine. “And then I realized I want to be able to do all of that,” she says, “so I will go into family medicine, and from there I hope to work with underserved populations.” Beginning in childhood and continuing through her years at Nogales High School, Evelinda knew she wanted to be a doctor. Her dad was her big inspiration. Carlos Gonzales, MD, was the first in his family to go to college. He graduated from the UA College of Medicine in 1981. He practiced medicine in rural Patagonia while Evelinda was growing up, then joined the faculty of the UA Department of Family and Community Medicine. “I grew up seeing everything that he worked for and everything that he did to try and improve the lives of those around him,” Evelinda says. “I can’t deny that influenced my world view and my concept of seeing medicine as more of a calling than a job.” Evelinda initially wanted to go into a different field. “I tried to convince myself that I wanted to do something other than family medicine, but it didn’t work,” she says, with a smile. Father and daughter also both graduated from Med-Start, the UA College of Medicine’s five-week summer program for rural, minority, or economically disadvantaged high-school juniors. “It was a fantastic experience,” she says. “The classes were great, but I also got to meet other like-minded young people and made some really good friends.” Evelinda is one of only ten medical students at the UA College of Medicine–Tucson who will graduate with a dual degree (six MD/MPH, two MD/MAand two MD/PhD). In addition to her medical degree, she also earned a master’s degree in public health from the UA Mel and Enid Zuckerman College of Public Health. “During my third year of medical school, I realized that while I was learning so much about caring for individuals’ health, I could increase the impact I could have as a physician if I gained training on how to affect the health of communities as well.”
30 | Match Guide 2013
University of Washington
University of Michigan Match Guide 2013 | 31
Timeline and Tips for Residency Applications
The life of an aspiring doctor is not unlike the life of a politician: No sooner is one election won then you have to start thinking about the next one. The process of applying to residency begins early in medical school with USMLE step 1, but really starts during the clinical years as you select a field of medicine and solidify relationships with the faculty members who will recommend you. The difference between mastery of the residency application process and several months of nail-biting and worry lies largely in advance planning. Here is a guide to the timeline of residency application as well as some tips for minimizing your stress along the way. (Specific dates here are for the 2013-2014 cycle. Dates may change from year to year, but the general timeline will likely remain the same.) As soon as you know what specialty you want to go into, meet with a faculty member, dean, or the residency director of that specialty at your school—anyone who would be familiar with the specialty-specific requirements of the application process. Ask him or her who you should choose for your recommenders (people in the specialty versus people in other key specialties, recommendations from clinical attendings vs research mentors), what electives would be helpful, and what qualities you should emphasize in your application materials. Also identify someone one or two years ahead of you in the process who applied in your specialty and is willing to answer questions during the process. Older mentors are helpful, especially folks in the dean’s office who have extensive experience with the match, but people who have just gone through the process will be in touch with the most current quirks and may even have specific feedback about the programs in which you are interested. During clerkships and subinternships, identify faculty members with whom you have a good working relationship, who seem to think you are doing a good job, and who would write a strong letter of recommendation. If possible, choose five or six people, knowing that you will only use four letters. Word to the wise: sometimes that famous-but-uber-busy division chief may not have the time to craft a letter than shines. Use your judgment.
recommenders will ask for them and you want to have a reasonably polished version at the ready.
June Officially ask faculty members to recommend you. It can be helpful to meet face to face. They may ask you about your career plans, goals, and the kind of residency programs you are looking for. Don’t be afraid to answer definitively based on your current thoughts. If major things change during the application process, be sure to touch base with them so that their letters reflect the most up-to-date information. Provide them with everything they need—ERAS form, CV, personal statement, envelope or fax number where they should send the letter. It can also be helpful to establish a gentle deadline: “I am planning to submit my application on September 1st. Would it be okay for me to check back with you at the end of August to see how things are going?” Choose a date that is one or two weeks before your internal drop-dead deadline to accommodate late letters.
July 1st The MyERAS website opens and you can begin populating your application, but you can’t submit your application until September.
May of third year Begin preparing your CV and a draft of your personal statement. These do not have to be the final drafts—likely they won’t—but many
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Revise, perfect, and finalize your CV and personal statement. Check in with your recommenders at the agreed-upon time to make sure they are on track to finish your letters in time. If you asked five or six faculty members, you will be okay if one backs out at this point or doesn’t finish in time. Finish populating your ERAS application.
Interview season. Stress-reduction tip: do not check baggage containing your interview suit. This is the time for packing light enough to carry on your bag. Do not plan travel for the morning of the interview. The interviews begin early—typically 7am—so there is little margin for error or mishap. Arrive the night before.
September 1 Registration opens for the NRMP match. This registration is separate from MyERAS and is required to submit a rank list and match.
September 15 Applicants can begin submitting applications and programs can begin downloading applications through ERAS. It is a good idea to submit your application on or as soon after this date as possible, but it is better to submit a polished application several days or a week later than to submit a less-than-perfect application on the first possible date.
October 2 The MSPE (Medical School Performance Evaluation) is released to schools. Many programs wait for the MSPE to begin offering invitations. Interview invitations will begin to arrive after this date if they haven’t already. If possible, schedule your first interview with a program you are not as excited about to give yourself the opportunity to practice. Interviewing is exhausting. We recommend avoiding more than three interviews in a week and more than two interview days in a row.
Last week in January If you have identified a top choice, send a letter of intent to the program director. This should be a one-page email detailing why the program is your top choice and should contain the phrase “I will be ranking your program number one.” It is absolutely taboo to send a letter of intent to more than one program or to rank someone else first once you have sent this letter. Do not do this! Your reputation in your chosen field will suffer.
February 26 Catch lists are due. Stress-reduction tip: create and submit a rank list at least two or three days prior to the deadline, or earlier if you are planning exotic travel for around this time. You can always change your list, but if disaster strikes and your computer dies at 11pm, you get stranded with no passport in Siberia (this actually happened to someone we know!), or you get hospitalized with stress-induced hysterical blindness (this has not yet happened to someone we know), you will still be able to start residency the following fall.
March 21 Celebrate Match Day! Ivy Eyes Editing (www.ivyeyesediting.com) specializes in editing essays for medical and other students. Journal readers get a 10% discount on their services by entering code JMMSCODE!
Louisiana State University, Shreveport Match Guide 2013 | 33
University of Pennsylvania, Perelman
Washington University of St. Louis 34 | Match Guide 2013
University of Nevada
Questions you might encounter on the residency interview Questions about personal characteristics and goals • • • • • • • •
What are your strengths and weaknesses? What are your goals? What do you see yourself doing in ten years? Do you see any problems managing a professional and a personal life? What motivates you? How well do you take criticism? Give an example of a problem you solved and describe how you went about solving it. Can you handle stress without the resources you are accustomed to relying on? OR, how well do you function under pressure?
Questions about the specialty and patients • • • • • • • • • • • •
Why are you interested in this specialty? Why did you choose this specialty? If you could not do this specialty (for whatever reason), what specialty would you choose as an alternative and why? If you could not be a physician, what career would you choose? Are you interested in academic or in clinical medicine? What will be the toughest aspect of this specialty for you? What do you think is the number one issue facing our specialty today? What problems will our specialty face in the next five to ten years? What clinical experiences have you had in this specialty? List three abilities you have that will make you valuable as a resident in this specialty. Tell me about the most interesting patient you saw this year. Tell me about the patient from whom you learned the most. What would you want your patients to say about you?
Questions about the residency and residency program • • • • • • •
Why are you interested in our program? What are you looking for in a residency program? Why should we choose you? What do you think you can contribute to this program? Are you prepared for the rigors of residency? What one thing do you want conveyed to the residency committee? If you were the director of this program what would you look for in establishing the best group of first year residents?
University of Louisville Match Guide 2013 | 35
Questions about time in medical school (or even before this) • • • • • • • • •
Tell us about your research experience. What leadership roles have you held? What was your favorite course in medical school? If you could do medical school over again, what would you change? Describe the best/worst attending with whom you have ever worked. Describe a particularly satisfying or meaningful experience during your medical training. Why was it meaningful? What was the most difficult situation you encountered in medical school? With what subject or rotation did you have the most difficulty? What have you learned from your volunteer work?
Wild Card Questions • • • • •
What ethical questions will the healthcare delivery system face in the future? What is the nurse’s role and how much responsibility should a nurse be given for patient care? Have you ever faced death? How did you handle it? If you could no longer be a physician, what career would you choose? What is the greatest sacrifice you have already made to get to where you are?
From: Georgetown University School of Medicine
University of Massachusetts Medical School 36 | Match Guide 2013
Interview Insights Former Georgetown Students Give their Advice on How to Ace the Residency Interview •
Save the places that you really like for the middle to last half of your interviews; you get much better at interviewing during the process.
Know your application inside and out. It’s all fair game for questions during the interview.
Be informed about the program.
Relax. Be yourself. Always be on your best behavior as everyone is evaluating you even if they say they aren’t.
Thank everyone like they are doing something that is above and beyond.
Be confident. Speak clearly. Try not to be nervous. They are just trying to get to know you.
Think about a few anecdotes from your clinical rotations or experiences that illustrate positive characteristics about you.
Be happy and enthusiastic. Genuine interest is important.
Send thank you cards and be polite to everyone you meet at the facility on interview day.
Always have questions prepared! Sometimes your interviewer will begin with “So, do you have any questions for me?”
Don’t get lazy! You must be “on” 24/7.
Do not get drunk at dinner the night before. Do not whine on the interview day.
Be yourself; remember that you are selecting the residency as much as they are selecting you.
Ask pertinent and plentiful questions (without being overbearing or overwhelming the interviewer). Anything less may be perceived as disinterest, or at least as not doing your homework.
Remember that you are “on show” from the first email correspondence with a program coordinator regarding an interview date to the day a program’s match list is finalized.
Always have a final question for your interviewer (even if you already asked someone else).
Stay positive. Don’t tell your interviewer why you decided against another specialty, but rather why you decided for your chosen one.
Be prepared to explain all outliers, e.g. lapses in education, any grades or comments which are not your usual pattern, etc.
Have good manners; don’t check your phone during conversations, stay alert and be yourself.
Medical College of Wisconsin
Match Guide 2013 | 37
University of California, Davis
Chicago Medical School
38 | Match Guide 2013
University of Rochester
University of Arizona, Phoenix
Chicago Medical School Match Guide 2013 | 39
Match 2013 Profile Toni Ramirez, MD
Graduated: Brown University School of Medicine Matched: Family Medicine at Sutter Medical Center, Santa Rosa, CA Tony Ramirez, a native of El Paso, Texas, came to brown via the ultra-competitive Program in Liberal Medical Education, an eight-year program where applicants are admitted to both the undergraduate college and Brown’s medical school as high school seniors. It has an acceptance rate of ~4%. She received her bachelor’s degree in community health from Brown in 2008 and graduated with the MD Class of 2013 in May. During med school, Toni and some classmates created an elective course on the realities of health care delivery in the U.S., which was shaped by her upbringing in an underserved community and her own family’s lack of health insurance.
What was the most exciting thing about the Match process? I loved getting to go on interviews and explore what my opportunities were. It was really inspiring and exciting to know that I was taking the next step in my career.
What was the most challenging thing about the Match process? At the beginning, I had general nervousness about the whole process. After being a student for so long, this is one of the last opportunities for formal training you’ll have, and so it puts a lot of pressure on choosing the right program that will set you up for your whole career. Also, I was worried about all of the travel involved—it’s very expensive. But I knew that you have to make sacrifices when you’re working for the long-term, and overall, it turned out to be a wonderful experience. I’m going into a program I was really passionate about, that has a very welcoming community that shares my values in terms of medicine.
What one piece of advice would you give to someone going through the process next year? Take ownership of the process, not only in terms of looking at it as them interviewing you, but that you’re interviewing them to make sure they are meeting your goals and values. Most of all, enjoy it as much as you can!
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Residency Director Interview Salahuddin Kazi, MD, Residency Program Director, Internal Medicine UT Southwestern Medical Center, Internal Medicine Number of Applications: 2,500 Number of Residents: 70 UT Southwestern has an extremely popular and competitive internal medicine residency program, but are all 70 residency spots ‘categorical?’ We actually have 52 categorical residents, and then eight oneyear residents, who are spending a year in the internal medicine residency before moving into a different specialty. We also have ten residents for a combined internal medicine/neurology program. We are one of the more competitive programs across the country, because we’re large, we have a good reputation, and we’re the only big medical school in North Texas. We have a lot of regional interest, but we’re also attractive to schools from around the country, and we get some international medical graduates. It creates a very inclusive, diverse environment. Our community itself is very diverse, so we train people who can serve that community. Even though you’re hiring from a diverse range of candidates, what are some of the characteristics you find your matches sharing? First, out of all our applicants, we trim it down to the people who have all of the technical skills we’re looking for. We look at all of the data available to make those judgments, and then we get a group of people that we interview. By and large, the interviewees are technically equal, but through the interview, we try to choose the people who have the characteristics that make them good doctors. That means they’re compassionate and have a sense of calling for medicine. Those days are gone when all that you needed to be a good doctor was either in your brain or in your pockets. Now you need health care systems, and that means you must not only be individually exceptional, but you need to be an exceptional leader, so that you can provide care in a collaborative, interdisciplinary fashion. How are you able to determine these characteristics from the interview? We pay attention to professionalism, because the way you act and behave in your interview is reflective of whom you are. And beyond that, we are looking to see how you interact in various group settings. We have a pre-interview dinner with our residents and we have a social hour at the end of the interview season, where we have lunch with the potential residents. We’re looking at people’s personalities and their communications skills.
It’s also promising when applicants are prepared for the interview; they know something about the program, so they can ask the second-level questions, which is always refreshing. You mentioned that residents have the ability to serve a diverse population. Can you elaborate on what this looks like at UT Southwestern? We provide all of our residents with a rich clinical experience by exposing them to three hospitals with three distinct populations. We have a VA hospital, serving veterans. We have a county hospital, with a very diverse population with many previously undiagnosed patients who are coming in for the first time to seek health care. We also have a tertiary university hospital that sees to advanced, complex problems like pulmonary hypertension, advanced congestive heart failure, cystic fibrosis, and rare diseases. To this we add a highly structured curriculum with very talented faculty that then helps the students learn the most from
Match Guide 2013 | 41
their clinical situations. The majority of our residents go on to fellowships, and they get to interact with people who act as role models and guides for their future careers.
much. If you get eight or nine admissions, you might be doing too much. We’re always trying to find this middle ground, and that’s true of any residency.
What are the fellowships most of your residents often transition into? Our most popular fellowships are cardiovascular medicine, and pulmonary and critical care, followed by hematology, oncology, nephrology, and others. But there are other residents who take a year off between residency and fellowship and work as a hospitalist somewhere, partly because that’s often what they feel the most prepared to do, and it allows them to make some money and pay off some loans. A small percentage of residents go into primary care. Our hope is that more people will do this, because medicine is getting subspecialist heavy and thin on the primary care side.
What is the thing you might learn as a resident—or someone just starting to apply for residencies—that you won’t learn in medical school? Assuming you want to do internal medicine and you have a love for it, you need to be prepared to interview in at least ten locations. You need to always ask if you fit in where you’re interviewing. Most well-known residencies will provide you relatively equivalent experience, and it’s often the other factors that should determine where you want to go. Do you have family close by? Do you fit in? Is there a fellowship pathway? You should also pay attention to what patient populations most excite you. Would you like a community program, where you’re dealing with people just like you? Would you like to work with veterans? Do you like indigent care? Do you have a strong sense of service, and desire to take care of people less fortunate than you? Where you go depends on your mindset. You learn that even though we do a lot for patients, patients do a lot for us, too. They make us feel fulfilled in our mission. Go where you’ll feel fulfilled.
What are some of the major challenges of this sort of residency? Unlike an assembly line, where work comes at a steady rate, work comes at its own rate in hospitals. You might get three or four sick admissions or you might get two or three easy ones. Some efficiency and time management are required, but because we’re in charge of large health care systems, there is also always a question of what is service and what is education. We have duty hour restrictions that need to be managed, and there’s certainly a bit of a balance between learning and service and managing productivity and fatigue. If you make it so easy that you only get one or two admissions a day, you won’t learn that
—Benjamin Van Loon
Albany Medical College 42 | Match Guide 2013
Residency Director Interview Michael Leitman, MD, FACS; Chief of General Surgery and Program Director Beth Israel Medical Center, Surgical Residency Program Number of Applications: 1,400 Number of Residents: 13 When you receive an application to your program, what’s the first thing you look at? In particular, we set an emphasis on USMLE scores as the initial screen. That’s the first thing we make sure the applicant has in place: reasonable USMLE 1 scores. Beyond that, we’re looking at demonstrated commitment to surgery as expressed in good scores and grades in surgery in medical school, strong letters of recommendations, and any publications, as well. The application process can be stressful. What are things you recommend for redressing application anxieties? First, I think students should have a dialog with some of their programs of interest before the application season, just to get a sense of their level of competition. In our program, one of the things enhancing people’s chances of getting a position is if they can have at least four weeks of internship here. This allows them to get to know the program, and the program to get to know them. Students can have a dialog with the program director during that period of time just to get a sense of how likely it is that their application is going to be considered. Should any of this play into the personal statement? To some extent. What we’ve seen is that some people try to have a bold personal statement. Once in a while, you see a candidate that is competitive, but they almost knock themselves out of the running by saying things that are a little bit unusual in those statements. I think it’s a good idea for students to vet their statements with others, like faculty people. That’s a good idea. Good personal statements should generally indicate preferences, specialty, and the potential resident’s long-range goals—where they see themselves in their specialty 10 or 15 years down the line. When it comes to recommendation letters, what are you looking to have highlighted? We don’t usually see bad recommendations, but what we like to see highlighted—and we are most comfortable with—are recommendations from people that we know; either people that are local or people that have a national reputation. We see a lot of their letters, so having some familiarity gives us an opportunity to know a good letter from a less complimentary one. But, really, what we’re looking to have highlighted are admonitions of the
student’s fundamental knowledge, work ethic, and level of participation during a rotation about which the writer is commenting. And what about the interview? The interviews are really how we narrow down the field. Out of the 1,400 applications, we usually invite between 75 and 100 people to the interview, and that interview is a two-way street. It’s an opportunity for students to really see the program and get an idea of what the program is about, and also, to meet the other people in the program; to see where they came from, what their experiences are, and try to see if they’re going to have some synergy with them. The interview also gives us an opportunity to know some of the less tangible things that you don’t see on an application, such as their ability to get along with others, their sense of teamwork, and a general sense of what they’re like as people and as professionals.
Match Guide 2013 | 43
So it’s true that, in residents, you’re not only looking for people technically apt, but you’re looking for particular types of people, or attributes. In general, we want people that are team players; students that are hard working, that enjoy the science of surgery, and who are excited about a career in surgery. It’s also important they have an understanding about where the health care industry is going. It’s good for students who are at least conversant in some of the new federal initiatives and have some vision as to where they want to fit into this. Do you ever recommend students follow up after the application? We don’t base any decisions as to whether or not our applicants follow up. However, when students we like come back for a second look, or when they call, it does show some mutual interest. We might be willing to push people further up the match list because we have been able to identify that there is a mutual interest there. We want people who want us, so if people show some genuine interest after the interview process, it can be helpful. What can potential residents look forward to in your program in particular? What we offer is a very diverse and broad exposure, not only in terms of patients and socioeconomics, but also in terms of
surgery. We have a huge volume of patients and cases and are very active with new technology and applying that to surgery and surgical training. We have a well-developed simulation program and surgical robotics program, and this allows someone who trains with us to be prepared for what surgery is going to be like in practice. I also consider it my job to help our residents find their next jobs. We’ve been very active and successful in placing our graduates either in practice or into top fellowship programs around the country. What about the challenges you don’t read in a book? Residents need to understand that training is a lot more highly regulated now than it was 20 or 30 years ago. It’s a challenge getting a lot of exposure, experience, and autonomy in the context of very strict regulations, especially in New York State. Secondly, surgery is a field that requires tremendous support from patients and commitment by residents. Thirdly—though not exactly a challenge—we try to ensure that all residents publish research in peer-reviewed publications while they’re here. It’s extra work, but if you do that, we’ve learned that it helps resident applications compete with other applications and also sets them up for a career in academic surgery, if that’s what they want to do. —Benjamin Van Loon
Match 2013 Profile Obinna Ndum, MD, MBA
Graduated: Stony Brook University School of Medicine Matched: Emergency Medicine, Albert Einstein Medical Center, Philadelphia Obinna Ndum, or Obi, is from Washington, DC and is the first student to graduate with a combined MD/ MAat Stony Brook University School of Medicine. Right after graduation, Obi went on a two-month medical mission to Ghana as part of the National Medical Fellowship’s GE/NMF International Medical Scholars program. When he returns, he’ll start his Emergency Medicine residency at Albert Einstein Medical Center in Philadelphia.
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Obinna Ndum (left) and Dr. Latha Chandran, Vice Dean for Undergraduate Medical Education at Stony Brook University School of Medicine at Match Day 2013.
Residency Director Interview Thomas K. Swoboda, MD, MS, Associate Professor, Residency Program Director, Department of Emergency Medicine Louisiana State University Health Sciences Center, Emergency Medicine Number of Applications: 530 Number of Residents: 8 for emergency medicine, 2 for combined emergency/family medicine LSUHSC offers two types of residencies. What’s special about the combined residency? The combined program of emergency medicine and family medicine is really for someone who wants to work in a rural environment, like a small town. The resident might be interested in being a family physician in that community. But, the combined residency is also good for someone who has an interest in making sure that if there’s a small hospital in their selected town, that its emergency department runs efficiently. The main theme seems to be emergency medicine. You really need to try to know everything you can about the specialty you’re getting into if you’re going to make a commitment to that specialty. One of the things we look for in applicants is a sign that the applicant has spent some time either on rotations in emergency medicine or has mentorship with someone like an emergency physician. There are also groups like the American College of Emergency Physicians, of which the Emergency Medicine Resident Association affiliation has a medical student component. That just gives us a sense that the applicant is taking the time to figure out their specialty. How important are academic scores in this context? Beyond experience, we look at everything else the applicant has, like academic and board scores. Board scores are important because they’re what all applicants have in common. It’s hard to judge people’s transcripts and dean’s letters from different institutions, but board scores are good because everyone takes the same test and the scores are scaled relatively to each other. We can look at these and make sound judgments. But letters of recommendation are also important—maybe just as important. We like to see letters from places that already train residents in emergency medicine because that way, when people are evaluating you as a student, they’re evaluating you as a potential resident. So you’d say you’re also looking for someone with a particular character? Emergency medicine is not a very picky specialty. That is, you don’t necessarily need to do research or be active socially or in the community, but we still like to see people who are more
active. If you’re doing some volunteer work, that’s good. Same with research. If you’re in a lot of leadership activities in medical school, that’s good, too. We want to see people who don’t just show up, do their work, and leave. We want to see a track record of people who try to leave a mark on where they’re working and the communities in which they live. We want to see something more in your life. Would you say your residency program helps complement or develop these ‘immaterial’ attributes? In our residency, there is plenty of room for residents to be involved within leadership and advocacy, within our institution, as well as regionally and nationally. We support that, and we also have people who are interested in research, and we facilitate those interests. We have a lot of different academic niches within emergency medicine—emergency medical services, operations within the emergency department, education within the emergency department—and those are the areas residents can get involved. All residents are also required to do a scholarly activity while in residency, and this ends up being a natural fit for a lot of people. It’s partly how we make residents use the fact that they’ve been active in the past and now that they’re in residency, they’re going to need to follow their initiative. There is mentorship and leadership around you, but you need to be willing to start the projects and see them through to finish.
Match Guide 2013 | 45
We like seeing that sort of activity and that sort of mindset in an applicant before we take them. You’ve mentioned that the number of applications you get every year is increasing. This means more competition, which means more anxiety. What do you recommend for redressing that anxiety. I think anxiety has to do with the unknown, in terms of where you’re eventually going to end up. There is more anxiety induced when students perhaps attempt to secure a residency that their academic record doesn’t really qualify them for. For example, if a student just got by in medical school, and did okay on the boards, and was trying to get into a surgical subspecialty, like neurosurgery, he or she will probably have more anxiety knowing that the majority of the applicants are going to have better academic records. But, even if you’ve done well academically and had lots of interviews, and you feel good that you might have some matches, there’s still anxiety because you’re not sure where you’re going to end up. What you need to do is be honest with yourself. So you might say honesty might qualify as a type of ‘immaterial’ attribute? When it comes to the interview, I think the most important thing for applicants is to be honest at all times. If you end up being my resident, I need to be able to trust what you tell me. That trust begins during the interview process. In the interview, you
Meharry Medical College
46 | Match Guide 2013
might get tough questions, and the answers need to be honest. You should take your time answering those tough questions. Applicants sometimes feel like they need to answer right away, but I prefer to see applicants think about their answers before they give them, because that means they’re being thoughtful and concerned about what they say. How does all of this translate to the experience of serving your first day as a resident? In general, when they start, most residents have never been in a position where they’re responsible for patient care directly. When residents start here, it’s a big change. It’s scary. I think a lot of new residents feel they shouldn’t be scared, but it’s clear they’re nervous. When I get my new residents together, we acknowledge that as being normal for everyone. My main advice is, simply: if you don’t know something, ask. When you’re just starting out, it’s better for everyone to assume that you have something to learn from this point onwards. —Benjamin Van Loon
Rocking the USMLE Step 1 by Cam Medlin, MD As everyone knows, doing well on the USMLE board exams is very important. I was fortunate enough get scores well into the 99 two digits for Step 1, 2, and 3. I wanted to share some of the things I learned along the way, including some tips that may help you increase your score.
A bit of background When I started medical school, I did not do very well at first (I actually failed my first test!) because I did not have a clue how to study and was not that good at standardized tests. But as medical school progressed, I learned the methods I will share here, and by the end of the first two years was doing very well. Fast forward two more years to the end of medical school, and I was very competitive; I ended up matching at the residency of my choice.
University of Hawaii
Here’s my USMLE Step 1 Prep Guide Preparing for USMLE Step 1 is daunting. You want to rock it because it’s the one of the most important tests you will ever take and it will determine what type of residency you will be able to get into. With the correct preparation, you can do well on Step 1. You should give yourself about four weeks of very intense preparation time. Any shorter will probably not be enough and too much longer may cause you to burn out. Set up a reasonable study schedule before you start and try to stick to it (see example later in this article).
Read a review book. Most people use First Aid for the USMLE Step 1, and I did as well. It is not bad for reviewing much of the high-yield material, but do NOT use this as your only resource. It has many mistakes in every edition, so make sure to also find the First Aid errata web page. I am not sure how much it really helped me on the exam, but I would do it again just to be safe. Supplement your First Aid reading with other, topic-specific review books when you don’t completely understand the concepts in First Aid.
Do practice tests. The most important thing you can do to prepare for Step 1 is to take practice tests. Why? Retrieval significantly improves memory. The more you are tested (i.e., the more questions you answer) the better your memory will be of those subjects tested. My personal experience supports this as I remember the explanations of questions I have done far better than any other kind of studying.
Enroll in an online program I used USMLE World (www.usmleworld.com) and tried a friend’s Kaplan Q-bank (www.kaptest.com/Medical-Licensing/ Step1-sl-gbank.html), and I can say without a doubt USMLE World is much better. It is more difficult than Kaplan, so you end up learning more from all the questions you missed, and the format of the questions is more like the real thing.
Use the USMLE website Go to the USMLE website and download their tutorial and practice questions so you can get an idea of what the test format will be like.
A couple of days before the exam— relax One to two days prior to the exam you should not do any studying. Just relax, do something that you enjoy, and rest your mind.
“The most important part of preparing for Step 1 is learning as much as possible and doing well in the first two years of medical school.”
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USMLE 4-WEEK STUDY SCHEDULE Here is an example of a four-week study schedule for USMLE Step 1 using First Aid and USMLE World Step 1 Q-bank. Notice that the primary focus in this example is doing practice questions, as they are the most effective study tool. The reading material is less important and you will be moving very quickly through First Aid. This is assuming that all the First Aid content is a review for you—hopefully you already learned everything that is in First Aid during the first two years of medical school. However, if you did not do well in your first two years of medical school, especially in pathology and physiology, you may need to spend some extra time in First Aid and the review books.
Weeks 1 & 2
Monday through Thursday
• • •
Read approximately 50 pages of First Aid per day. Supplement your First Aid reading with review books if you feel weak in certain areas or do not understand concepts as they are presented in First Aid. Do about 50 Q-bank questions per day, making sure to completely review the explanations of missed questions.
Do a full-length practice test on USMLE World. Do seven timed 60-minute blocks of 46 questions with one hour of break time.
• • •
Monday through Thursday
• • •
Monday through Thursday
Washington University of St. Louis 48 | Match Guide 2013
If you haven’t already, finish First Aid early in the week. Do about 100+ Q-bank questions per day in order to finish all the questions this week, making sure to completely review the explanations of missed questions. Study any problem areas using First Aid, review books, or online.
Rest and relax.
Rest and relax.
Review missed questions from Friday’s practice test.
Review missed questions from Friday’s practice test.
Do full-length practice test on USMLE World. Do seven timed 60-minute blocks of 46 questions with 1 hour of break time.
Read approximately 50+ pages of First Aid per day and try to finish it this week. Supplement your First Aid reading with review books if you feel weak in certain areas or do not understand concepts as they are presented in First Aid. Do about 50-75 Q-bank questions per day, making sure to completely review the explanations of missed questions.
Rest and relax.
Take the USMLE Step 1 Exam!
Dr. Medlin pursued a radiology residency. You can find more of his thoughts on the USMLE at usmlegunner.blogspot.com.
Match 2013 Profile Tosha Vann, MD
Graduated: University of Cincinnati School of Medicine Matched: Pediatrics, Case Western/ MetroHealth Medical Center, Cleveland What was the most exciting thing about the Match process? Match Day! It’s hard to describe how nervewracking the process was, even to friends and family.
What was the most challenging thing about the Match process? The most challenging thing was managing the work load of school and rotations and still having to do all of the application process, prepare for interviews and then travel to see programs. And I only chose to rank five programs because I knew I wanted to stay close to family.
What one piece of advice would you give to someone going through the process next year? My story is a bit different in that I had taken time off after college to work, and I had a family. I knew I wanted to be a doctor, but I wasn’t a premed, I didn’t have an advisor. So I was at my job Googling the med school application process; I joke that I Googled my way into medical school. Anyway, the thing I wish I had known at the start of med school is how important it is to have a good mentor. I didn’t have one, and by the time I realized I needed one, it was too late; I was already overwhelmed. Now that I’m going into residency, finding a good mentor is going to be very high on my priority list.
Tell us about your choice to do a pediatrics residency. I did pediatrics on my third rotation, and after that, I found myself comparing every other rotation to it. How happy or sad was I was to go in? How irritated was I? For example, family medicine made me happy only when there were lots of kids on the schedule. I realized I just didn’t like anything else quite as much.
Match Guide 2013 | 49
Match 2013 Profile Sungjin Song, MD
Graduated: Oregon Health & Science University Matched: Otolaryngology/Head & Neck Surgery at Tripler Army Medical Center, Honolulu, HI. Why did you decide to become a physician? I have always believed in the importance of service, community, and overall health and wanted to help others around me reach the same level of well-being that I have been blessed with my entire life. However, it wasn’t until a two-month volunteering operation in rural Gambia when my personal experiences with doctors, nurses, and patients affirmed my ambitions to pursue medicine.
Can you talk about the type of community service you have done? I chose to attend the United States Military Academy at West Point and while there, I volunteered with the Special Olympics and various community organizations. I am currently involved with Big Brothers Big Sisters Columbia Northwest and enjoy being a mentor/friend to my Little Brother, William. Its been a privilege to be able to spend time with him every week on our outings, such as playing soccer, eating Korean food, and going to Blazers games.
Were there any unique challenges to you as a member of the armed services that other students might not have encountered during medical school? There aren’t many differences during medical school between a student who is a member of the armed services (I’m in the Army) and a civilian, because the main purpose for medical students is to be fully present in their education and be ready to be the best physician, to serve America’s best. However, there is a officer basic course to help transition medical students who have not had any exposure to military customs and courtesies in the summer between their first and second years of medical school when their civilian colleagues have that time off.
What attracted you to/why do you want to get into Otolaryngology/Head & Neck Surgery? Pursuing otolaryngology stems from my love of vocal music. ENTs can preserve and restore voice-in patients who have lost their voice due to cancer. After witnessing the rewarding feeling of helping give a patient a second chance at life and giving her a voice, I realized that I needed to pursue otolaryngology. I wanted to pursue my goal of giving others a voice and restoring their life’s music.
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It’s hard to predict, but where do you see yourself down the road? I initially pursued medicine to serve those who serve, so I plan to practice as an Army physician throughout my career. I also plan on sharing my experience and passion through teaching others and being involved in my community. As an aside, I also have a passion for traveling and food, so I hope to open a restaurant someday.
A SECOND OPINION, PLEASE
The Case of the Cool Custodian By John Dunn, MD
Anthony: Man, that is one cool custodian! And I don’t mean the kind that lets you smoke in the dugout! Yvonne: I guess you should know, Anthony. Isn’t that what stunted your growth? Anthony: Hey! That’s enough with the little-guy jokes, all right? Yvonne: Who was talking about physical growth? Anthony: What do you mean? What other kind of growth is there? Yvonne: Your Honor, I rest my case.
Yvonne: Like learning something. Heard of it?
Maria: Why thank you, Yvonne! I didn’t know you honored me so!
Anthony: Yes…yes, it sounds familiar…it’s all very foggy, though.
Yvonne: Oh definitely, Sister. We have to band together to protect our end of the gene pool from certain types (gestures towards Anthony) taking a sh-(Holmes enters)-uh, a shower, in it… Holmes: A shower? Are you referring to the meteorological kind or the metaphorical variety? Anthony: Huh? Yvonne: Uhm, well, we were having a shower, Doctor Holmes, to, uh, celebrate, Maria’s…engagement. Maria: What?!? Anthony: What?!? Holmes: I beg your pardon? Maria? Maria: Yvonne? Yvonne: Well, I mean, no, she’s not engaged now. I just meant, we were, uh, planning the shower for when she does get engaged. Right, Maria? Sister? Sister Maria? Maria: Uh, right… Right! You never can be too prepared, isn’t that what you’ve always said, Doctor Holmes? Holmes: True. True, indeed. Preparation is the stone that makes the foundation possible. Without a foundation, where would we be?
Yvonne: Ain’t that the truth. So I didn’t hear anything about this at all, Maria. What’s the scoop? Maria: AY is a forty-five year old school custodian who came to the ED by ambulance in a hypothermic, unresponsive state early this morning. Anthony: Like North Dakota? Maria (ignoring him): He’d apparently been out lining soccer fields yesterday evening, and for some reason must have become incapacitated, and was found this morning by one of the teachers. According to his wife he had complained of some fatigue recently, and general malaise, but nothing specific. As far as she knew he had had no fevers or other symptoms of infection, no significant weight change, no unusual pains, cardiopulmonary, GI, GU, neurologic or other symptoms. His past medical history was significant for hypertension, type II diabetes, hyperlipidemia, bipolar disorder, and osteoarthritis of the knees. He takes metoprolol, metformin, simvastatin, risperidone, and celecoxib. He is married, with two high schoolaged children and, per his wife, doesn’t smoke and only drinks an occasional beer on a weekend. Yvonne: So, you said he was unresponsive?
Anthony: Uh, meeting outside?
Maria: Yes, the teacher called 911 right away, and when the ambulance arrived they found him lying on his side in a fetal position. He withdrew slightly to painful stimuli but did not open his eyes or make any intelligible sounds.
Holmes: Indeed, Anthony, and speaking of outside, I understand that is where Maria’s patient was found.
Yvonne: Wait a minute, Maria. Are you sure this wasn’t Anthony?
Maria: That’s right, Doctor Holmes! How did you know?
Maria: No, I said he wasn’t making any “intelligible” sounds, not “intelligent.”
Holmes: Ah, we sleuths have our ways. Please regale us with the story of your, how shall I say, “congeal’d custodian?”
Yvonne: Ah, right. Go on. But sometimes he doesn’t make either.
Maria: Yes, I guess you could say that, all right. We’ve just about got him thawed out now, though, and I hope he can give us some answers.
Maria: His respirations were 8 and steady, his pulse was 96, and his blood pressure was 90/60. In the hospital his rectal temperature was 30 degrees centigrade.
Holmes: Indeed, and I will suggest we go visit your gentleman, after he gains a few more degrees, and you add a few measures to yours.
Anthony: Wow! That’s below freezing!
Anthony: Measure what?
Yvonne: Anthony. Centigrade. Thirty degrees centigrade!
Maria: I think he means a few more measures to our medical degrees. Match Guide 2013 | 51
A SECOND OPINION, PLEASE Holmes: Well, this is certainly a curious case, Maria. Let’s talk a bit about human thermoregulation first. As you know, our bodies produce heat, a process known as thermogenesis, by two basic mechanisms. The first is our basic physiologic processes, such as digestion of food, respiration, and so on. The other major source of heat production is by muscular action, which can be in the course of normal physical activities or, when the core temperature drops a degree or two, by shivering. Both physical exercise and shivering are capable of producing a tremendous amount of heat. The maintenance of a normal body temperature requires a careful balance between heat produced and heat lost, and our hypothalamus acts as a thermostat. Hypothermia develops when the amount of heat lost exceeds the amount of heat produced, and the normal regulatory mechanisms are unable to rectify the situation. Maria: I guess I never thought about it that much, Doctor Holmes. Maria: The crew found no signs of trauma and no evidence of drug or alcohol abuse at the site. They put on a cervical collar as a precaution, placed him on a backboard, covered him with blankets and transported him to the ED. Holmes: And do you know how cold it was outside last night, Maria? Maria: Not very. About 6o degrees, I think. Yvonne: That’s Fahrenheit, Anthony. Anthony: Hah, hah, hah… Holmes: And was he wet when they found him? Maria: No, apparently not. I saw his clothes in the ED, and they looked perfectly dry. And there were several layers, so I don’t know how he could have gotten so cold. Holmes: Fascinating! One would certainly not expect a reasonably healthy, well-dressed, middle-aged man to become profoundly hypothermic while lining a field on a sixty-degree evening, would one? Anthony: No, I don’t think one would. (pause) As a matter of fact, I don’t even think two would. (pause) Or three… Yvonne: (aside) Don’t worry, Maria. He’ll stop soon. Maria: Oh? How do you know? Yvonne: That’s as high as he can count. Holmes: Ahem! That’s all very well, ladies. What did you find on exam, Maria? Maria: A very lethargic but responsive 45-year old man, with somewhat better vitals than found in the field. His heart rate had risen to 104, his blood pressure was 100/64, respirations 10 and temperature was up to 32 Celsius. His skin was clammy and cold, of course. His pupils were dilated and sluggish and the rest of his HEENT exam was normal. Breath sounds were distant, as were heart tones, and he was bradycardic as noted. His abdomen was soft and non-tender, with no masses or organomegaly. His extremities were cold and pale, with diminished pulses. Deep tendon reflexes were absent and motor response was sluggish.
Holmes: Well, when things are going well, there’s no need to. The body adjusts itself perfectly. Most of us, when we think of hypothermia, think of extreme environmental situations of severe cold, but actually, anything that either impairs the body’s ability to produce heat, that accelerates heat loss, or that throws off the thermostat, can produce hypothermia. Other than severe environmental exposure, who can think of other common ways in which patients become hypothermic? Yvonne: Well, we think of elderly people alone in their apartments in winter. Holmes: Indeed, Yvonne, and is this because their apartments are brutally cold? Yvonne: No, I don’t think so. Maybe somewhat cold, but I always thought it was because they weren’t moving too much, and maybe didn’t have such good nutrition. Holmes: Excellent! Indeed these are major factors, but there are others to consider. What else might affect an elderly person’s ability to either produce heat or retain it? Anthony: Chronic diseases? Holmes: Very good, Anthony. Such as? Anthony: Well, neurological ones that make it hard for them to move. Holmes: Exactly! Strokes, Parkinson’s Disease, multiple sclerosis and so on can all afflict the elderly and decrease their heat production. What common metabolic conditions cause hypothermia? Yvonne: Uh, hypothyroidism? Holmes: Very good. Hypoadenalism and hypopituitarism can do it as well. There are two medical conditions that commonly cause hypothermia and altered mental status. The first is hypothyroidism, and the other, even more common. Maria: Hypoglycemia! Holmes: Indeed, Maria! You will frequently note hypothermia in your diabetic patients who arrive in the emergency department with hypoglycemic emergencies. What was your patient’s glucose level, Maria?
Holmes: Yvonne! That will suffice, please.
Maria: It was about 80; not that unusual for someone who hadn’t eaten all night. The rest of his labs were OK, too, his CBC, chemistries and thyroid function. His EKG showed a normal sinus rhythm with a broad, biphasic QRS.
Yvonne: Sorry, Doctor Holmes.
Holmes: Ah, yes! My good friend Mister Osborne!
Yvonne: Huh! Once again I ask, has anyone checked Anthony’s temperature? Of course, they may not make a big enough rect-
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A SECOND OPINION, PLEASE Anthony: Huh? Holmes: John J. Osborne was a physiologist who definitively described the somewhat broad, positive deflections following the QRS in people suffering from hypothermia or, in some cases, hypercalcemia, brain injury or cardiac ischemia. In addition to “Osborne waves,” they are also sometimes referred to as J waves, late delta waves or camel’s hump waves. Yvonne: It seems like a lot of our hypothermic patients are alcoholic, aren’t they? Holmes: Yes, both drugs and alcohol can be significant risk factors. Not only do they decrease movement and behavioral adaptations to cold but alcohol, in particular, being a potent vasodilator, accelerates heat loss from the skin and extremities.
Holmes: Possibly not. This is certainly a challenging case from the standpoint of figuring out the cause of your patient’s hypothermia, Maria. In fact, I had just about decided there were no clues at all, when I noted there was one finding that did not quite fit with the others. I believe this one unexpected finding may be the key to our mystery. Yvonne: It figures! Holmes: Let’s go visit Maria’s gentleman and see if he is sufficiently warm to converse. On the way, I believe if you review his vital signs carefully, you will discover one that does not quite fit with the others and that, coupled with his past medical history may be the keys that unlock the mystery of our congeal’d custodian.
Yvonne: So what about Maria’s custodian? It doesn’t sound like he was drunk, or had any of those medical or neurological diseases we talked about.
A SECOND OPINION, THE ANSWER
Maria: Doctor Holmes, how on Earth did you figure that out? Holmes: Well, Maria, we in western medicine often overlook the importance of our patient’s vital signs. As you know, many eastern practitioners of medicine place great importance in the assessment of their patients’ pulses, and indeed they are probably right. The most common cardiac arrythmia in a hypothermic patient is what?
used in a person with a normal temperature will not work in a hypothermia victim, due to stasis of blood in the extremities and decreased metabolism. A hypothermic heart is very susceptible to arrythmias, and even the slightest physical disturbance can provoke them, which is why hypothermia victims must be handled extremely carefully. Yvonne: Yeah, well, we’re pretty good about that.
Maria: Heart block?
Holmes: Handling people carefully?
Holmes: Yes, that can occur, but even before that?
Yvonne: Yeah, we have to be real careful how we handle Anthony, you know. Speak slowly, simple words, that kind of thing.
Anthony: Bradycardia? Holmes: Excellent, Anthony! Yvonne: He rises from the den of mental hibernation! Holmes: Hypothermic individuals are almost always bradycardic. Maria’s patient, however, was tachycardic, with a rate of 104. So I began to think of things that might make him tachycardic despite his hypothermia. Sepsis, of course, could do both, but there was nothing in the history to suggest that. Then I began to review his medications. Of the five he was taking, three can contribute to hypothermia: metoprolol, risperidone and celecoxib. Your patient, Maria, was taking a virtual “hypothermia cocktail,” and yet, of all his medications only one, risperidone, causes tachycardia in overdose. From there it was a simple matter of confirming that he’d been confused as to the dose he was supposed to be taking, counting the pills left in his bottles, et voila! Maria: Wow… I guess so. Yvonne: So how did you warm him up? Maria: They told us in the ED that is was important to warm up his core first, so they used warmed iv fluids and a warming jacket with warm water in tubes wrapped all around his chest. Holmes: That’s a good point, Maria. When someone has been hypothermic for a period of time, cold, acidic blood will pool in his extremities. If you just throw him in a hot tub, the blood vessels in his extremities will dilate, dumping that cold, acidic blood into the central circulation, which can provoke a fatal arrythmia. It is also important to note that many medications that would be
54 | Match Guide 2013
Holmes: I see. And how do you feel about this, Anthony? Anthony: It’s OK. Simple words are all she’s got. See you! (He races out of the room) Yvonne: (In hot pursuit) Why you little...!
BRIGHAM & WOMEN’S HOSPITAL
CINCINNATI CHILDREN’S HOSPITAL MEDICAL CENTER Cincinnati, OH
The Internal Medicine program at vham & Women’s Hospital is a national leader in clinical training and research. As a major academic center, we are at the forefront of medical research and innovative curricular development. We draw patients from a large international referral base as well as our large local diverse population, and we are one of the largest providers of free medical care in the state of Massachusetts. Our vision is to promote health care and health equality throughout the region, and we are dedicated to recruiting, training and retaining a housestaff and faculty that reflect the diversity of our patient population. We will be accepting applicants to our categorical medicine, primary care medicine, combined medicine/pediatrics and preliminary medicine programs. Key Hospital Information: Number of beds: 777 Inpatient Admissions: Over 45,600/annually Ambulatory Visits: 773,000/annually Emergency Department Visits: Approximately 58,000/annually Contact: Nora Y. Osman, MD Assistant Program Director Office of Minority Affairs firstname.lastname@example.org (617) 732-5775 www.brighamandwomens.org/residency
Want to get your residency noticed by the nation’s best and brightest? Contact: Gail Davis Account Executive Gail Davis email@example.com
Cincinnati Children’s is a national leader in pediatrics. As a major academic pediatric medical center, we attract patients from all over the world, conduct pioneering medical research and offer outstanding teaching programs. We work closely with community based caregivers. Our vision is to be the leader in improving child health andv in preparing tomorrow’s pediatricians. We are proud to be ranked third in National Institutes of Health funding to children’s hospitals and pediatric departments nationwide. In addition, US News and World Report consistently ranks Cincinnati Children’s Department of Pediatrics as one of the top three departments in the country. Running the Numbers Number of beds: 475 Annual admissions, including short stays: 27,392 Radiologic procedures: 150,000+ Outpatient visits (includes satellites): 790,949 Emergency department visits: 93,456 Surgical procedures (inpatient and outpatient): 29,168 Critical care admissions (cardiac, ICU, NICU): 3,287 Interactive Team Care Each ward team is made up of four PL-1’s, with primary responsibility for patients on their ward and two PL-2 or PL-3 supervisors. Each team also includes a faculty member who makes rounds and plays an integral role in teaching. The teams cover wards that admit primary pediatric and subspecialty patients of all ages. Please contact us or visit our website: Pediatric Residency Training Program Cincinnati v Medical Center 3333 Burnet Avenue, ML 5018 Cincinnati, Ohio 45229 (513) 636-4315 www.cincinnatichildrens.org
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A dvertiser ’ s I nde x
American Academy of Family Physicians.................4 American Academy of Orthopaedic Surgeons..........5 American Academy of Pediatrics..........................10 Cincinnati Children’s Hospital..............................14 Harvard Medical School.......................................9 Kaiser Permanente...........................................CV2 Michigan State University Kalamazoo...................10 North Shore Long Island Jewish Health System.........2 PASS Program....................................................26
U.S. Army.......................................................CV3 U.S. Navy.......................................................CV4 University of Alabama at Birmingham...................56 University of California, Davis..............................17 UCLA Medical Genetics Residency Programs..........18 University of Missouri, Surgical Residency Program.................................14 Vanderbilt University...........................................12 Western Connecticut Health Network....................20
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PEDIATRICS Cincinnati Children’s Hospital Medical Center...55
internal medicine Brigham & Women’s Hospital..........................55
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Make The Commitment To Medical School, And We’ll Make The Commitment To You. The University of Alabama School of Medicine offers you more than a world-renowned medical curriculum. We also provide you with opportunities to succeed. Our Office of Diversity and Multicultural Affairs was created specifically to assist students like you to make the most of your education and enjoy all of the advantages of medical school. Phone us at 1-800-707-3579, ex. 6 and find out more about our: • •
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Combined M.D., Ph.D. and M.D., M.P.H. degrees and the Early Decision Plan Newly sponsored programs through HCOP º The Summer Health Enrichment Program (SHEP) for undergraduate students º The Summit Scholars Program for high school and middle school students º Pre-matriculation program for entering medical school students º Post-baccalaureate program on the campus of the University of Alabama in Tuscaloosa Financial assistance and scholarships Assistance in securing research and clinical opportunities Counseling and support for academic and personal concerns Liaison activities among the School of Medicine’s, diverse students and medical organizations
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Visit our website: https://www.uab.edu/medicine/home UAB is an equal education opportunity institution
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