Medical School = Almost Finished!

I am more than halfway through my 4^th and final year of medical school, and more than halfway through residency interview season. So much has happened since my last blog post that I could never adequately summarize my experiences in a single entry. Instead, I’d like to take this opportunity to discuss five things about which I am commonly asked and/or about which those unfamiliar with the medical training process can be mystifying:

(1) What happens prior to residency?

(2) What is residency?

(3) Which residency am I pursuing?

(4) What is the interview process like? and

(5) What happens between interviews, graduation and residency?

What happens prior to Residency?

Medical school is a four-year education during which time everyone receives roughly the same training nationally to establish a core medical knowledge and clinical skillset that will be refined and specialized in residency.

The first two years of med school are typically lecture-based basic science with some clinical skill education thrown in. At the end of these two years, we take the USMLE (United States Medical Licensing Exam) Step 1, the first of three rounds of boards required for medical licensing. The score for Step 1 largely determines your competitiveness as a residency candidate (see below) and thus it is common for 2^nd year medical students to spend 8 hours a day for 2 months (give or take) in preparation for this 8-hour exam.

The 3^rd year of medical school is spent in rotations at the hospitals and/or clinics. At OSU, they were divided into 6 core rotations, about 8 weeks each of Internal Medicine, Surgery, Family Medicine + Elective, OB/GYN, Neurology/Psychiatry and Pediatrics. This is largely where students discover or confirm their specialty interest, which helps plan the 4^th year.

4^th year is essentially a fine-tuning of skills and a preparation for residency. In the early part of the year, students take more in-depth and rigorous 4 week rotations (called sub-internships), begin the residency application process and take the second round of boards called the USMLE Step 2. The second third (or so) of the year is interview season (more on that below), and the final third of the year is spent in elective rotations and assembling a residency match rank list.

What is Residency?

Broadly speaking, residency is a specialized training that all medical school graduates must complete during which a doctor’s knowledge and clinical expertise are expanded and refined in a field they elect to pursue somewhere along the course of medical school. Depending on the specialty, it can range from 3 years (e.g. internal medicine) to 7 or 8 years (e.g. neurosurgery). Because surgery residencies differ a bit from medical residencies, I will restrict my discussion to the latter since I am more familiar.

The first year of residency is synonymous with “internship.” So a medical intern is a medical graduate (M.D. or D.O.) in their first year of residency. This is also referred to as a PGY-1 year (post-graduate year). Regardless of the medical specialty, it is spent in internal medicine in order to lay a firm clinical groundwork crafted from broad exposure. For those pursuing specialties other than internal medicine, this intern year is referred to as the “preliminary” or “transitional” year, but it is nearly always identical to the “categorical” year of an internal medicine intern.

The next several years are spent in the specialty of interest. As the years progress, their training wheels begin to fall off and there is less and less oversight from attending physicians (the truly autonomous docs who have completed residency).

Upon completion of residency, there are still two options: (1) Pursue a fellowship to subspecialize or (2) go straight to autonomous practice and become an attending physician.

It might be useful to note here that although resident physicians live comfortably (around 50k/year), it’s the attending physicians who make the real “doctor money.”

Which Residency am I Pursuing?

It will come as a shock to none of you that I will do my residency in neurology. However, I did have brief love affairs with dermatology and hematology/oncology, but these were before I had the neurology rotation in 3^rd year that reinforced my ardor for the field. Here is an excerpt from my personal statement (a component of the residency application) that drives the point home:

“My very first neurology patient during clerkships sparked a fascination with neuroimmunological conditions. Before I examined her, I read on the census that she was a young girl with “NMO” written in the diagnosis column. Neuromyelitis optica was not even mentioned during the first two years of lecture, so this was an exciting opportunity to investigate something new. She shared invaluable insights concerning the myriad ways her condition impacted her life and raised my consciousness to the daily struggles of patients with chronic neurological challenges. Researching NMO precipitated an enthusiastic drive for exploring related neuroimmunological conditions such as multiple sclerosis and stiffperson syndrome. I never imagined the thrill I would experience from eliciting neurological exam findings and analyzing MRI films. Enraptured by my patients’ stories and sympathetic to their struggles, I was awed by the growing assortment of available treatment options and excited by prospective managements emerging from current research and clinical trials.

The compelling features I recognized in neuroimmunology extrapolated easily to all of neurology, and before long I felt that I was truly in my element… [redacted]… I experience the neurologic exam as a pleasurable and illuminating puzzle that, with the aid of a few tools, actively engages my critical thinking skills and medical repertoire. Graceful in its refined simplicity, when combined with logic and reason it yields powerful clinical information.  Moreover, it became evident to me the enormous impact neurologists have on patients. They wield the potential to restore cognitive function and rehabilitate bodies, essentially returning normalcy to the human experience. Even for patients with debilitating neurodegenerative diseases, the neurologist is a supportive companion who offers interventions to lessen disease burden and provides comforting care.”

What is the interview process like?

The residency application includes a personal statement, multiple letters of recommendations, medical school transcript, summary of USMLE board scores, lists/descriptions of research, awards/honors, extracurricular activities, etc. It is submitted electronically via ERAS (Electronic Residency Application Service) to any residency program of interest. The residency programs may then invite you to an interview. They typically interview 10 times as many students as they have slots for residents.

The interviews themselves, which take place in the late fall and early winter, are quite fun. Although we must travel to the program at our expense, most of the time they will accommodate a night’s stay in a high-quality hotel. The night before each interview includes a free dinner at a fancy restaurant (often with bottomless wine servings), the purpose of which is to get to know the current residents. This is vital, since we will be working closely with these individuals for several years. It also provides insight regarding the affability of the social atmosphere at the institution.

The structure of interview day varies, but a typical outline might be this:

8AM: Welcome and program overview (breakfast often included)

9:30AM: Interviews with faculty

-Anywhere from 3 to 8 docs; ranging from 15 to 30min each

12:00PM: Lunch with residents and/or faculty

1:00: Tours

Afternoon: Miscellaneous things like PGY1 year overview from the department of internal medicine, dinner receptions, option additional tours

The interviews are initially intimidating, but I learned quickly that they are generally much fun. When else do we have the complete and uninterrupted attention of some of the nation’s most intelligent and talented physicians? That said, it can feel a bit like speed-dating, a sentiment which I have discovered is largely shared among applicants.

The number of programs to which one applies and the number of interviews one attends varies with the specialty of interest. For instance, it is not uncommon to apply to more than 50 programs in a very competitive specialty like dermatology, or to attend many interviews for bigger programs like internal medicine. For neurology it is recommended that one attend around 10 interviews for the average applicant in order to statistically guarantee a match (more on that next).

What Happens After Interviews, but Before Graduation?

Three main things happen.

First, and most obviously, the final clinical rotations of medical school are completed. For me this will include outpatient cardiology, ophthalmology and radiology. I think all three of these will assist me both in my intern year and my neurological training, which is why I chose the latter two as my electives.

Secondly, both residency applicants and residency programs assemble their respective rank lists for the match. To find out more about the match, you can go to www.nrmp.org but I will provide a summary:

Each applicant and residency compiles a list that ranks a program or candidate, respectively. Then the NRMP uses a sophisticated algorithm (in fact, the inventor won a Nobel prize) to fill all the available positions in a double-blind fashion while attempting to give each applicant and program their top choices. There is never a guarantee that you will get your top pick, regardless of competitiveness, thus it’s important to rank only those programs to which you’d be happy to attend. On the other hand, one must be careful to rank enough programs to avoid not being matched.

On March 15^th, otherwise known as Match Day, every 4^th year medical student and every residency program discovers, at roughly the same time, who matched where. It is a very exciting day. (Yes, that is an understatement.)

I will become a doctor on May 2^nd, and begin residency on July 1^st.

I hope that clarifies things. If you have questions, please leave a comment and I will address it there directly or alter the post. Thanks for taking the time to read this lengthy entry!