Tag: psychiatry

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How To Prepare for Intern Year of Residency

One of the most frequently asked questions that I receive from medical students is about how to prepare for their first year of resident. It parallels one of the most common fears among medical students in that they will not be adequately prepared for day one of residency. It’s a valid concern because you will never truly be ready for intern year but if you’ve made it this far in your training then you are likely ready enough. Almost everything you learn intern year isn’t taught in medical school because you have to do actively do it to learn it. At least that’s what I thought until I came across OnlineMedEd.. It’s the only resource I’ve found that actually prepares medical students reasonably well for intern year. Again, nothing is going to make you fully prepared but this is as close as you’re gonna get.

 

I started using OnlineMedEd during third year of medical school

OnlineMedEd is an amazing resource with videos that help explain complicated topics that overlap real world experience with the textbook. They do an amazing job of translating all of that USMLE step 1 material into actual practical knowledge so you can look sharp on all of your third year rotations. I would watch a few before each rotation started and it showed. Dustin and the OnlineMedEd team also drill home all of the important facts that are frequently tested on step 2 CK. Sure, nothing will ever replace UWorld but OnlineMedEd gives it a run for it’s money. Start using OME early and often.

 

A curriculum for fourth year medical students

Your fourth year of medical school is a magical time especially after interview season is over and your rank list is finalized. You’re basically just waiting to graduate and planning your vacation to South East Asia. It is all to easy to fall into a trap of laziness and forget that you are going to be a full fledged doctor in 6 short months (well technically you’ll be an intern but a doctor nonetheless). If you dedicate yourself to the structure of OnlineMedEd during your fourth year you will have a dedicated curriculum that keeps you fresh and sharp on the wards. Sure, you’re still gonna forget a lot before intern year starts but at least OnlineMedEd will get you into some good habits.

 

It prepares you for intern year

My advise to all of my fourth year medical student is always the same- go home because life is too short to be spent in the hospital watching me type notes and at least one of us should see the sun today. I also tell them that the best way to be a good intern is to develop good habits while you are still in medical school. The dirty truth about residency is that you don’t need to be all that intelligent to be a good intern. You simply need to be efficient, thorough, and work hard. The sooner you develop habits that enable you to work smarter, and not harder, the better off you will be. OnlineMedEd has developed a fantastic Intern Boot Camp that helps you do exactly that. If I could do my fourth year all over again I would use the Intern Boot Camp and test out what does and does not work for me while I was still on the wards in the hospital. That way when I show up day one of residency I at least had a system that I knew worked for me. It’s like when I had to learn how to actually study in medical school- I wish I didn’t have to go through the process of figuring out what works best for me. I wish I knew how to study more efficiently back in undergrad. Likewise, take the time to learn the ropes of what it takes to be an intern while you are still a medical student.

 

Start studying for step 3

Ugh I know. Sorry for bringing up the USMLE’s again but you have to get it over with eventually. I’ve written extensively about when you should take USMLE Step 3 as well as how to study for USMLE step 3. If you use OnlineMedEd during your fourth year of medical school you will get a head start on it. You don’t need to use OnlineMedEd as your primary study aid but it will certainly help cement concepts in your head and make it easier for you once you start your dedicated step 3 study period as you transition from medical student to resident.

 

They also have great study products

Last thing I’ll mention are their study aides. The Intern Guide Book and the Quick Tables Book are great study tools for medical students. They succinctly provide you with a ton of well organized material. You have to fill in the blanks and annotate it just like any guide book. But if you are going to use OnlineMedEd then these books are essential as they go hand in hand with some of the videos. Just like any resource, the more you use it the more results you get from it!

 

So if you are interested in using OnlineMedEd check them out here: OnlineMedEd.

 

*Full disclosure: sponsored content. That being said, I only support brands that I believe in.*

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What happens when you don’t match

What happens to medical students who don’t match? Here’s what one unmatched psychiatry applicant had to say.

 

Thanks for letting me interview you Steven. You have a pretty unique story that my readers would love to hear about but before we delve in can you tell us a little bit about yourself? Who are you professionally? Did you go straight from undergrad to Ross? Who are you outside of the hospital?

My pleasure, Marc. I appreciate the opportunity to share my story as I feel people can learn from any experience in this process, both good and bad. I graduated from NYU in 2010 with a Bachelor of Arts in Mathematics. After graduation, I had about six months before starting with Ross University’s MERP (Medical Education Review Program) and I knew I needed to make money. So I took a job that any medical school bound person takes – working in the jewelry and diamond industry. I did mostly bookkeeping but I also prepared orders for a wholesale company that dealt with Macy’s, JcPenney, Sears, HSN, QVC, etc. It taught me a lot about dealing with large staffs and it was a nice break away from the science and math world I had spent so much time with in undergrad.

Professionally, I’m the one making jokes in the office but I focus on the patient when I’m in the room. I like to be a reason people enjoy coming to work, because they know it’ll be fun and productive. On the same token, I’m also someone who isn’t afraid to call someone out for their BS because I expect someone to do the same to me if I ever act out of line. I also am one of the first people to teach someone how things run in the office, how to order labs, do procedures, etc. Not only do people feel comfortable if it’s a peer teaching them but it helps me better my skills as well.

 

 

What specialties did you apply for? How many programs in each specialty? What was your reasoning for that number of programs?

I applied to psychiatry, internal medicine, and internal medicine-psychiatry combined. For psychiatry, I applied to 76 programs. For internal medicine, I applied to 10. And for IM-psych, I applied to all 9 programs in the country. My step scores weren’t that competitive and there are only 196 psychiatry programs in the country. I went through each program on FREIDA and checked to see if I matched their step requirements. If I did, I tried to see who the residents were. If there were zero or one Caribbean grad in all the PGY positions, then I didn’t apply as I felt that that one particular Caribbean grad may have had a connection there or had stellar scores. Plus, why would I spend money on programs that were going to outright reject me?

For IM, I applied to where I had rotated and since I could apply up to 10 for one fee, I applied to some hospitals in the NY/NJ area (which is where I’m from). And for IM-psych programs, there were only 9 so it made the most sense to apply to all of them.

 

 

How many interviews did you end up receiving? How did you feel your chances were at matching?

Formally, I received three interviews, but in total, I ranked four positions. I received 2 for psychiatry and I was taken off the waitlist for 1 IM-psych program. All of them were university-based programs. At the IM-psych program, I had mentioned that I had also applied for a psychiatry categorical position at the same place and I wanted to know if I had to come back for another interview, which I was totally willing to do. Ten minutes after that mini-interview, I had an impromptu meeting with the program director of psychiatry and she told me that she will see what the other four interviewers had to say about me from that day and she would let me know if I needed to come back or not. Two weeks later, I’m notified that she had enough to consider me for a position. Throughout the next two months prior to match day, I had received several emails about how the psychiatry program is expanding and there’s new facilities and all these wonderful things. I didn’t think I was a shoo-in but I felt that maybe I had a great shot.

 

 

So, it’s Monday, March 14th. The day applicants find out if they matched. You open the e-mail and find out that you did not obtain a residency. What’s going through your head?

Before that day, I told myself whatever happens, happens. I actually slept well the night before! I was driving in Fort Lauderdale and taking care of some errands and I happened to look at my phone. For five seconds, I was completely numb. And then it hit me. My biggest fear came true. All that work, all that money, all the stress, and for what? Nothing.

*cue Kim Kardashian ugly crying*

I can honestly say that it is one of the most devastating experiences and I would not even wish it upon an enemy. The e-mail just says “you did not match”. Not even a “good morning” or “hey girl!” Just one line that says you’re not good enough to continue in your career. After quickly doing my errands and a few snot-filled tissues later, I sped home passing several cops on the way and began on SOAP.

Most of us aren’t familiar with the SOAP, or the Supplemental Offer & Acceptance Program. Can you walk us through your experience with it? (Here’s a link to the SOAP schedule for my readers)

SOAP is a chance for unmatched applicants to apply to unfilled spots in all fields of medicine. However, this means that you will have to come up with new personal statements in the matter of hours, which is exactly what I had to do for family medicine. As Markus said in a previous posting, the website was down and no one could send in applications (because like LOL, heaven forbid the ERAS website works when it needs to).

I spoke with a friend who match into IM the year before through SOAP and she guided me through the process while she was at work. She told me to apply to the IM prelim, IM categorical, and family med programs that had the MOST open spots. I had only 45 spots to pick from and I used 5 of them on psychiatry programs that were unfilled. Then I went through family medicine and internal medicine. In retrospect, I could’ve used those 5 on family medicine or IM spots but what’s done is done.

 

 

So on Monday you found out that you didn’t match. Then during the week you went through the SOAP.  Friday comes along and you find out that you didn’t SOAP into a residency. How did that feel?

By that point, I had already gone through the five stages of grief. Denial set in when I was in the car. Then anger when I was cursing at anyone on the road that was slowing me down from getting home (which is what I do on a regular basis and I’ve been trying to work on but YOU try driving on I-95 in Fort Lauderdale and Miami and tell me you don’t have road rage, but I digress…). Bargaining was SOAP. Depression set in when the 5th round of SOAP happened and I hadn’t received any offers. It continued for a week when all I saw on Facebook were my friends posting that they matched at their number one or number two choices. It wasn’t that I wasn’t happy for them. Every single one of us had a unique journey and even the people I didn’t like, I respected them enough in a professional sense to be proud that they get to continue their journey. It was more about the fact that I didn’t get to continue my journey with them.

Several months had passed and I hadn’t reached the acceptance stage of grief. It wasn’t until I went to the AAFP National Conference in Kansas City at the end of July that I had realized that I had been in the wrong field all this time. I realized within the first hour of the conference that I had such a wrong idea as to what family medicine and primary care entailed. There are so many opportunities for me as a family medicine doctor, whether it be to provide medical care for a whole family, work as a hospitalist, deal with mental health issues, or even perform procedures. After I didn’t match, I had told myself that something big was in store for me, and I finally believed it. Networking at the expo hall with the residency programs made me realize that I was a perfect fit for family medicine and that there are programs out there that WANT me. As I’m writing this, I can definitely say that I wasn’t supposed to match into psychiatry because I realized that I was meant to match into family medicine (I’m hoping). It feels good to be in that acceptance part of grief!

 

 

Why do you think you didn’t match? What were your step scores? Was your application particularly weak in any one specific area?

I had thought about not giving exact numbers here, but in all honesty, who cares? Step 1 was a 208, and step 2 CK was a 209 (yes, the EXACT passing score). Step 2 CS was a pass and everything was on the first try. I expected my Step 1 score but my CK was an absolute miracle. I had worked harder for CK than I did for step 1 and yet, I was not getting anywhere with my studying. I took a UWorld assessment two days before just to get more questions in and I had about 179. So in two days, my score JUMPED 30 points. (This is NOT a plan I recommend to ANYONE, by the way.) I know I’m a terrible test taker and that in rotations, I shined and my letters of recommendation reflected that.

In addition, I had failed one course in basic sciences, and THAT was a reason why a program didn’t take me. They were too worried that I may not pass step 3 (which I’ll go into below) and therefore, not be able to be licensed. However, my scores were good enough to get some interviews at university programs so I must have done SOMETHING right.

 

 

Do you think the fact that you attended a Caribbean medical school played a factor?

Not at all. The places I had interviewed at were very IMG friendly, as were the residencies I spoke with at the AAFP National Conference.

 

 

What do you plan to do while you wait to apply for the 2017 match?

I am currently a Clinical Teaching Fellow for Ross University. Some of my colleagues know it as “junior faculty” but teaching fellow is the formal title and you better believe I am using that on my CV. For those who don’t know what that is, my role is to act as a standardized patient for the incoming 3rd year medical students and assist other junior faculty in teaching how to handle difficult patients and certain common primary care cases, as well as how to begin to formulate an efficient style of medical interviewing. I also assist in Ross’s Ambulatory Care Competencies elective, where we prep the 4th year students for Step 2 CS by presenting cases and critiquing their notes.

Outside of Ross University, I tutor for Huntington Learning Center (which I have been doing since 4th year of med school), where I mostly do SAT/ACT math and high school subject tutoring in math as well. In addition, I’m getting my MBA in Health Services Management through Keller Graduate School of Management, which is one of the sister schools of Ross University. What’s great about that is that they have an “MD to MBA” program where I was able to get credit for 5 out of the 16 courses, so now I only need to complete 11 of them. In addition to working, I plan on taking Step 3 by the end of October. Needless to say, I only know one speed and it is full speed ahead.

 

 

How are you handling your loan debt?

Some of my loan debt could not be deferred or put into forbearance, so I have been paying that off. However, since starting grad school, I’ve been able to defer most of my loans while taking out more. Thanks, Uncle Sam!

 

 

What words of wisdom would you give to someone knowing what you know now?

Have plans A through Z ready to go from the jump. You don’t want to rely on them, but you want them ready if you have to execute them.

Go to as many networking conferences as you can. I know those things can cost money, but at the very least, go to the big ones run by the specialties to which you are applying.

But most importantly, it’s not a matter of “if” you become a resident, but rather it’s a matter of WHEN. 2016 was not my time and I realize that now. However, come 2017, I will be a better applicant and in a better frame of mind to continue on in the next chapter.

 

 

Thank you Steven for an informative and entertaining interview. I look forward to finding out where you match in 2017.

 

Next week I interview a Ross University graduate who matched into a categorical general surgery position. Be sure to subscribe to my blog, like me on Facebook, and follow me on Twitter so you don’t miss it!

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When will we start taking mental health seriously?

As a fourth-year medical student in a sub-internship in internal medicine, I have something that no doctor in America has. I have as much time as I want to spend with my patients. Don’t get me wrong, I am still a student. I’m still paying hospitals to let me be there, and I only have a maximum of four patients per day, but I inevitably end up spending more time with each patient than the average resident.

Today, I spent my time with one patient in particular. She was a Caucasian woman who was a previous intravenous drug abuser who has been sober for fifteen years. She is on methadone and takes Xanax for anxiety. She presented to the emergency department for a week of worsening malaise and generally feeling unwell. She also suffers from chronic respiratory failure secondary to chronic obstructive lung disease (COPD) due to her extensive cigarette smoking history.

We worked her up and ruled out pneumonia, a COPD exacerbation, urinary tract infection, an underlying malignancy, infection, or anemia. She was stable and not acutely ill, so we readied her to be discharged from the hospital. When we told her the good news, she broke down, cried, and begged us to help her. Not exactly what we were expecting.

She told us that she didn’t want to take the Xanax anymore. That she was becoming increasingly dependent on them. She understood that she was physically healthy but flat out told us that she was mentally ill. I remember she said, “It feels like something clicked in my head, and I don’t know what to do to get better. I just want help.” The problem was that she was physically healthy, wasn’t a good candidate to be transferred to the psych floor, and that she could simply follow up as an outpatient. She understood but was distraught.

“Please help me,” she insisted. I can see how more experienced doctors hate these types of patients. Previous drug abusers who end up in poor health and are looked upon as a succubus who drains the healthcare system of its resources. Occasionally however you find someone who just wants to get better. I believe, maybe naively so, that this was an example of the later.

At what point will sickness of the mind be treated equally as sickness of the body in our society and culture? There is a terrible mental health epidemic currently occurring in the United States, but the only thing I know about the problem is that we need to fix it. I believe that the first step that we as physicians, friends, brothers, daughters, and loved ones can do is to perceive and prioritize illnesses of the body equally to sickness of the mind. Maybe then we can start to take care of the patients who truly want to get better.

 

The original post was published on KevinMD.

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How to Study for the Psych Clerkship Exam

Psych is generally regarded as the easiest of all the shelf exams. That doesn’t make studying for it any easier. Here’s how I approached it and what I would have done differently:

Overview: There is always overlap when it comes to clerkship exam content. On the psychiatry shelf you will be tested on neuro, pediatrics, OB/GYN, and some internal medicine along with psychiatry. It’s annoying but it makes sense if you think about it. For instance, if a patient comes in with increasing forgetfulness your differential list can be quite wide. This being your psych shelf you might be anchored to a diagnosis like pseudodementia secondary to depression but you also have to think about Alzheimer’s and hypothyroidism.

Psych Specific Tips: Know the timeline for psychiatric illnesses cold. You need to be able to differentiate brief psychotic disorder from schizophreniform from schizophrenia based on the timeline. And acute stress disorder from post-traumatic stress disorder. And both of those from adjustment disorder. It seems easy and it is. But the diagnostic criteria and various timelines can blend together quite easily when you are taking a two hour hour test and each question has the same differential diagnosis list. Also, psych meds are huge on this test so don’t neglect them.

Resources: First Aid for the Psychiatry Clerkship is gold. It has everything you need for both the clerkship exam and step two. My primary resource when I studied for step two was Master The Boards (MTB) by Conrad Fischer. It provides a good skeleton but leaves you dictating a lot of stuff that isn’t in the book. If you know everything in MTB then you will likely know all the high-yield stuff. But it is entirely comprehensive. That’s why I suggest the First Aid for Psych Clerkship. And as always, UWorld is the gold standard for practice questions.

Practice Questions: As I said, UWorld is the gold standard. Finishing the psych section is doable. I would also attack the neuro section while you’re at it. If you finish all of that then redo all the questions you got wrong. If you finish those questions and want more I would next use PreTest for pysch. PreTest presents a lot of good information that isn’t in any review books (FA, MTB included) or even in UWorld. Granted, some of these questions are beyond low-yield and you should always know the basics inside and out before you delve into the esoteric. That being said, PreTest is a good resource if you’re looking for a couple hundred more new practice questions before test day.

tl; dr: Use First Aid for the Psych Clerkship, annotate Master the Boards, finish the psych and neuro UWorld questions…and basically just know everything.

As always, this isn’t anything groundbreaking but I wish someone told me this when I started psych. Feel free to leave any follow-up questions you may have down below!

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Now Is The Time To Develop Your Style With Patients

I’m thankful that my first rotation was family medicine out in Youngstown, Ohio. Youngstown is a small town halfway between Cleveland and Pittsburgh. Everything moves a little slower out there compared to what I’m used to in Brooklyn and Manhattan. Similarly, my family medicine rotation as a whole was slower and calmer compared to my other rotations. I didn’t see any emergency conditions or an excessive number of rare pathologies in the doctor’s office I rotated through. I saw routine diseases that affect the majority of Americans- hypertension, diabetes, chronic pain, concerning moles and freckles, so on and so forth.

While I was in the doctor’s office I didn’t necessarily learn about the pathophysiological mechanisms underlying these diseases. That’s not what my physician primarily taught me. I had to dedicate time to study that stuff on my own. Instead, my attending taught me the art of practicing medicine.

What still strikes me today is how well my attending knew his patients. He had entire families coming to see him. We would check grandma’s blood pressure, grandpa’s blood thinners, mom’s thyroid hormone levels, dad’s sugars, and give a vaccine or two to the kids and send them on their way with new scripts and clean bills of health. But he also knew which grocery stores had the cheapest, or sometimes free, medications. With a patriarchal nurturing tone, he would warn his patients not to end up spending too much money at the big chains because they often offered free or bargain-priced medications that a majority of their customers needed as a ploy to get them in the door. He reminded me of my dad telling me to behave before a night out with my friends after an exam.

And the sincerity was a two way street. On many occasions patients would offer my attending help repaving his driveway or moving an old tractor from a ditch with the same nonchalant manner of someone asking to please pass the water from the other side of the dinner table. It was like a tight-knit community out of a corny television commercial. I mean, I had always heard that people are much nicer in the Midwest, or just about anywhere outside of New York for that matter, but are people seriously this nice?

After my six weeks in Ohio came to a close I moved to Brooklyn to complete my third year rotations. I started with psychiatry. My first psych patient came to the office for routine pre-surgical clearance for a gastric sleeve operation. Most patients are required to start a weight loss regimen to help smooth the post-surgical transition and increase the surgery’s success rate. After I finished conducting my portion of the patient’s history, the patient and I joined my attending in his office.

My attending got up from his comfortable reclining padded leather chair that you would expect to find in a psychiatrist’s office and joined us on the other side of his desk. He moved the third empty chair and positioned it to make a small triangle with the patient and me before sitting down. He sat, paused, acknowledged both of us, and asked the patient how she was doing.

Our patient was excited that she was continuing to lose weight and my attending was proud of her too. You could feel that he genuinely cared. It was like they were gym buddies encouraging one another.

The patient was cleared for surgery leaving my attending and I alone for a few fleeting seconds before the next patient was called in. Without looking up from a paper on his desk he remarked, ‘By the way, I liked how you interacted with that patient”. Stunned, I kind of just gazed at him unsure if he was joking in the most extreme of sarcastic ways or if he was actually being serious. Realizing I should probably say something I finally asked him, “What do you mean? I didn’t say anything”. He answered simply, “Yes. But you listened very well”.

His comment made me realize that the warm comradery, earnest candor, and trusting temperament wasn’t unique to Ohio or to family medicine but is intrinsic to all high quality caring physicians. It allowed me to recognize the art of the physician as the exquisite ability to convey trust and compassion not only through what you say but how you say it. By using your eyes, your attitude, and your posture alongside what you actually tell your patient.

That art takes time and practice to perfect. There are physicians who have been practicing medicine for longer than I’ve been alive. Their ability to connect with patients and make them feel comfortable, safe, and heard is engrained in their routines through decades of practice.

As a medical student and future physician, now is the time to develop your personal style of how you interact with your patients. How do you want to be perceived when you walk into your patient’s room? How do you want to make your patients and their families feel when you discuss their health or treatment options? As a physician, how do you want to be remembered? These are questions that only you can answer but you can start figuring that out now. Actively observe how your attendings, residents, and even your peers interact with their patients. Mimic what you like. Avoid what you don’t.

Ultimately, how you interact with your patients is part of your style. It’s a reflection of your attitude and personality. It has the ability to affect the people around you, including your patients, and can be greatly beneficial, or conversely detrimental, to your career. So start developing that style now. And whatever you do, do it with confidence.