April 13th, 2022
“God on high, Hear my prayer
In my need, You have always been there
He is young, He’s afraid
Let him rest, Heaven blessed
Bring him home”
Jean Valjean praying for Marius in Les Misérables
I was back in my childhood bedroom on the outskirts of Cairo when I first met our wonderful executive editor and my fellow chief bloggers virtually. I was excited to start sharing some of my thoughts with the readers while, at the same time, trying to overcome the imposter syndrome feelings swelling in my chest. But mostly I was overjoyed to see my family again. This was my first time back in Cairo after 2 years and 3 months. I couldn’t help but think how representative this moment was of what it’s like to be an International Medical Graduate (IMG) in recent years. I do not claim to represent the voices of all IMGs, but I hope sharing my experience can shed light on some issues and possible solutions.
“Why did you come to the U.S.?” is a common question I am asked. The majority of the time, it’s out of genuine curiosity rather than implicit microaggression. At those moments, I ponder — what drives anyone’s choices in life? Probably running away from something or toward something else. It’s trying to avoid meeting our worst fears or chasing the stars.
A common misconception among the medical community in the U.S. is that IMGs are a monolith. But IMGs come to the U.S. for graduate medical education for many reasons — looking for a more humane, high-quality, structured graduate medical education experience that leads to a more predictable career path. We’re hopeful for a more fulfilling life and career — whatever that may mean to each of us. Some came to the U.S. as a legitimate pathway to immigration. Others are escaping wars, seeking reunification with their loved ones, or fleeing discrimination. We’re eager to learn about how the U.S. pushes the limits of science and medicine.
One quarter of licensed physicians in the U.S. are IMGs
Whatever that reason may be, the fact is, IMGs represent 25% of licensed doctors in the U.S., according to the AMA. More than half of IMGs who match in residencies every year, including 2022, are foreign nationals. This number is steadily increasing. IMGs are invaluable to the American healthcare system. That was perhaps most clearly elucidated when our visa status was in jeopardy due to a proposed rule change in 2020. This rule would have impacted “12,000 J-1 physicians engaged in training at approximately 750 teaching hospitals” and would have had a “devastating impact on U.S. patient care” according to a letter signed by numerous organizations opposing the rule that was eventually put on hold.
As foreign nationals, when we match into residency, most of us start an arduous process of paperwork to apply for a U.S. exchange visitor (J1) visa. This visa category encompasses many visitors to the U.S., is only valid for 1 year, and is not exclusive to physicians. Visas are renewed yearly in the physician’s country of origin’s U.S. embassy. A trainee can stay in the U.S. with the renewal of the ‘Certificate of Eligibility for Exchange Visitor’ (J-1) status (also known as DS-2019) but must renew the visa to reenter the U.S. should he or she exit.
In other words, many trainees need to travel to their home country every year, book an appointment with the embassy, and have an interview with a consular officer to renew their visa (although visa renewal by mail is an option in some countries). Before the pandemic, it was challenging to schedule vacation time in residency, align it with a visa appointment, and return to the U.S. in time. These challenges became almost insurmountable during the pandemic due to very limited appointments in U.S. embassies, travel restrictions, and other reasons. Leaving the U.S. during training, even for an emergency, without an appointment at one’s home country’s U.S. embassy, can jeopardize one’s training. Not to mention the risk of having an application in administrative processing that can take days to weeks. This has effectively deterred many foreign physicians in training from traveling to their home countries to avoid endangering their careers.
Some programs even gently advise their trainees against international travel during residency. This is mainly to avoid being ‘off-cycle’ in training, burdening their colleagues with their absence, and risking fellowship or job prospects. I can write pages on the angst of renewing a visa and my anxiety as I stood in line awaiting admittance to the U.S. embassy in Cairo. That simply should not be the case. U.S. GME training is so desirable that even if these conditions were to stay the same or get worse, it would still be in demand. So the main incentive to change and improve the process is U.S. healthcare institutions’ desire to make it less stressful for young physicians who undeniably deserve better.
Can the visa process be improved?
I cannot begin to fathom the complexities of the U.S. Immigration and Customs Enforcement or the requirements to safely grant someone a U.S. visa. I can only speak to how difficult my experience has been over the past few years. Like many aspects of our lives, the pandemic has uncovered the inadequacies of administrative systems. Visa issuance for IMGs is certainly one of them. Can this process be streamlined? Physicians in training may need a separate visa category that’s tailored to their needs. Other countries, like the U.K., have implemented visas for healthcare workers. Could visas be renewed in the U.S., where we live all year long? Could the yearly renewed DS-2019 suffice as proof for maintaining lawful status if we got a visa for the duration of residency?
I realize that there are many pressing issues in the U.S. and around the world. I understand that, as a society, we have a finite capacity for empathy. It is not lost on me how privileged I am to remain employed at an excellent institution. However, having lived in the U.S. for the past few years, I have learned that we should not settle for mediocre but strive for excellence, that reform only happens when we speak up until our voices are heard, and that tenacity, solidarity, and empathy are core features of the American character, not temporary fads. ECGMG, AMA, and other organizations have advocated for foreign physicians in training. We need to amplify these efforts.
What can GME programs around the country do, while we advocate for a better process?
- Having an excellent Training Program Liaison makes all the difference in the world!
- Faculty members, please check on IMGs in your program, especially those who have not seen or visited their families for months or years. We are all acutely aware of the stressors of residency, and separation from loved ones adds to these.
- Be as flexible as you can with vacation requests to renew visas (within reason), and understand that it’s a difficult process.
- Don’t shy away from choosing excellent IMG candidates. I can assure program directors that, despite the hassle, we’re well worth it! We’re grateful and appreciate the opportunity.
For medical students and residents, I would recommend the following:
- When interviewing for residency or fellowship, choose a program that will actively support you.
- Surround yourself with your local “family” in the U.S. My UConn family has kept me going throughout the pandemic. I couldn’t be more thankful.
- Residency is incredibly busy. Schedule the time to stay connected with your loved ones. There’s nothing more important.
- Plan ahead! Plan your vacations and your visa appointments. Stay on top of your paperwork. It does not always work out the way you intended, but if you don’t plan at all, it will be more difficult.
It’s overzealous of me to compare bringing IMGs to their home countries to renew their visas to Jean Valjean dragging the wounded French revolutionary, Marius, to safety in Les Misérables. But that’s how these words touched me as I listened to them again, after a long period of absence from home. If you don’t agree with my take, I hope you can at least enjoy Colm Wilkinson’s angelic voice as he sings “bring him home.”
I realize that this essay and my experience are Middle East/North Africa centered. I recognize that IMGs from other regions of the world face unique challenges. Please share your experience and any suggestions you may have.
April 5th, 2022
“Does this look professional enough for Twitter?”
My co-resident holds up her phone to show me her newly minted Twitter profile. A picture of a distant, shadowy figure in sand, framed by a circular thumbnail, is her profile picture. Underneath this vague portrait is what could only be presumed to be her twitter handle: her initials followed by a series of 6 or 7 numbers.
“This… looks like a bot’s profile.”
Despite having a decade-long dalliance with Twitter, I was reluctant to join the MedTwitter space, which (to a Redditor like me) sounded akin to a stunted faux-LinkedIn profile. However, about 2 years ago when I started my foray into digital education, my mentors in this realm over at CardioNerds seemed to view it as a necessary medium in the quest for creating decentralized, open-access medical education. So, I dusted off my decade-old account, deleted my tweets to AT&T regarding their customer service, and set sail. Fast forward to today, and I truly believe it is an invaluable resource. After revamping our residency twitter page, successfully convincing unwilling residents to join, and even ghost-writing a few bios, I wanted to share some insights on the benefits and pitfalls of being a part of the platform.
Why Should You Join?
By and large, the greatest return on investment is for those seeking residency or fellowship positions. I get it — in a time where trainees are expected to be productive researchers, effective educators, and excellent clinicians, it seems unjust to ask us to be our own brand ambassadors, too. But the truth is, more and more national organizations and programmatic leadership are seeking out the social diplomats of our time to usher us into this inevitable digital era.
The rise of social media ambassadors for conferences, for spotlighting and disseminating research, and for frequent posting of open positions are a testament to the fact that being able to navigate this space is viewed as a necessary skill. With the world available at the push of your fingertip, networking possibilities are infinite, even without flagrant self-promotion. Speculating further, from a program’s point of view, it doesn’t hurt to be a familiar face in a stack of endless applications. However, in my experience, this is probably not as much of an advantage as is being perceived as a conscientious ‘professional’ social media user.
Perhaps the most valuable aspect (and the primary reason I remain on the platform) is the medical education content. The latest research, journal clubs, “Tweetorials” on various topics, and the resultant discussion from experts in the field is the true value of this community. I was surprised to see not only the vast number of leaders in medicine, but also how active they were in sharing their knowledge and experience (which may underscore the need to have a presence on social media even for those well established in their field). What once was privileged access to information and people is now open; there is no more gatekeeping. The leaders of medicine, and of our world, are just 280 or fewer characters away.
There are some very effective teachers too; I find myself referring to certain Tweetorials by faculty across the country just because they explained how to approach a diagnostic dilemma so well in 5 to 10 tweets. The opportunity to have a virtual seat in other program’s teaching rounds — without having to watch an hour-long YouTube video — is pretty surreal.
And of course, another reason to join is to follow everyone’s favorite ophthalmologist, Dr. Glaucomflecken:
Why You May Have Avoided MedTwitter…
The medical community on Twitter is a bubble. That’s what makes it so easy to use as a networking tool, especially within your specialty, but it is also what makes it a vulnerable space. Certain ideas and personas are over-amplified in the echo-chamber of Medtwitter, and the space is particularly prone to groupthink. In a place where people are eager to break through, honest opinions that are not considered part of the mainstream are suppressed and, at worst, posters are sometimes “canceled” entirely. Unfortunately, this leads to behaviors like humble-bragging, self-aggrandizing, and virtue signaling, which are as easy to identify as they are off putting. Not to mention, just because someone is famous on MedTwitter doesn’t always mean they are as approachable and supportive to their colleagues in real life. The differing realities can make the community feel disingenuous.
Furthermore, sometimes a post may get some unwanted attention from someone outside of the community. An innocent picture of a group of residents getting the vaccine may diverge from the usual algorithm and show up in the wrong feed, and you end up with jarring comments from strangers calling you an agent of big pharma. It can be unnerving, especially for those who haven’t dealt with trolls before.
Personally, I try to avoid anything outside of the educational content of the bubble. I do this by being deliberate with which tweets I interact with and/or retweet to keep a semblance of control over ‘the algorithm.’ When it comes to the inevitable unwanted comments, I will impart age-old advice that was passed down generations of my family: Don’t Feed the Trolls.
Let’s face it, being a trainee on social media is complex. For the most part, medical students/residents/fellows potentially have the most to gain from being in the space with networking opportunities, digital education, and ability to keep apprised of advancements in their field in an efficient and interactive way. The key is to take it at your own pace. It doesn’t really matter if you want to interact peripherally with a de-identified account as a picture of sand or build an online presence, so long as you get value from it, and Don’t Feed the Trolls.
If you’re on the fence, here are some threads I keep coming back to (links included below):
- Why is azithromycin considered anti-inflammatory? By @Tony_Breu
- A practical approach to primary aldosteronism by @AmitGoyalMD
- CVD in Women by @JHoltzman3
- Tips for orthostatic hypotension by @sargsyanz
- Differentials for VT by @InbarRaber
- Academic writing tips by @rodriguesjm6
- Iron studies simplified by @sargsyanz
- Prophylaxis tips by @sargsyanz (and the NEJM article here)
- Really anything by @gradydoctor
May 17th, 2021
My friends and I spent Thanksgiving 2018 attending surf school in Jacó, Costa Rica. We spent that week fully immersed in twice-daily surf sessions interspersed with conditioning, balance exercises, and of course, downtime to explore the town and rainforests of Jacó. Having been on a surfboard only a handful of times previously, this was a new experience for me. Our surf instructors quickly got us out on the water, and onto wave after wave, helped us start to stand up on our surfboards. During video review of one of our surf sessions, our head instructor explained to us that the key to surfing was to “feel the musicality.” While I noticed a few raised eyebrows in response, this exhortation immediately resonated with me, through my experiences learning other skills, as well as through my surgical training.
My mentors often remind me that the learning that happens in residency is only the beginning of a lifelong journey: 20 years into practice, 80% of the procedures one will be performing will be ones learned after residency. Of course, 5 years of surgical training provide a firm foundation, but how does one develop the tools to learn more easily, efficiently, and constantly? In residency, we need to learn how to keep learning. As I have cultivated other hobbies and skills over the years, I have found common themes emerge regarding how I learn best. These themes overlap significantly with how I have approached my own surgical training.
In college, I took up guitar. I was largely self-taught, from online tutorials and YouTube videos. I can still remember going from being barely able to curl my fingers around the guitar fretboard without significant pain, to playing my first chord, to eventually strumming through an entire song. I practiced the riffs from Sultans of Swing so many times one summer, that my family still cannot hear that song without a visceral reaction. I would occasionally hit a wall while practicing. I would practice 40 or 50 repetitions on a particular riff and still not have it come out perfectly. The next day I would wake up, pick up my guitar, and find my fingers able to effortlessly play the same riff I had been struggling with the previous night. Time after time, I have found this process repeating itself. Get the repetitions in. And then keep the faith. In surgical residency, especially in the early years, I found myself practicing a certain maneuver or procedure, wondering if it would ever make sense — and with practice, over time, it always has.
In the summer of 2017, I set my sights on a lofty goal — sailing a boat in the Mediterranean to Santorini. The only obstacle? I had no idea how to sail. But how hard could it be to learn? I started by taking two weekend-long courses — the American Sailing Association 101 and 103 courses, Basic Keelboat Sailing and Basic Coastal Cruising. I then went on numerous practice sails with an instructor to gain experience, and took an extensive online sailing theory course, learning about docking in various winds and currents, basic engine repair, and the effects of the sun and moon on tides and the weather. As my eyes opened to the vast body of knowledge I would have to master, Santorini seemed to be falling farther away from me, so I set an intermediate goal — sailing a boat by myself, locally. That fall, a friend and I solo-chartered a sailboat in Key West for a week. As prepared as I was from my courses and practical training, nothing could have truly prepared me for that final leap of independence. With no one to fall back on for advice, a new phase of learning commenced, and I grew tremendously from this experience. In surgical training, opportunities for independence result in tremendous surgical maturation, and in my chief year, I have come to greatly appreciate these opportunities.
One of the hobbies I pursued in medical school was ice skating, toward my larger goal of learning how to play ice hockey. A medical school classmate took me to buy hockey skates and then took me out on the ice for the first time. Like learning to ride a bike, there was a significant disconnect between watching others glide effortlessly on the ice and doing so myself. I would wake up early on Sunday mornings, watch ice skating tutorials online, then take the subway down to Bryant Park and practice for a few hours. I learned quickly that words and instructions are only a coarse approximation of a complex set of moves that you ultimately have to feel out, discover, and eventually master for yourself. In early sessions, with the benefit of a beginner’s mindset, I could fall on the ice multiple times and think nothing of it. But as I progressed, I found myself trying to avoid falling, and in the process, risking less and advancing less. So I resolved that I would lay it all on the line and push myself until I fell at least once every session. In surgical training, similarly, I have found great value in embracing discomfort. Leaning into the discomfort that accompanies a lack of knowledge, technical skills, or expertise and pushing past it has motivated me to grow tremendously. In residency, every 4 weeks, when we finally become comfortable on a service, we are whisked away to the next rotation, so we continue to progress, advance, and learn.
What exactly is this musicality one feels when surfing, sailing, ice skating, playing guitar, or even performing surgery? With a surfboard under your feet, you strive to feel a oneness between your mind, body, feet, surfboard, waves, and the ocean at large, so that you feel the exact right moment to get up on the board and drop in on a wave. Instead of having to think through the complexity of which way to turn the sails, tiller, and boat, given the wind angle, point of sail, and direction you want to go, you instead feel the water streaming past the tiller of your boat and the pull of the wind on the sails and instinctively push the tiller in just the right amount and direction needed to adjust your course. Instead of focusing on how the tutorial video said to “make c loops on the ice with the inside edge of your skates,” you relax and instead feel the traction between your feet, skates, and the ice, and the balance of your body, and adjust your position as needed to continue the motion you want. Your brain no longer has to calculate what key a song is in, figure out what notes are part of that scale, and then what frets and strings are used for that scale; instead, your fingers move to make music and express the song coursing through your mind! But how do we get to this joyous unconscious stage of expertise? How do we use our surgical instruments as unconscious extensions of our fingers and hands, and learn to separate tissues in accord with their natural tissue planes, in the beautiful dance that is surgery? Embrace the discomfort. Put the repetitions in. Then, keep the faith. And with humility and grace, in that final leap to independent practice, you’ll find yourself more than capable of serving your patients.
April 30th, 2021
I just finished attending one of our inpatient teaching services, and it felt like the panel was one of the most varied and medically complex I have ever taken care of. This was my first week as an inpatient attending — as an ambulatory chief, most of my clinical time is with the residents in longitudinal clinic — and as each day brought new challenges to reason through, I kept asking myself, “Am I just rusty, or is something actually different?”
Midway through the week, I started to sense the answer was the latter. We admitted a patient for further management of multiple complications from a prolonged COVID-19 hospitalization. On the same day, one of our patients who had been with us for several days revealed she had been diagnosed with a hematologic disorder before the pandemic, but had been forced to stop treatment because it was deemed nonessential. That night, I realized almost all of my patients either had symptoms that had not been worked up because they did not see a physician (or in one case, a dentist) during the past year; because intervention had been delayed due to a freeze on nonessential services; because of long-term complications from COVID-19; or, in one case, because of a reaction to a COVID-19 mRNA vaccine. None of our patients were actively being treated for COVID-19, however the pandemic had contributed to each of their hospitalizations.
Disaster medicine experts could have predicted this composition of patients on my team, as well as the increasingly complicated patients presenting to my clinic. In “Delayed Primary and Specialty Care: The Coronavirus Disease-2019 Pandemic Second Wave,” Weinstein et al. write:
The second wave will comprise patients with chronic illness who have patiently waited to reschedule or schedule their primary or specialty care appointment to refill medications, obtain durable medical equipment, and undergo surveillance laboratory or imaging studies to gauge effectiveness of titrated therapy. This will include patients who have waited and have symptoms, signs, and other indicators of a serious illness that requires a timely diagnosis to maximize effective treatment. This will include the patients with mental illness or substance abuse who have had their outpatient treatment routines disrupted while doing their best to accept their individual, family and community stress. Eventually, these patients will need care and, like the COVID-19 response, there will be an exponential curve of presentations and consequences of delayed care: the second wave.1
Published in Disaster Medicine and Public Health Preparedness in May 2020, the piece is a proactive call to action, outlining tactics based on proven natural disaster recovery frameworks that American healthcare institutions can use to prepare for this secondary surge of patients as they simultaneously work to rebuild their functional and financial capacities. Vital to the U.S. healthcare delivery system and deeply affected by the pandemic, residency programs might find many of these strategies helpful and directly applicable. Paraphrased examples include identifying those needed to care for acute COVID-19 patients, determining the duration of redeployment needs, creating a timeline to return to pre-pandemic functional status, keeping the non-redeployed up to date on COVID-19 best practices so that they can easily transition into the acute management role, adopting telehealth, and finding ways to protect the physical and mental health of their trainees.
Residency programs will also face unique challenges from the second wave, which they should anticipate as they prepare for the upcoming academic year. They should be aware of their institution’s social distancing protocols in order to request any necessary ancillary workspaces or workstations for the residents. Knowing this information will also help plan for the transition from virtual to in-person lectures. They need to recognize that the means by which hospitals and clinics work to recover from the losses of the past year will undoubtedly have an effect on their programs. Complex patients require more time and attention. Residency programs will likely be asked to provide more house staff to account for increased clinical demands, with additional needs in transient times of redeployment or employment freezes. The more the residents are relied on for functional capacity, the stricter time-away policies will have to be. Strategies to navigate interview season, parental leaves, and medical leaves will be of particular importance. Finally, they will need to find creative ways to support wellness, research, and education, as ongoing budgetary restrictions might continue to limit funds for these initiatives.
A beach lover from New England, I have spent much time wading in the Atlantic Ocean, anxiously awaiting the moment when that first wave crashes over me, knocking me off balance and chilling me to my core. Yet, as I endure successive waves, my feet root in the sand, and my body temperature adapts. To me, the second wave of the pandemic is aptly named. We are recalibrating to a post-acute COVID-19 world, and in spite of a surge of upcoming obstacles, there is also much to embrace. Taking care of these patients forces us to grow clinically and provides ample opportunity for bedside education. Furthermore, the universality of the pandemic has given us shared experiences that allow us to connect with our patients in a way that we previously could not. We just have to make sure we prepare for what is to come. Otherwise we will be swept away with the tide, and it will be difficult to make it back to shore.
- Weinstein E et al. Delayed primary and specialty care: The coronavirus disease–2019 pandemic second wave. Disaster Med Public Health Prep 2020 Jun; 14:E19. (https/doi.org/10.1017/dmp.2020.148)
April 14th, 2021
What I Wish I’d Known
Here is my advice for medical students, interns, and senior residents. These are things I wish someone had told me. I write from the perspective of an outgoing Internal Medicine Chief. Many thanks to my co-chiefs for their input and their support throughout this year.
- Be honest about your career interest. If you’re a through-and-through surgeon on an internal medicine rotation, tell us you’re going into surgery. Your team can then find ways to engage you in medicine from a surgical lens. We know not everyone will choose internal medicine.
- Avoid discounting your skills by saying “I’m just a medical student.” We all were medical students once. If you’re genuinely trying (and not hurting patients), no one will fault you for being completely wrong.
- If you are actively listening to your team, you’ll never have to ask, “what else can I do to help?” Figure out what your senior needs, and do it. If it’s unclear, a secret way to ask would be, “what’s left on your checklist that I can take over?”
- Don’t answer questions directed at other learners. Don’t interrupt presentations. If you’re asked a difficult question, say, “I don’t know, but let me look into it, and I can present it later.” Then, do that!
- Be in charge of the patient room! Write down team names and updates on the dry-erase board, return the tray-table and TV and blankets to their previous positions, ask whether the patient wants the door open or closed. These are little things, but we will notice you doing them. They matter more than you think.
- I know everyone tells you this, but PUT YOUR NICKEL DOWN! Giving us three treatment options and choosing the wrong one is MUCH better than giving us three treatment options and stopping! For brownie points, tell us your clinical reasoning when choosing that treatment (wrong or right), and we’ll be very impressed.
- You want your evaluations to read, “he/she worked at the level of an intern.” Figure out what this means within your team, and strive for it.
- If someone offers you the chance to go home early, take it! It’s not a trick.
- Keep a log of all the patients you see (last name, first name, and date of birth will do the trick for all EMRs). If that’s too much, at least keep track of all the patients you saw whose cases kept you up at night.
- If your expectation is to work hard, reality will certainly be easier. Those who expect a 40 hour/week residency all the time are the unhappiest.
- When picking up overnight admissions: read the H&P last. If you review the chart and come to the same conclusion as your colleague, chances are… you’re both right.
- Write less when pre-rounding. Try your best to present mostly from memory. As this gets easier to do, you’ll know your clinical reasoning skills are improving. It is possible!
- You’ve never seen HHS, and you never will. Order the DKA protocol.
- For prelims: Don’t be known as the “XYZ-prelim.” Be known as the person we want to convince to stay in internal medicine.
- The calmer you are, the more your interdisciplinary colleagues will listen. Take a deep breath, don’t show your inner panic.
- Start thinking about the patient’s disposition location and outpatient medication reconciliation from day 1.
- No talking behind the backs of your intern or medical student. No talking down about other specialties in front of your learners. If you need to vent, do it with a trusted peer or chief.
- If you can afford it, buy your interns and students lunch one Sunday.
- Most conflict arises from poorly set expectations. So set the tone for your team by setting expectations. If you can joke around within your team, work will become fun.
- If you’re frustrated by a system or situation, have a strategy to prevent that from affecting the care you’re providing to the patient in front of you.
- Take responsibility. Be there for your patients and colleagues on your bad days and your good.
Bonus: While there are no ‘stupid questions,’ seek an answer before asking the question. Make an effort. Shed the helplessness.
Advice is seldom welcome, and those who need it the most, like it the least. — Lord Chesterfield
What advice do you all have for us chief residents? Do you have any other ‘must-get’ advice that I missed?
March 19th, 2021
Rank lists are finally in, and Match Day is here! As I think back to my own Match Day and major decision points in my life, I remember feeling the gravity of making what I felt were life-changing decisions. Looking back, I smile when I reflect on how little of what I thought was so important has actually mattered. I am equally surprised by how large a role chance has played in these decisions, yet I am extremely happy with the outcomes! While we can’t control random chance, there are certainly some ways applicants and residency programs can better assess each other. (Disclaimer: these observations reflect my own thoughts, not those of my program).
How should residency programs evaluate applicants?
What constitutes a successful resident? If you ask 10 program directors, you’ll likely get 10 different responses. A more actionable question might be what selection metrics to optimize.
Minimize attrition? Or address the root cause?
Surgery programs nationwide have a 20% attrition rate. To minimize this, residencies seek out “grit” and “resilience” in applicants. While helpful, this conceals a larger problem. The problem is underscored by recent observations that, “Only in medicine does the death of the ‘canary in the coal mine’ lead to a search for more resilient canaries.” It is time we address the root issue instead of applying band-aids.
Programs need to honestly reflect on the etiology of attrition at their institutions. Where mistreatment or toxicity is the cause, the situation must be corrected. But maybe attrition for the right reasons is acceptable and should be normalized. A resident may realize with time that the specialty or program is not right for them, or that their priorities in life have changed — and this should be ok! How do we allow for this?
- Pre-match: medical schools should ensure students experience an accurate portrayal of the field so they aren’t surprised on July 1. Exposure as a student to the rigors of being a surgical intern (e.g., taking night-time call) has been associated with feeling more prepared as a resident and with decreased feelings of burnout.
- Post-match: residents and programs should feel empowered to discover a mismatch soon and make appropriate corrections. Normalization of a process for relocating to a specialty or program that is a better fit for a resident would provide a post hoc way of dealing with this issue.
Maximize board passage rate? The ‘objective measures’
Programs select on the basis of test scores, class rank, publications, and leadership roles. This makes sense, given the association between higher Step 1 scores and likelihood of first-time board passage.
However, we are realizing that standardized tests reveal implicit bias and might disadvantage underrepresented minorities. In response, NBME is making USMLE Step 1 pass/fail. UCSF, Stanford, and Harvard no longer participate in AOA rankings. In line with a prior NEJM Chief Resident blogger, we must look to holistic measures of a person, such as their character. But how does one measure character, and how does one do so objectively and reproducibly?
The fundamental uncertainty of ‘subjective measures’
Currently, we turn to our limited experiences with the applicant during the interview process, and the specific perspectives provided by letters of recommendation. Overall, we do not yet have adequate proxies for the qualities we need to gauge.
Fit – the solution?
Programs are fundamentally looking for people who will thrive at their program and have a positive impact. In many ways, a resident’s and program’s success are inseparably coupled. A resident may find success at a certain program because of the complementary alignment of his or her strengths/weaknesses with those of the program. While interviewing for residency, I was advised to “Trust your gut, go where you perceive the best ‘fit’ between yourself and the residents/faculty/program.” Only now, after the breadth of my experiences over the past 6 years, am I beginning to appreciate the value of this advice.
What should students look for in a program?
As a student, you can’t possibly know the full extent of what you’re getting yourself into. It wasn’t until my senior years of residency that I began to appreciate the gravity of the field — the loneliness and depth of responsibility one feels for one’s patients when having to make life-altering decisions.
There are other aspects of uncertainty from a student’s standpoint. Ranking a program because of well known faculty carries the risk that they might leave before you graduate or even get there. I believe the answer to the uncertainty, on the student’s end, too, is fit. Honestly assess yourself and your core values. Then find a place whose values match yours. Seek out examples of how they have demonstrated commitment to the things you find important. And do your best to get an accurate exposure to the field, the programs, and the culture: Seek out opportunities to act as an intern on sub-internships, take overnight call, and do visiting rotations.
Lessons learned from interviewing in tech
Prior to medicine, I worked in the tech industry, where technical interviews are used as a means to assess a candidate’s ‘technical chops’. Despite improvements over the past 30 yrs, these interviews still don’t predict who will succeed or fail at a company. Only 20% of the best coders perform consistently well at technical interviews. But it seems that practice makes perfect: applicants who attend more practice and actual interviews end up performing better than those who receive less practice. As I went through residency interviews, I found myself becoming progressively more calm, confident, and truly myself. Residency applicants too would benefit from additional practice sessions until they feel they have achieved the confidence to put their best foot forward.
From applicant to interviewer — insights from the other side of the table
Applicants and programs both seek to put their best foot forward. So how does one cut through the chaff and start to really understand someone’s character? One way is to explore character-defining experiences. I understand much better now the intent behind the questions, “Tell me about a weakness” or “Tell me about a difficult experience.” These are meant to allow an applicant to showcase their character, humility, trustworthiness, work ethic, stress response, and ability to grow.
We often end up selecting people similar to ourselves. We like an applicant when we find something to connect with them about. Often, I found two interviewers would have disparate experiences with the same applicant. One person viewed the candidate as engaging and passionate, while the other found them disinterested. If you’re looking for more than “people like yourself,” you need interviewers with a variety of backgrounds and interests so that a quality applicant is not overlooked.
In medicine, we are comfortable making decisions based on imperfect information. The applicant selection process is no different. No matter how exhaustive the process, invariably, we must make a leap of faith. A lot of luck and chance also factors into the process. During residency interviews, I eagerly anticipated my interview at a program in Miami. However, unforeseen circumstances clouded the visit. My most lasting impressions are a late flight arrival (at 2 am on interview day), and a belligerent taxi driver at the airport! All the same, I am very happy with how the overall process turned out.
To the programs:
- Structural issues causing attrition should be fixed. Attrition for the right reasons should be destigmatized.
- Help your medical students get an accurate exposure to the field.
- Seek to better assess an applicant’s intangible traits.
- Ensure applicants meet with a variety of interviewers.
- Optimizing for fit = mutual success
To the applicants:
- Immersive sub-internship experiences can help you accurately appraise a specialty.
- Practice makes perfect!
- Get real exposure to other programs through visiting sub-internships.
- Understand a program’s values and assess its alignment with yours.
- Check your boxes and, in the end, trust your gut when looking for the right fit.
March 5th, 2021
Chief year has taught me that, although residents progress through training linearly, the educational year itself is cyclical, with predictable “seasons” that are marked by specific events and focus on different populations within the residency body. With the completion of intern orientation, the fellowship match, and residency recruitment, there is a palpable shift to the progress and futures of members of the PGY-2 class. Filled with the planning of leadership retreats, selection of future chief residents, and preparation for the imminent fellowship and job application deadlines, I have deemed this time of year the “Season of the Second Year.”
Second years are the proverbial middle children of the residency program. Already onboarded and not yet needing post-graduate placement, they often feel overlooked. Yet in reality, PGY-2 is one of the most challenging and transformational years in internal medicine residency. With the change of a calendar date, residents suddenly gain significantly more autonomy, lose the security of having a senior to help with clinical reasoning and writing orders, and, in many programs, shift their responsibilities from being a task manager to being a supervisor. In the midst of this huge clinical transition, they watch their third year peers going through the fellowship match and job processes, only to realize that there is a limited time to define themselves within the program and to make crucial decisions about their own career trajectories. From the fear of being a senior on nights by myself, to the anxiety of not yet having chosen a specialty, to the insecurity of comparing my productivity and qualifications to those of my peers, I remember these feelings vividly.
As it has with so many aspects of medical education, the pandemic has made the experience of being a second year significantly more difficult. Between intermittent clinic and consult closures, the need to pull residents for redeployment, and some residents missing rotations for COVID-19-related medical leave themselves, this class has had less access to electives that would otherwise help them evaluate different specialties, establish in-person mentorship, and be evaluated clinically by the faculty who will write their letters of recommendation. Furthermore, as all of us have experienced, they are unable to access the people and activities that help relieve stress outside of residency, and many have suffered significant loss from the virus itself.
The way that this year’s second year class has managed to find opportunities amidst the aforementioned limitations speaks to their resilience and adaptability. However, the inequities of their access to clinical experiences and mentorship due to the pandemic has made me question whether the timeline and expectations prior to applying to fellowship need to be adjusted to allow for residents to have the opportunity to optimize their clinical growth before solidifying and propelling their career. Even under normal circumstances, when residents focus too much on research or other projects that they take on to improve their CVs, their clinical performance sometimes suffers. Further, if they feel the pressure to commit to a specialty so early in residency, they may miss out on the realization that they are better suited for something else.
Moving back the timeline for fellowship applications by even a few months would not only relieve stress on the individual residents, it might also have widespread program benefits. If third-year residents interview later in the year, they will be more present to mentor and teach the interns in their early months; by the time seniors are interviewing, the second-years will have enough experience to easily cover the teams. Further, it could alleviate the need for program leadership to focus simultaneously on onboarding new interns and ensuring all fellowship documentation is appropriately submitted, both heavily administrative processes with strict deadlines in June and July.
Creating such a substantial change in the seasonal pattern of the residency year would require buy in from myriad stakeholders across multiple specialties and within the graduate medical education community at large. If considered, it may take years to achieve. In the meantime, we in program leadership must focus on measures that help residents flourish within the current framework:
- Provide structured advisor, mentor, and coaching programs that prepare residents for crucial points on the residency timeline for skills acquisition and career decisions.
- Ensure broad exposure to clinical rotations early in training, with buffered time for the resident to explore electives.
- Allow interns to practice skills that will be unique to being a senior resident. This can be through embedded education and graded autonomy on the floor, workshops, or retreats with opportunities for reflection and goal-setting.
- Encourage fellowship directors to be transparent about their expectations of what constitutes a strong applicant. This will help residents prioritize what they should be working on outside of their clinical responsibilities.
- Anticipate that the pandemic is not over, and that the closures we previously faced may recur. Work with subspecialty education coordinators to find creative ways to achieve alternative education and mentorship if the residents cannot rotate with their fellows and faculty in clinic or consults directly.
- If your jeopardy pool can afford it, try to minimize calling in residents off of electives when they are rotating in their desired specialty.
The Season of the Second Year is as invaluable for the program as much as it is for residents. As we evaluate the clinical and academic progress of our trainees at such a pivotal point, we are forced to reflect on our own strengths and weaknesses that may have engendered or hindered their success. Further, the yearly process of selecting new chief residents allows us to focus on the future of the program, as well as what qualities we seek in our leadership.
With that, I open the discussion to the readers. How did you feel when you were second years? What measures did your program take to help you succeed, or that you wish had been offered? Do you think it would be feasible or useful to shift the seasons within our academic calendar?
February 26th, 2021
“If we teach today’s students as we taught yesterday’s, we rob them of tomorrow.”
— One summation of philosopher John Dewey
The Why can’t I just Google it? Problem
Imagine seeing a patient with symptoms you suspect mighty be the result of a medication side effect. But you’ve forgotten the mechanism of action of this medication. You left your pocket pharmacology book at home, and the hospital library is 15 minutes away. There are no pharmacists on the wards for you to consult. I imagine there was a time when memorization in medicine was crucial. I am not saying it isn’t now, but I propose that it is less so. In less than 1 second, Google can tell me the mechanism of action of any medication. By conceding that the availability of lightning-fast information at our fingertips is an argument against memorization, are we doing a disservice to our learners?
Pedagogical shift, proposal 1: Let’s teach our learners how and when to appropriately utilize modern, web-based tools. More importantly, let’s teach them why it is still important to engage in some memorization instead of always reverting to “Why can’t I just Google it?” If you’ve ever run a Code Blue, you know there are times when your memory must serve you under extreme pressure. I would like to see medical education emphasize the why instead of the what. Any modern learner can Google the what (i.e., what is the mechanism of action of labetalol?). So let’s set aside testing learners’ memories and instead re-allocate time to teach them why a master clinician chooses labetalol instead of another agent.
USMLE is already moving toward making Step 1 Pass/Fail; many medical schools are shifting to a longitudinal curriculum. As someone who has come from “bench to bedside” and now is arriving back at “the bench” for ongoing enhancement of my understanding of pathophysiology, I wish I would have been taught with the above lens.
The I don’t have time Problem
Residents of today have quite a bit asked of them! Pre-round efficiently, present that data flawlessly, tend to sick patients, admit new patients, run family meetings, discharge patients (ideally before 11AM), write your notes quickly but without copy forward so the attending can co-sign, and sign-out in a timely manner so you don’t break duty-hour restrictions. All this, along with the added pressure of attending educational conferences and reading about patients. It’s hard. I worry that the residents (and the perceived “cheap labor” they provide) have been misappropriated to doing more and more. Is there a way for residents to see a similar volume of patients but re-allocate their limited duty hours back to being learners?
Pedagogical shift, proposal 2: Let’s challenge our learners to practice mental dexterity. With the ubiquity of workstations on wheels in many hospitals, is a model of “discovery rounds” better? Here, time typically spent pre-rounding can be spent at the bedside, reading about illnesses, and prepping the rest of the afternoon for success. This model may be more difficult for junior learners (medical students and interns), as it requires one to synthesize data quickly, assess the patient’s condition, and derive a plan. For senior residents, this may be the necessary way forward for critical clinical reasoning. This method might also help shift the traditional model of data transference (from the pre-rounder to the rest of the group) to one of dialogue.
The Stuck in a routine Problem
Everyone learns differently — some visually, some aurally, and some in a tactile manner. One of my favorite education philosophers is Paolo Freire. In his Pedagogy of the Oppressed, he writes, “education is suffering from narration sickness.” It is not by pretending we are empty vessels to be filled with medical knowledge that one becomes the type of provider they want to be; but rather by experiential learning through a growth mindset and empathetic dialogue will we become our best physician self. That’s a bunch of fancy words to say, as a chief, I notice a decline in enthusiasm toward attending educational opportunities and wonder why this is the case? What changes would the learners prefer?
Pedagogical shift, proposal 3: Let’s bring back the joy of teaching and learning. Celebrate being wrong in a safe space and use a dialogical and interactive model of teaching rather than narration. This has been a priority for me and my co-chiefs this year. We even created a “Stump the Chiefs” conference to get in the hot seat ourselves — which you can find on our YouTube channel. Why not try “reverse-pimping” while you’re on the wards? Here, the learners ask questions of the attending to determine how he or she catalogs a patient’s presentation and how a treatment plan is developed. It is our duty to keep our learners engaged. It’s time to get creative, pique some curiosity, and make learning fun again!
Let us no longer rob our students of tomorrow.
February 18th, 2021
“The life of the dead is placed in the memories of the living” — Marcus Tullius Cicero
Growing up in a family of physicians, I was exposed early to healthcare from the provider side. Some days, my father would come home late after a long surgery with an unanticipated complication or an unexpected outcome and would silently eat his dinner while listening to us talk about how our day went. As an animated child, I always had many things to tell him, but I realize that I never asked him how his day had gone. Throughout my career though, I have come to realize the power of being comfortably silent with your loved ones. We all need that unique outlet to destress, and now I understand that it was his family for my dad.
Losing patients is never easy — the permanence of loss with death highlights our lives’ temporary nature. Having been trained to save lives and treat diseases to help cure our patients, it is challenging to deal with loss emotionally, physically, and intellectually.
The ongoing pandemic has definitely tilted this equation even more and has left most of us with hardly any time to truly internalize and reflect on losing patients. It has been surge after surge, with the continuous onslaught of COVID-19. Fortunately, one of the success stories of this decade will be the vaccine and its role in reducing the number of deaths, provided we reach an adequate number of vaccinated individuals. Politics and conspiracy theories aside, we must not forget the power of science and choose it over our own personal differences with each other’s thought processes. As we start seeing the beginning of the pandemic’s end, the road to recovery will be a long one ahead. We need to continue planning the rollout of vaccines, including mass production and administration to the general public, consider our response to the newer viral strains, and, at the same time, address the loss we all have seen so far. I think it is high time to restart (continue) the conversation about physician grief and better ways to deal with it.
Dealing with a patient’s death is a profoundly personal experience, and coping mechanisms will vary. Although our ways of dealing with adverse outcomes may differ from each other, there is a root paradox with confronting death, since it negates everything we are taught and inclined to do — be it saving lives or curing diseases. Acknowledging this paradox can be a valuable starting point, as we learn to recognize our own feelings and patterns of dealing with loss. Some insightful pointers that I have received from my mentors are these:
- Honesty and Empathy: Being completely honest with our patients and their families is vital and goes a long way in overcoming their fear and uncertainty. Prioritizing their comfort is essential and helps address common goals. Choose a private area to communicate bad news and express sincere empathy. Always ask if anything else can be done to help families with the grieving process. We often learn how to be better in these trying times by listening to what families have to say.
- The power of choice (letting go of guilt): Remember that it was our choice to be here in this role, caring for patients. We must not forget our conviction for helping others and reducing suffering, which led us to medicine. Refreshing our perspective regularly helps us realize how far we have come, while we continue to learn from our ongoing experiences. Unfortunately, medicine is not an exact science. Sometimes, practicing it can be an art, especially while traversing through some grey areas. Being comfortable with not knowing it all makes us human. Setting ourselves on a path where only saving lives is acceptable may not be an ideal goal; instead, focusing on respecting patients’ autonomy and wishes will help us see life and death as more than success and failure.
- Seek support and normalize grief by creating a safe space: Physicians are not superheroes and cannot fix everything. One of my mentors uses the “Magic Wand” analogy and tells her patients that she would surely fix everything if she had a magic wand. Unfortunately, none of us have one. I have found that being honest about my inability to fix everything is very powerful during patient encounters. I have seen it humanize physicians. Remember, it is okay to cry with your patient’s family, and it does not make you a weak person or any less of a doctor. Showing your emotions in such a situation helps physicians and patient families grieve together and achieve closure. It also helps to talk about losing patients among peers in a supervised setting and perhaps with professional psychologists present, if needed. It also helps to listen to your colleagues’ experiences. Creating safe spaces at work on a regular basis can definitely be therapeutic. We are a team, through life and through death.
- Gratitude and prioritizing self-care: Being thankful to the people who care for us and the blessings we have can be very powerful and definitely can add meaning and purpose to our lives. Caring for others can continue to be fruitful only when you begin with yourself. Practicing personal wellness regularly results in professional wellness. Finding a hobby and doing something you genuinely enjoy outside of medicine helps heal your body, mind, and soul.
To conclude, any new disease will always bring with it its own uncertainties. Although we have had coronavirus infections before, we have never had them at such a pandemic proportion. This has resulted from many factors, the scope of which is beyond this blog piece but, needless to say, we have many things to unwrap in the time that lies ahead. Not knowing the natural history of a disease and the pathogenesis of its symptoms made many of us feel like we were stuck in a tunnel, blinded by its darkness, trying to find a way out.
How can we treat a disease we do not fully understand? As we answer this question, I am appreciating the power of fundamental principles and basic research with all the developing literature. I thank all the great scientific minds and the gallant efforts of our healthcare workers/allied staff members as we even begin to see the light, hopefully, at the end of this tunnel.
I invite the readers to share their experiences with grieving through this pandemic to continue this narrative and help with the healing process.
February 4th, 2021
The reflections and photos in this post are a result of the immersive experience I had via the Fellowship at Auschwitz for the Study of Professional Ethics in 2016.
Many assume that Nazi physicians were antisocial, sadistic psychopaths. But viewing the perpetrators of the Holocaust as morally deficient is simply inaccurate; in fact, the Nazis physicians were often well-known, highly respected individuals at the tops of their fields. The Nazi philosophy was based on scientific and historical factors that developed over many years and culminated in the Holocaust. In the actions of Nazi physicians, we can see how many important principles in the practice of medicine were broken. Studying the actions of Nazi physicians reinforces that we may all be capable of violating these principles, and we must be constantly vigilant to maintain our compassionate, humanistic, ethical practice of medicine.
Enhancing patients’ right to healthcare
The Nazis had a warped view of “public health” that centered on “racial hygiene,” a concept that represented the evolution of ideas introduced in Charles Darwin’s Origin of Species. By 1920, the phrase “life unworthy of life” was commonplace in Germany in referring to terminally ill patients and psychiatric patients. When Nazi doctor Fritz Klein was asked how he was able to murder people after having taken the Hippocratic Oath, he responded, “Of course I am a doctor and I want to preserve life. And out of respect for human life, I would remove a gangrenous appendix from a diseased body. The Jew is the gangrenous appendix in the body of mankind.” The moment we believe that certain groups of people, whether elders, socioeconomically disadvantaged, incarcerated, disabled, or with whatever other trait we choose, are less worthy of healthcare is the moment we start to invalidate their humanity and their worthiness of life. The American healthcare system unfortunately often makes it difficult to ensure that all groups receive equitable healthcare. Thus, it is our job as physicians to advocate for our patients to the best of our ability at the individual, state, and national levels.
Informed consent is critical in clinical medicine and research
The Nazi doctors enacted a variety of non-consensual human experiments. These experiments included determining the “most effective” means of killing people (e.g., injections of phenol vs. starvation vs. gassing), freezing subjects to identify effective treatments for hypothermia, and bone grafting experiments to test the efficacy of newly developed medications. The purpose of many of these experiments was to identify efficient methods for killing people the Nazis deemed “undesirable” and to perform general basic science research in which a given Nazi doctor had a special interest. From post-war scrutiny of these experiments arose the Nuremberg Code, a set of guidelines that outlines principles of research ethics in human experimentation. From consent in research projects to day-to-day consent for medical procedures, it is critical that we ensure our patients are well-informed of the risks of the procedure to which they are consenting and that they are voluntarily agreeing to undergo the intervention.
Importance of challenging the hierarchy
The sociological phenomenon of people’s willingness to follow orders also played a prominent role in the actions of the Nazi physicians. Stanley Milgram’s famous 1961 obedience experiment showed that people exhibit a chilling willingness to follow orders, particularly when there seems to be a greater cause and an authoritative figure giving orders. In his testimony in the Nuremberg Trials, defendant Dr. Karl Brandt was asked whether the ultimate responsibility for the medical crimes that took place in the Nazi concentration camps should fall on the state or on the physicians. Dr. Brandt responded, “In my view, this responsibility is taken away from the physician because the physician is merely an instrument. The feeling of a special professional, ethical obligation has to subordinate itself to the totalitarian nature of the war.” The dissemination of responsibility from an individual to a group of people can enable individuals to engage in unethical actions. Impenetrable hierarchies in medicine continue to exist to varying degrees, often differing between specialties and institutions. However, the idea that strict adherence to a hierarchy can negatively affect patient safety and patient care is commonly taught in medical schools. As a result, there are measures in place that intentionally disrupt the chain of authority in medical practice. For example, a patient’s nurse may be specifically sought out during a medical team’s rounds to ensure that any of his or her concerns are addressed. Formal avenues exist for medical students to lodge concerns regarding mistreatment of themselves or patients. Centers of professionalism and ethics abound in medical schools to address these types of violations.
Taking action against dehumanization and decreased empathy in medicine
In their participation in concentration camps, Nazi doctors were able to psychologically distance themselves from their actions by dehumanizing prisoners (e.g., using prisoner numbers instead of names, stripping people of their clothing and other belongings, viewing individuals as animals instead of people). In the modern practice of medicine, constant exposure to the pain and suffering of other people often has a numbing effect. Medical professionals may eventually become less susceptible to having an emotional response to another person in pain. It is a well-studied phenomenon that medical students become decreasingly empathic as their training progresses. This apathy towards pain and suffering that may develop over time in physicians is concerning, because it may enable a similar apathy when immoral actions occur. Those who commit evil do not necessarily have evil motives. This decreasing empathy and lack of self-awareness in the medical profession is a systemic problem that physicians should be aware of and which needs to be continually addressed. Some possible interventions, many of which are already occurring, are to include courses and activities in medical practice that enable reflection and empathy. Examples include patient memorial services, reflective writings, and facilitated small-group discussions on the role of empathy in medicine. Encouraging and enabling physicians to have other roles in their lives can also be helpful, as a person who functions as a physician, a mother, a wife, and an active community member has the opportunity to re-orient herself and look at her role as a physician from other perspectives.
Ultimately, every historical age has its own outlook and attempts to solve the problems it faces in unique ways; it is by studying how these historical problems arose and the results of their attempted solutions that we can start to have a basis for solving problems of our own time. By learning from the atrocities committed by Nazi physicians, we can hope to avoid similar actions in the future and hopefully better the practice of medicine.
Alexander L. Medical science under dictatorship. N Engl J Med 1949 Jul 14; 241:39. (https://doi.org/10.1056/NEJM194907142410201)
Chen D et al. A cross-sectional measurement of medical student empathy. J Gen Intern Med 2007 Oct; 22:1434. (https://doi.org/10.1007/s11606-007-0298-x)
Lifton RJ. The Nazi doctors: Medical killing and the psychology of genocide. 1986. New York: Basic Books.
Milgram S. Behavioral study of obedience. J Abnorm Psychol 1963 Oct; 67:371. (https://doi.org/10.1037/h0040525)