Creating a NRMP Rank Order List is as difficult as online shopping

It's that time of the year - you have completed your residency interviews, celebrated the completion of a major milestone that you have no intentions of revisiting and now are gearing up to create the ultimate Rank Order List (ROL) that will determine where you spend the next 3-5 years of your professional career in graduate medical education.

So why is it so difficult? Why does it sound so complicated? Why do medical graduates get anxiety attacks just by thinking abou the ROL? Why do medical graduates dread creaing the ROL, knowing fully well that it's important to think through all the options?

Let's understand why this is. Just try shopping on Amazon for 'android phone' and you get millions of options. And what is the most common response then? You close the website hoping to revisit it in the future. How do you then narrow down to choosing that one phone? This is called 'analysis paralysis'.

You see, it's because there are so very many possibilities, no one has a way to know what is the right ROL that is perfect for YOU. The stress of missing out on the right one is just too much for some to bear. Remember iPhones? Apple has kept it product line to 2-3 models and is much simpler to choose from and buy.

Still don't believe me? Let's look at an example.

Let's assume there are 3 internal medicine programs that you interviewed at and are trying to rank:
Emory University, Atlanta GA
University of Connecticut, Hartford CT
William Beaumont Hospital, Royal Oak MI

Now before we proceed to rank these programs, let me tell you that what I am going to discuss next are purely my opinions and are in no way trying to tell you which program is better or worse and that you need to use your sound judgment and research when creating your ROL.

Now if you have 3 programs, mathematically there are 6 possible ROL's. Which applicant opts for which ROL depends entirely on 'What's important for him/her'.

For an applicant, if the allure of fellowship opportunities or name/Prestige of the hospital is important [ie the name of the hospital should contain "University"], then that applicant is likely to rank Emory University as 1st, University of Connecticut the 2nd and William Beaumont Hospital as 3rd.

If the applicant is an international medical graduate seeking an H1 B visa, think that applicants rank order list is likely to be Emory 1st, Beaumont 2nd and University of Connecticut 3rd.

If the applicant likes variety and exposure to different hospitals with different healthcare systems and EMR and patient population then that applicants rank order list is likely to be UConn first, Emory second and Beaumont third.

If the applicant has family in the Northeast or lumps no then that applicant would prefer programs in northern part of US and the rank order list would then be likely UConn first, Beaumont second and Emory third [no snow in Atlanta].

If the applicant prefers small class size and collegial LAT from interactions between the residents and attendings and does not want to be in a big city with high cost of living or deal with traffic then that applicants rank order list is likely to be Beaumont first, UConn second and Emory third.

Lastly if the applicant is a cardiology freak and wants to work in the best interventional cardiology centers with liters and cardiology and has an eye for participating in ground breaking cardiology research trials, and that applicants rank order list is likely to be Beaumont first, Emory second and UConn third.

So the bottom line of this exercise is that a ROL is very personal and no one but YOU alone can create and justify your very own ROL. - Dr Ed.

What are the criteria or tools that can help me rank the programs? I will be discussing this in my next post. Subscribe to this blog at www.ed4medus.com to stay updated on latest information and posts by me.  Also, check out my Facebook group Facebook.com/groups/Ed4medUS/to interact with other applicants like you, post questions, obtain answers and share your knowledge wealth.

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'Report card' for you to fill out at the end of every residency interview.

Here's my take on how an applicant can create a 'report card' at the end of every residency interview. This very much helps you organize all the facts and information about each program especially creating a rank order list.

"Now that you have seen our program, how do YOU think the program can become better?"

 

As your interview is coming to an end, the interviewer throws THIS question at you.

"Now that you have seen our program, how do YOU think the program can become better?"

That's right, the interviewer is asking you, dear applicant, to use your critical thinking skills, identify the shortcomings in the program and offer suggestions. 

But remember you need to be careful in your recommendations and not insult the program or the hospital.

How do you handle this tricky question? Your responses now.

Here are 4 possible answers. These examples are just to get you thinking and you would need to customize these answers to the specific program where you are interviewing.

In general, I would suggest that these improvements be directed only for educational purposes.  That is, do not tell that the program would do better if the hospital had the ability for LVAD or TAVR.  Small community hospitals will not be able to provide that level of care and are very likely to transfer patients needing intense treatment to a larger referral center.

 

1. Simulation center (or simulation lab).  Many university hospitals have a simulation lab for medical students and residents to try out a code situation or intubation.  Some sim labs also have standardized patients to allow you to learn certain communication skills such as end of life discussions. Such sim labs add immense value to your medical education and communication skills to work seamlessly in a team. So if the program that you are interviewing at does not have a sim lab, ask if there are any plans to open one. The cost to setup a sim lab to develop the scenarios, rooms and technology can be prohibitive - in that case, ask for standardized patients (not much investment needed) to learn important communication skills.

 

2.  Fellowship programs.  If there is no fellowship program (or a fellowship program that you are interested in), suggest to your program director to start a fellowship. For example, in a busy hospital with a couple of subspecialty fellowships, if it does not have endocrinology fellowship, suggest to the program director that given the number of patients and learning opportunities available, fellowship in endocrinology would certainly add value to residency training.  You can even get more fancy with the fellowship recommendation. If for example they have a cardiology fellowship, you can say that patient have an electrophysiology fellowship or a heart failure fellowship. Or if there is any other fellowship that you have interest in such as palliative care fellowship, do make it a point to bring it to the program directors attention.

3.  Point-of-care ultrasound training.  Some programs have started point-of-care ultrasound training but do not really offer a certification.  If you are interested in learning point-of-care ultrasound skills, talk to the program director or suggest to the program director about having a structured point-of-care ultrasound rotation to allow you to be certified and trained in ultrasound. 

4.  Medical students rotating in the hospital.  Having medical students rotating allows you to develop or enhance vital teaching skills.  So if there are no medical students, suggest to the program director about having medical students by developing an affiliation with a medical school.

Do share your thoughts in my facebook group and I can comment on your response. Plus, you can see other's responses too. 

That’s all for now. Hope you like this post. I would love to hear your thoughts and comments. Join the mailing list or my facebook group and check out Ed4medus.com to learn more about personalized services to help you get into a US medical residency program.

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"If not a doctor, what would you be?"

 

Many a times, I am sure you have been told that medicine is a very noble profession. I am sure this is valid even today, though some may argue that medical practice is now run more as a business. Nevertheless, what would you do if this profession did not exist? What would you do if you just had no way of becoming a doctor? What other profession would you consider?

Here are THREE examples: TWO are from online interviews that I chose to include because of the very high quality responses - responses from other applicants were also very exciting, but for lack of space, I have not been able to include those in the current post. May be I will include them in a future version of the post. The third example is from my own personal experience.

Make sure you watch the video clips to get a feel for the interview. 

These examples are taken from 2 online practice interviews that I performed at ed4medus.com. Click on the links below and see the 2 video clips. You can also read the transcript of these interview clips. (Identity of the applicants have been withheld to ensure confidentiality). 

                Video: Teacher Video: Archeologist         

GM: “Well, I would love to be a teacher. I love to teach people and many times I have got feedback that I am a good teacher. In my medical school, we used to have a small group and my fellow used to tell me different topics which were difficult to understand. I used to first learn and then I used to teach them because they thought that I am a better teacher. And many times such topics which were really tricky ones in which simply we had to cram a lot, I used to teach them and they really found that it was useful to them. So soon, my juniors also approached me and I had a small tutorial group in my med school. And me along with my two other fellow colleagues - we were the three main teacher who used to teach the juniors and our batchmates also -  small topics which ever they felt they needed help with. I think I would be a teacher.”

AR: Back in the days, because I was a curious child, so I wanted to be an archaeologist. You know __ is in the Mediterranean coast and we have the second largest amount of Roman and Greek rows in the entire Mediterranean basin.  So back in the days, I was very curious about going to all the old cities and archaeological sites and spending hours with my family.  My brothers and sisters did not like it. So I would just go down, explore the caves, see how ancient civilization took settlement in this country and tried to build something.  I guess it was the curious side of me - that desire for me to understand how who we are and how we came from going back to our ancestors. I wanted to do this, but my aunt was really happy when I ended up not doing it and ended up doing medicine. I guess both share aspects of curiosity and the need for continuous discovery and working on it being a researcher. I would have done it I think and I guess I am still interested in it. I still love reading about archaeology and anthropology as well.

Dr Ed: If not medicine, I would really like to be a musician and play the piano. Music has been a passion of mine. I started learning the piano when I was in middle school but I had to give up playing music because of needing to spend more time for studies. What I find interesting is that many of the traits in music are similar to what is required in being a successful physician. Just like you have to practice, practice, and practice to play a beautiful song, one has to keep learning medicine by revising, reviewing and revisiting medical conditions and learning from each patient to add to his or her experience. So, the more you practice, the better you become and that also applies to being a great physician. Practice can sometimes be long and hard but the fruits of success and the beautiful music that comes with practice is amazing. In the same way, saving even one life or helping out a patient really makes the practice of medicine very worthwhile. You have to be able to play as a band otherwise if you play out of tune, then you can spoil the song. Similarly, while taking care of the patient, one needs to work in a team and collaborate with other consultants and nurses to deliver the best outcome for the patients.

So there you have it. When answering this question, make sure you explain the similarities between medicine and your passion outside medicine. This demonstrates high level of thinking and self-reflection.  

How should you not answer this question? Avoid controversial occupations (from the medical point of view) like being a bartender or owning a cigar shop (you may choose to do those after residency). 

Do share your thoughts in my facebook group and I can comment on your response. Plus, you can see other's responses too. 

That’s all for now. Hope you like this post. I would love to hear your thoughts and comments. Join the mailing list or my facebook group and check out Ed4medus.com to learn more about personalized services to help you get into a US medical residency program.

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"Tell me about an event where you did not agree with your senior or attending. How did you handle it?"

 

You may wonder why there would be disagreement between a medical student and the attending? This is commonly because an important piece of detail often gets overlooked or missed because of error or preoccupation with another event.
Just like the movie ‘Batman Begins’ where Bruce Wayne is asked to hurt a civilian for some wrongdoing, instead of hurting the man, he lights a fire in the league of the shadows and escapes to Gotham City. This is an example where he disagreed with this superiors. What are possible scenarios appropriate for the residency interview?

Here are two examples where the applicant was in disagreement with his or her superior.

 

Example #1 

This is taken from an online practice interview that I performed at ed4medus.com. Click on the link below to listen to the audio clip. You can read below the transcript of this clip from the interview. (Identity of the applicant has been withheld to ensure confidentiality).

"Tell me about an event when you did not agree with your senior or attending. How did you handle it?"

Dr Ed: ...and so certainly you were working as part of a team like you mentioned with the senior resident and attending. Was there any time you came across a situation where what the attending or what the senior resident was telling you was something that you felt was not the right thing to do. Something that was wrong and so what did you do in that situation? GM: Well, there was one case. It was a surgical case. We were at the OT (operation theater) and my attending was performing an operation. I was the one who was assisting him. It was a neck node dissection (radical neck node dissection) and while he was operating, I could see the pleura, the pleural lining of the lung coming out of the surgical field. But he missed it. And he was about to reach it. So, I immediately pulled his attention towards it and made him stop. At first, he didn't believe me. He never thought the pleura was a bit higher than the usual level because the patient already had fibrosis due to the previous surgery due to scars and all. And the pleura was much elevated than the usual site. But I could see it blow in and out because from the position that I was standing I could see it clearly. But he missed it because he was standing in a sideways position. So, I made him see it through my position. I cleaned the whole surgical field and made him see it clearly and he understood his mistake and apologized and he really thanked me that day for not letting him do such a mistake. Dr Ed: Fantastic!

Example #2

(Source: facebook.com/groups/ed4medus/) There was this time when I just finished writing my research paper and I had a disagreement with my mentor about which Journal we should be submitting that paper to. I wanted to submit my manuscript to Circulation, a high impact journal, as I felt that would be great for my research career and it could reach a much larger audience though I did realize that Circulation is a very competitive journal and it is difficult to get a paper published in it. My mentor felt that we should submit it to American Heart Journal, a respected cardiology journal but with a lower impact factor.  I looked at the papers published in Circulation and found a paper published just under a year ago that was very similar to my study design and the question that it was trying to address. This gave me confidence and I approached my mentor with this information. I asked him for his thoughts about trying our hand in Circulation and that the worst that would happen is they would decline my manuscript and we could then submit next to American Heart Journal. He reluctantly agreed and I submitted my paper to Circulation. After a few weeks, we heard back from Circulation and the editor and 3 reviewers were willing to reconsider our paper after a major revision. Both I and my mentor were very happy about this response and very glad that we chose to submit to Circulation.

When answering this question, make sure you are not suggesting that your senior resident or attending has a poor character or incompetent or lacks sound judgment (this maybe true but the residency interview is not the place to belittle those who contributed in whatever minute way to your medical education).  

How should you not answer this question? When recounting the event, NEVER show that (1) you know more than your attending or (2) you can get away with doing things behind their backs especially ordering medications or tests (requesting additional medical or surgical input is not too terrible, though as basic courtesy, do let your attending know what you are doing). 

Do share your thoughts in my facebook group and I can comment on your response. Plus, you can see other's responses too. 

That’s all for now. Hope you like this post. I would love to hear your thoughts and comments. Join the mailing list or my facebook group and check out Ed4medus.com to learn more about personalized services to help you get into a US medical residency program.

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"What are the problems in the US health care system that you have come across and its solutions?"

I will start off by saying that no healthcare system is perfect.  When you think about healthcare being free and completely covered by the government [such as the National health services in UK or Canada], you hear about the long waiting times, difficulty being able to see a specialist and so forth.  Then when you consider a healthcare system like in US where you wish to do your residency training, you hear a lot about costs of healthcare and that the rising costs are not sustainable.

While this can be a very long drawn political discussion, let us focus on this question that may be asked at your interview on US healthcare.

"What are the problems in the US health care system that you have come across and its solutions?"

Now the list of TEN problems in the US healthcare can be long and daunting, but remember we need to answer from the point of the applicant who is getting ready to train for independent practice. Here are the problems that one may face practicing in the US healthcare system and FOUR solutions for the problems that I feel are practical and feasible:

1.  High drug costs:  There is a lot of debate as to how to control the drug prices in this free market.  Sadly, it is the patient who suffers the most. I really do not know how to address this by myself.

2.  Costs of care.  Again the reasons are numerous and no one knows whether the drug prices by the pharmaceutical companies, rising number of administrators who are turning healthcare into a business or growing complexity of medical care are the reasons behind this.  Again this is something that I myself would not be able to resolve.

3.  Access to care.  This is with regards to the long waiting times that some communities may face in trying to get to see a physician or healthcare provider [physician assistant/nurse practitioners].

How can I help improve access to care? Without going into the details of which insurances my practice would accept, the way I try to improve access to care is that when a primary care physician or the patient themselves call and request to be seen urgently, I always make room in my clinic and accommodate them as best as I can. This is especially important in a place of practice that has limited physicians.  Being available to meet with the patient's and/or their families in my opinion resolves prevents any conflicts and at the very least shows that you are putting an effort to listening to the patient and addressing their concerns. I agree this is not a sustainable option, but at the very least you are trying. 

Another method that I believe can help access to care is telemedicine.  I really think there is a lot of potential and telemedicine can reach out to patient's quickly and efficiently and also interact with other physicians especially in rural hospitals.  A lot of work still needs to be done with regards to regulation, reimbursement and malpractice coverage but imagine how great it would be if a Dr. can check you out with available technology at the comfort of your own home.  This is one area that if you read up a little bit more about you can actually identify specific strategies to help the healthcare system.  In this day and age, I would also encourage young physicians like you to take up creative projects and embrace the use of telemedicine to improve access to medicine.

Having more physicians is going to be tough especially with the high tuition cost of medical school and salary to pay the attending physician. More PA/NP is another attractive option, but I don't like the fact that hospitals are 'replacing' physicians and the administrators are loving this idea. I still think there needs to be regulation/supervision of PA/NP providers, so instead of improving access by just hiring more PA/NP, you could say that you would like to be in a setup where you can supervise them and see more patients in a day. I think that would be a great idea.  

4.  Fear of being sued.  The fear of being sued dictates some of the decisions that we physicians make while providing medical care.  Some have an approach of CYA [cover your bottom] that can sometimes lead to superfluous and extraneous care.  Where to draw the line on medical care is difficult to know though some states have a limit as to how much the physician can be sued for.  Again this is not something that I can fix by myself.

5.  Abuse of the healthcare system.  There are situations where a person may ask to be in the rehab center if they have minimal support at home.  This is a rare occurrence though.  Things like opioid abuse really strain the healthcare system.

6. Lower focus on preventive (and patient education) rather than curative care.  It certainly makes a lot of sense that focusing our efforts on prevention such as with vaccination, cancer screening, screening for cardiovascular disease, healthy lifestyle choices to prevent obesity will yield much higher returns in population health than curative care.  This is something that a physician can strive to implement in his or her clinical practice.  For example, in the field of nephrology, a lot of important work has been done with regards to patient education before dialysis and her chances of getting a kidney transplantation, vascular access and some studies have even shown an improved survival with patient education after that patient starts dialysis.  I think this is a growing field and the hospitals are really starting to use social media to improve patient awareness of health conditions. Diabetes care diabetes care is improved a lot after having diabetes educators and other chronic health conditions should also follow this trend.

7.  Healthcare wastage.  Every physician witnesses provision of care that is futile such as an elderly patient with terminal cancer getting a tracheostomy, tube feeds and being on dialysis.  Again, better patient communication, research in these complex areas of medical care can help address this problem.

8.  Patient safety.  Because of the growing number of teams taking care of different parts of the patient's medical care, patient safety has become an important concern especially when there is breakdown of communication.  This is something that you as a physician can fix by being a better communicator, talking with patients, families, other physicians and being more collegial and collaborative with other providers of the care that can help improve patient safety along with better documentation. Having safety systems in the hospital, AI will be employed in the near future to catch the near-misses. You can also participate in the hospital safety committees and strive to improve overall patient safety. 

9. Reimbursement of care.  Physician practices suffer a lot financially because of inconsistencies in how practices are reimbursed for care.  There is a lot of unhappiness about this and some practices even tried to game the system to increase reimbursement.  Sometimes these practices can be unethical.  Again this is something that I do not know how to fix by myself.  Some physicians are looking to practice " concierge medicine" that might avoid these problems but it is not perfect and is still evolving.

10. Last and my favorite is physician burnout.  Yes you heard me right 'physician burnout'.  About half of the medical doctors across-the-board [residents, attending physicians] in US report symptoms of burnout.  These physicians feel exhausted emotionally in their ability to take care of the patient and sometimes have reported feeling callous about the patient's concerns.  A lot of research is actively being done to study causes and Rx of physician burnout.  There are a host of personal (compulsive behavior, striving for perfection, lack of social support) and workplace related factors (workload, lack of control over schedule, non-clinical work) that lead to burnout.  You may have also read in the news about physician self-harm and suicide.  It is felt that the rising nonclinical workload such as documentation in the electronic medical records have added and contribute to the menace of burnout.

This is an area that you can actively intervene upon and make changes.  It is no surprise that if you are in the best mental and emotional state, you will do a better job taking care of your patients.  The solutions can range from personal [better lifestyle choices, exercise, yoga, meditation, mindfulness], trying to achieve better work life balance [this often means refusing to take on additional responsibilities when your plate is already full], better electronic medical records training, use of scribes [if possible], extracurricular activities such as music, art or community service, or cutting down on part of the work that makes you unhappy such as night calls/weekend calls especially when financially independent, improving collegiality with your other team members at work are very possible strategies to improve the joy of clinical practice.

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