"Do you have any questions for me?" Part 2 of 3 - clinical practice and training questions

In my last blog post, we looked at some very engaging questions in teaching and research that you can and should ask the interviewer. Here's a continuation of that blog post. We will now focus on questions pertaining to clinical practice and training. Let's dive right in.

Clinical questions:
You will be spending an enormous time of your residency training at work. No wonder that your title is going to be a 'resident' who lives, breathes and works long hours in the hospital. You need to make sure the program can cater to your personal and professional needs.

A few years ago a common question was "does the hospital use paper or electronic medical records (EMR)?". But now as EMR is so prevalent in every hospital, more practical questions are "which EMR is used in the hospital?" "Is this the same EMR in the clinic (or at any other locations that you will need to rotate)?" "Do I have access to the EMR from home?" The VA hospital has its own EMR and so if you are in a residency program where you need to rotate in a VA hospital, it is very likely that you will need to learn a second EMR. While the learning curve to master a second EMR is going to be steep, some residents like the idea of exposure to a second EMR in case they have to eventually work at another hospital that has an affiliated VA hospital. Just make sure you understand what you are getting into. Every hospital provides orientation at the start of residency so it's not necessary to ask the interviewer how you would be trained to operate the EMR. I don't believe scribes are available to residents yet.

The cross coverage responsibilities are clearly addressed so that's not really an important question to ask. Also with ACGME duty hour regulations,  the clinical responsibilities in every program are usually standardized.

For IMGs, you want to be sure that patients and hospital staff alike respect you, your hard work, your skills and experiences and willing to work with you despite your accent, personal preferences or skin color. I was once asked "What has been your experience about racism in this community?" I was taken a little aback by this question, probably because I never expected it. In the current times, I think this is a fair question to ask. You want to be in a program that embraces diversity and inclusion among your colleagues and everyone in the hospital. You want to make sure that you will have support if a colleague or patient makes racist comments against you. If you don't wish to be blunt by asking "Has the program witnessed events where racist comments were made to the resident? How was that handled?", you could rephrase to ask "How does the program support diversity and inclusion for residents who come from other countries?"

"Are there any characteristics about the patient population such as insurance coverage, special populations such as refugees or patients speaking a different language that I need to be aware of ?" Now this is not to be a factor in deciding whether to rank the program or not. But if you are interviewing at a program that has a large Spanish speaking population and if you do know Spanish, make sure your interviewer knows about it! Or, if you happen to find out that Dearborn MI, a suburb of Detroit, has a large middle Eastern population and if you have a middle eastern origin, letting your interviewer know this fact assures the interviewer that you will fit and settle down well in the community. When I interviewed at my current program, I was told about a large refugee population from Nepal and Bhutan in the community. So I asked the interviewer whether "interpreter services are readily available?" Thanks to this wonderful service available anywhere in the hospital through iPad, taking care of non-English-speaking patients is not an issue at all.

"I am very interested in developing point of care ultrasound (POCUS) skills as a resident. Could you let me know about the resources available for me to learn this skill? Are there dedicated faculty members to train me in POCUS? Is there a way for me to get certified in POCUS?" Point-of-care ultrasound training is being increasingly available to medical students and residents and is a fantastic skill to acquire. Some programs are just starting to incorporate POCUS in their curriculum. So make sure you will have some training in POCUS. "What procedures will I do as a resident? Are there a certain number of procedures that I need to do for graduation?" If you are in a procedure based specialty, make sure you know your responsibilities in doing procedures and the kind of  interventional radiology or surgical support and backup available to you.

"Is there a simulation lab for me to learn codes or CPR training?" If they have already talked about the sim lab in the morning introduction, you may choose to ask more details such as "Which scenarios are simulated in the sim lab such as the ICU, cardiac arrest or line placement?" or "Who leads the sim lab for residency training?" or "How accessible is the sim lab at different times of the year?" Residents commonly have access to a simulation lab, especially if there's an adjoining medical school.

"Could you let me know how does the program provide balance between learning and clinical work?" "Are there any specialties that have a non-teaching service?" "Is there a non-teaching service?" While the goal of residency training is learning while working, sometimes it is debatable whether a resident would attain any educational value from taking care of a patient with chronic stable issues or who is waiting for placement into an outpatient nursing home. Some programs have  hospitalists or nurse practitioners take over care of a patient as a non-teaching service. Do be careful when you ask this question as you don't want to sound to the interviewer that you are lazy.

"Is Uptodate easily available?" Uptodate is this wonderful resource available to physicians in the hospital commonly at every computer terminal (or even on phones and tablets nowadays) that serves to provide the latest evidence based information on any medical condition. It is also very helpful while you are preparing your case presentations for morning report and need help with a comprehensive summary of the research literature. You can also look up drug doses. In the current times, I can even say that any hospital that does not provide access to uptodate is doing disservice to its physicians and residents.

A question that can lead to more questions:
"Is there anything you feel I need to do so that I can best prepare myself if I were a resident at your program?" Now this is a tricky question. You are subconsciously putting in your interviewer's mind that he or she should accept you into their program. Some interviewers may fumble as this would mean a critical review of your application to identify deficiencies or areas for improvement. But some may counter your question with "Nothing that sticks out right now. What exactly do you have in mind?" Caught in your own trap? How do you answer this? "I was wondering if I may need an accent reduction program?" or "I was wondering if being able to observe the residents a few weeks before the start of residency can help me get off the ground quickly especially with learning the EMR?" Don't over do this. I would suggest asking this to just one interviewer (probably the program director).

That's all for now!  The next blog post will have questions on resident evaluation, the back well-being and other questions that you can ask the interviewer at the residency program.  All the best! Do join the mailing list to get the latest blog posts delivered right to your mailbox and leave any comments below.

Before you go: Here's your golden opportunity to have your voice heard! Write down your ONE question regarding your US residency program application, personal statement, interviews or anything that has been bothering you and keeping you up at night. You can reply at the end of this blog or post a message at my Facebook page or email me at varun@ed4medus.com

The top 10 popular questions will be featured on my next blog posts at https://ed4medllc.blogspot.com/ and the winners will receive a coupon each for a FREE practice interview at Ed4medus.com ! Put those thinking caps on and hurry up!

Photo credit for image on top of blog post: http://www.spellerinternational.com.au/wp-content/uploads/2014/07/shutterstock_180206270-1000x445.jpg

What are my expectations of a clinical observer in an observership? Five things an attending wants you to do and NOT do.

As a followup to my last blog on clinical observership at my institution, I felt it would be very useful to share 5 pearls of wisdom on what I expect from a clinical observer. These specific pieces of advice may turn out to be very useful for an observer who strives to make the most of his or her limited time in an observership.

1. As your teaching attending, I am fully aware that your goal as an observer is to obtain a letter of support at the end of the observership. There is no secret about it.

So when a faculty member asks you as to what you aim to achieve in your observership, yes you can certainly talk about 'wanting to learn clinical medicine', 'gain exposure to US health care system' or 'learn about residency training or evidence based practice'. I would also urge you to be upfront and state that you wish to obtain a letter of support from me. This demonstrates honesty and that you are not hiding anything from me. The words may need to be carefully chosen, for example: 'I wish to learn how residents work as a team and with consultants to take care of the patient. My observership is 4 weeks long. I would greatly appreciate you writing me a letter of support at the end of my observership as the US clinical experience and your letter of support will greatly strengthen my residency application."

This way, I can be on the lookout for strengths in your performance and presentations during the observership for inclusion in a glowing letter of support. Also, sometimes if the division chief (whom you may or may not have interacted with) takes the role of being the author of the letter, I can apprise you of this arrangement and then I can make sure I rightly forward my feedback of your performance to be included in the letter. Be ready with your CV (your ERAS CV or a traditional CV) as this is needed to write a letter of support. Also, instructions on how to upload the letter to ERAS would be needed.

As a corollary to this advice, I recommend that you stick with an observership period of four weeks at the least as opposed to two weeks. A longer duration in the division gives you the chance to interact in multiple occasions with many different attendings who can provide the necessary input to the one faculty member writing the letter of support. This may also give you a chance to work with the division chief whose letter carries the most value in the academic hierarchy.

2. At my first meeting with an observer, I always ask an observer 'which topics should we focus this week (or in the next few weeks)?'. A common response is 'whatever you wish'. The intention behind this question is to gauge your sincere interest in learning. You should be ready to answer this question in as much detail as possible. Here are few examples from a nephrology perspective:

• "Could you introduce us to a patient on dialysis and show us how dialysis corrects electrolyte imbalances?"
• "One of the patients that I am following has hyperkalemia. Could we review the causes and management of hyperkalemia?"
• "Could we go down to Pathology and see the kidney biopsy slides?"
• "Could you show us how to do urine microscopy?"
• "I noticed that one of the dialysis nurses was doing plasma exchange on a patient. Could we review the indications of plasmapheresis?"
• "I have always struggled with choosing the right diuretic. Could we review the indications for diuretic use and which diuretic is to be used in a specific situation?"
• "I have only read about kidney transplantation but have never seen a patient with kidney transplant. Could we review the rejection medications in a kidney transplant patient?"

The above requests send out a clear message that you are sincerely interested in making the most of your observership time and want to improve your knowledge of medicine and the clinical practice. Since you know much in advance which specialty you will be rotating, it is best to review an intern's book such as 'The Massachusetts General Hospital Handbook of Internal Medicine' or 'The Washington Manual of Medical Therapeutics Paperback' and do your very best in identifying topics of interest.

In case you are not asked as to your goals of observership (maybe because the attending is busy with other work), don't hesitate to bring these to the attention of the attending.

3. Be polite and courteous to everyone. From the fellowship coordinator to the nurses, techs, medical students, residents, fellows, patients and just anyone you encounter before, during and after observership.

Yes, I realize that you are trying to project your very best and wish to make a lasting impression on me. But doing so at the expense of another person by belittling or proving them wrong will not be tolerated. I shudder when I recall the observer who would just not wait for the attending to finish her question and would just cut her short to make a point. Or the observer who just did not show up when she was supposed to start observership and did not have the basic courtesy to notify the coordinator well in advance. We could have another observer in her absence.

So please be patient and appreciative. As a busy attending on service, we are really going out of our way to accommodate you and your needs just for an altruistic cause i.e. your professional success.

Please be respectful of my time as I have multiple responsibilities including documentation, chart review, interacting with the medical and surgical teams, family members, nurses, dietitians, social workers, administration roles and teaching. Try not to hang around me in an attempt to seek my attention when I am in the middle of other work.

4. Be productive and keep yourself busy during the short observership period and make the most of your time. See if you can be of assistance in the teams daily work. For example, you may assist the student, resident or attending in completing the assessment and recommendations in the patient note especially on the patient that you are following. While observers usually are not allowed to write a note in the electronic medical records, I still fondly remember the observer who typed the complete history and physical including assessment and recommendations in a word document that he sent to me by email that I copied and pasted into the chart after making minor edits. Remember that anything you do to make the life of an attending easier will surely be greatly appreciated and well remembered.

Offer to research topics on Uptodate or on Pubmed either on a question that may have come up during rounds or at any time. If you find yourself dozing or getting bored waiting for a consult, do not start chatting on Facebook. Have a lunch break or check out the library. If you are starting on the inpatient side, ask the attending if you can go to the clinic to observe. Attending medicine resident morning report or noon conferences are other great learning opportunities and will help you in your residency (plus you can add to youe personal statement).

5. Finally, be proactive. You will soon realize that the work culture in a US hospital demands a thick skin at times. You cannot be soft spoken or modest as this is usually equated with lack of confidence. Make eye contact. You don't need to be loud but sometimes one needs to be forceful to get the work done. A university officer shared with me his opinion that the work culture in US is a bit unfair to introverts.

Making presentations to the entire division especially a case presentation that generates a discussion and literature search for evidence is a very high level of learning and is appreciated in any academic program. These skills will surely be highlighted in your letter of support (and you can describe these experiences in your personal statement). Try to do one PowerPoint presentation each week to your rounding team.

Be bold. Be smart. You can do this. And don't forget to remind your letter writer towards the end of your observership for the letter of support and send them your CV.


Always thank the letter writer and any teaching attendings for taking the time to teach and draft the letter. Oh and don't forget to tell them where your matched. All the best!

Note: I just found out that some observership programs ask for payment (for example, this program charges upto 18k for observership) likely to cover liability and teaching efforts. This puts a strain on an oberver's financial resources as any observer needs to bear the expenses for travel, stay and food which can quickly add up to a lot and can be burdensome when not having an income. Use your best judgement and understanding of available resources when deciding where to do your observership. All the best!

Ed4Med LLC (www.ed4medus.com)

Before you go: Here's your golden opportunity to have your voice heard. Write down your ONE question regarding your US residency program application, personal statement, interviews or anything that has been bothering you and keeping you up at night. You can reply at the end of this blog or post a message at my Facebook page.

The top 10 popular questions will be featured on my next blog posts at https://ed4medllc.blogspot.com/ and the winners will receive a coupon each for a FREE practice interview at Ed4medus.com ! Put those thinking caps on and hurry up!

Photo credit of image on top of webpage: https://www.reviewjournal.com/life/health/medical-societys-mini-internship-gives-perspective-on-doctors-jobs/

Observership - what is it like in an academic hospital?

The Division of Nephrology and Hypertension at the University of Vermont offers opportunities for observership to IMGs (no payment required). I am a faculty member in this wonderful division. For the last two years, we have been hosting 1-2 observers at any given time round with the inpatient Nephrology team at the hospital. I believe we have been able to do so as the declining interest in Nephrology left us with no first year Nephrology fellows for two years in a row.

The observers have been visiting us from India, Pakistan, Nepal and Greece. Typically, the observers (through some discussion forum) would reach out to me or a faculty member in this division. We would then have them contact our fellowship coordinator who then reviews the observer's CV, obtains permission from the division chief and arranges for the observer for a two or four week observership period. This is usually done anywhere from 4 to 8 months in advance. Certainly, the the longer you can stay the more likely you will get a chance to interact and be assessed at multiple levels thus allowing more details to be included in the letter of recommendation that you request.

After the observer obtains his or her ID for hospital use, they are usually expected to be available starting Monday from 9am to 5pm. I would meet with the observer usually in the fellows office and assign them 1 or 2 patients to follow (chart review only). Everyone would have 1-3 patients to follow. Because of rules regarding patient confidentiality and liability, observers would go into the patient room only with a medical student or resident, talk with the patient after a brief introduction, do a focused exam and prepare a brief progress report for presentation at rounds. After I complete my rounds on new consults or followups by 10.30am, I would touchbase with the observers, other medical students and residents in the inpatient team.

At rounds, we would listen and learn from every patient seen. At the bedside, we would discuss any questions at rounds or in the fellows office using a white board if more detailed discussion is warranted. A example would be to discuss the pathophysiology of hyponatremia or hyperkalemia and their management. It needed a little fine tuning on how to improve their case presentation but the observers I interacted with were quick to learn. One observer realized early that a platelet count of '3 lakh' was incomprehensible to many listeners.

I usually give reading assignments to the observers (either research or review papers) and assign them topics to help me with a literature search. For example, one observer whom I worked with recently reviewed the indications for use of tolvaptan in patients with polycystic kidney disease, a novel treatment strategy approved by the FDA. He did an amazing job creating a short PowerPoint slide presentation from available guidelines. Another observer was following an ICU patient with suspected toxic alcohol ingestion and finding of acetonemia. She reviewed the biochemical pathways of acetone production and very elegantly identified causes of acetonemia, thus excluding isopropyl alcohol toxicity and diabetic ketoacidosis (the patients acetonemia was due to alcoholic ketoacidosis) in our patient. These efforts greatly improved the learning environment in our small learning team.

They went a step ahead and using available library resources including Uptodate and printing resources, they presented a PowerPoint talk each on Friday of the week (attending rotations in our division are one week long). I would review their ppt slides with them to ensure that the content is concisely presented and pertinent to the Nephrology division. For example, a thorough family history is needed for a case presentation of a patient with polycystic kidney disease. The observers each presented their 10-15 minute talk to the entire faculty Division on Friday afternoon with rest of the time being used for discussion. In the absence of fellows and having a variable number of medical students and residents every week, the observers filled an important void in the learning environment by their case presentations and evidence based practice. These talks have been greatly appreciated by the faculty members. I also feel thrilled at having been able to contribute, in some minute way, to the careers of these wonderful observers.

Some days when the service was slow, the observers would go to the outpatient clinic in the afternoon and had assigned attendings in that clinic. They would have opportunities to observe at a general nephrology clinic, kidney transplant clinic or kidney stone clinic. I have not been able to have observers in clinic, but I hear that the attending first goes into the patient room with the observer, introduces the observer who then takes a brief history and reviews followup information since the last visit (as he or she has electronic medical record access). The observer would then report to the attending and they would go back to the patient, examine and talk with the patient in 10-15 minutes. Patients have been very appreciative of our learning environment in this busy academic hospital.

In the next blog post, I will discuss how observers can make the best use of his or her time in a clinical observership.

Before you go: Here's your golden opportunity to have your voice heard. Write down your ONE question regarding your US residency program application, personal statement, interviews or anything that has been bothering you and keeping you up at night. You can reply at the end of this blog or post a message at my Facebook page.

The top 10 popular questions will be featured on my next blog posts at https://ed4medllc.blogspot.com/ and the winners will receive a coupon each for a FREE practice interview at Ed4medus.com ! Put those thinking caps on and hurry up!

Photo credit of image at top of webpage: http://www.barriedoctors.ca/medical-learners/observerships/