We have an amazing culture of teaching at Emory. The best part, though, is that not only do the faculty get really into it, we also pour an incredible amount of time and energy into building the most junior of our learners into teachers, too.
This photo was snapped during our resident conference yesterday. This particular session is a unique monthly lecture series where resident physicians are coached by faculty members to deliver high level, evidence-based lectures--but here's the kicker: They can only be 8 minutes long. We started doing this last year and it was an immediate hit. I think part of it has to do with young people just enjoying the inspiration of being taught by their peers. But also there's something to be said about somebody only talking for 8 minutes and that's it.
Of course, I had to come up with a witty title for the conference. We call it "BST Mode" (pronounced BEAST MODE)--short for "Bite-sized Teaching." My diabolical plot--of which BST Mode is a part--is to get us to a point where nobody ever lectures to anyone for more than 20 minutes. Okay, thirty minutes tops.
*insert wicked laughter*
The four residents were answering questions from the audience when I took this snap. It got me thinking about how critical of a skill the question and answer period is after a lecture. I've found that it can really make or break someone's merit at the end of a great talk. This fab four did great with theirs. That said, the nerdy teacher in me sees this as a great opportunity for some future focused teaching-learning-growing exercises. I like to think of it as "The Art of I Don't Know--But Here's What I Do Know."
Ha.
I love my job. And this is one of the main reasons that, even if I had won the Powerball, I'd be right here at Grady. (That is, after being dropped off by my personal Uber driver.)
Choosing a residency program is such a tricky thing for medical students. After working so hard, it only seems right to climb on what most would agree is the highest ladder rung attainable. In every specialty, certain programs at certain hospitals hold that distinction. Those sit high on shiny platinum pedestals far out of the reach of most. These are the ones that you utter aloud and immediately garner raised eyebrows. Not the suspicious kind but the affirming kind that say, "Daaaaaamn. It's like that?"
Yeah.
Honestly, I'm not fully sure how it all happens. And by "it" I mean a residency program becoming so sexy that everyone loses sight of the details of what really should be considered in such an important choice. The name flies so high like a gigantic flag in the sky that what it represents (or even if the place is right for a particular individual) becomes moot. Everyone wants to be down with them and thus, one of the cool kids. It isn't a far cry from middle school, actually.
Yeah. I said it.
In all fairness, I should say that there are sexy, platinum programs in every specialty that are perfect fits for certain folks and also ones filled with people dedicated to creating great learning and training climates. But I guess what I'm thinking about right now is this simple truth:
Just because a residency program, or even medical school, is the most recognizable and shiny on paper doesn't mean it is the very best one for you.
Nope.
I will never forget my residency application process. I'd done fairly well in med school and was a student leader. As an underrepresented minority to boot, sexy programs found me sexy, too. And I hope everyone is getting my use of that word--sexy. I mean it in the "it place" and "thing-of-the-moment" way. Not the Pretty Woman-knee-high-patent-leather-boots way.
Just saying.
Okay, so where was I? Oh. Yes. Me applying to residency. So yeah, I applied to these sexy places and they granted me interviews. I'd walk in and see how I felt and hope for something inside of me to ignite so I'd know. That was my experience with medical school and college. That "eureka!" feeling. But for the majority of my residency trail, it just wasn't happening.
Ugggh.
I was flattered by the number of interviews I received. I caught planes, trains and automobiles to places that any and every person, even the non-medical ones, would recognize when they saw the name. My chest would poke out a bit and my step would pep up some, too. And that? Yeah. That was cool.
The thing, though, was that nothing ever really stood out to me. I mean, the names sure did when I told people, but when I was in my quiet time, nothing else did. And here's the thing: I know I'm scrappy and that no matter where I went, it would ultimately be fine. But some piece of me kept hoping that "being fine" wouldn't have to be the goal. I wanted to be more than fine and I kept hoping that, just maybe, one of these places would blend the sexy with the tailor-made fit I was looking for.
It came to a head half way through yet another two day interview back in 1995. I was shuffling around in my taupe heels and feeling mostly "meh" about this program that I was supposed to be jumping for joy over. I smiled politely during the resident lunch and asked a few questions. But mostly I was lost in my own thoughts.
What was I looking for? I think up until that moment, I had only asked myself that in a general sense. Again, I was just aiming for the highest rung on the ladder; the places that would puff my parents' and my deans' chests out and garner the eyebrow raise of approval when spoken out loud.
Yep.
But in that moment, I realized that this wasn't enough. So I began to really, truly think about it. Finally, I distilled my needs down to seven critical things--the absolute essentials without which it might be a deal breaker. And in full transparency--NO, this wasn't written down in a journal back in 1995. But I did shift my thinking to reflect these things that I'm about to share.
Hand over heart.
My hope is that by sharing them, someone who is preparing to start this process for residency--or even medical school or a fellowship--can use them as a springboard to think of their own specific needs.
Oh, and spoiler alert: It probably isn't the stuff you think it is. Although hopefully after this it will be.
Like to hear it? Here it go.
Seven ESSENTIALS to look for in a residency program, medical school or fellowship program beyond just how SEXY the name and reputation are
Need #1 Genuine interest in me as an individual
No. Not the fake kind where you shake my hand and act all nice for a few moments. I needed to feel like someone there would be genuinely advocating for me, on my team and slugging it out with me to help me succeed. That would require time over time. Interest. Sacrifice.
Yes.
How could I tell? Well, for starters, the places where folks were genuinely invested in my potential there were prepared. It was obvious that at least someone in leadership had not only read but thought about my application and how I'd fit in. Some piece of my interview day was built with this knowledge in mind, too. They made eye contact with me and listened when I spoke instead of clearly calculating their next talk point during mine.
Yes. That.
We all know it when we feel it. And we all know it when it's absent. The key is just to not ignore the truth when someone is, well, blowing you off.
Need #2 A climate that won't force me to assimilate into someone I'm not
Look, y'all. I'm a black girl from inner city Inglewood, California. My high school was pretty much 80% African-American, 15% Mexican, 5% Pacific Islander and 0% anything else---and I attended both a historically black undergraduate college and medical school. Sure, I can speak standard English as well as the best of them and my fund of knowledge isn't or wasn't inferior to my non-black counterparts.
But.
By this point, I'd had 25 years of experience at being comfortable in my own skin. I am a woman who identifies with black culture and doesn't pretend it doesn't exist. I'm down with celebrating all that is you but don't really see the need to downplay my own identity in the process. And I learned quick that not every place is good for that kind of person. I'm not one of those people who, like plain yogurt, takes on the flavor of whatever gets mixed into it. I guess I like it more when our ingredients enhance but don't overpower. But still pop out as their own to create an awesome blend. So that? That was important to me.
Yeah.
Need #3 People in leadership with whom I can identify
I'll be completely transparent and admit that it definitely was a common practice amongst my Meharry classmates and me to immediately open a brochure (this was pre-internet, remember?) and count up the black faces in the residency program and on the faculty. Yup. That said, this need isn't only about how many underrepresented minority folks there are in the midst.
Nope.
So check it. You ever meet someone or watch someone in action and think, "That person? Now that's somebody I'd like to be like." Or even, "That person? He/She is my kind of people, man." And it's cool when you say that about someone who could be a potential peer. But man, oh man is it uber-awesome to be able to say that about one of the head honchos.
Okay, so the race thing. Let me go on ahead and further address that before going further. If you are an underrepresented minority (which, in my case you should read to specifically mean black person) whether or not a place hires and retains a significant number of people who look like you should be noted. If there is only one or two total in a really big program? Well. Honestly, that doesn't portend the best prognosis for a person like me.
I'm sorry if that sounds harsh. It's true, though.
Remember in that old movie "Do the Right Thing" by Spike Lee when that character Buggin' Out rolled up in the pizza spot and asked Sal, the owner:
"Ay yo, Sal! How come it ain't no brothas on the wall up in here?"
I mean, I'm not saying you should say it like Buggin' Out did, or even at all. But you should note it if you are an underrepresented minority in 2015 thinking about going there. Am I saying DON'T go? No. But I am saying, make a note of it.
Yeah man.
Okay, so with all THAT said, here's another thing I know for sure: It is not a prerequisite for someone to share my race or gender to be one with whom I can identify. Case in point: During my interview day at the program where I trained, I had an interview with two individuals that blew my mind. Seriously, they did. And guess what? Both of them were--wait for it--white men.
Yup.
They were both enthusiastic teachers and in love with caring for patients in the indigent setting. Even though they were leaders, they were still very much entrenched in clinical care and teaching. They were nice to their secretaries (which I always notice) and they also called nearly every person they encountered by name.
Including me.
I watched them both in a teaching conference interacting with the house staff and students. What's funny is that I'd made up my mind to go to that interview strictly because I'd waited too late to cancel it--and not showing up at all would be rude. Had this happened in the email and text message era? Chile please. I would've cancelled that interview quicker than you can say Rumpelstiltskin.
Which reminds me: True story--I wore a mustard-colored blazer, black full leg trousers, a multicolored silk neck scarf and a bold red lip. Why? Because it's not like this California girl was going to actually train in Cleveland, Ohio. (Did I mention? It was snowing?) Plus this wasn't even the sexy program for Internal Medicine/Pediatrics in that city. Matter of fact, a lot of folks hadn't even really heard of it outside of the midwest and--real talk--I'd only scheduled the interview because I'd already planned to be in town for another program (the sexy one. Ah hem.)
But.
The first of those two interviews was the first time that whole interview cycle that I felt that feeling that I'd been looking for. These were folks I wanted to be like. And they struck me as the type who'd do any and everything to help me not only be like them but exceed them.
And so. I recognized this as a need. People around me that I'd want to emulate and who had the time and interest in me to let me into their worlds. And--yes--a place with a decent representation of women and underrepresented minorities at all levels. Because even as wonderful as those two guys were--and still are since they remain two of my mentors--never seeing your phenotypic reflection in anyone makes it not only lonely but hard for people there to imagine your full potential.
#truth
Need #4 Openness to innovation and new ideas
For as long as I can remember, I've always been a creative type. Someone shows me something one way and I immediately start brainstorming ways to put a different spin on it. When I don't see what I have in mind, I set out on a plan to build it (within reason, of course.) That's always been my way.
Now. Raise your hand if you know what it's like to suggest something and to have it immediately flicked down like a gnat in someone's ear. Raise your other hand if you've been in that place where every suggestion is met with either a "yeah, but. . " or some other trivializing comment that tells you in so many words to "take a damn seat and go with the status quo"--even when it's an idea worth trying.
I sure have. So, you know? I now know that I don't do so well in such situations. By the time I reached the end of residency, I knew that this would be an absolute need for whatever place signed me on as a faculty member. Room to build, man. And not just tables that welcomed me to sit at them as a leader but a climate open to me busting out my own tool kit with a team--and building some new tables.
Yep.
What I know is that some of the sexiest programs and hospitals--due to their sheer sexiness--don't really have to give a shit about you and your new ideas. They can just look at you or through you and then nudge your little idea to the back burner. No, worse than that. To the trivet behind the back burner where it will go bad and stagnant.
Do some big name places welcome innovative ideas from young faculty and trainees? You bet. But not all. And what I now know for sure is that the platinum pedestal isn't shiny enough to make up for a place that doesn't foster development of new ideas and initiatives from people other than the highest folks on the food chain. I was looking for a place where hard work and a growth mindset mean something--and where ideas are at least genuinely considered.
Do you have to go with all my harebrained schemes? Nope. But I sure appreciate someone listening long enough to think about it.
Need #5 A soft place to land and a place of redemption
Being a doctor is hard. Combine that with life and other factors and it can feel suffocating. Not having a place to turn beyond your peer group makes for some tough terrain. What I know for sure from doing this for this long is that we are all human and humans are guaranteed to get something wrong or not live up to what someone thought we would. The bible calls this "falling short" which always sounds better to me than "screwing up" don't you think?
Ha.
Either way. I want to know that if I do something and it isn't perfect or if I feel lost or lonely or burnt out or upset or overwhelmed or whatever. . . .that there will be somebody there in that hospital standing ready to support me. This is CRITICAL in residency and medical school. Without it, you can make it, yes. But it's exponentially harder and more unpleasant when you are fending for yourself.
I also know that sometimes things just aren't fair for people who look like me. I mean, it just is what it is. So one thing I always hope for is that there's someone fearless and fair high up on the food chain who isn't scared to go to bat or offer another chance should one be needed. And no. Not some hand out of a second chance. Just the same second chance afforded to everyone else.
#truth
Everybody knows that falling down isn't the issue. It's how we get back up again. Having somebody there to give you a ring of gold and redeem you sure as hell helps.
#realtalk
Need #6 Opportunities for growth and challenge--and mentors to help identify the right ones for you
Are you a researcher? Then a place with ongoing research and a track record of funding is definitely one step. But if there isn't room for you in the lab or a chance for you to get involved in something that fits for you? That's a problem. And just because U.S. News said some medical center is THE place for the thing that you were hoping to investigate, unless you have numbers 1 through 4 on this list, it's likely to be a pretty lumpy experience for you.
Yup.
Are you someone who wants to teach? The place for you needs to have the combination of teaching opportunities and mentors who are ready to show you the ropes. Ones that are involved in national organizations and regional meetings that can connect you to people and push you to the next level. Folks who've gone far enough to drop some chafe for you to pick up behind them. And who aren't so caught up in themselves that they only do things out of self interest--not YOU interest.
I should say that sexy places often have money and resources. And, honestly, opportunities do require resources. It's important to consider this--but not at the sacrifice of everything else.
Especially your sanity. Hello?
Here's a question: Are all the leaders at the place you're considering folks who've been in the position for seven thousand trillion years? Are things dynamic--in a good way? Are you interviewing with people who've been on faculty for 25+ years--but who are still at the Assistant Professor level? And for the underrepresented minorities and women, here's another question: Has there ever been a chief resident, chair, dean or program director that looks like you or that has the same number of X chromosomes as you? If you don't ask yourself that question, you should. Because chances are that you aren't the first talented woman/person-of-color to enter that place as of 2015. And you should wonder what's up with that.
Even if no one has noticed or considered it, you should. So if in 2015 you don't see any diversity in leadership? Or some history of it? Something IS up with that.
Yeah, I said it.
Look. I'm just saying--just maybe--no matter how sexy the place is--a homogenous leadership or leadership history just might be a red flag. Or at least a reddish one, depending upon what you have in mind for yourself. It could say something about the amount of opportunity there--just maybe. Especially if you don't fit the look of the homogeneity in the high ranks, nah mean?
Look, man. For somebody with leadership potential who's hungry to go further? This is a big deal. And for me, a black female with interest in such things, this was the case. Which is why this proved to be one of my 7 essential needs.
You feel me?
Need #7 High Expectations and Motivated Peers
Man. This is perhaps the most important one of all. Let me explain.
Okay, so check it. My parents expected SO much of us growing up. They had a fit when we brought home a 'B' in a class where our potential was an 'A' and they never shot down our dreams to try hard things. Expectation is a mighty motivator for young people. Over time, I began to realize it was something that, when absent, caused me to sag like a heavy load.
Yup.
They also put us in activities and challenged us with things in the presence of other kids who were striving to do well. The competition was healthy. Being an intellectual standout around those who don't challenge you can make anyone lazy or bored. And everyone knows that this never ends well.
Nope.
What else? Oh. Yes. With residency and medical school, people selectyou. I mean, sure, you somewhat have some say in it, too, depending upon how academically superstar-ish you are, but still. The sexiest programs have the most say. And the super-duper-sexy ones have even more say than the top percentile applicants.
Yeah, I said it.
And guess what? I'm also going to say this: Depending on the place, those academic superstars aren't immune from being tossed into a giant stack of nondescript high achievers on a roster. And given not much more than the gold star on their lapel that comes with being a member of the training program at "Sexy-everyone-thinks-it's-awesome Hospital."
Yeah, I said it.
See, just because you got straight A's and were a student leader and got on their radar doesn't guarantee that someone will be there interested in you on a daily basis, pushing you and recognizing your talent enough to expect something uniquely better from you year after year.
Did you catch that? Uniquely better.
That means they have see you. Then recognize your talents and consider you for things that might be a fit. It means checking in with you and seeing if you're following through on things and giving you a kick in the pants when you aren't. Without expectation, it can feel like no one ever knows how hard you're working or worse, they do know but don't care.
And look. Maintaining expectation is exhausting for clinician-educators and administrators. But, in my opinion, any program that isn't willing to work at this for each and every resident or student in their program or school? Well. It simply wasn't the one for me.
Nope.
So. There you have it. My seven essentials.
Oh. So what does this all mean? Well. It means that there are things far, far more important than being on the platinum pedestal "it program" list. It means that the gold star on your lapel as your only prize short changes you regardless of how dizzy with glee it makes everyone to say when asked about you.
Now. I do need to add this disclaimer:
I know some amazing, amazing human beings at sexy programs--or who trained in those sexy med schools and hospitals--who get all of this. They get that no matter what, every person--students and residents and young faculty included--want to know that someone is seeing them and being intentional about helping with their future. And no, it doesn't have to be everyone. But someone.
Someone.
So that brings it back to me and my experience. College was at Tuskegee University. I am proud of my alma mater, but would be lying if I told you that I've encountered scores and scores of fellow Tuskegee alums at my medical meetings--even all added up after nearly 15 years of going. Nope. As far as being pre-med goes, in the early 1990's when I was there, Tuskegee definitely was not a sexy pre-med choice. It was more of an engineering and pre-vet med place. But did it have #1 - #7? Damn right it did.
Next? Meharry Medical College. Teeny tiny. Historically black. And frustratingly the place that people either mispronounced or looked puzzled over when you told them that you went to medical school in Nashville but didn't attend Vanderbilt. Historic? Absolutely. Sexy? Meh. That said, I left there strong and a leader because of the nurture given to me in the form of #1 through #7.
Yep.
Then came that tricky residency choice. Did I have good interviews? You bet I did. And were a good bit of them sexy? Without question. But the place I chose was the county teaching hospital affiliate of Case Western Reserve University in Cleveland, Ohio--MetroHealth. Those who know Cleveland know that this isn't the "it" program in that city by a long shot. But once I knew what I really and truly needed to succeed and ultimately thrive, that didn't matter. MetroHealth in Cleveland, Ohio was my very first choice on my rank list--and I was delighted to open my envelope on match day and learn that I was among one of theirs, too.
And guess what? Three non-sexy choices later, here I am. Happy. Whole. Confident. And dare I say it? Pretty darn successful so far. I'm proud that these places all get credit.
The take home for any and every person reading this--especially medical students and pre-medical students--is this:
Know what's important. Don't be so caught up in a name or a brand or the reaction you get when mentioning a place that you ignore your own unique needs as an individual applicant. Don't be afraid to rank the place that feels right. You know, the one with the kind, empathic, and innovative program director in the city that you worried wasn't sexy enough or the program that is only sexy-ish. Fight the urge to count that place out. And please-- don't be tricked into thinking that, by definition, just because you performed at a high level academically that you shouldn't look into places that seem like they might have what you need in your #1 - #7--even if they aren't on THE (insert your favorite media source) Top Ten hospitals or programs.
*Eye roll*
Oh, and medical students who just matched? If for some reason you didn't get your first choice and ended up somewhere you didn't expect to get, please--for the love of God--don't show up like a wet noodle or assuming your life has ended. Don't arrive already plotting your transfer or repeatedly telling people about all that is better, shinier, sexier about the other four programs that didn't pick you. Instead, refocus your attitude. This could be the best thing that ever happened to you. Just because people don't wet their pants when you say where you're going doesn't mean it's not a great program. Look for the things in that list. Chances are, if the place has those things, it will work out great.
Take that from a Los Angeles native who spent five years in Cleveland, Ohio. And who has historically chosen places that garnered the other kind of eyebrow raises (amongst majority folks.)
Which brings me to the last point:
This was MY list of seven essential needs. While I do think that most of these are important to any and all people facing this step, maybe some don't. I would urge you to sit down and create your own list. Ponder what you need and push yourself to think of the abstract things that can't be found on program websites or your CV but that can guarantee misery if ignored or not considered.
For me those are:
Genuine interest in me
Permission to be authentic
Some people with whom I can identify (professionally, genotypically and phenotypically)
Openness to new ideas and vision
A soft place to land
Opportunities for growth
Great expectations
And you know what? Last time I checked, none of those were among the factors that get any place ranked number one on any lists.
But you know what? They should be.
That's all I've got. And hey, that's just how I feel.
***
Happy Sunday. (And congratulations on reading that entire ramble.)
The electronic applications for residency programs just opened up on Sunday. Four plus years of medical school and lifetime accomplishments all nestled inside of one click of a mouse. Medical students all over the country have been sending off emails that escalate in their urgency to faculty who've agreed to write letters of recommendation and the residency program directors who will be reading them. I happen to wear both of those hats.
And so. Over the next week or two, students finalize this really important profile of who they are. They cross their fingers hoping that they crossed all of their t's enough to get the attention of the right program in the right city offering the right training in the right specialty. For them, that is. And it's funny because what many of them forget is that we, the program directors, are doing the same thing in a way. Hoping our programs appears attractive to the most attractive applicants. Attractive in terms of academic profile, that is.
All of this--these electronic applications, the interviews that follow, and the subsequent mind-wracking that ensues as everyone tries to finalize a decision ultimately leads to that big day where medical students all over the country find out their temporary destiny. But long before the tears and hugs and scraps of torn match day envelopes is all of this. Students putting their best face forward on this computerized application and us, the programs, doing our best to get a glimpse of who these people are based upon what we find when we click on their names.
How apropos that it all leads up to Match Day, isn't it? I mean, really, it is considering all of this is a bit like "match.com" if you ask me. One person creates this shiny, pretty profile on line complete with their most cheerful and I'm-so-super-nice looking snapshot so that some other person will look at it and say, "Hey. I'd like to meet that person." That is, after learning that in addition to going spelunking on weekends they also won the gluten-free cake baking contest for the entire region last year. Or something or other.
And we, the programs, tidy up our websites with chummy photographs of our trainees plastered everywhere. Their eyes are earnest during bedside teaching and then on the handful of candid shots, the esprit de corps is so palpable that any student viewing it feels a yearning in their soul to belong to our group.
And really, isn't that a lot like match.com?
And let's be clear. I see nothing wrong with match.com. I know several people who have met awesome mates there and have even found a spouse. Yep. But they will all tell you -- just like we who open those ERAS (electronic residency application service) files will -- that sometimes the profile doesn't quite match up with the person. Good, bad, or indifferent.
So check it. I can't speak for what somebody looks for specifically on match.com. I can't. I'm not fully certain if there are a set of rules for how you can know if it's going to be eHarmony or not, man. Surely every person is different and they want different things just as every residency program or applicant varies in what they want. But you know? There are some things that are fairly universal that no one seems to talk about. And, for me, this is what I'm always sifting through the application to find. Then, during the interview, I try to confirm that impression.
Yep.
So what is it, you ask? I'll tell you. I believe that the very best applicants--no matter WHAT the specialty they have chosen--meet this criteria on most days:
Nice.
Hardworking.
Smart.
In that order.
I am NOT kidding. Literally, I have a little scrap of paper where I create a score for myself to see if the person is nice, hardworking and smart. Then, when I meet them, I try my best to see if, on most days, it's in that order. And if it is? Eureka. But even if it isn't, all three qualities are imperative. And when they aren't? That is, when ALL THREE of those qualities are not evident to me from the application and/or the interview? It's a no for me.
Not. Even. Kidding.
Let's look at this more closely. Let's say an applicant got straight A's. Let's say they scored high on the boards and made honor society, too. But then, when you read the letters, you see that they're all nondescript and the personal statement is bland. You meet them and they sit in front of you smugly or come across as bored and disconnected. This applicant might be smart. And I'd go so far as to say that they are also hardworking since they achieved such a great academic record. But nice? That could be debatable. Really.
Then there's the person who is super-smart and mostly nice. But lazy. And that? That's a horrible combination because you get tricked. By the time you realize they're lazy, it's too late. And laziness is really, really hard to remediate. Matter of fact, it could border on impossible. I think of "hardworking" as kind of synonymous with "professionalism" in the medical field. It's hard work to uphold our end of the bargain. And what makes a person do that without cutting corners is professionalism.
Lastly, there's the sweet-as-pie person who works their behind off. And, okay, just maybe they aren't the sharpest crayon in the box. But honestly? Of all of the combinations I've listed (outside of the preferred triple threat) I'd take this combination over the others. Yes. I'll take nice-and-hardworking over hardworking-and-smart-but-not-nice or nice-and-smart-but-lazy any day of the week. Because at least with hard work the not-super-smart part can get better as far as medical knowledge goes. And sure. I'll admit that to do this--medicine--there is just some amount of intellect required. But I am a firm believer in the "growth mindset" which says that diligence and hard work can make up for what we lack in "natural" ability. Not to mention the fact that not working hard can make innate talents a total waste.
Yup.
What does this mean concretely for medical students? Simple. Nice people do things outside of just studying. They do things for the greater good of the world and others. They do. They also have a life and hobbies and personal richness to talk about. Because medical school is a selfish pursuit. It's easy to get wrapped up only in yourself and your grades. But what is the point of getting that far and not having your eyes on the real prize? To be a competent and empathic provider? That requires more than books.
It takes a certain amount of "nice" and unselfishness to volunteer somewhere or tutor or participate in anything other than studying. So me? I look for that. I look to see if you worked hard in something, anything other than just sitting on your bum with a laptop. I look to see if you bake cakes or organize students to do good things. I want to know if you learned to speak Spanish or ran a half marathon or painted with water colors. Something. Anything. Not just books. Because being a doctor calls for more than that. It calls for humanism and a scrappiness that can't be found just with studying. That part comes from living.
"Hardworking" people complete things. They finish things they start and if they don't, there's often a reasonable explanation for it that doesn't sound like a typical excuse. They are resilient. They don't crumble under pressure and they keep trying no matter what. And again, they do things outside of just studying. And yes, that can mean a research paper or project. But a lot of times it can mean something else. I look to see if you did something that required planning and time to execute. Because that kind of thing requires hard work. And being a hard worker is a good quality to have in medicine.
And perhaps "smart" is the easiest part. Because to reach the finish line of med school, either you were simply smart or you had a growth mindset and worked SO DAMN HARD that you grew smarter. And we can see that easily on paper. Or from just talking to you.
But the other parts? Those are more nebulous and tricky.
So listen up med students. And residents applying for fellowships and jobs. This is what we want. We want the triple threat. We are looking for people to come to our residency programs that are:
Nice.
Hardworking.
Smart.
IN. THAT. ORDER.
In other words, to use a term coined by one of my favorite students of all time Antoinette Nguyen, we are looking for someone who is a "non-douchebag."
Yes. That. A non-douchebag. (So all-encompassing, that word.)
Ha.
Is this what your application says about you? Is this what people would say about you? Are you nice, hardworking and smart--in that order? If you are, you're a great candidate. If you're not, you need to ask yourself why that is and you also need to recognize that this is what OUR PATIENTS want, too.
Our patients. Remember them?
Right.
***
Happy Residency Application Process! May the odds be forever in your (and my) favor.
Bryan O., MD -- who personifies nice, hardworking and smart--in that order.
"Here comes the sun Here comes the sun And I say. . . It's alright."
~ George Harrison of The Beatles _____________________________________________
On December 2, 2008, The Institute of Medicine released their greatly anticipated report on “Resident Duty Hours.” Like many academic physicians, I sat in front of my computer listening to the live webcast, trying to make sense of their recommendations for more sleep and less continuous duty hours for resident physicians. I perused the New York Times article that followed, but it wasn’t until I read the subsequent barrage of online commentary that it really set in. Let me tell you--folks were not happy.
“We are officially in the ‘No Accountability Era,’” one physician wrote. “Our patients will be the ones who suffer from the ‘clock in-clock out’ monsters that we are creating.” I read on, serving as my own amen choir with exaggerated head nods. Another passionately added, “Our residents are becoming more interested in getting out of the hospital than getting to know their patients. No one seems to care anymore. This will only make it worse.”
Ouch.
Next came recommendations from the Accreditation Council for Graduate Medical Education (ACGME.) These recommendations first came as ones that weren’t etched in stone. They said, “Okay, interns—meaning first year resident physicians—need to get up out of the hospital after sixteen consecutive hours of work. Oh, and you faculty? Y’all need to do a little, no a lot, more supervising. For real.” Okay, maybe this isn’t exactly how they said it, but that was my take on it.
After that, the ACGME solicited input from a bunch of academic institutions and professional societies. We had a slew of institutional meetings at Emory to discuss our suggestions and with the help of leaders in our Graduate Medical Education Committee, sent them off. Organizations like the American College of Surgeons sent theirs in, too, and man. . . they didn’t sugar coat things. Like I said. . .folks were concerned. No, more than concerned. Folks were worried. And folks meant us.
The thing is this: If an intern can’t work beyond sixteen hours straight, it means that they can’t work overnight. A lot of folks will tell you that their biggest learning during training went down in the middle of the night. I wish I could say that I didn’t agree with that. But for me, it’s true.
Well, turns out that the ACGME came back with the official recommendations after getting all of that feedback, which essentially was:
“Okay, interns—meaning first year resident physicians—need to get up out of the hospital after sixteen consecutive hours of work. Oh, and you faculty? Y’all need to do a little, no a lot, more supervising. For real.”
Um yeah.
Faculty weren’t so giddy about this. In fact, the “new duty hours situation” was smattered throughout our conversations in the resident continuity clinic that day. Between patients we pondered what these changes would mean to us as faculty. We worried about two years from now when more inexperienced second year residents were being expected to teach one when they hadn’t yet seen one or done one. What would that mean to us?
When the residents were out of the room, the discussion got pretty unfiltered—everyone was sharing their unsolicited stories of residency in the “real” trenches, and collectively tsk-tsk-tsking this mandate that would further pull house staff away from the hospital. Next thing we knew, the conversations kept going even with house staff around. Before we knew it, we had all exploded into a fraternity of “old school” doctors unabashedly hazing our young learners by insulting their potentially soon-to-be inferior training experience.
The irony is that there’s really nothing new under the sun. No matter when a person starts their training, there is bound to be some omission in the “new way” that appalls the village elders. We’ve all been there and felt the sting of criticism for things out of our control. The “new way” always seems to lack the pieces necessary to build intestinal fortitude and sear the heart with nostalgia. And it has been this way for years. The freshman experience never ceases to be a day late and a dollar short.
I can still recall this snapshot from my own internship in 1996—amid the late lunchtime crowd, I wolfed down a sandwich in the cafeteria with my senior resident following my first night on call. I couldn’t tell if the nausea that churned in my gut was a factor of the inexplicable exhaustion I felt or the pre-packaged hoagie that my two-dollar meal ticket afforded me. My upper level resident described our evening as “not so bad” when a classmate asked in passing. Not so bad? I silently protested. She must have read my mind. She turned toward me, rolled her eyes and trivialized the mere nine patients I had just admitted with the dreaded “when I was an intern” preamble. (Major emphasis on ‘I’.)
Her, perhaps tall, tales of working up eighteen patients alone with virtually no supervision or chance of sleep in sight were further encouraged by my incredulous gasps. How could I possibly become as fearless, decisive, and knowledgeable as she with a measly one night in four call schedule and someone enforcing a patient cap? I can still feel the way my shoulders slumped down that day; ashamed for believing that it was impossible to do more than I had just done the evening before.
I grew up, and despite the patient cap and less frequent call schedule, I turned out all right. My medical knowledge increased, I accrued my own arsenal of lessons, and eventually became a clinician-educator. Time marched on, and at some point, I forgot those hunched intern shoulders. More rules came along, and eventually, I found myself duly initiated into the “old school” fraternity of those who “really” trained.
In my ten years of teaching residents and medical students, I have certainly had moments of disappointment with their work products. But honestly, I have had far more hopeful moments about the physicians we are helping to mold. The more I reflect on the myriad of driven, selfless, and responsible residents I’ve worked with over the years, the more conflicted I feel about labeling them all products of the “No Accountability Era.”
Our attitudes suggest that they don’t stand a chance, when the truth is that, more than likely, they really, really do. The rules were out of my control in the mid-1990’s, and today’s learners have little to no say about the current mandates. In fact, when researchers asked them what they thought about it, in a paper published last year in the New England Journal of Medicine, they made it real clear that they, too, took issue with all of these changes. Interesting situation, ain't it?
Anyways. . . . just as we can recall the incredibly empathic and the egregiously irresponsible during our own residencies, the same exist today. Just because you work less than twenty-four hours doesn't mean you are automatically shady. Oh, and the converse absolutely applies, too--and to that I can personally attest. Alas, there's really nothing new under the sun.
Let's be real. I can’t say that I am thrilled about the idea of trying to figure out how to do the same amount of patient service with less manpower. I also would be lying if I said I wasn’t extremely worried at times for specialties like general surgery and obstetrics and gynecology whose unpredictable schedules make the continuity of working a full twenty-four hours critical to learning the ropes.
But still . . . I am inspired by so many of the learners I know. Many, if not most, do feel accountable for their patients. They do shed tears for their patients in a locked bathroom on the wards, and just like we did, and they are still plagued with the need to read all about their patients’ conditions.
So I guess what I’m saying is. . . .contrary to what the message boards (and sometimes we) are saying, I can say firsthand that there are legions of caring, earnest, and accountable young physicians waiting in the wings. On July 1, these recent medical school graduates will come rushing on our hospital lawns looking for their chance to be initiated. Now I guess it’s just up to us to find creative ways to welcome them into the fraternity.
*** Here comes the sun, man. With nothing new under it. And I say? It's alright. It has to be. Now playing on my mental iPod (Geo. Harrison with a super-gnarly line up behind him!):
*Disclaimer: This is a slight rant. If you are easily offended, please skip this post as I have much touchier, feelier offerings for your reading pleasure. . .
You DO realize that we can hear you, right?
_____________________________________________
"To all the learners that we've taught before
Who traveled in and out our doors
We're glad they came along
We dedicate this song
To all the learners that we've taught before. . ."
(Remix on Julio Iglesias and Willie Rogers' "All the Girls I've Loved Before")
_____________________________________________________
I started medical school in July of 1992. Back then, we called every doctor "Dr." and were so formal and deferential that you'd think it was a military academy instead of medical school. Although the internship I started in 1996 was slightly more relaxed, we regarded every faculty member highly, and never dreamed of anything that might come across as overly familiar or presumptive--especially when it came to our attendings and their time. Now, I'm not saying that there aren't students and residents who hold their attendings in the same esteem now. . .but sometimes. . . .just sometimes, it seems like the culture today in medical education is different than it was back then. The Generation Y learners seem to have a certain chutzpah that took us some time to grow into. . . . (I'm just saying.)
Case in point:
Just about every week, I find myself in a water cooler chat with a colleague about something an intern, student or resident said that was so . . . .uhhh. . ."no-he-or-she-di'in't!". . . that it leads to more discussion. All from off day "requests" to emails about being excused early for flights to texts about getting out of teaching sessions to you name it . . .all approached with such nonchalant audacity that it, literally, blows the minds of faculty. Our water cooler conversations are almost always punctuated by an emphatic,
"I wish I WOULD have even THOUGHT to say something like that to my chief/attending/program director/senior resident! No way, no how!! I would have been torn a new you-know-what!"
::five way faculty fist bump::
The verdict: Times have changed. Learners are much more comfortable making suggestions to us that never occur to them as outlandish. I can honestly say, I have heard them all. I have been a senior resident, a chief resident, an attending, and now a residency program director--and with every year, the ante gets upped with boldness that makes me (and my colleagues all over the country) say, "Awwww, hell naww!"
Now don't get it twisted--everyone knows how much I love me some interns, residents and especially medical students. . . .so for this reason, out of sho' nuff love and nothing else, I cannot allow this to go on any further. So. . . just for all of you-- my beloved learners, here is a guide to what NOT to say to your attending, program director, chief resident or adviser, no matter how extraordinarily cool and approachable they seem.
Yes, it is 2010, but no, assuming that we do not have a life (or feelings for that matter) is NOT cool. So this is an intervention of sorts. And lucky you, I'll be as concrete as possible by providing a few examples . . . . . balancing it all with some viable alternatives. Yeah. . . . this is a love-filled intervention indeed.
Let's jump right in, shall we?
***
Examples of "No-he-di'in't/No-she-di'in't" Correspondence:
What you said over an email (three days before the start of the rotation):
Dear Attending,
Hope you are well! I am looking forward to working with you next month on the wards. I am emailing you because I made a schedule request with the chief residents to be on this schedule so I wouldn't be on call over the three day Weekend. I have plans to go to Vegas for my best friend's bachelorette party, and was hoping to fly out early (around 4pm) and get that Saturday and Sunday off. I already spoke to the senior resident who said she's fine if you are. Touching base with you to make sure it's okay.
Thanks in advance!
Dr. Pria Sumptive
Let's try a better approach, shall we. . . . .(One month or more before the rotation starts)
Dear Attending,
My name is Ina Turner, and I will be rotating with you on Team X in September. I am contacting you to discuss a scheduling issue that I have considered for next month. My best friend and roommate from college and medical school is getting married this year. I have been fortunate enough to be asked to be her honor attendant, and already scheduled vacation to be able to attend her New England nuptials. She is also an intern, and she, as well as several of our mutual friends, have coordinated their schedules to meet out of town for a bachelorette celebration in her honor over the Labor Day weekend. I recognize that so early in the month and in my internship that this could be a hardship. I am respectfully asking for the consideration of being afforded two consecutive off days for my best friend's celebratory weekend. While our team is not admitting, I realize that this could potentially inconvenience others on our team, especially you. I have not yet purchased a flight, and would absolutely understand if this were not possible. The specific days are Saturday, the 4th and Sunday, the 5th. I will be post overnight call on Friday the 3rd. Thank you for your consideration and I am very much looking forward to working with you next month.
Very best,
Intern
That's what I'm talking about! Okay, maybe it was a bit longwinded, but it was definitely unassuming and respectful. (You would SO get that weekend off if I received this correspondence! Again, I'm just sayin'.)
***
What you said. . . .
Text message:
Hope u don't mind but gonna pass on our special session this afternoon. Long day for me in the hosp and feel a migraine comin on. BTW feel pretty up to snuff on stuff ur covering. Hit me back if an issue --thnx. Holla--
Noah Di-int, Medical Student
What about this approach instead. . . . . .
Good afternoon, Dr. Attending. I am concerned that I am feeling a migraine coming on. Do you have a moment to call me to discuss our session this afternoon? Thank you, Noah D. Medical Student
Isn't that better?Was that so hard? (Even if I say no and make you come anyway, at least you won't get the hairy eyeball when you arrive.) By the way, note that not everyone is cool with the text message. If you do get the green light to text, I might suggest avoiding "text speak:" e.g.
"OMG Dr. M! LOL ur blog is awsme! TTYL!"
***
What you emailed the Chief Residents or Program Directors. . . .
Dear Program Director/Chief Resident,
I was counting my shifts on the ER schedule and noticed that I have one more shift than everyone else. John got ten shifts and Jasmine got ten shifts, too. I have 11 which is not fair. I also noticed that I did not get a full weekend off, which doesn't allow me to make any kind of plans such as travel, etc. While I do not celebrate Christmas, I am kind of annoyed that I got picked as the one to work during that time. I just don't think this is fair and hoped you could step in. Also, is it normal to have two calls that fall one on a Friday and another on a Saturday? Jasmine did get one Sunday, but she didn't get a Friday which does not seem fair. You can tell me if I'm being irrational.
Wine E. Resident
Try this approach. . . .an invitation to talk--not an email about this (which almost always sounds whiny.)
Dear Chief/Program Director,
Would you be available to meet with me soon? I wanted to discuss a couple of concerns about my schedule with you and hoped I could get on your schedule. I am at Grady all this month, and am available whenever you are open. Thank you for your consideration.
Resident, Pager 12345
So simple, yet so effective. Ya dig?
****
See? It isn't really that hard.
Here are the take home points:
Assume nothing.
Our time away from work is just as valuable to us as yours is to you.
If you just started your residency or medical school, factor that into your requests.
Sometimes you just can't go.
Do NOT buy plane tickets before speaking with the attending. Don't do it.
When you have a request, make it formally and make it EARLY.
You are NOT entitled to your request unless there are special circumstances.
Why? Because this is what you signed up for.
THINK about what you are sending and to WHOM you are sending it.
We work harder than you realize on teaching students and residents. It is hurtful when that is not considered.
Just because our response doesn't sound like we want to go off on you, doesn't mean that we aren't going off about what you said/did/assumed/requested in our heads/to our spouses/at the water cooler.
Formality gets you further than overly familiar assumptions.
You signed up for this.
To quote my friend and fellow Grady doctor, Ira Schwartz, M.D.--"This ain't college."
On a serious note, medicine involves sacrifice. Be smart before you speak and ask yourself if what you want is actually realistic and appropriate for the timing, rotation, and even your profession. If the answer is no, let it go. Know that we work hard to strictly adhere to duty hours rules, off day regulations and all measures designed to protect you from burn-out, stress, and not having a life during training like we experienced. Despite those measures, medical school and residency involve work. They also involve missing out on a couple of things sometimes. It is our job to help you achieve work/life balance through it all--but you must know that the word "work" is a part of the equation, too.
Capisce?
***
For the record, I am 100% serious, and hope that the medical students and residents out there who run across this take it as such. Feel free to save a med student and forward this to a friend. . . .
~ With nothing but love and hopes for your very best future, Dr. M ***
**Students, Interns and Residents that I saved today:
You can thank me with Target giftcards, red wine, or key lime pie. :)
Honestly? I write this blog to share the human aspects of medicine + teaching + work/life balance with others and myself -- and to honor the public hospital and her patients--but never at the expense of patient privacy or dignity.
Thanks for stopping by! :)
"One writes out of one thing only--one's own experience. Everything depends of how relentlessly one forces from this experience the last drop, sweet or bitter, it can possibly give."
~ James Baldwin (1924 - 1987)
"Do it for the story." ~ Antoinette Nguyen, MD, MPH
Details, names, time frames, etc. are always changed to protect anonymity. This may or may not be an amalgamation of true,quasi-true, or completely fictional events. But the lessons? They are always real and never, ever fictional. Got that?
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