Failed clerkship, chance for surgical subspecialty

[Hoihoihoi]

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[GoSpursGo]

It's time to have a frank discussion with your home ENT program, if you have one. They are by far going to be your most likely program to match at.

If you don't have a home ENT program, you really need to strongly consider your risk tolerance. You're at high risk for failing to match if you try to apply ENT.

 

[operaman]

You’ve got an uphill battle ahead. Home program is definitely your best bet. Sadly your other clinical grades are also weak and having the F makes it look more like you barely passed OB and FM. It starts to look more like a pattern rather than a fluke. Seeing that up against a solid step 1 and an H in surgery is strongly suggestive of substance abuse or poorly controlled mental illness; big swings in performance like a 90th percentile step and then a 5th percentile shelf score x2 usually point to serious underlying issues.

Your home program is most likely to give you a solid look but that’s only because they know you and have time to see your performance. This only works if your performance is good though, so make sure you deliver the goods.

You’ve done a lot of work already so maybe worth applying, but you’ll want to have a backup plan that you can dual apply.

 

[Mass Effect]

Seeing that up against a solid step 1 and an H in surgery is strongly suggestive of substance abuse or poorly controlled mental illness

That's kind of harsh and in my opinion it's inaccurate. There are a lot of people with the solid Step score, an H or two and the rest P's. What screws the OP up is the F, but I don't think even that is suggesting of substance abuse or poorly controlled mental illness as much as it's likely indicative of someone who slacked off on a rotation he didn't care about and likely thought he could skate through. The latter is far more likely and far more common.

 

[operaman]

That's kind of harsh and in my opinion it's inaccurate. There are a lot of people with the solid Step score, an H or two and the rest P's. What screws the OP up is the F, but I don't think even that is suggesting of substance abuse or poorly controlled mental illness as much as it's likely indicative of someone who slacked off on a rotation he didn't care about and likely thought he could skate through. The latter is far more likely and far more common.

I’m afraid I have to disagree on this one. What always screams mental illness and/or substance issues to me is when I see truly disparate performance.

How does someone go from a 90th percentile step score, Honors in one of the hardest clerkships, and then fail their peds clerkship…twice? The fail cutoffs at many schools are around the 5th percentile for shelf score, so to score that low twice points to something else going on. Add in a couple other Ps and now it’s becoming a pattern beyond phoning it in on one clerkship.

Peds isn’t even that hard of a shelf and staying awake during your peds rotation is probably enough for most people to pass, especially those coming fresh off 250 step scores. A sane and functional person would get that first failure and bust their arse to pass the second attempt, so the second failure makes MI/SA even more likely.

Someone like this would be a very high risk resident, and when the ENT applicant pool is overflowing with high step scores and nearly flawless grades, it seems an outsize risk to take. This applicant would be a DNI for me.

 

[Lawpy]

The real question is what specialties will be ok with OP’s situation given the fail in peds situation. It looks like a major red flag in any case

 

[Mass Effect]

I’m afraid I have to disagree on this one. What always screams mental illness and/or substance issues to me is when I see truly disparate performance.

I mean, all I can say is that as a board-certified psychiatrist and someone who sits on residency rank and interview committees, what you're describing is far more reflective of a student who slacks off than of substance issues or mental illness.

How does someone go from a 90th percentile step score, Honors in one of the hardest clerkships, and then fail their peds clerkship…twice? The fail cutoffs at many schools are around the 5th percentile for shelf score, so to score that low twice points to something else going on. Add in a couple other Ps and now it’s becoming a pattern beyond phoning it in on one clerkship.

I'm not saying it can't point to something else. But that something else is pretty wide open and includes the most common cause which is a student who is either burned out or just arrogant enough to think they can pass without trying. It also includes family issues, romantic issues, personal illness that is not necessarily mental, and a number of other things. I would not automatically jump to substance or mental illness as in most cases, that assumption would be wrong.

Peds isn’t even that hard of a shelf and staying awake during your peds rotation is probably enough for most people to pass, especially those coming fresh off 250 step scores. A sane and functional person would get that first failure and bust their arse to pass the second attempt, so the second failure makes MI/SA even more likely.

No it doesn't. And I object to the word "sane" being used in the context in which you're using it and feel even more strongly that you're wrong now that I know how you're conceptualizing mental illness (as opposed to anxiety or ADHD).

Someone like this would be a very high risk resident, and when the ENT applicant pool is overflowing with high step scores and nearly flawless grades, it seems an outsize risk to take. This applicant would be a DNI for me.

And that's cool, but don't blame it on insanity or substance abuse. That's just plain inaccurate in majority of cases.

 

[operaman]

I mean, all I can say is that as a board-certified psychiatrist and someone who sits on residency rank and interview committees, what you're describing is far more reflective of a student who slacks off than of substance issues or mental illness.



I'm not saying it can't point to something else. But that something else is pretty wide open and includes the most common cause which is a student who is either burned out or just arrogant enough to think they can pass without trying. It also includes family issues, romantic issues, personal illness that is not necessarily mental, and a number of other things. I would not automatically jump to substance or mental illness as in most cases, that assumption would be wrong.



No it doesn't. And I object to the word "sane" being used in the context in which you're using it and feel even more strongly that you're wrong now that I know how you're conceptualizing mental illness (as opposed to anxiety or ADHD).



And that's cool, but don't blame it on insanity or substance abuse. That's just plain inaccurate in majority of cases.

I think I’m using mental illness in a much general sense which would definitely include things like poorly managed adhd, anxiety, etc. Ditto my use of other terms like “sane” - intended to be more colloquial than clinical.

My intention is not to make a diagnosis, but rather to say that this looks like a case where there is some underlying issue that would make this person a high risk trainee. My own anecdotal experience thus far has shown this tends to be substance or MH related. I simply don’t buy the “family issues” explanation given how extreme the swing. Plenty of people have family issues in school and don’t flunk; there’s something else at work here.

Maybe it’s just a combo of adhd and anxiety, but I would still prefer not to deal with those in a resident. If they can’t even pass a shelf exam during a stressful time, how are they going to handle a rigorous surgical residency? In many ways, I’d be more apt to interview someone who had less stellar step scores and surgery shelf scores in this case because then it would be more believable to me that some external stressor tipped them over the edge. For the OP, it looks much more like there are serious underlying issues that haven’t been addressed and I’d rather not have to deal with those in a trainee for 5 years.

This is why the home program or away rotation are the best options because they have enough time to see how OP works and place this incident into context. I think other programs will probably be just as averse as I am to taking such a risk.

 

[Mass Effect]

I think I’m using mental illness in a much general sense which would definitely include things like poorly managed adhd, anxiety, etc. Ditto my use of other terms like “sane” - intended to be more colloquial than clinical.

You should stop. Especially with "sane". There is nothing "insane" about someone with ADHD or anxiety. It's not cool.

My intention is not to make a diagnosis, but rather to say that this looks like a case where there is some underlying issue that would make this person a high risk trainee.

Yes this is accurate and I don't think anyone would disagree.

My own anecdotal experience thus far has shown this tends to be substance or MH related.

And my experience as a psychiatrist whose practice is filled with these students (and residents) tells me that it's not.

I simply don’t buy the “family issues” explanation given how extreme the swing. Plenty of people have family issues in school and don’t flunk; there’s something else at work here.

But if that's the metric, there are a lot of trainees also using substances who aren't failing. Most commonly, students abusing substances are using marijuana or performance enhancing meds, like stimulants.

Maybe it’s just a combo of adhd and anxiety, but I would still prefer not to deal with those in a resident. If they can’t even pass a shelf exam during a stressful time, how are they going to handle a rigorous surgical residency?

That's ok. Like I said, I don't think people would disagree that students who fail clerkships are high risk and not competitive for competitive residencies. But honoring surgery while failing peds is not indicative of a substance abuse problem or serious mental illness (both of which would be expected to affect the surgery shelf as well). And I don't think SMI or substance abuse should be what we automatically jump to when a student is struggling.

 

[operaman]

You should stop. Especially with "sane". There is nothing "insane" about someone with ADHD or anxiety. It's not cool.



Yes this is accurate and I don't think anyone would disagree.



And my experience as a psychiatrist whose practice is filled with these students (and residents) tells me that it's not.




But if that's the metric, there are a lot of trainees also using substances who aren't failing. Most commonly, students abusing substances are using marijuana or performance enhancing meds, like stimulants.



That's ok. Like I said, I don't think people would disagree that students who fail clerkships are high risk and not competitive for competitive residencies. But honoring surgery while failing peds is not indicative of a substance abuse problem or serious mental illness (both of which would be expected to affect the surgery shelf as well). And I don't think SMI or substance abuse should be what we automatically jump to when a student is struggling.

Sheesh this is like arguing on Twitter! I think any sane person understands the point I’m making and isn’t confused by the verbiage.

Im probably being a bit unfair in making such assumptions about students with widely disparate performance. I’m also ok with being wrong in some cases because so far this approach has prevented some bigtime problem residents from matching. I know of at least 2 who were able to match elsewhere and were subsequently fired by their programs, and one who is/was the problem child of his program last I heard. Whatever you want to call it, the failures in executive functioning or mental illness or whatever that led to the issues in Med school and made me DNR them are probably a big part of what got them fired elsewhere.

I’m ok missing a couple diamonds in the rough to avoid getting stuck with a problematic resident.

 

[Mass Effect]

Sheesh this is like arguing on Twitter! I think any sane person understands the point I’m making and isn’t confused by the verbiage.

Don't know how you'd know since it doesn't seem you understand the definition of the word "sane" but you do you boo. Carry on.

 

[Lawpy]

Ok while the discussion on the unfair psychiatric characterization of OP is noted and important, i’m actually struggling to see how to help OP make the case for any specialty (keeping aside the home ENT possibility) with the fail in peds situation, because i was under the impression that a fail in clerkship is a red flag and programs can screen for clerkship failures

 

[Matthew9Thirtyfive]

I think you guys are a bit out from med school to say whether the peds shelf is hard or not. I just took it like 6 months ago and it was harder than the surgery shelf.

 

[operaman]

I think you guys are a bit out from med school to say whether the peds shelf is hard or not. I just took it like 6 months ago and it was harder than the surgery shelf.

Have they altered shelf exam content that much? I took my shelves in 2013-14 which doesn’t FEEL that long ago but I guess it is. I remember the main challenges of the peds shelf being syndromes, developmental milestones, various guidelines, vaccination schedules, and then basic pediatric medicine. Aside from material, I think I view peds as easier because the hours tends to be better than Med/surg so you have much more time to prepare.

What makes the surgery shelf so challenging is that it also contains a lot of IM-related concepts in addition to covering a wide array of surgical material. There’s also the challenge of studying while on the clerkship with the worst hours for most people. For OP to have taken surgery before medicine makes it even more challenging since they lacked that knowledge base; surgery was my very first clerkship so I keenly felt that knowledge gap myself.

 

[Matthew9Thirtyfive]

Have they altered shelf exam content that much? I took my shelves in 2013-14 which doesn’t FEEL that long ago but I guess it is. I remember the main challenges of the peds shelf being syndromes, developmental milestones, various guidelines, vaccination schedules, and then basic pediatric medicine. Aside from material, I think I view peds as easier because the hours tends to be better than Med/surg so you have much more time to prepare.

The rotation was definitely easier than surgery. The shelf was more difficult. I had questions from every subspecialty. It was very, very broad. Wasn’t as hard as IM, but it was challenging.

What makes the surgery shelf so challenging is that it also contains a lot of IM-related concepts in addition to covering a wide array of surgical material. There’s also the challenge of studying while on the clerkship with the worst hours for most people. For OP to have taken surgery before medicine makes it even more challenging since they lacked that knowledge base; surgery was my very first clerkship so I keenly felt that knowledge gap myself.

Eh, having done all the shelf exams now, I don’t think surgery was very much like the IM shelf. Yes, it had a lot of medicine in it because they aren’t going to ask you about steps to surgeries and stuff, but the topics were all very surgical and definitely came from a surgery perspective. The IM shelf had a totally different feel. I had fill in the blank questions on my IM shelf ffs.

 

[Mass Effect]

I think you guys are a bit out from med school to say whether the peds shelf is hard or not. I just took it like 6 months ago and it was harder than the surgery shelf.

I agree with this. Seems like everything has gotten harder in the past 5-10 years, likely a response to the test prep bubble. Regardless, I make no judgments on anyone who fails a shelf exam. Like all exams, some people have to fail to satisfy the scale and there are a number of reasons someone might fail.

 

[TelemarketingEnigma]

I think many people find the peds shelf challenging because of a)breadth and b) you spend VERY little time on peds topics throughout Med school. I don’t know that the concepts or questions were any harder than other shelves, it was just a whole different (and huge) set of information that doesn’t overlap with other specialties as much as say IM/surg do

 

[Matthew9Thirtyfive]

I think many people find the peds shelf challenging because of a)breadth and b) you spend VERY little time on peds topics throughout Med school. I don’t know that the concepts or questions were any harder than other shelves, it was just a whole different (and huge) set of information that doesn’t overlap with other specialties as much as say IM/surg do

It’s like with anything else in med school. Few of the topics are actually very challenging. It’s just that it’s so broad that it makes it difficult to study everything. I did very well on the peds shelf, but it felt a lot more difficult to do that than say the OB or surgery shelf exams.

 

[Dral]

OP, I would agree with Gospursgo's advice. I help interview for a competitive specialty and any medical school course/rotation failure is just not easily ignored. We have so many superstars applying, that a failure like yours makes a decision algorithm fairly simple if you catch my drift.

Your home program could more easily look into your background and hopefully overlook the failure. It will be much more difficult to convince outside programs that you would be a resident they could count on and eventually pass a board exam without issues.

You could try to dual apply if you don't want to give up ENT altogether. However, just applying ENT, while it just takes one match, is fairly risky in your case.

 

[efle]

Do not apply ENT unless your home program is going to take you or you're willing to dual apply backup gensurg/gas/rads

PS shelf exams and steps have changed a great deal. Old practice Q samples from 10+ years ago are a joke

 

[Lawpy]

Do not apply ENT unless your home program is going to take you or you're willing to dual apply backup gensurg/gas/rads

PS shelf exams and steps have changed a great deal. Old practice Q samples from 10+ years ago are a joke

You think gen surg or gas or rads would be okay with the double failure on peds? All of those are becoming more competitive iirc

 

[Matthew9Thirtyfive]

You think gen surg or gas or rads would be okay with the double failure on peds? All of those are becoming more competitive iirc

Could probably get a prelim surg year somewhere but I have a hard time believing youd match gen surg with two rotation failures.

 

[efle]

You think gen surg or gas or rads would be okay with the double failure on peds? All of those are becoming more competitive iirc

Red flag will still be there but his odds are much better of being in the 90-95% matched in something like gas or rads than the 70% in ENT. Remember that 70% is AFTER most people with a barrier like OP self-select out. Dunno if gensurg is different, I thought that was considered very average competitiveness too

 

[Matthew9Thirtyfive]

Red flag will still be there but his odds are much better of being in the 90-95% matched in something like gas or rads than the 70% in ENT. Remember that 70% is AFTER most people with a barrier like OP self-select out. Dunno if gensurg is different, I thought that was considered very average competitiveness too

? In what world would someone match rads with two failures? Am I grossly misjudging its competitiveness?

 

[efle]

? In what world would someone match rads with two failures? Am I grossly misjudging its competitiveness?

I think you're misjudging the low end yeah, there's no such thing as forgiving programs in ENT, but in a field like rads we are filling around 1/3 seats with IMG applicants. Even US MDs with board scores 30 points below the specialty median are matching ~90% of the time in recent years.

 

[Lawpy]

I think you're misjudging the low end yeah, there's no such thing as forgiving programs in ENT, but in a field like rads we are filling around 1/3 seats with IMG applicants. Even US MDs with board scores 30 points below the specialty median are matching ~90% of the time in recent years.

Ok i fully admit i didn’t expect rads to be that noncompetitive

 

[Wordead]

Ok i fully admit i didn’t expect rads to be that noncompetitive

I mean OP is a research machine with good board scores and apparently not very good at clinical rotations. Sounds like a good rads candidate to me.

OP, sorry man, but failing peds twice is a huge red flag. If you apply ent would apply to a backup.