23 March 2007

Preparing for USMLE (United States Medical Licensing Exam)

Medicial students (allopathic) who attend medical school in the United States will typically take the first step of the United States Medical Licensure Examination (USMLE Step 1) in the summer between their second and third year. This examination tests the pre-clinical science subjects and is supposed to test the readiness of a medical student for entering their clinical clerkships during third year. Students must register http://www.usmle.org/

This examination, along with USMLE Step II Clinical Knowledge and USMLE Step III are given on computer in a Thomson-Prometric Testing Center. Once you are eligible for each step, you may register and schedule these exams on a day of your choice. USMLE Step II Clinical Knowledge tests a medical student's readiness for the supervised practice of medicine i.e. internship. Most medical students in the United States will take this exam at some time during their fourth year. Step III is usually taken after graduation from medical school with application for permanent medical license at the time of Step III. Some states have a seven-year rule in that you must take and pass all three USMLE steps within seven years of taking USMLE Step I so keep your dates and years in mind. Optimally, get Step III out of the way as soon as you can.

In addition to USMLE Step II Clincal Knowledge, there is a USMLE Step II Clinical Skills (USMLE Step II CS) that must be taken. This Clinical Skills exam has been required of all graduating medical students since 2005. This exam is also staken during fourth year as it usually involves some travel to a specified testing center, Atlanta, Chicago, Los Angeles, Philadelphia and Houston on a specified date and hotel accomodations unless you have friends in this city that will put you up.

Now, for the "nuts-and-bolts" of USMLE Step I: First of all, the test is intergrated which means that each question block has subject matter from your all of your pre-clinical courses. The questions may test a specific type of subject matter but there are intergrated questions throughout the test. This means that you probably should not study for this test in a "subject-specific" manner but rather intergrate the materials. For example, a virus might attach the heart muscle and cause a myocarditis that leads to biventricular heart-failure. This may be presented to you in a case-scenario but you have to know the physiological and pathological effects of heart-failure along with the effects of myocarditis. This is why memorizing individual questions or attempting to study before you are done with your coursework is counter-productive.

Another popular USMLE Step exam technique is to ask secondary learning questions. A scenario might go like this: "A , neat and well-dressed young man comes to the office of your psychiatric practice. He states, ' I don't know why I am here but I came anyway. My friends seem to think that I have a problem but I don't think or see that I have a problem. It's just that when I see something out of place, I feel compelled to put it back in its place. I like things neat and orderly." A likely diagnosis for this patient is: A. Schizophrenia B. Acrophobia C. Obsessive-Compulsive Personality Disorder D. Obsessive-Compulsive Disorder.

In order to answer this question, you have to know something about the characterictics of the disorders in the answer choices and be able to differentiate between them. You also need to READ every answer choice and make distinctions between them especially the last two which, are the key to answering this question. Again, you just cannot memorize a bunch of facts and definitions without putting this information into the context of the disorder/pathology or entity that is presented in the case.

What about those expensive USMLE Prep Courses? What about using review books and memorzing them along with your course work? The problem with most of those expensive review courses is that they present the material by subject and the actual USMLE exams are intergrated. The problem with review books is that they are often superficial summaries of what you already have in your coursework. It is far better for you to organize and thoroughly master your coursework before you attempt a "review". You cannot "review" what you haven't thoroughly "learned" in the first place.

Most second-year medical students will take USMLE Step I the summer between second and third year. At my medical school, a passing grade was required on Step I before we could start our clinical rotations in September therefore USMLE Step I had to be taken before the third week in July so that the Dean had received our passing scores. Our coursework was completed at the end of April so that most people took Step I the second or third week of June.Those of us (myself included) who had summer fellowships were required to take our exams before June and thus had to be more efficient. I took Step I the third week in May.

Inevitably, those people who failed the exam, were among the later takers and thus were delayed in starting on the wards. If you took the exam early, you would have time to re-take and start one rotation into your third year but if you waited unti August and then failed, you would drop an entire year of medical school. Bottom line: Take that exam when you are thoroughly prepared and reviewed but don't wait too late.

How about USMLEWorld and Kaplan's Q-Bank? These are currently the best question resources available for students. They simulate the actual exam in terms of computer interface and can be used in both the "Test" and "Tutor" mode. The best way to use these resources is to work in 50-question blocks using "All Disciplines" rather than subject by subject. You can use the "Tutor" mode where you can review why the correct answers are correct and the wrong answers are wrong.Beware of feeling confident that if you have a specific percentage correct on USMLEWorld or Q-Bank that you are guaranteed a pass or a specific score. Also beware of memorizing the questions because the questions on the actual exam are different from either of these resources. Both of these on-line question sources have many questions that are more difficult and more specific than USMLE Step I.

These sites are nicely utilized with a study group too. You should do your review and then do a couple of question blocks discussing the answers with each other. You would be surprised how having these types of discussions can enhance your retention and understanding of the material.

Also beware of "one-source" reviews out there. USMLE Step I is an exam that is scheduled for 8-hours over one day. There is no audio "high-yield" review tape or single resource that will give you everything that you need for this exam. You need to practice questions and reveiw systematically.

After you have completed your second year coursework:

  1. Figure out when you are likely to be taking the test. Second or third week of June is generally the most popular dates.
  2. Figure out how you are going to review: Systems-based or subject based.
  3. Gather your resources meaning review books, on-line question systems.
  4. Set a study schedule and stick with it. Don't make the schedule so tight that you can't get everything accomplished. Be sure to put in some "down-time" so you can relax as you review.
  5. Use USMLEWorld or Q-Bank as measures of your progress and do not attempt to memorize these questions. For example, if you miss a question, use it again in under test conditons and see if you get it correct. If you miss it a third time, use one of your review books and review the subject matter of that test.
  6. Be wary of subject-based reviews as the actual tests are intergrated. If you do review by subject, be sure to question yourself in an intergrated manner.
  7. Try to have a study group where you can help each other and discuss the questions.

19 March 2007

Microanatomy or Histology

This course was second semester first year at my medical school. It was a combination of Cell Biology and Histology lab. The material presented here was in the form of lectures with lab in the afternoon. We were given slide boxes for each exam. Each slide box contained slides of all tissues and structures that we were required to master for each of the three sections. I was pretty fortunate here in that my undergraduate Histology course was more rigorous as far as the lab was concered but this course was far more comprehensive than my undergraduate course. We also were required to be able to identify electron micrographs in this course.

After I received my slide box, the first thing I did was take some lens paper and Windex to clean each slide. Next I organized them according to each lab and topic. At the end of this task, I had a box of shiny slides that were in order. I purchased a small slide box (one that would hold about 10 slides at a time) for transporting my slides between home and school. I kept a microscope at home in addition to the scope that was issued to me at school. This was not necessary but I looked reviewed my slides on a daily basis.

Our Microanatomy syllabus contained excellent notes which the instructors followed quite closely. In addition, I used the Wheater Atlas for reference and the Lange Histology as a text. I would preview the material in the syllabus, read the sections of the text and study the slides using the Wheater Atlas ahead of time. Then I could go to class knowing what to listen for and make sketches of things that were shown in class. Some lectures like cell adhesion molecules or cell signalling took more time than others.

During lab, I would look at the demonstrations and look at as many slides as I could. If I could pick out the structures on any slide, this was a good indication that I knew the material. I wanted to be sure that I could recognize the normal because pathology in the next year would place emphasis on the abnormal.

Microanatomy is not well tested on USMLE Step I but the course presents some topics that were vitally important in other classes such as pathology. By being totally familiar with the normal, it made study of the abnormal a bit easier. Many of the same skills that allowed me to excell in Microanatomy allowed me to excell in pathology. I became quite adept at being able to identify structures based on their microscopic characteristics. The electron micrographs brought many aspects of physiology and biochemistry to life as I examined the cells and their characteristics.

I found Neurohistology especially interesting because the neural structures microscopically, looked far different from the cartoon representations found in most textbooks. It was interesting to learn the characteristics of most types of stains and immunohistochemistry. At the end of my Microanatomy course, I had a deeper understanding of how to correlate and identify structures and link these structures with their functions.

As with most medical school courses, keeping up is crucial to doing well. Microanatomy was very easy to keep up with. The course was not as volume intense as Gross Anatomy and far less concept intense as Physiology. For me, this course was a welcome change from sitting in lecture or spending hours in lab. Again, there were topics such as cell adhesion or cell signalling that were covered so thoroughly in Microanatomy that by the time we reached Pathology and Pharmacology, these subjects were second nature.

Since I had something of a "handle" for microanatomy, I spent loads of time helping my classmates who had problems. We had loads of teaching scopes and we would often study as a group. Again, my medical class was quite cooperative which made learning fun.

18 March 2007


Physiology is the medical school course that links cell biology, physics and biochemistry with the function of systems in the human organism. Under a classical curriculum, this course is usually presented second semeter of first year after biochemistry is completed. In a system-based and PBL-based curriculum, this course is presented system by system or topic by topic.

Physiology demands that the student have a thorough grounding in the basics of physics as much of this course revolves around cardiovascular functioning (plumbing), respiratory functioning (gas piping) or renal functioning (more plumbing). Often students have difficulty with physiology because of the math utilization requirements in terms of being able to understand diagrams and interpret graphical data. In terms of USMLE Step I, physiology is one of the heavily tested subjects and thus is the major course of first year that must be thoroughly mastered for a good USMLE Step I score.

The major components of physiology are Cardiovascular, Respiratory and Renal. The minor components are G.I, Endocrine/Reproductive and Musculo-skeletal. Many schools present Neurophysiology within the context of Neuroscience and thus this important component is out of the second semester physiology course and under its own course. USMLE Step I generally focuses on Cardio, Respiratory or Renal with plenty of diagrams for interpretation.

As with Biochemistry, it is vitally important not to fall behind in your physiology course. The best way to avoid falling behind is to organize your study of this discipline carefully at the beginning of the semester. Your syllabus is your first stop. As soon as you get the syllabus, look at the manner in which the course is divided. It is usually along the lines of Cardio, Respiratory/Renal and everything else. This usually follows first test, second test, third test and final.

  • What is the subject matter headings for each lecture?
  • How much material will be covered in each lecture?
  • What are the objectives for each lecture?
  • How much reading is expected for each lecture?

After you have looked at the topics, you need to make a list of any terms that you encounter in your reading and define them. Physiology will present loads of new terminology such as "homeostasis, positive-feedback systems, negative-feedback systems, futile cycle etc. You need to be thoroughly familiar with every term that you encouter in this subject and try to link function with structures that you studied in Gross Anatomy.

As with Biochemistry, you should prepare for each lecture. Physiology is one course that you really do not want to be going into lecture "cold". In order to avoid this try doing the following before the lecture:

  • Skim the syllabus and assigned reading noting topics, graphs and any tables.
  • Look at the previous lecture and see how it ties into the material to be presented.
  • Read the text and make a note of which topics are emphasized as outlined in the syllabus objectives for that reading.
  • Listen to the lecture taking any notes and fill in any gaps as quickly as you can.
  • Study your lecture on the evening after and repeat the above steps.
  • On the weekend, review the entire week's lectures with your main topic index next to your lecture notes. Answer the objectives out loud as you move along.
  • If you have difficulty with a topic, make an appointment with your professor and have a list of specific questions or things that you do not understand.
  • Try to organize a study group and meet together once a week so that you can test your understanding of the topics.
  • If old exams are available to you, look at how the material is tested but do not memorize the old tests. Your study group is a good time to review old exams.

If you fall behind, go immediately to where the class is and do the above. Do not try to catch up during the week and you may fall further behind. If you fail a test, let that material go and move into the next block with even more resolve. You will get another chance (during your USMLE Step I study) to review and go over the material that you didn't do so well on so let it go for the present.

Don't make the mistake of believing that every student is "getting" physiology except yourself. Many medical students have difficulty with this course. Physiology can be burdensome as it is presented within the context of the rest of your coursework which is demanding. If you are having difficulty make sure that you are in the professor's office during office hours and taking advantage of any tutorials that are available to you. There is always a course in medical school that is going to demand more attention at one time of another. It may be physiology this week but neuroscience next week and microanatomy the week after. Adjust your study up or down within the context of mastery of the material but do not neglect anything. Ask for help when you first think you need it and keep asking for help until you master the course.

Pay very close attention to the graphs and figures in your textbook. Often there are many nuggets of testable materials directly from these pictures, graphs and tables. Read the captions and make sure that you understand what is presented. Lecture the material back to yourself or make summary lectures/drill tapes (don't re-listen to class lectures) that you can listen to while you work out. Having a discussion with yourself is a good method of mastering physiology.

Your physiology textbook can be a great asset. The major texts are Guyton & Hall , West, Berne & Levy or Tanner & Rhoades. They are all comparable but Guyton is the master of cardiovascular physiology, West is the master of Respiratory Physiology and Berne/Levey are masters of pretty much everything else especially neuro. If your text is difficult to understand at first, stick with it before you move to an alternate text. (Consult your instructor on this). Sometimes difficulty reading a textbook happens because you do not have a purpose in your reading. If you use your syllabus to organize your material before you go to your reading, you have purpose in your reading.

In terms of review books, you need to thoroughly master your coursework before you attempt to review. That being said, Costanza, BRS physiology or NMS Physiology can been helpful if you are having difficulty seeing the big picture. Do not substitute a review book for your coursework. You have to learn your coursework before you review for USMLE but having a solid review book like Costanza can be an excellent adjunct to your daily work.

Finally, don't beat yourself up because you are stuggling with anything. Find any means that you can to get this material mastered within the context of your course. If Physiology is your "problem-child" at the time, give it more attention on the weekends but do not neglect your other courses during the week. Keep up with everything and organize, organize and do more organization. Time-management and organization are always the keys to the mastery of anything in medicine. Don't talk yourself out of getting this subject matter under control. In the long run, you will find that a bit of struggle makes you that much stronger overall.

15 March 2007

Biochemistry Revisited

I thought I would spend a bit of an essay discussing the nuts and bolts of Biochemistry. This class is usually taken along with Gross Anatomy and thus it can be a problem for some students.

My prevaling theme in all medical school classes is to keep up with the material. I cannot emphasize this more because good medical students find themselves failing because something (illness, family illness, emergency) interferes with their studies and they fall far enough behind and are unable to catch up or keep up. Biochemistry can be one of the most "unforgiving" courses if you fall behind. This class ranks right up there with Gross Anatomy in terms of volume of subject matter. It is vitally important that you do everything that you can, not to fall behind. If you do fall behind, you must catch up the very next weekend. Again, weekends are catch up days so don't use weekdays to catch up. Go immediately to where the class is and keep moving until Saturday.

Biochemisty is the "chemistry " of large molecules. These molecules are proteins, lipids, carbohydrates and nucleic acids. Since you are dealing with chemistry, you have to remember the subject matter of chemistry. This includes polar versus nonpolar, molecular shape, molecular funtion and chemical reactions. Most of the biomolecules are composed of carbon, hydrogen, oxygen and nitrogen and thus you need to be fairly familiar with the chemistry and characteristics of these elements. You also need to be familiar with the effects of water, pH and electronegativity. Throw in some enzyme kinetics and some equilibrium chemistry and you have the basis of biochemistry. The rest is application of the above characteristics and principles.

Biochemistry is NOT organic chemistry though we are a "carbon-based" life form. You need to understand carbon in terms of its covalent bonding and simularity in electronegativity when it is hooked to hydrogen but get rid of sp3, sp2 and sp1 bonding, free radicals and all of those synthetic schemes that you memorized in organic chemistry. In biochemistry, you are studying how reactions take place not why these reactions take place. They are already there but you have to put them together. Most of the reaction pathways in biochemistry involve hydrolysis, dehydration, hydration, oxidataion and reduction. You also need to know enzyme catalysis and you will be largely set.

Carbohydrates are polyhydroxy (poly alcohol) aldehydes and ketones. Amino acids have the amino and carboxyl characteristics (weak acid and base) and nucleic acids are based on their sequences, formation and degration. Lipids are non-polar and thus have the simpliest chemistry and function. That's the essence of the biomolecules.

Now all of these biomolecules have pathways, locations and functions. You can sit down and rote memorize the pathways but it is far more effective to ask yourself, "What are the substrates of these pathways?" "Where is the pathway located?" "Why does the body need this pathway?" and finally "What are the products of this pathway?" From that lauching pad, you can look at the individual reactions and enzyme characteristices (oxidation, reduction, hydrolysis, hydration, dehydration) and figure out where the regulation points are found. "Is the body building up a macromolecule?" or "Is the body tearing down a macromolecule for storage, ATP production or production of reducing equivalents?".

Other subjects of biochemistry are signal transduction pathways, hormones and functional characteristics of important molecules like hemoglobin, collagen and elastin. You will also study post translational modifications of proteins and how these relate to their function. Always remember to link structure with function when you are studying macromolecules. Think about glycogen and its function as a storage form of glucose. Glycogen is made up of multiple molecules of glucose and thus the pathway for its formation and degradation is going to involve glucose molecules. You need to know where other sugars feed into this pathway (where they feed into glucose metabolism), etc. You need to know where glycogen is stored (muscle and liver) and what the regulatory points of glycogen synthesis and degradation are. After that, you can look at the individual reactions of glycogen synthesis and glycogen storage in relation to the regulatory points of each pathway.

Bottom line for biochemistry is that you need to see the "big" picture and fill in the details. Never lose complete sight of the ultimate reason why you are studying the details. This is why my method of scanning the syllabus at the beginning of the semester (gives you an overview of how the course is organized), pre-viewing the next days lecture and reviewing the previous day's lecture before you study and learn the present lecture is very important. Again, you have to organize the material so that you can learn it efficiently.

Finally, a good review book like Harvy & Champe's Biochemistry is good to have but it cannot be the major source of your study. The best use of this book (also known commonly as Lippincott's Biochemistry) can help you summarize things or put things together but cannot substitute for your class notes or text book. Review books do reviews and you cannot "review" what you have not "learned " in the first place. Don't make a major mistake of believing that you can memorize a review book and that is what you will need to do well in your coursework. Review books can be good adjuncts to study but cannot replace your text, syllabus and notes. You can use your review book as a means of pre-viewing your lecture but your syllabus and the objectives that it contains are you guides in mastery of the material.

There are loads of new terms that will be introduced to you in your medical biochemistry course. You do not need to have taken undergraduate or graduate biochemistry before medical school. If you have throughly mastered your undergraduate pre-med chemistry coursework (that is general chemistry and organic chemistry), you have more than enough tools to master medical biochemistry. Do not fall into the trap of taking an undergraduate biochemistry or graduate biochemistry course unless you have plenty of time to master these courses or a passionate interest in the subject matter. If your medical school requires undergraduate/graduate biochemistry, then you have to take the course to meet a pre-req but most medical students are able to do well and pass this course without a previous biochemistry course. Also, most organic chemistry texts contain a very nice introduction to biochemistry that will get you on your way.

Do not fear Biochemistry because like the rest of medical school, its mastery depends more on organization and diligent mastery. In that first week (as soon as you get the syllabus in hand), start making out your study schedule. Never go to class unprepared (you can at least skim the syllabus) meaning that you know what the important points of the lecture will be and you know what is in the book so you are not trying to listen to the lecture cold. Don't forget to review the previous lecture (you have already studied and learned it at this point) before you tackle study and learning of the present lecture. A review book is an adjunct to your lecture material and not a substitute. Use a review book to review and supplement your class lectures if you like.

10 March 2007

Gross Anatomy

I thought I would write a short essay about my experience with Gross Anatomy class when I was in medical school. This class can cause some angst and turmoil for some freshman medical students because it generally requires the greatest adjustment in terms of study skills and habits.

First of all, Gross Anatomy does not require any great feats of intellectual insight. The material to be mastered takes diligent and systematic study. In short, there is NO substitute for just grinding through the process and taking the time to organize the material for study. At my school, Gross Anatomy also included Embryology which, made Gross Anatomy (GA) far easier to organize in my opinion.

During orientation, we were given a huge syllabus complete with objectives, lecture schedule and lab schedule arranged by topic. We were also given an exam schedule which allowed us to know exactly how much material each exam would cover and when the exams would be given. The breakdown was along the lines of Exam 1 - Extremities and Back Muscles, Exam 2- Thorax, Abdomen and Pelvis, Exam 3 - Head and Neck. This division made sense because dissection and study of the Back Muscles and Extremities requires far less manual precision than dissection of Head and Neck Structures. By the time we reached study of Head and Neck, we were old "pros" at dissection and finding structures.

My best tools for study of Back Muscles and Extremities were my embryology book and one of the skeletons. Our anatomy department had loads of bones and skeletons everywhere in the gross lab. My first approach was to sit down with the syllabus and look over what would be covered in lab and lecture. My next approach was to skim the material in the syllabus looking carefully at the objectives. This usually took less than 15 minutes tops and I was on to the reading making notes in the margins of the text that corresponded to material that was mentioned in the objectives.

My GA textbook was Moore's Clinical Anatomy for Medical students. I had the binding removed from this book so that I could place the reading pages in a three ring binder. I always had something readily available for reading. My next step was to photocopy or scan the Netter plates that corresponded to the lecture that we would be covering. I would note with a pink highlighter, any structures that were mentioned in the syllabus. That was my prep for each lecture. After hearing the lecture, I would study my notes (or the noteservice notes) and do the same prep for the next lecture.

In prep for lab, I would take out my dissector and make a check sheet of every structure that were expected to observe in lab. I would organize them according to superficial, deep, nerve supply and blood supply. When it came to the muscles, I would list every origin and insertion and action on a sheet with a check list. Before I began dissection, I would visualize them on a skeleton and visualize the actions. I learned the nerve and blood supply at this point too. For example, let's say that I was looking at the muscles of the back. My first task was to organize them into extrinsic back muscles (associated with the movement of limbs) and intrinsic back muscles (associated with movement of the spine). I would then organize them into superficial and deep layers.

My coverage of the anatomy of the back would have started with organizing the anatomy into surface anatomy (my fiance was a willing model for this stuff), bony anatomy (learning all of the vertebral bones), spinal cord anatomy and then the back muscles. Associated with all of these lectures were embryology lectures on development of the muscles, bones and nerves. But back to the my organization scheme. The embryology lectures took place before dissection so that we had that background before moving into the lab.

Let's say that today's lecture included the muscles of the back. I would have my Netter plates (with annotations) and my key words from the objectives in my folder for that lecture (the material that I had prepared the evening before). I would listen to the lecture taking notes as I needed them and adding notes to my plates or on paper. We would then head off to the lab where I would look at the skeleton and trace out every origin (medial attachement) and insertion (lateral attachement) for each of the back muscles. Lets look at the Latissimus dorsi for a specific example. The medial attachement is the spinous processes of the six most inferior thoracic vertebrae and the lumbar vertebrae, inferiorly: the iliac crest and the thoracolumbar fascia and the inferior 3 to 4 ribs. This muscle inserts on the floor of the intertubercular groove of the humerus. By locating the origins and insertions of a muscle, I would be able to picture the action of that muscle as it contracts. In the case of the latissimus dorsi, I knew for sure that this muscle was not an intrinsic back muscle but functioned primarily on the humerus (an arm bone).

I would also learn the blood and nerve supply as I studied the skeleton. The nerve supply is the Thoracodorsal nerve which can be found heading through the axilla and to this muscle. One of my instructors like to say that the extrinsic back muscles "crawled out onto the back and took their blood and nerve supply with them". This statement easily explains why the thoracodorsal artery is a distal branch of the axillary artery and that I could trace the small branches on the anterior surface of the latissimus dorsi muscle back to the distal part of the axillary artery which is a continuation of the subclavian artery. The nerve system is the same as the thoracodorsal nerve is a branch off the posterior cord of the bracheal plexus which travels to the LD muscle that is located on the posterior, inferior portion of the superfical back. In short, by organizing the material before heading into the dissection lab, I knew where to look for nerves and vessels; the actions of the muscle and bony landmarks all at the same time.

My GA class also required that we study radiographs, CTs and MRIs in addition to our dissection. I studied the available materials along with my dissections. When I came to the dissection lab, I had a checklist of all of the materials that I wanted to review and master. I can tell you that I was in the dissection lab at least 10 hours per week outside of the dissection lab times. On the weekends, I would review the week's materials which usually took three or so hours. This study was done with my study group. I also looked at every cadaver in the lab weekly in addition to my own. We kept a running list of excellent dissections (more likely to be tested) at different tanks. We always asked permission before entering another group"s tank.

Another thing my study group did was ask one of the instructors (usually the course director) to spend 30 minutes quizzing us a week before the lab practical. He was totally willing to work with a five-student group. We asked him to be picky and brutal. Usually these sessions made us go back and work a bit more on our identification of structures. Our instructor was very good about telling us how to identify structures on a lab practical. He always liked to show us great landmarks.

The most important aspect of GA study (any course study) in medical school, is not to get behind. If you miss something (illness) you need to go immediately to where the class in and catch up on the weekend. Some students get behind and attempt to catch up and never get there. Again, catch up on weekends (they don't lecture on Saturdays and Sundays). Also, don't underestimate how much your classmates can be great resources for you. I never found a classmate who wasn't willing to review structures with me in the lab. The biggest gunner gets an extra boost by helping classmates who are struggling. Everytime I reviewed something, I learned it that much better.

Some caveats: You cannot organize the material for your classmates. Each person has to find their own system and each person has to learn the material for themselves. Working with a study group helps to reinforce the material but each person is responsible for their own learning. Don't even try to work with a group until you have done a thorough mastery of the material for yourself. If you are isolated, you lose out on the great reinforcement so don't isolate yourself. If you have a family and other outside obligations, schedule some study group time even if it is minimal. Medicine is not a solo activity and you will have to rely on your colleagues when you are in practice. Medical school is good practice for learning to work as a group.

Well, the above is the essence of my system for GA and embrylogy. I can tell you that I spent plenty of time in the Gross lab and working on GA. It was interesting and it helped me appreciate my classmates even more. We all worked together and we all learned together. GA is not a course that you can sit down, memorize and master in a vacuum. You need feedback and your instructors/classmates are great resources. While there is much to learn and master, it's not all rote memorization. My classmates that were great rote memorizers did fine on the tests but crashed on USMLE Step I in most cases. The understanders and intergrator (like me) did equally well on the exams and on USMLE Step I. It takes both.

I would also say that GA is not a course to be feared but a course to be mastered. A full 75% of my class failed the first GA lecture exam but only about 2 people failed the course itself. In most schools, you are not penalized for getting off to a slow start as long as you figure out what you need to do to get your information mastered. For me, GA was daily study, preparation and mastery. I also forged a great relationship with the GA instruction staff (I was the class rep for this course) so that we all could do our best. The instructors were not there to "fail" us but to help us master this neat course. In the end, it worked out fine.

07 March 2007

As Match Day Approaches...

The residency interviews are over and you have submitted your Rank List to the NRMP. If you have been fortunate as I was, you have been guided along this process by more senior medical students and/or a good faculty advisor. In any event, at this point in the process, that is less than a week to the point where you find out if you have matched or not, you are nervous but excited; depressed but hopeful; and a couple of hundred other emotions that fit the situation of having your immediate future in the hands of a computer.

During your third year of medical school, as you moved through your clinical rotations, you should have been collecting your letters of recommendation from your clinical preceptors. At my medical school, these letters were sent to the Dean of Students for inclusion in your file and made available for you to designate when you filled out your ERAS application. (ERAS is Electronic Residency Application Service). It was up to you to ask for the letters and up to you to make sure that the letters were in your file by the appropriate deadlines.

I had the added advantage of making sure that my personal statement, CV and letters were done very early. I had to apply for one of my away-rotations which had an early deadline. This rotation application needed the exact same content as my residency application so I was done long before I needed to be done. My application for this away rotation netted me a full-scholarship to cover travel costs and housing costs at my rotation location. During third year, investigate some possible away rotations that have scholarships attached. This does cut down on expenses during travel season.

As Match Day approaches, there is a tendancy to listen to all kinds of rumors that abound. Some people will try to say that you need 15 interviews in order to insure a match. If you are a marginal applicant to a competitive speciality, you might need 50 and still not match. If you are limited by geography and have a solid relationship established with a program, you actually only need one interview especially if you are a strong candidate for that program.

If you do not match, the Monday before Match Day, you will receive an e-mail that lets you know that you did not match. If you find that you are the recipient of this e-mail, you should contact your Dean's office immediately and find out what services are going to be availble for you during the Scramble.

The Scramble allows unmatched applicants to apply to any unfilled positions in any programs across the United States. In order to receive the list, you have to be unmatched, and in order to make sure that you application is ready to be faxed or e-mailed to programs with openings, you need to have all of your materials. You can print out a copy of your ERAS CV but you will need copies of your Dean's Letter and LORs which you should be able to get at your Dean's office. In addition, you need to have copies of your USMLE score reports and you need a copy of your personal statement.

A great advantage of being in your Deans office is that there are usually plenty of phone lines and fax machines available for you. If a program has an opening, they usually notify Dean's offices and your Dean can speak directly to a program director on your behalf. In any event, scramble from your Dean's office if at all possible. You can also find plenty of great classmates to help you man the fax machine and speak to program directors for you. (I helped a couple of classmates scramble and thus I learned loads about the process). Another advantage of being in the Deans office is that the Dean gets the unfilled list 30 minutes before it is available to the unmatched candidates. This gives you a 30-minute head start on getting your materials loaded in the fax machine and ready to go at nooon.

If you matched, you have to wait another three days to find out where you have matched. This can be more unnerving than finding finding out that you didn't match. On Match Day, many people have so much emotion pent up that they end up crying or depressed. I can tell you that as soon as you find out where you are going, you need to start looking for a place to live unless you have interviewed at places in the same location as your medical school and know that you don't have to move.

My medical school held a Long White Coat Ceremony on Match Day. On that day, we all received letters that told us where we would be going. At noon, we could open those letters and thus, we waited until everyone had letter in hand. We also received a Long White Coat with our names and the specialty that we had matched into. For some folks, they didn't know the specialty so they ended up with a nice long white coat that had their name and M.D. In any event, it was a great ceremony. We all open champagne and celebrated for the rest of the day. The first and second year students got the afternoon off so that they could participate in out fun too. I must say, that every year, I always enjoyed Match Day but I enjoyed it more when I was the "Matchee".

Match Day is a time of high emotions and expectations. It's far more charged than graduation day. On graduation day, everyone is just happy to have the whole situation over and done with. On Match Day, the anticipation is very high and we really do not know what to expect. The whole Match algorithm makes little sense and it is difficult to know why you ended up in the position that you ended up in. It's great to get your top choice but ask anyone who has scrambled and they will tell you that it is good to get any match at all. If you planned on going into a competitive specialty and found that you did not match, it can be pretty unsettling to end up in a preliminary position in a town or city that you did not plan to move to with the prospect of going back into the Match next year.

I have to say that going into the Match for fellowship is much better than residency. If I don't match into a fellowship, then I know for sure that I at least will be able to practice my specialty. It's a small victory but it's a victory.

05 March 2007

Interviewing for medical school

You have filled out that AMCAS or ACCOMAS application and you receive an invitation to interview from one of the medical schools that you have chosen to apply to. It has been a long wait but now you have moved closer to your goal by one step. Your next goal is to maximize your chances of acceptance now that you have received an interview.

First of all, you need to schedule your interview. Logistics should play a huge part in this process. Don't schedule a medical school interview during exam week at your undergraduate institution. You will be under stress to do well on your exam and you don't need the added stress of an important interveiw to add to this mix. Don't schedule a medical school interview if you have planned any major dental or medical work either. You do not want to show up for an interveiw with cheeks that look like a chipmunk or not being able to speak clearly. Try to keep your major dental/medical procedures away from interview season.

You need to look at your means of travel to the interview site. My rule-of-thumb is that you should not drive unless the distance one-way is less than 100 miles. If the distance is between 100 and 200 miles, you should plan on taking a bus or train. If the distance is more than 300 miles, you should fly. If you have a driving trip of more than 100 miles, you will have more than 2 and 1/2 hours in the car with this trip. Even under the best of traffic circumstances, you may experience delays due to construction, motor vehicle collisions etc, that greatly add to the stress that you are already under. If you have the option, drive to the interview site the evening before and stay overnight.

If you are taking the bus, train or plane, you should definitely plan on an overnight stay. While the expense of a hotel room adds to the costs of application, this is money well spent. If you arrive the evening before, make sure that you KNOW the route to the interview location. Do a MapQuest, MSN Maps or Google Map search (satellite photos too) and know the route from your hotel to the site. You also need to know how long the trip will take so that you can allow extra time for increased traffic (especially a problem in urban areas) and your cabbie getting lost. Pack your maps in your carry-on baggage so they will be with you.

If you make plane, bus or train reservations, be sure that you do not schedule your return trip so tight that you are rushed during the interview day. Walking into the interview site with the demands that you have to be done in time to catch a flight creates a very negative impression. If you end up having to stay an extra day, then you won't risk your career over an airline, train or bus schedule. Beware of discount air fares and scheduling. Put more laxity into your schedule not less. Again, know how long it takes to get to the airport, train station or bus station from your hotel or from where ever you are leaving and allow for things like "rush" hour or construction. (Boston & DC are notorious for these hang-ups).

If you did not drive and you have an extra day, you can use that extra day to unwind and relax. Even if you drove, it's not a bad idea to stay overnight, rest from the stress, take some extra time to look around the city and then drive home in the morning when you are rested, informed and refreshed. There is no substitute for keeping your mental health in order throughout this process.

Once you have decided on your transportation, decide on your attire. Your attire should be business attire. This means suit and tie for men and professional (suit, business dress or pantsuit) for women. Women should wear no heel higher than 1 and 1/2 inches and shoes should be well "broken-in". Most interviews involve a walking tour which becomes downright hazardous if you are teetering around on 3-inch heels. Use a check-off list as you pack and don't forget things like small stud earrings (for women), nice conservative cufflinks for men, clean hankerchief and conservative tie. (Men-take the diamond stud out of your ear; women-no dangly earrings and take the stud/ring out of your nose) For both, get rid of the tongue ring.

If you travel by air, curb/runway check your interview suit. This means that your garment bag will go in the plane just before you get on and will be waiting at the entrance of the jetway as you get off. DO NOT "counter-check" your interview attire and do not crush your suit in a small carry-on bag. You may find that you cannot remove wrinkles if you stuff your suit into anything. Carefully pack your entire outfit (use a check list), toiletries in doubly-wrapped small containers placed in a toiletries bag and an extra shirt, underwear and socks into your garment bag. You can pack a separate bag with fitness clothing, travel clothing etc. Also, check the airline regulations in terms of what you can pack and carry on.

You should travel in the most comfortable clothing possible. For me, that is jeans or scrubs, running shoes and a T-shirt. Your interview clothing should NOT be your traveling attire even if you are making the drive to the site in the morning. You should arrive, change into your suit and then attend your interview. Nothing can ruin your day like spilling coffee or dripping something onto your interview clothing. You can also scuff your shoes if you drive in them. Again, if you can arrive the night before the interview, you will have plenty of time to make sure that your suit is pressed, clean and ready to go.

Men should be well groomed with beard or moustache neatly trimmed. You should invest in a professional haircut or style (if you wear dreds, pull them back neatly). You should NOT wear any cologne as your interviewer may be allergic. Use rubbing alcohol or ice-water if you can't live without aftershave. Make sure that you have no dandruff flakes or lint on that nice conservative suit.

Women should have a conservative hair style. If you have hair that reaches your collar, put your hair up. While three feet of hair may be your signature, fussing with it on an interview makes you look instantly unprofessional. If you have braids or dreds, pull them back and get them off of your collar. If you wear a head dress (for religous reasons), then make sure that it is neat. As I said above, no dangly earrings, nose rings or tongue rings. Try to make sure that your tatoos are covered. Keep your hair out of your face (get a good cut or style) and don't fuss with your hair. Nail polish should be a conservative color (not black) or clear. Keep rings to a minimum along with other jewelry. Watch, conservative earrings and wedding/engagement rings are enough. Keep the cologne to a minimum (none is best), keep make-up to small amount of foundation, powder and lipstick with NO eyeshadow or mascara). Check your make-up in front of a window in daylight. If you can see make-up, you are wearing too much. Also, put on your makeup before you put on your blouse. Makeup is difficult to remove from a white blouse or shirt. Don't wear a short, short skirt that shows too much when you sit.

Things to bring with you: A COPY of all correspondence that you have sent this school. If anything is missing, you can provide your return receipt and your copy. A copy of your personal statement and secondary - often interview questions will come from these documents. Bring these items in a folder along with an index card where you can write the names of anyone (office staff, dean of admissions, interviewer etc) that was especially helpful to you for thank-you notes. You should write your thank-you note to the Dean of Admissions with courtesy copies to everyone who helped you out on interview day especially current medical students and office staff.

Also, as I mentioned above, place your Driving Directions from hotel, your index card, your documents, your tickets, your hotel reservation confirmation numbers and any other vital information in your folder which you will carry in a portfolio or case. Include any important phone numbers on this folder such as Number to the Office of Admissions (you can call if there is an emergency delay), number to the hotel etc. I also liked to place a schedule of the day, if you have received this information. For most schools, you can download a campus map (great for getting around) which should be in your interview day folder.

When I arrived at the medical school, I went to the ladies (mens) room, checked my shoes, checked my hose and popped in a breath mint (no gum please). I also checked back and front of my suit, checked my make-up (just a bit of powder and lipstick). Do a last minute check of the hair and head into your interview confident and energetic.

Be early, I repeat, be early. This is not an interview to be late. If the school is late, be early. Rushing into an interview looks unprepared and very unprofessional. Be cordial to your fellow interviewees and to all staff (especially the cleaning personnel). Hold doors for people who come in behind you. Guys do not need to hold chairs for women but holding a door for anyone is just common politeness. Don't forget to speak to everyone but don't be "overly" friendly or formal. Your fellow interviewees are not your buddies nor are they your competition.

Nerves are very much a part of this process. Another good reason for arriving at the interview the night before, is that you can go down to the hotel's fitness center and "work off" some of your nerves. Don't let your nerves cause you to: chatter too much, bite your fingernails, fuss with your hair, chew gum, constantly clear your throat (get a sip of water if all of your saliva is drying up) or get depressed. A small amount of stress can make you appear energetic but too much can make you appear frantic. Before you leave home, look at yourself sitting, standing and walking. Observe how you hold your head, hands and shoulders. Guys, do the old "anchorman's trick" and pull your suit jacket down so that it doesn't ride up at the shoulders when you sit down. Practice calming yourself in front of the mirror.

Don't eat or drink anything that has the potential to spill. If you are ravenous, have breakfast before you leave the hotel so that you are not covered with powdered sugar from the donuts when you enter the interviewers office. Avoid coffee or if you must have coffee, fill the cup half-full and be very, very careful. Avoid spaghetti or foods like fried chicken, that must be eaten with your hands. Avoid anything with spill potential. Check your teeth after lunch. You can always nibble at lunch and have a good meal on your own later after the interview. Avoid sugary sodas and energy drinks too. These can cause a caffeine/sugar rush followed by a huge depression if you over-indulge.

Your medical school interview is a time for the interviewer to get to know you. Your individual interviews will "sell" you to the rest of the committee. Don't make the mistake of trying to anticipate what you believe the interview "wants" to hear. Answer each question truthfully and carefully. Take your time and don't blurt out anything. BE sure to shake hands with the interviewer upon entering the office (unless you have been greeted elsewhere) and when you leave. Make eye-contact and don't be put off if your interviewer is rude or rushes. Being able to redirect is a good characteristic. Redirect if the interview gets off course.

When your day is done, try to relax. Resist the urge to re-play the entire interview in your mind. You are far too subjective to have good recall and you always have the tendancy to believe that the interview went worse than it actually did. If you are taking a plane, train or bus, you can relax and enjoy the scenery. If you are driving, relax a bit before you drive home. Even better is to change into your comfortable traveling clothes and relax before attempting to drive home. Don't drive home in your interview suit (you may need it for your next interview). Be sure to prepare for the weather where you will be interviewing by checking Accuweather http://www.accuweather.com any other national weather service like The Weather Channel.

On a final note, if you are staying with a student host, bring along a small gift. This can be Starbuck's gift certificates, Bed, Bath and Beyond gift certificates, any restaurant chain gift certificate or something small for the house or apartment. (Remember that they are saving you to cost of a hotel room so make the gift of appropriate value.) Bring your own towels and soaps and clean up after yourself. Check your host's schedule and make sure that you do not interfere with their study routine. Offer to take them to dinner or breakfast if possible and be sure to write a "thank-you letter" (with a courtesy copy to the Dean of Admissions). Do not expect your student host to entertain you but you should have some questions for your host and ask when they have a bit of time to answer them. Plan on providing your own transportation to and from the interview site, the airport etc. It's nice if they offer but don't plan on your host being your cabbie.

Finally, enjoy your interview. This is an opportunity for you to get the "feel" of the medical school. Take some time (outside of the interview day schedule), walk around, talk to students and get the feel of the campus. Are there plenty of safe and comfortable places to study? Do the students have social events? Do you NEED a car? Where do students live? Find out what you need to spend three years (fourth year is often away electives) in this place.