The Interview Trail

August 6, 2011 Leave a comment
This is just a short list I compiled once I was done with the interview process, basically outlining what I learned. The process itself lasted months of fall and winter months, full of traveling, eating catered chicken salad sandwiches, pressing suits, and learning how to not look disinterested. Just a few things I learned:

  • Interviews are almost identical to online dating, except that you are in a group as opposed to one on one. They are a lot like first dates – everyone putting their best foot forward and not knowing very much about the other party. You have a very short period of time to make an informed decision on whether you want to spend a significant chunk of time at an institution. And both parties are trying their very damndest to hide/minimize any problems.
  • Keep a list of hard questions and your responses to them in a book. Chances are they will pop up again
  • Take notes. Details are important and everyone says go with the gut, but you have to agonize – it’s sort of required unless there really is a clear place you want to go.
  • Grade your interviews/programs after the interview so that your impressions are recorded in your memory. Don’t make a laundry list of detailed items to “score” programs. Waste of time.
  • Be prepared for shit. i.e., bring umbrellas, rainboots, snacks, water, etc.  because natural travel “disasters” definitely happen, especially in the winter months.
  • Go to the interview dinner the night before if you are available for it – they almost always schedule one at a local dinner place/bar – and get to know the residents a little outside of work.
  • Don’t constantly touch your face/hair, bounce your feet, bite your nails, or engage in physically neurotic conduct during the interviews or the dinners.
  • It is never appropriate to:
    • ask out a hot resident at a program at which you are interviewing. Even if she is digging on you.
    • get “slammed” (“trash-tacular”) at a resident dinner the night before the interview, even if everyone else is doing it.
    • “diss” a resident at one of  said dinners (i.e. regarding sports rivalries, and such). I saw an applicant do this at a dinner because he was trying to be funny and it did not go over well.
  • Vary your suit and tie combinations. Most interview circuits are small. You will run into the same people over and over and it looks weird to have the same combination, because to other people, it will seem as though you do not wash your clothes, or you are too uncomfortable with varied style options and can only feel comfortable in one outfit.
  • Most male fourth year medical students have no clue how to dress. Their pants do not fit and collect aimlessly around their calves in bunches. Their shoes are large, ugly, K-Cole “year 2000 GQ” blocky-heeled things with zero finesse and square toes. Their collars are obstinately point, with awful looking, uneven, cheap ties that might match but are tied in unattractive, lumpy knots that do not suit their collars. Jackets are too big and boxy. My point: dress well, you will stand out and people will remember you. I have heard people to recommend not dressing well so as to not stand out, but I disagree.
  • Get sleep the night before your interview. Take a pill, chamomile tea, whatever. Get it done and get the f*** to sleep.
  • In Neurology, most of the programs are small classes, and the faculty are very invested in getting to know you personally. Therefore it is not uncommon to have 4,5, sometimes 6 or 7 short interviews back to back.
  • Be relaxed and smile during the interview. They are trying to get to know you, not quiz you or make you feel bad (except for the surgical specialties, which operate on a culture of fear).
  • Try to get the most information about your interviewer before you go into the interview, if possible. If the coordinator emails you out who you are interviewing with, google them. Look up what they like to do, what they have given talks on, etc. There is so much information out on the web that once you have a name there is no excuse for looking people up randomly on youtube or on the web. You can easily own an interview this way by placing a couple of astute comments at the right time, or getting them to talk about what interests them.
  • Arrive at the interview with at least 2-3 detailed questions that prove you at least visited the program website.
  • If you are a cut-throat asshole, the best way to make sure someone else messes up their interview (so they don’t get your spot) is to get in their head. If you are not a cutthroat asshole, realize that this is a strategy that cut-throat assholes commonly employ.
  • I am a very competitive person in general, and sometimes acted competitively on the trail. After my interview experiences, I realized that this is NOT COOL behavior – people notice it and tend to remember it. Be nice to EVERYONE on the trail, especially admin people and other candidates. Bear in mind that these people are your future colleagues, that you will run into and work with at conferences, and might even match with. Being mean to people is contagious and people notice it. This has burned me several times.
  • Write thank you notes promptly. Don’t hand write that shit. Email is the way to go. Do it personally, not as a mass email (poor form).
  • Always include the admin person/coordinator on your thank you notes.  They work hard to make interview days happen. This can go a very long way and do not underestimate it.
  • You can spot insecure douchebags very easily and your handling of their insecurity can torpedo their entire interview day if done a certain way.
  • Insecure people talk about their accomplishments non-stop. The most secure people are the quiet ones that share, but never over-share and can take social cues. If you are lucky, you can put pressure on a candidate that might feel like they have something to prove (FMG, DO) and they will reveal their entire “game plan” – what their angle is on the specialty, what their plans are (which is usually what they say to sell themselves). Do not get personally involved with these people. Let them talk.
  • Medicine people in my opinion (this is obviously not fact) are best described as VANILLA – just sort of the regular, straight-laced, traditional, conservative and nerdy people that were in med school with you. They book their trips 6 months in advance, read ahead in class, value their accomplishments as a reflection of their personal worth and tend to not like to push boundaries. Neurology folks are actually interesting — quirky,  focused intellectuals, that have both originality and introspection. They were some of the coolest people I have met on the trail.
  • People making decisions at the other end of the rank list are people. Schmoozing is important, but needs to be done intelligently. They are not idiots and can distinguish flattery from praise.
  • Name dropping at a key moment can be an awesome power move. Most of the time, though, it doesn’t work very well.

The Match

The match is a weird process. That’s basically the best way to sum it up.

Overview

In theory, your quest for a residency position is supposed to be guided by your comfort level at different programs as determined through interviews, tours, phone conversations with residents, reputation, etc. For me, for some reason, my comfort level seemed to be contingent upon very few things – namely, location, reputation and general “vibe”. Overall, throughout the whole process, I felt like I wasn’t choosing “programs” in and of themselves but more “reputations”.

In retrospective – sometime in March, the match just “happened”, like the completion  of a test, or some sort of professional advancement. It was over. I had avoided, successfully, the real fear that came from not potentially matching because I had chosen a relatively non-competitive specialty, Neurology. I interviewed at top programs but knew that even then my scores and recommendations put me above many of the applicants. You can see my list of “things” the interview trail taught me” in another post here.  

I found it very difficult to judge a program rationally, in general. A vast amount of data was available to us med students – either directly through the NRMP website or through “med student craziness” – that intense OCD like behavior that causes us to research, plan, compare, compile and spend tons of time looking over data for the various programs, from reading StudentDoctor.net’s bogus and self-assured rankings of American Neurology programs to the AAMC’s publication on average starting salaries in each specialty in medicine, to mapping out distances between hospital centers and attractive city centers in which to live on Google Maps…

 When I started interviewing, I became OCD myself. I made generic score-cards with questions and scales in it, promising myself to fill it out for each institution after the interview had been completed. They were tedious and detailed, and the data points were almost arbitrarily selected. Towards the middle of the season, I found myself going back and re-arranging some of my previously written grades/scores. I also found that the details all started to blend together. A lot of the hospitals I applied to had similar characteristics – large university programs in big cities in the Midwest and the East Coast. – although they all had different feels, and I wasn’t satisfied with the classification I had devised for myself through these self-administered scales. I also noticed that, not surprisingly, a lot of the data points I thought would be important or even supplied to me were not really as important as I thought they would be. Many hospitals didn’t even give out some of the information I had initially set out to collect. Most of all, I was shocked at how superficial a view of a program these forms gave me. They essentially amounted to being quite useless.

 “Your GI system”

The buzz phrase of 4th year was “go with your gut” and I decided to rely less on grades and scores. My good friend, going into neurosurgery, claimed, “this process should have nothing to do with details.” There was a feel associated with each program, at the dinner, during the interviews, among the applicants, via email. It all factored into “gut” feeling – something that ‘SPOKE’ to me beyond the mind. And then there was the rank list making process. Even though my specialty was technically “non-competitive”, I’d interviewed at some of the finest programs in the US – many of which created a real dilemma for me in terms of choice.

 I think I learned a few things about myself throughout this very weird, sorority-rush-like process. One is that I tend to argue – immediately – against any of my decisions whenever they have been made, even if any of them are based on sound logic. I rearranged my rank list innumerable times until the rank list deadline – the top choices all being big academic centers with excellent reputations in big cities. The other thing I learned is that I valued reputation and name-branding very highly – almost above personal comfort. This was an important part of my decision making process and ended up being the deciding factor in the list of my top 5 choices.

Match Day

The morning of the match – March 17th, 2011, my girlfriend and I drove out to my medical school campus and filed into a large auditorium where envelopes were being distributed to the candidates, our names stamped on the envelopes with stickers, as well as plastic glasses of champagne – likely Korbel or something – as family members and significant others looked on from the back of the room. The tension in the room was palpable – not a negative energy – but a nervously positive one that tried to cover up so aggressively the deep seatd anziety that lay underneath everything, in the souls of even the most lackadaisical medical students.

I’d been fine in terms of the full-out anxiety up until the morning of the match, when, as I walked into that room and picked up my envelope, I essentially felt like I had gone 22 years back to my childhood competitive swimming days. That nervous, twisted momentum in the bottom of my stomach that would not go away. I couldn’t take the room and its ridiculously cheerfully stressed out people – so I decided to leave the building. We walked out to the parking lot. As I walked out of the building I remember telling myself, “this is it, there is nothing you can do any longer”. It didn’t settle my stomach.

 The air outside was still, warm, spring-like, with butterflies and birds chirping through the morning of a March day. I walked to my car, and put my glass on the roof. I sighed and looked at my name printed on the sticker on the envelope. As I did this I heard a huge roar from the auditorium – shouting, yelling, clapping and loud voices, all conglomerated in one instant of distant noise. They had done it. So in my own time, I turned over the letter and opened it.

 On the top of my page was my name, information and below, a small picture with text next to it: “Congratulations, you have matched!” I looked immediately below and saw that I had matched at my number two program.

***

My instant sensation was:

“Dude, you got to be happy about this…”

combined with:

“F&^&^^%… how am I ever going to cut the mustard”

It was that sinking feeling you get when you know you are in over your head. I imagined the computer program of the National Resident Matching Program (NRMP) running through its algorithm for my account number, skipping my number one choice because I was not ranked high enough there, before settling on my number 2 and spitting out a line of text.. and moving on to the next number.

This was not my number one for a reason – it was in the city I really wanted to be in – but had the reputation for being the hardest program as well as the finest. I had spoken to many residents that sounded miserable and over worked but it was an awesome name, and awesome legacy, and it was at the almost-top of my city list. It just was “HARD” in every respect – based on everything I had heard about it –

I felt a combination of surprise, yet smugness and assurance that it was meant to be. But I also felt anxious, empty, and somewhere, not satisfied. I knew this was a good program, but I knew I had blatantly ignored all the red flags, some of them almost too honestly disclosed by unhappy residents, I had heard during the interviews and thereafter. Then I thought to myself – “there is nothing you can do”. My brain tried to muster an aggressive resistance of what was, but my heart simply stepped in. I realized that this was it.

My girlfriend cried tears of joy and in what seemed like a second later, I was talking to my parents, and family, and others, accepting congratulations and agreeing to statements affirming my new program’s reputed greatness. I had matched. I had a job. The year was basically over. It was a strange moment.

The celebration was begun.

Vegas

(post originally written late last year, on my way to an away elective)

Vegas is ludicrous, in the true sense of the word – game-like, game-involved, and completely absurd as well as disorienting. It is a giant shopping-mall of sinful pleasures, a playground for adults and the businesses that thrive on them. The SW steakhouse is good. But everything is over priced, but it’s like sitting in a warm bath slitting your wrists – the pain of parting with so much money for so little food is surprisingly painless.

One of the other aspects of Vegas is the people. The predominant style is impregnated with that awful “west-coast vapid physical culture” — hairless, tan, starved and toned and bleached to perfection. Made up, tweaked, controlled, plastic, gross and suffocating, like a heavy cologne in an elevator. The city itself I think is only tolerable for <48 hours, much like Amsterdam for a weekend… I couldn’t deal standing in the casino, watching people gamble away their savings. Money for nothing, but I realized there was a reason I reacted to it all this way – I was never smart enough to understand how to win; there is always a way, but I never got it.

So I imbibed instead. And became tolerized after drinking about half a bottle of Scotch. I left the next morning after mistakenly ordering a gigantic frozen yogurt in the airport. There is a reason I never applied to any LA programs.

Categories: Uncategorized

Inversely Proportional 2

Another aspect of medicine that I think impacts all this is, ironically, something I only learned in my residency orientation modules – the “person based model of blame”. In other words, the tendency within a system to blame individuals for their mistakes, rather than looking at the systems in which they work and the inherent flaws in system designs that bring people to make the mistakes that they do. Translated to the medical student on the wards’ purposes, I guess it would be “the tendency to view mistake-making as a negative reflection on the student themselves”. I also guess a corollary of this would be that making mistakes would act as a proxy for bad grades. In many rotations, if was pretty clear that when you didn’t know something, the residents would think less of you. The people that “knew stuff” on rounds or in the OR (in surgery) typically had better grades. Other examples are medicine attending rounds pimpage, patient presentation criticisms in pediatrics and the tons of pimp questions on surgery.

Putting yourself in the attending or resident’s position – when you ask a question of a student, you’re more likely to ask a detail question than a concept question. And when the student gets it wrong vs. gets it right, you are more likely to judge them as a less performant student – even if you don’t value pimp questions as a way to grade students. There’s a lot to be said about the general intellectual culture that promotes this sort of reaction to failures. Not knowing a detail or making a mistake on rounds is often whispered about in the cafeteria and often causes people that make the mistakes themselves to suffer a lot of blame and feel terrible about themselves because the preponderant medical education culture has conditioned them to believe that there is something wrong with them. When MDs make mistakes, they are often blamed personally – and blame themselves personally – to a devastating effect.

Mistakes are the perfect learning opportunity if the system in which you are learning – and yourself – are able to accept them. Holding yourself to an ideal about the way you see something or understand it – and then fighting for it and being wrong …really teaches you what may be right. It helps you understand your initial thought process, just like understanding the limitations of an economic model allows you to have a better grasp on the real way the modeled economy works. Acceptance of this is really important – but it’s not taught as a concept in medical school and it is not exemplified in the educational culture/ teaching philosophy of the clinical wards where we did our clinical clerkships. Students and MDs are too obsessed with being “perfect” to really learn – and the system/teaching tradition fosters this. I think my experience in Medicine and other rotations where I really obsessed over details and not making mistakes actually decreased my true learning of the subject.

And to “do well” in clinical rotations – what does it really mean? It’s generally speaking, to “not get things wrong” and “know stuff”. Not to “learn”. I think it’s safe to assume, like I said previously, that “being wrong” will mean, somewhat and to varying degrees, that you will suffer in terms of grades. If we could reform this grading system to reflect learning concepts vs. details – and to tie grades to learning and not pure knowledge and encourage residents/attendings to embrace a certain level of vulnerability, I think medical education would be done a good deed. Medical students and residents would feel accepted and positive about their personal setbacks and finally turn their professional development into less of a struggle. Ultimately learning is best promoted in an accepting, flexible, relaxed environment. I think this really raises the question of what “makes a good student”? Should it be someone who “performs well”? Or should it be someone who “knows a lot”? Or should it be someone who “learns well”? Or should we do away with pimping?  Something to ponder.

Inversely Proportional

As a surgical clerk, I finally realized that there was a huge amount of busy work designed to take advantage of the medical student’s anxiety and desire to please – at the service of the resident’s work load. After surgery, I was on Peds and I really had trouble learning because I couldn’t stand people. Although this was true, on the other rotations I came to the following conclusion: Good performance on rotations, as reflected by grades, does not necessarily translate to high degree of clinical learning. 

This is related to the way we are taught medicine. Many of my third year rotations left me with a mark of “Honors”, which roughly translates to an “A”. I was always going the extra mile on my rotations in order to get the best grade possible, sometimes being the “gunner”, sometimes throwing my fellow med student mates under the bus. I am not going to lie that my shelf exams didn’t let me sleep some nights, as you can tell from a few previous posts from third year.

For me, it was always bloodily important to get “good grades”. In clinical and pre-clinical work – it made the transcript stand out, it meant you took work seriously, and reflected well on you as a medical achiever. This is fine, right? There is a catch, though, especially in the clinical disciplines, where your performance on the wards/floors/clinics is hugely important. Most, if not all, of these third year rotations rely heavily on your roundsmanship, i.e. your manner with patients, your presentation quality on rounds every morning, your ability to take care of shit when it happens on the wards, your general level of “laziness”, and your ability to answer/deflect pimp questions that are so frequent in our glorious intellectual brotherhood.

Most of all, though, I think these grades all had a lot to do with one’s “likeability” as a student. The people grading third years are residents, interns and attendings – sadly, not the most objective of judges, rife with their own irrationalities and different appreciations for quality and learning. Ultimately, I feel like “how you got along with residents/attending” – i.e. “how you play in the sandbox”, as the Neurology Chairman from SUNY Downstate explained to me – which in turn depended on your personality, humor, work ethic, etc.. and not necessarily your medical knowledge – really influenced your grade more than anything. This is sort of frustrating when you think of how much time we all spent learning all the things we aw on the wards and how to present to residents and attendings.

For instance – I knew precious little in Medicine, but I spent most of my time obsessing over patient presentations, mindless lab details on patients, and roundsmanship rather than understanding important concepts like CHF and how to manage diabetes or an acute MI – to the point that I was shitting my pants before my Medicine shelf, as you can clearly see from one of the third year posts. But people noticed my obsession with roundsmanship. Residents wrote good reviews, attendings wrote glowing ones. Not one of their comments said – despite being very commendatory – anything about my clinical reasoning, which I think is the most important thing to learn in medical school.

I’m of the school of thought – if there is one of course – that values relationship-knowledge acquisition and logic mastery over hard-coded factual knowledge acquisition that is tied together as an output stream of logic.Example: learning pathophysiology of MI before going to the EKG findings, or learning pathophysiology of diabetes and diurnal blood glucose cycles before learning the names/functions of all the insulin preparations.

You can call it big-picture vs. small picture, but I like to think of it more as dynamic/framework learning vs. hard-coded learning. I don’t know where these cheesy terms come from, but it’s probably from working as a business analyst at a software company in Excel and SQL Server. Performance in medical school taught me, despite the fact that exams often heavily tested details – tha understanding and learning the internal logic behind medical phenomena always promoted longer-lasting learning and knowledge retention than accumulating individual facts that were end-result-points for the aforementioned pathophysiological processes.

So, in essence, I approached third year of med school with a “hard-coded” approach and not so much the first one. I did not grow an extra brain to make sure I stocked up on long-lasting learning. But the attendings and residents didn’t notice that I was a little too small picture and spending too much time on the details rather than understanding the big picture. If you had to ask me, I’d think it would be relatively easy to spot. Focusing on details and roundsmanship – did not promote learning for me. But it did promote superior performance, as reflected by my grades in medicine and surgery and neurology, etc. I felt as if people were giving me the highest available grades but that the rationale behind these grades rested on an imperfect basis for judging true medical learning.

I’ve heard of these things called the “impostor syndrome” and it’s apparently rampant in high-intensity intellectual spheres, like law, scientific research, medicine to name a few. Maybe that is what I am describing for you now, but I feel like there is something immutably true in emphasizing concepts over details in order to promote superior learning in the medical education arena. I am not advocating eliminating details, but I think teaching through details causes poor retention. In general though, I feel like the medical student’s performance – grades – which may translate to AOA status and then possibly to the residencies the student might be able to apply to – rely on personal attributes and aspects of knowledge that, when focused on intensely for the purpose of success, end up impairing the student’s true, deep-seated and personalized learning of a medical subject through clinical rotations. I actually think the drive towards good performance actually inhibits good learning – but I will get to that later.

Career

June 24, 2011 1 comment

It’s basic. I originally thought I would like surgery, but realized only at the end of that rotation that I was fighting an uphill battle and gave up. I saw that a career in surgery would have been trying to fit into a role that never suited me.

 Dilemma

I liked two things about medical school, at least, theoretically: one was the nervous system. There is no doubt in my mind at this point that that is what I love. It speaks to me. The other is analyzing and solving complicated medical problems, and asking “what else could it have been”, being that person that figures out the puzzle. I hated pediatrics, so that was out. I liked OBGYN, but realized it was limited despite its amazing effect on a significant part of the human population, and it struck me as being, in gross simplification, “surgery for girls”. Women that did not want to deal with the still male-dominated world of surgery went into OB, so they could take care of their gender-matched-colleagues. It also had a very strong estrogenized flavor that I could not stand, similarly to Peds. I could not do that. Surgery was too difficult for me. I couldn’t balance puzzle-solving and interventionalism at the same time, both of them involving a fair amount of uncertainty and needing a stronger degree of confidence and imposed structure to guide one through the management of such uncertainty. Psychiatry was uninteresting, and unclear. It felt like most of the psychiatrists I spoke to really weren’t making decisions on data. It was nebulous and uncharted – and going nowhere fast.

I realized, somewhere during my Pediatrics rotation, that I really needed to decide upon the fundamental division between medicine and surgery. I struggled with the idea of not being a surgical person – my main problem being choosing to live a life of “observation and receptive structure” versus activity and “fixing things”, but I realized that a life of struggle was not necessary, having already struggled quite a bit in my life. So I listened to my heart. I turned my back on the surgical path and chose medicine.

Mind vs. Body

Medicine and Neurology were the obvious choices left. Neurology is its own specialty, but really is a specialty of Medicine. Most foreign countries train neurologists as fellows after completion of a medical residency, even though in the US, you only have to do 1 year of medicine before it. Medicine is interesting, versatile, powerful, challenging, intellectual and traditional. Neurology is fascinating, yet not versatile; challenging in its own way, hopelessly intellectual, and almost to its own detriment. Those were my two considerations as I entered the Match for 2011. I was psyched, because Neurology is not very competitive. My board scores and performance during my first three years of medical school were enough to make me competitive for excellent programs. However, the outcome of neurological residency was more uncertain. What would I go into? And would my sub-par skills in research and intellectual criticism destine me to a life of boring clinical work? The emphasis seems to be so much more on diagnosis than treatment. There is always an intellectual discussion about localizing the lesion, but there is imaging, which confirms the brain-work and is rampant as a crutch in many training programs. The treatment options in neurology are basically fourfold: tPA, steroids, IVIG, plasmapheresis, antibiotics, and more steroids. Deferment to neurosurgery for tumors, subdural hemorrhage and epidurals and the endless turf battles that come from this.

I kept having fantasies that I would pioneer some amazing new treatment for a neurological disorder that affects many people… but the bottom line of it is, I am not that special. I am not really anyone out of the ordinary, medically speaking– just some dude who was diagnosed with cancer in medical school and fought through it like a champ, balancing the difficult task of being a doctor and a patient at the same time. That is my claim to fame. For some people, it would be enough.

Medicine is more powerful than neurology… but less interesting. Neurology is more interesting, fascinating even… but I was incessantly asking myself the question: what would I really do for patients? Chronic steroids and modulating the immune system – what are we really doing but fumbling around with balances of systems we understand so little of?

A wise person might answer that that’s just what medicine is. And what does one choose if one were presented with the option of keeping one at the loss of another: the heart, or the brain?

Surgical, After All

It made much greater practical sense to choose Medicine. The pay would be better, I would have more options for specialization, and I seemed to fit the mold, at least somewhat. However, there was only so much renal failure, bleeds, and diabetes I could handle. Sure, I’d even be able to do neurology after three years of medicine. But that involved being a junior resident all over again, when I would have suffered through THREE years of medicine and being, for all intents and purposes, a medicine attending. There is so much cardiology and diabetes that I absolutely HATE. I don’t like reading EKGs. I didn’t want to be on call working my nuts off after being a third year resident, at age 34, 35. That would put me being done with residency at age 37. 37!!! And by the time I’d be done with one thing… I wouldn’t want to practice both. It’s one or the other. It has to be that way. Neurology meant being done with residency at age 34.

I knew the match is a difficult process. These things tend to be more difficult for me, in general. The reason these things are more difficult, usually, is because I take more time than usual to figure out what I want. The reason this happens is really because of separation problems. Much like surgeons make an “in-cision”, now it would be time for me to be making the “de-cision” – the cutting of another sort. One needs scissors to cut… but one also needs the desire to cut. Otherwise nothing is done.

I applied to both in the match. I got much better interviews in Neurology. I am not a touchy feely person, but saw this as some sort of sign. So I went forth and cut. I followed my heart and chose Neurology.

Categories: Uncategorized

Fourth Year (or the Beginning of the End)

March 24, 2011 Leave a comment

A. Introduction

I think the last time I wrote was about 3-4 months ago, regarding some encounter I had with a smoking hot patient in a waiting room and the uncomfortable nature of examining a hot young woman with a UTI. This was sort of a reflective, introspective post, but it didn’t relate what had been going on in my life recently. To be honest, I found it kind of soft and mealy, like a piece of bread that has been left in the microwave.

A lot of things have happened since I realized the “top ten things that annoy me” in medical school, namely, the beginning of the end (or the Fourth year of Med School), my decision of a specialty, interviews, and the Match. For those of you that were wondering, my blog was made private after I realized that program directors were likely looking at my blog and might use some of this information against me. Now that the match is over, that shit doesn’t really matter anymore. Actually, nothing really matters anymore now that the match is over, as you will come to understand.

B. Sub-internship

I started my fourth year last summer, late, after finishing pediatrics — the awfulness of which you hopefully got a sense of– and doing a gastroenterology elective and Neurology sub-internship at two away sites, which I will not name.  I then did my Medicine sub-internship at a small, crappy community hospital named after a Catholic saint over the month of November. It was at that time that I wrote the “Things That Annoy Me” post, mostly from my observations at said hospital and all the sloppy care that took place on those floors.

I’ll begin by defining what a sub-intern is in the US medical educational system. A subinternship is supposed to be a fourth-year level course – one where you move beyond the typical 3d year medical student (clerk) work — helping with scut work, writing notes, and going to lectures — to actually managing your own patients with close supervision. It is meant to be a transition to internship in a controlled environment. This, however, is all in theory.

I didn’t like my sub-I in medicine. But it was a dislike rooted in something completely different than my reasons for disliking medicine as a clerk on medicine — which you can find, if you try to go back to my posts from last year around January-February-March. As a clerk, I didn’t see any of the big picture and was getting bogged down in the details of scut work and making good impressions. After surgery – the rotation I completed after Medicine (and best encapsulated in the post “You Gotta Get Out of Those Rooms“), I realized how obsessing over details and people-pleasing were detrimental to learning, and my perspective changed on clinical rotations. I became more interesting in learning by doing, as opposed to listening to people lecture. I wanted more challenge — to be given a small amount of supervised responsibility where I could struggle with my own lack of knowledge and balance it with new experience.

C. Why It Sucked

In this case, on my sub-internship, I had a crappy experience because the people in charge of teaching refused to treat me differently than a third-year medical student. Probably for cultural reasons. They refused to let me play any role where I might have the slightest bit of authority on my patients and refused to let me to participate in the team to the extent which I had proven myself to be able in my previous rotations. Add to that the setting (small community hospital with not-very-good residents), monotonous case variety, and the tunnel-visioned FMG house staff I worked with– who, it seems, had been educated with the stubborn belief that authority always trumps intelligence in medicine.

My intern and my resident, both foreign medical graduates (FMGs) that had been offered spots at this program via pre-match (usually a deal extended to non-US medical graduates, who have lower chances of getting a residency in the US — outside of the regular match process), were my two supposed teachers and guides through my medicine sub-I. I spent my first week trying to assert my position & write orders on rounds for my “patients”. I had done this on my previous sub-internships at away sites, and as far as I knew, when I was assigned a patient as a sub-intern, it was MY patient. After I got yelled at for this- clearly overstepping my bounds as a sub-intern– and demonstrating too much authority, I decided that in response to them wasting my time, I’d take the rotation as seriously as I wanted to.

They were real winners at teaching. They worked hard to get the correct answers in the chairman’s Harry-Potter-with-a-South-Asian-twist board reviews every morning and “get patients out” so they could make room for the alternating admission schedule that would top off our patient list with malingerers and rule-out-acute-coronary-syndrome patients every other day. But they didn’t teach a single thing, and had no idea how to delegate. Despite their hard work at being “good” residents, they had a very poor gasp of what a “sub-intern” was supposed to do in a US hospital, and spent little time teaching the third year medical student on the team, and me, anything. They would interrupt my case presentations to show the attending that they knew what was going on, and then claim that I needed to “work on my presentations” in mid-block evaluations. They would scurry around the hospital trying to discharge as many patients as possible, making very cursory diagnoses. They would demonstrate rushed and downright awful patient encounters that were devoid of any Western cultural literacy. Patients looked at them confused. I had to fight to present my patients to the attending every morning on rounds and they explained almost nothing to me or the other student on the team. They delegated the smallest amounts of patients, kept switching them every day, wouldn’t let me write any orders, and almost never paid attention to any notes I wrote.

It was a total waste of a fourth year rotation, which was supposed to teach me the skills that would be needed of me as an intern — writing orders, admitting patients, organizing the consultations and tests before rounds, etc. I got none of that, in what was supposed to be a crucial part of my fourth-year education. It made zero difference to the residents whether we were there or not. At the end of the rotation, I wrote the site director a scathing evaluation about how it might have been more worthwhile to re-label the course “Medicine Clerkship” rather than “Medicine Sub Internship”. It really boiled down to the fact that none of the residents took the student’s roles seriously.

D. How It Ended Up Not Being So Bad

The attending, a sharp-tongued Middle Eastern nephrologist, provided many a pearl to the team, including a very intuitive way to approach acid-base disorders and hyponatremia. The other reason why this ended up not being absolutely terrible and soul-destroying was that I started interviewing for residency positions (I’ll get into my specialty choice in another post). I had applied to most of the programs I was interested in in September and October. I had my first set of interviews scheduled for the month of November… and once those started taking up my attention, something changed. My focus, which had been on doing well in class and rotations during almost all of my first three years of medical school, shifted to doing well on interviews, impressing people, developing a good career story, and finding the program I liked the most.

I stopped caring as much about working hard on rotations and about staying late – because in November, it doesn’t matter anymore. I remember one time I slept through signout at 7 AM after spending a night being “on call” at the hospital. I could have blamed it on my broken iPhone, which automatically turned down the ringer on the alarm, but in all truth, being on call on this rotation was a total waste of time, anyway. That night, I spent the evening in the emergency room shadowing residents as they saw admissions, then when I was lucky enough to get a patient to see on my own, getting kicked out of the rooms by ER nurses that wanted to free up their rooms quickly. Then, when the decision to admit was made, I would “write practice admission orders” on pieces of paper, that were never official, or checked by the resident. It was a joke.

E. That’s Whassup Now

In short – it was, on the face of it, quite crappy. But my interests had shifted. Senioritis — the early symptoms of the overarching transition from medical student to resident — had begun. This was truly the start of the Beginning of the End.

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