Application process: Looking back as a 4th year

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MikeS 78

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I am currently in my 4th year of medical school. I am here to say that most of what people allow to weigh in on their decision to attend medical school is pretty irrelevant. I base this statement on 1) what I took into consideration 2) what other people I met on the trail into consideration 3) talking to prospective applicants 4) discussions with fellow classmates. This is in large part because most information about schools comes from is from first year students, who really have no idea of what the school is like, sales angles of schools attempting to reel in students etc, and random discussions from people who don't know much more than you do.

What is not important:

1) Impression of students: this is bogus, totally bogus. Every school has a fairly similar mix of a few types and if you think you can tell what students are like by meeting the tour guide and 3 other people you are fooling yourself.

A) Gunners- Every american medical school has gunners. Furthermore, your interview process will not allow you to prove or disprove my theory, as these people generally aren't doing interviews. Also don't let anyone tell you that theres no competition at their school because there is always someone who wants to do ortho at the hosp for special surgery, even at DO schools.

Moreover if you are really worried about dodging the "Gunners" then 90% chance that you are observational experience

B) Slackers- These are the real people I'd be worried about: they tend not to show up to stuff and make everyone look bad.

C) Superstars- Every school has these, good schools have a few more.

D) Everyone else (prob 45-60% of a class)

2) Curriculum- Guys I hear this alot and read this on this board alot....looking back I thought this was a big deal, now I say "who really cares." Here's my breakdown of the issue

A) PBL- you have no background to base your case based learning on...and will not have it until year 2 and probably 1/2 through that (when you start organ system pathology/pathophys). Really how can you expect someone to understand CHF related fluid retention with no prior knowledge of renin-angiotensin and the kidneys...silly

B) lectures vs no lectures- For all practical purposes, you are going to teach your damn selves 90% of the first 2 years.
The reason for this is that most of the first two years really is vocab and getting your mind around a few key concepts so that third year you can actually understand what your residents and attendings are saying. So despite all the hype about new novel ways of learning it boils down to you hanging out with Robbins pathology, a microscope/online slides and a cadaver and figuring it out.

As far as clinical relevant knowledge year 1-2 is more or less the about the same, deal with it. I say this coming from an Ivy so trust me.

3) Quality of facilities- Theres three reasons why this is pretty irrelevant
A) they never show you all the facilities-

B) Does learning in an old building really impact your education

C) When you're trudging in the snow at 4 am to rounds on surgery are you really going to notice or care what the outside of the hospital looks like......highly doubtful

4) extracurricular/social stuff- This is +/-. If you have a passion for playing the violin...can't live without it and are willing to do it despite significant other time committments..this can be a plus

however, do not get the false impression that a medical school class remains this cohesive bunch of social butterflies for 4 years. Generally, everyone is very busy and alot of people are overwhelmed. The attendance at class events dropped preciptiously year 2.

5) early patient contact- I think this is a total sales pitch: To provide an anecdote: It was january of my second year. we were in our physical diagnosis class, having our first group interview with a patient with renal failure and volume overload causing CHF.

so the encounter goes like this.....

A classmate "so what brings you to the hospital today"
patient: "I am having a tough time breathing, it feels like im drowning when I lie flat"
Classmate "that sounds bad"

long silence.

This classmate was a smart guy and ended up being AOA and this was 1 1/2 years into medical school.....

so if thats 2nd year what are you really going to do interviewing patients 1st year.......basically acquire bad habits that you will need to fix later in life. Is it a total waste? no. However do not make this any more than a minor consideration.

Things that are important

1) What is the 3rd year like and how is it structured?:

I almost never hear any real questions or comment from applicants regarding this topic. In the end this is the only real difference between schools, and probably could be the only real question to ask? more specific questions?

a) How are the rotations structured? What is your role on the wards? Do you have a clear role Do you get your "hands dirty" alot, or is it alot of shadowing? This is very important. You really don't learn much by watching people do stuff and if they work you down to a minimal role you will not gain much experience and will suck for several months into internship.

Now I'm not saying you demand the right to cross clamp the aorta during a CABG, but medicine is not a spectator sport and if the school doesn't have a culture of teaching (i.e. alot of patients are private patients, medical students aren't allowed to do anything) it will be a long, boring 3rd year.

2) Where do 3rd year evaluations come from?

Alot of people go in with this attitude "I am here to learn not to get grades." I agree with this attitude 85%. However, using that attitude indiscriminantly is impractical and can lead to some evaulations that you are not too happy with, it happens

You probably can't please everyone equally. This is especially true on surgery and medicine where there is not enough hours in the day.

Thus, the recommendation I make to everyone is to figure out roughly who writes the evaluation and what they expect and make sure you do a really good job on that. I do not recommend kissing up....However, it is really easy at times to get caught up in "which 5 minute presentation do I spend preparing for tomorrow. " This is why if you know who is grading you you can prioritize which person you pull the NEJM articles out for, and who gets the 15 minute before cram session off up-to-date.

Understand however while this happens at all schools (its how the beast works) not all schools do a reasonable job at making this fair or letting you know who is grading you or what you are supposed to do. Thus you should really make an effort to ask questions such as for every rotation do you have an attending directly responsible for evaluating you, or a preceptor (someone not taking care of patients that you are caring for who evaluates your academic abilities and analytic abilities? ideally your grade should come roughly equally from both.

3) Where do the students end up? If you dont want to do primary care, and 75% of school X does. Guess what, you are signing up for 15 weeks of primary care rotations at that school. Conversely, if you want to do general internal medicine or family medicine....and you come to a school that puts out 25 orthopods and 10 neurosurgeons a will spend alot of time learning about surgeries that you will never perform in your life.

4) How are medical students protected from scut?

If they cannot give you a real answer to this question expect to learn alot about running bloods to the lab and wheeling patients to the CT scanner and very little about managing an MI.

Some schools do a good job of setting up systems to prevent this, however I have also met interns who told me that they failed the surgery shelf because their school was rampant with scut and they didn't learn anything. I think my school did a very good job at scut control, however I have wheeled my share of patients to CT at 2 am.

5) How receptive is the administation to fixing problems and/or disciplining out of line behavior, espcially from residents?

trust me when you have an ID class where the course director is terrible, you will really appreciate it when a new course director is hired the next year.

6) how is the research opportunities at this school?

If you want to end up at an academic program, there will come a time when you will seek papers and if they are not there to be written then you will understand the meaning of this question. If not then forget I mentioned this.

7) how good is this school at focusing on the bread and butter?

This is especially relevant if you are looking at an academic powerhouse type place. Typically alot of times you will find that big tertiary centers tend to be filled with people who A) study esoteric diseases, B) specialize in highly uncommon or speciallized surgeries or diagnostic tests, or C) only doing big commando surgeries on cases people in the community looked at and said no way im touching that.

This is something you may be interested in as an attending or at the end of your residency. However in medical school most of these areas will not be your field and learning the literature on steroid tapers for patients with the CREST syndrome, the signs and symptoms of spinocerebellar ataxia 8 or how to resect a pseudomyxoma peritonei is probably not the best use of time in your only exposure to the area. Its easy to get caught up in that stuff, however good schools recognize the nature of the academic beast and try to make sure that you leave knowing the stages of active labor, how to read an EKG and how to manage childhood asthma.

I hope this helps

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Wow, Mike, great post! Thank you.
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Excellent post!
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thank you mike! this kind of info is so important. thanks for taking the time to type it all out.
Wow! I'm saving this one...
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Originally posted by ATPase
Wow, Mike, great post! Thank you.

ditto. Thanks for giving us a down-to-earth perspective on med school. :thumbup:
Thanks a lot Mike! I wish I had known some of these points before I went to interviews. I hope I'll still get a chance to inquire before deciding on the school.
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This is great post!:thumbup:
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Best Post EVER.

-The Comic Book Guy
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Lets get rid of the rest of the stickys and put this one up, minus all of the praise responses.


Originally posted by irie
If the last 15 posts in a thread say "great post", what inspires people to create yet another post that says, "yea, great post"?

What the heck? Oh, I think I get what your saying. Well, It can be stickied and closed.
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I concur with much of what was said. But I have a few points where I vary a tad.

1- Early patient contact is very important. However, this can definately be a sales pitch. When you hear 'early patient contact' its important to ask them what this means. If this is ten second year students standing around gawking at a patient, then yup. NOT helpful. However, where I trained, the first years started with standardized patients all year, doing h&p's. Second year, each person got thier own patients, on the wards, which they had to do full h&p's on, several times a year, and standardized patients. So by 2nd year, you might not know what all the awnsers to your questions meant, but you knew to ask them. So, like all things, ask them what exactly that means.

2- 'Personality' of the school can be important. I have known people who picked a school based on all that bs stuff when they really loved another school and were miserable for four years. While not the most important thing, its important to make sure ou will fit in and that you are in a place you can survive. And always remember, crappy doctors come out of 'great medical schools' and great doctors come out of 'crappy medical schools'. You will get out of medical school what you put in.

3- Have a life out of medical school. They all have gunners, don't let them suck you in. Be cautious of the competitors. of course, in my class, it was just who could drink the most. *g*

4- Realize that being AOA doesn't gaurantee your residency of choice. Your letters 3rd year are crucial. Period. And definately agree about the scut. watch out for it.

otherwise, I completely concur.
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This is helpful information, however I don't think the average applicant is going to be able to get the answers to a lot of these questions. Third and fourth years are hard to come by at most interviews (not all, I realize) and the lower years you meet usually won't have a clue about any of this stuff (sort of the point of your post). Perhaps asking the admissions office for the names of some 4th years who would be willing to answer questions over email might work.

I agree to ask about the nature of the early patient contact, but I wouldn't completely discount it. My stindts in the hospital have served to really calm my nerves about 3rd year, which is huge. But we get our very own patient and must do a whole history and physical, present it and write it up. May not be a big deal to a 4th year, but to an MSII it is really helpful. Perhaps in a couple of years I will have a completely different outlook. :D
Thanks Mike! It's always nice when you find out that life chose better for you than you would have chosen for yourself.

I'm at a school that does a really outstanding job at most of the things you listed as important. But it's likely I would have gone somewhere else, just for personal reasons, had I been accepted there. Not that that would have been a terrible choice, but I will definitely get more hands-on experience here. Which explains why every physician who finds out where I go to school is like, "that's a really good school!" When in fact, it doesn't even make the top 50 by USN&WR methodology, is housed in an old building, uses relatively little PBL, has an H-HP-P grading system, is not a research powerhouse (although starting your own project is pretty easy) and is expensive as hell.

But by the end of this year (my first), with any persistence on my part (and a little luck), I will have intubated at least one patient, started an IV, and sutured a surgical incision. I'm pretty sure that wouldn't be the case anywhere else I might have gone. The formal curriculum for first year teaches us vital signs, how to take a history, and a few basic physical exam maneuvers, like palpating the abdomen.
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Good question. I have an idea (scut = hospital work given to med students with little to no educational value; like wheeling patients to CT). Even so, an exact definition would be appreciated.


Very Nice.......Hey I want to know do medical students actually get into confrontations with the doctors?
I never got into a confrontation. (power structure and all, plus, its unprofessional) But I did go to the mat once or twice for patients, wanting a test or something done.

I had a run in with a *****ic attending once. He was also a sexist pig. I just kept my mouth shut and when the week was over, went and filed a complaint with the head of the department.
Best thread I've seen in pre-allo for a while. Even though the advice is very valuable and I'll try to take it into consideration when choosing a school, I think most of us will end up having to learn all this stuff the hard way in med school anyway. It's tres difficile to find a school that's a "perfect fit." Believe you me, I'm trying my best to see if it exists. :)

:thumbup: work, OP.

scut is anything you have to do, that may or may not have teaching value, that neither requires you to have taken medical schools classes, nor can reasonably be said to advance your skills as a doctor.

Examples include everything from running blood to the lab because the tube system is down, to writing labs off the computer onto a sheet of paper so rounds run faster in the afternoon, to waiting at a phone for someone to return a page.

Scut has to be done by someone, but when that someone is always you to the point that it prevents you from learning anything, thats when it becomes a problem. The key thing is that while scut can be educational at times, it is really the interns job and not yours. If the school doesnt make an effort to make sure that it the way the ship runs, trust me you will end up doing alot of scut.
as for confrontations with attendings: not if youre smart.

Most of the time they either ignore you (especially on short rotations), or really work hard to make sure you're happy.

Some times you get snipped at for some stupid minor thing. This happens more on gen surg and Ob/gyn, but can happen anywhere esp with "old school" type attendings. My recommendation is to put on a teflon jacket....usually its just the way to make sure you never forget to not put your hands below the table while scrubbed....and alot of times they don't remember it 15 minutes later
I would say that having your labs done in the am is not scut. This is crucial to the mgt of your patient. You aren't going to learn jack about managing pts if you dont' know what is goign on with your patient.

Now, running them to the CT scanner, etc, is scut. And occasionally to get things moving this is not a bad thing to do. However, if you are doing so much of this that you aren't able to follow up your patients and READ about them, then there is a problem.
I really enjoyed reading this gave me a great deal to think of as I apply to medical school...

one question, however....what is "AOA?" it's been referred to several times in this forum...
just bumping since it looks like we aren't going to get a sticky on this one.
Originally posted by docjolly
I really enjoyed reading this gave me a great deal to think of as I apply to medical school...

one question, however....what is "AOA?" it's been referred to several times in this forum...

Alpha Omega Alpha -- kind of like Phi Beta Kappa but for medical school.
bump. it's a great post and some people who haven't read it may be interested.
Excellent post!!

So which schools fulfill ?what is important list??
We should ask 3rd+ year medical students/residents.
My school definately did not let me down. A pleasant surprise as the whole clinical stuff during first year was brand new.

My school not only fulfilled my desires but exceeded them. And in retrospect, all the things they emphasized (key point being professionalism, etc) has stead me incredibly well in residency. Any specific questions I will be happy to awnser.
Brilliant post - thank you!

It is possible to get info about 3rd/4th-yr rotations during interview day, but you have to work at it or follow up afterwards. For over a month I've been pestering my #1 school to get answers to questions like, how much contact do students have with attendings? residents? how many students in a group on a typical rotation? are we competing with nurse midwifery students/PAs etc. for experience during rotations?

All this was motivated by a conversation with my student host during my first interview at UAB; she talked about how on 3rd-yr surgery rotations in Birmingham she had to peer over a huge crowd of residents, students, interns, etc. and had almost no contact with the attending or opportunity to do stuff. The students on rotations in Huntsville were much happier since they got a lot of one-on-one attention and training.
For God Sakes sticky this post!!!!!!!!...this is the most useful info applicants can get...what does it take to get a sticky? This is a thousand times more informative than accepts/waits/ us all a favor an sticky it...IMHO and all that...
Perhaps some more questions would help....
Excellent post, Mike. Very raw and amazingly accurate...kinda the "behind the scenes" at US med schools.

Originally posted by MikeS 78
Moreover if you are really worried about dodging the "Gunners" then 90% chance that you are observational experience

This is SO true! :laugh: :thumbup:

BTW, the examples of "scut" that I've read so far in this thread may be typical, but certainly not the most demeaning/irrelevant to medicine/waste of your time.

*Picking up a resident's dry-cleaning
*Picking up take-out from a nearby restaurant
*Driving to the mechanic's to get an estimate on an intern's car
*Driving residents around town to help run their errands


(BTW, all were real-life experiences. :( )
.....and very timely

One question, Mike, can you break down or translate your comment about Research in the important list? I am considering an "academic" institution but don't quite get your point and hence can't evaluate it now.
bump bump bump bump-a-lump-a-lump bump!!!
Is it true that for difficult residencies, it is better to go to school that actually has that program? Is this even something you should bring up during an interview if they ask you why you want to go to school A?

Also, as far as 3rd year rotations, are they pretty much fixed? You have do the routine stuff before you get to pick and choose your 4th year, I'm guessing?
3rd year rotations are generally set in allopathic schools. There are small variations and some 'elective' variablity (vascular vs cardiac vs anesth) within those. but everyone has to do surgery, med, ob/gyn, etc.

Fourth year is very mutable with a lot variation between states in terms of waht is required. You don't necessarily need to be *at* teh medical school that has the specialty you think you want but you will want to set up rotations there during your fourth year. (don't bet on knowing exactly what you want to do... it changes for a lot of people, myself included after 3rd year)
To the OP: Would you mind divulging some key info here..namely...where did you go to medical school? Also, (if ya don't mind)..where did you go for undergrad? Yes, I am aware that these are annoying questions...however, the post just piqued my curiosity.
BUMPing this **** back up
oldlady: in case he didn't respond to you: he meant that the emphasis on really specific research interests that exists at big academic-oriented institutions aren't going to help you be a doctor. so you might learn about something really cutting-edge, but you'll never use it and might miss out on the more relevant stuff like basic patient care (he used examples like managing childhood asthma).
excellent post

i really wish i read this a few months ago :p
Originally posted by avhart
oldlady: in case he didn't respond to you: he meant that the emphasis on really specific research interests that exists at big academic-oriented institutions aren't going to help you be a doctor. so you might learn about something really cutting-edge, but you'll never use it and might miss out on the more relevant stuff like basic patient care (he used examples like managing childhood asthma).

I don't really know what the origional post meant. However, I am going to disagree with this. Or maybe expound a little. I myself was an adamant research hater in medical school. HATED. IT. Knew I would never do it. Didn't like stats, just didn't find it interesting and beleive the same "doesn't make me a good doctor". As I have embarked on my own research during residency (and a moderate amount at the beginning of my fourth year) I have realized that research inyour field can indeed make you a better doctor. If you are doing *clinical* research you can be improved incredibly. It trains you to constantly question why things are done. You will become amazed at still, in this day and age, how much of medicine is not backed up by any research.

And how antecetal medicine can completely burn your a**.

Even bench research can increase your knowledge. This is because bench research requires you to understand what is importan in medicine. You have to have understanding of what are the problems and combine them with your 'bench' research. There are examples galore out there of clinically inspired and applied bench research.

I would *highly* recommend getting involved in ANY kind of research as a medical student. No matter where you end up goign, you need to understand how to do background research, how to develop ideas, refine your hypothesis, design a study, write an IRB, do your study, analyze the data, submit it for presentations, and present it to journals for publication.

What you don't need to be doing is running gels with no idea of what the point is for.