Insight into Pre-Medical Decisions from a Resident (factors in choosing a school, life outlook, etc)

Syncrohnize

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Hey SDN Pre-Med Community,

I'm now a resident physician and would like to type up a bit about some things I wished I'd known when applying. Forgive me if some of this stuff is now obvious. I know the stakes get higher every year and as a result, pre-meds are becoming more and more knowledgeable so the conventional pre-med SDN wisdom may have expanded. To give you some background, I originally joined the SDN community early in pre-med and this stuff wasn't super obvious (or maybe it was and I just ignored it). I'm now a medical resident (please respect privacy). Also, I hope this meant-to-be-advice doesn't offend anyone, but in the event that it does, I think my explanations are thorough enough here and I won't be going back-forth. I also don't like answer Inbox messages because oftentimes I get questions where I can't really help the person or maybe I can but it would betray too much anonymity. If you have questions, I'd prefer them down below where everyone can see so they can help others. Hopefully, this helps some of you! Other medical students and residents are free to jump in as I'm not the authority on any of this.

#1: Tier of a medical school matters if you want to pursue training after residency or a competitive field. As a curious person, I have looked at all sorts of match lists that are none of my business like surgical fellowship rank lists, other medical school match lists, and residency match lists outside my field. The obvious trend is a downsloping trend in prestige from medical school to fellowship (with the unsaid being not obtaining a fellowship because of low residency prestige). There are a significant number of exceptions (maybe a dozen or so per medical school match list), but for the most part, that is how the current flows. I remember debating between my unranked home institution vs. a non-Ivy but very respected medical school that was 25K more per year. I chose the home institution. 4 years later with decent scores, I ended up at a solid residency, but had I gone to the other school like my peers, I would likely have been at a top tier residency which helps for fellowship. 120K extra in loans for tuition+COL vs. a top tier residency? We'll see if that money saved was worth it come fellowship time. Just to reiterate, going where I did didn't limit me and I definitely deserved what I got in the end. Had I stood out in a group of already outstanding people, I could have matched higher but I failed to do so and that was in my control. In general I feel there are 3 general tiers for medical school. There's the non-US MD tier, US-MD tier, top US-MD tier and they are treated significantly different in the residency admission process. The overall point I want to make is if you want to do something competitive, the undergrad -> medical school jump is where you set yourself up for that. A gap year is not the end of the world if you are productive with it.

1b. After some thought, I wanted to write about prestige and what it translates to since I referenced it alot above and don't really explore it fully. Overall, in terms of medical school prestige, I think in order to determine its importance to you, you have to know what you want. If you want to be a leader in a field and have your medical opinion mean something to organizations who set guidelines, journalists, etc. you need to maximize prestige like it's currency as that's how it works. Then, there's a lot of people who want to be just doctors and they're not even picky. Some just want to be trained to be the best primary care physician they can be. In that instance, prestige means very little, but at the same time, understand that there are benefits to higher ranked institutions and there may be roads down the line that open up for you because of your school. For everyone else though, there's no clear consensus. I would venture that the mode of SDN pre-med users (especially males) see themselves doing Ortho, some other surgical specialty, or a procedural IM field, but they don't really care to climb the rungs of academia. For this group, I would say that it's very possible to do that any MD school , (and still a small possibility at DO schools, more so a possibility with IM fields). That said, you make the next 4-7 years (5-10% of your lifespan) spent getting to that point much easier by attending a highly ranked medical school. It is easier (but you still have to work for it) to match a surgical subspecialty if you apply broadly coming from a top medical school than it is coming from a lesser known state school simply because you bring your school's brand name to their lesser-known program. Regarding IM fellowship which is becoming increasingly popular, it's very simple. IM residencies are highly biased to medical school prestige (to be fair, you can make up for it by being top of your class...which is hard, see point 6). Then the most important factor for fellowship selection is where you did your IM residency because there are no more standardized tests fellowships look at.

#2: Medicine is more than just a means to a 6-figure salary job you swipe in and out of. Try to find a unique purpose within medicine and interests outside medicine. Don't just go into this thinking you'll just complete medical school, residency, +/- fellowship but then just forget medicine, get married, and live happily ever after. Everyone burns out at some point. While medicine seems really cool when you're first exposed to it, it becomes very algorithmic and boring the more you go through it. As a physician, you're expected to have the same level of inquisitiveness and enthusiasm for medicine throughout your career as you did when you applied for medical school. There's always more to learn and update yourself on. I've seen so many attendings who are over it at this point and treat medicine as a job they swipe in and out of and are unhappy. There's a term for this and it's called burnout. When people say medicine is a duty/calling some of its BS, but there's also some validity to that. Unlike other jobs, physicians are expected to keep their patients in their mind and take work home (unless you do ED/Hosp. Med). If you're following a patient that's hospitalized, you will get notified and it would be nice to keep track of what happened. When patients are sick after hours, you can keep a reasonable boundary, but most good physicians try to help where they can which takes some sacrifice. Additionally, practices/guidelines/sciences are constantly changing and you have to continuously learn throughout your training and after whether you're in FM or a thoracic surgeon. In order to have the mental desire to continue doing your job, you need to find something within medicine which gets you up every day. Whether it's caring for a unique population, doing research in a specific area, or doing some kind of innovative work to improve how medicine is practiced, you need something to point to that you can say you're adding to medicine. Otherwise, you won't ever feel like your work has meaning and you will do a poor job. Outside of medicine, it's very critical that you don't plan things so that all life stops until you're done with medical school. Medical school is busy, but you need to make time for other important things like dating and maintaining a healthy interest in your hobbies/exercise. I feel like other people have stressed this enough though so I'll leave it to that. .

#3. This ties in well with points #1/#2 . A gap-year is not the end of the world if used appropriately. This may be a by-product of the culture I was brought up in, but getting from undergrad to medical school on time seemed to be the biggest thing in the world to me back then and taking time off was seen as "wasting a year". Looking back, I kinda regret that mindset. There are a lot of skills I could have picked up in the meantime like enhancing my coding experience, exploring research in an area of medicine I was interested in, etc. not to mention the additional qualifications and life perspective that would have boosted my application. For those of you in the middle of unintended gap years who don't have notable academic red flags, if you're depressed because you didn't get accepted, get your depression treated, and then try to develop a skill-set that will give you purpose throughout your medical career instead of wasting time sulking for not getting in.

#4: The medical school curriculums do vary and it may be something worth looking into even though it's hard to find concrete answers. While selecting a medical school, I went in with blinders thinking they're all getting me my medical degree. The match lists (my ROI) look more or less similar, and the curriculums all the school's were talking about seemed like meaningless hype. While in retrospect, I don't think I was too far off on that latter point, I do think there is great variability in the quality of curriculum that is not transparent and I'll try to give some tips here on how to make it more transparent. I'm not saying that the big 3 (location, cost, prestige) shouldn't be main deciding factors. I just think that if you're a very strong candidate with multiple similar offers, it pays to do your research because these other factors (A-H below) aren't necessarily meaningless. For organizational sake, they're listed roughly in order of importance:

A) Clinical Education Quality: I may be biased because I'm a resident so the importance of this is magnified, but this is after all why you uprooted yourself and traveled somewhere else to pay rent, right? You come to learn to function as a doctor seeing patients. You can always learn basic science principles from books and the online market is getting better and better. While many schools do things similarly with basic science, there can be a dramatic difference in clinical education across certain schools that is not always apparent. There is also no real correlation between MD vs. DO either. I have, however, noticed that those from top schools tend to do a great job for the most part for obvious reasons (staff at top places are probably excited about teaching, etc.). Things you need to assess for clinical quality are how well students are prepared knowledge-wise post-Step 1 which can be found with Step 2 CK data. Other than that though, talk to 4th years about the confidence on aways and how their clinical experience has been. Did they feel like their clinical skills translated well and met or exceeded the expectations of the medical centers they traveled to? Ask them if they felt comfortable writing assessments and plans for the typical patient admitted to an academic hospital with minimal supervision. Also, there are some things you can ask about the clinical sites like what the typical responsibility of medical students are. You need to ask multiple people this because you'll get some people who weren't as proactive and others who made the most of their opportunities. For someone who is spouting only good things about the clinical education, ask them what their favorite site was and ask why the others weren't as good. Also, very importantly, ask them if they have a mentor who has guided them through medical school and the application process and try to figure out how close they were to that mentor. This isn't a mentor they were assigned for the sake of fulfilling some wellness requirement or someone who served as a mentor for everyone applying to a field that tour guides will tell you about on interview day. This is someone who took personal interest in a student's well-being and got to know them a bit outside of medical stuff. Again this is going to vary based on a student's proactiveness so ask multiple people. This is important because it basically measures how much faculty care and how accessible they are. Also, ask third years what their roles are in their clinical settings. Don't focus on procedural stuff. A lot of students brag about what they got to do physically as a medical student. Anyone can be guided through a central line. This doesn't tell you much about what they learnt. Procedural stuff is relevant to surgery, but even then knot-tying is 90% learnt on one's own and other things are learnt during specific electives or in residency. Instead, ask 3rd/4th years if they're encouraged to come up with plans or are if they feel they're just given busy-work while the stuff happens in the background. Ask them if they are allowed to complete their presentations from Subjective --> Plan or if they're interrupted. Ask how many students (including students from other schools and other professional students) are on clinical teams and if they feel that impacted their education. Ask them if attendings address them by name, know who they are, and give them reasonable feedback on a daily basis. Lastly, don't listen to a word an M1 or M2 tells you about clinical education because they don't know anything about until they've been through a rotation at their program, yet they seem happy to pretend they do during tour guide sessions.

B) Student Happiness: This is the hardest to figure out and you need to talk to multiple students from multiple classes. First years everywhere will tell you the courses have too much detail because that's the nature of medical school. Second years will complain about the useless activities the school mandates which distracts them from Step 1. Third years will complain about the latest injustice that kept them from receiving honors in a rotation. In general, you want to get in touch with 4th years because they've seen all the ups-downs, have experienced the full mandatory curriculum, and have a good idea of how much work they've put in, and where they're ending up because of it. They also have better insights into the match lists and can explain matches that stand out and have likely talked to people at other schools on interview days. As said before, you need to talk to multiple people and you'll hear things like "there's a competitive/collaborative" environment etc. That's useless information because even if there are grades, studying is 99% your own effort and so-called gunners ripping pages out of books isn't a problem anymore. You should ask more about the student's time to pursue research, other hobbies, etc. I've noticed significant differences across schools. The LCME has mandated that there be free-time for extracurricular work, but some schools apply that more effectively than others and it shows. For example, a school I know has lectures scheduled at 9 am on a Tuesday/Thursday instead of the normal 8 am and that extra time is scheduled for their required research project at home? Right...

C) Match Data: What?!? The ultimate ROI, i.e why I'm going to this medical school is third most important? Yes, it is because again, assuming you've already factored in the Big 3 factors as listed in paragraph 4, if you're looking at two places with similar prestige, their match data shouldn't be far off. That said, there are some hidden gems where faculty really go to bat more so than others in the same tier so you should still check it out. Look at trends, not matches. Don't jump to conclusions because there were no Ortho matches from Harvard in 2018 (not true), look at 2017, 2016, etc. Don't fall in love with a school because one guy/girl matched at your dream residency. You don't know the circumstances behind that. If He/she stands out, chances are he/she could have take a research year, known someone, etc. For some reason (and I did the same thing) the top matches are what’s everyone looks at but you’re served looking at where most people go. Also, there are a bunch of community programs that have Mt. Sinai, Northwestern, Mayo, etc. in their names so if there's a match, make sure it's at the main site and not an affiliate.

D) Latest USMLE Step 1/2CK/2CS data: It's not enough to get a number like "95% passed Step 1". That's the case at every medical school. What about the first time pass-rate (especially for CS)? The average score for Step 1 and CK? I wouldn't hang my hat on those numbers (231 vs. 235 is effectively the same) because they're largely influenced by the scholastic ability of students recruited but if you get an exception with a top 20 school with a lower average than you've seen at other places, it may be worth asking why (but then realize that coming from a top school with an average Step 1 score may not be so bad). Don't forget about CK. This test is truly the one that assesses practical medical knowledge and it can say a decent amount about quality of the clerkship education. CS data can tell you if the school's OSCE system is effective because that's all Step 2 CS is. If the admissions person or tour guides give round-about answers to these straight-forward questions, then ask a 3rd year/4th year student. They're mostly all emailed data on their classes average Step 1 score.

E.) Method of Pre-Clinical Curriculum Delivery: A lot of useless little curriculum gimmicks are advertised to sell the school that should be ignored. No one cares about using the latest software or teaching technique (CBL, TBL, etc.) and who cares about a school's cadaver lab? Also, providing Step 1 resources UWorld, First Aid, and Pathoma is nice, but is $500 really enough to sway you on a school? Don't worry about any unique ideas about the formation of class houses, new learning theory gimmicks, required scholarly work, etc either. Those were just put in place to fulfill LCME requirements. Instead, focus on how a curriculum is organized. Sorry if this comes off as overly paternal, but the best system is one where there's early clinical integration. The only way this can be established to its fullest potential is if a school has an integrated, systems-based curriculum. What this means is that the school has a brief "foundations" course that throws in all the real prerequisite basic science stuff (biochemical principles like signal transduction, basic anatomy/histo, action potentials) into 2-3 month introductory course alongside a clinical medicine course. Then you jump right into an organ systems like Cardiology (let's say) and go from physiology to pathophysiology to pharmacology all in a month block. This allows for early mastery of clinical material in even M1 so any early clinical exposure you get makes complete sense. You can do OSCEs after each unit, you can allow pre-clinical students on wards as they know the basics regarding managing conditions, and they'll be able to immediately apply the minutiae they learn instead of employing mental acrobatics to apply something they learnt in first year to third year. It also allows you to make use of critical board resources out right from the get go. The contrasting system(ie bad system) is a more "traditional" approach where you cover all the organ systems in a normal human biology context in M1 like biochem/physiology, then visit the same topics but in an abnormal context in M2 like Pharm and Pathophys. Proponents of this system say that it reinforces knowledge of the organ systems (Cardiovascular, Pulmonary, Renal) since you learn them twice. If you look closely though, by going through basic science in an integrated- organ systems approach, you're actually reinforcing the principles as you learn physiology, pathophysiology, etc. each time you do an organ system so there’s repetition regardless.

F) Grading Scheme: This one's actually not the most important, but it's good practice to get the exact details so you know what you have to shoot for. As you all know, there's pre-clerkship and clerkship grades. All you need to know about pre-clerkship grades is how they translate to your dean's letter. If they're used to put you into arbitrary groups (excellent performance, good performance, etc.) your pre-clerkship grades matter. If they're not, they don't. The reason I don't think the grading scheme is that important to consider when choosing a school is because you haven't even gone through a test in medical school yet to know which strategy will benefit you. I for one would have been uncomfortable if someone told me that pre-clerkship was all down to Step 1 with no other numbers, but now looking back that would have been pretty awesome. For clerkship, you actually really want there to be more than just P/F grades (unless there's a recognized top school that does it some different way in which case you're probably alright). The more gradations, the better actually because you don't want to explain why you just passed OB/GYN clerkship when you're going into the field. Having a HP in place makes things a lot safer. I actually have a peer at a school where they did just P/F for clerkships. He recently met the PD for a dream program of his at a national conference who told him they won't even consider people from his school because they have no data outside subjective narrative information on 3rd year performance. When evaluations are like, it’s easy for everyone to state that ABC was the best medical student they’ve worked with. Most schools have AOA which is an honor society with selection based on scores/grades that then tells us mortals how to study. There's also a checkmark for AOA or Not in the ERAS residency application and program directors can filter for it. If your school doesn't have one, it doesn't really matter because there'll be other ways they have students stand out. Take away points here are that if you're school isn't as well known, make sure they have clerkship grades. I would even go as far to say that if a lesser known school didn't give out more than P/F grades for clerkship, that should be a huge red flag. This is pretty uncommon though. Also, the pre-clerkship grading policy shouldn't be used to make decision on a school (unless both school are too schools) because you have no idea where you'll be on the curve.

G.) Medical School Class Size: The whole university from undergrad to grad school benefits from having as many medical students as possible to profit from. They make money on you. This isn't 100% set in stone, but generally a large class size in one place should raise eyebrows. Are there enough clinical facilities to give everyone individualized attention? Are there enough mentors for everyone? Will students truly be able to make deep connections with their faculty and peers? This is less likely with too many students per site. Even in pre-clinical education, class size would be a problem as trends are rightfully shifting towards early clinical integration, multiple modes of assessment, and a mix of formative in addition to summative assessment. Could a school hire enough support staff to regularly perform these critical tasks with 300+ students?

H.) LCME probations: The LCME is an imperfect organization, but its goal is to make medical school more effective and it generally tries to do that. Schools don't get placed on probation because they forgot to submit a form or something minor or whatever reason the local media is oversimplifying it to be. I have witnessed LCME stuff and there has to a theme or continual pattern of something major that is going wrong in order to place a school on probation. While the school may be reinstated, some underlying problems may still be lingering.


#5: The medical professional will test your mental health. I'm not saying you shouldn't go into medicine. It’s a great field, but just prepare yourself by forming good habits. Prior to medical school, I did not even understand mental health. Maybe I was sheltered, I don't know... but I'd never experienced any signs of even depression. That slowly changed throughout medical school as I developed mild depression and anxiety issues that still linger today that I have to remain wary of. The thing is that this is hardly uncommon in medicine. Some people with mild forms are resilient and never address the problem (not the smartest idea), some people do the right thing and get help, some people suffer through a crisis, get thrown off course and (never) come back. Everyone's different, but I bet that almost everyone (I'm sure there are some lucky exceptions) in the medical field has suffered with at least minor mental health issues and burn out at one point or another. I say this just to warn those like me coming in that there's a reason your parents taught you those good habits like sleeping at a regular time, staying physically active, and being socially active. These are some of the most effective barriers to mental illness in medical school. While you were probably chugging a Red Bull/5-Hour to cram the night before an exam in college, you probably did that once a week and your body could recover. In medical school, you're studying like that every day. I'm not trying to scare any of you or say that it's impossible because medical school when approached correctly is very manageable. If you do it right, you'll probably do very well and realize you still have free time.

#6. I've alluded to this in other posts, but don't get ahead of yourself in the beginning of medical school. You may go in with a set goal and that's great, but acknowledge the level of competition around you. Picture a 20 point quiz you took in undergrad. You'd never score below 16/20 and would be happy with 18/20 or above because it kept you on track for that 4.0. Now take away all those people who wouldn't study and get the 12/20s, etc. Now in medical school, below 16/20 is a fail, 18 is average, and 19+ is honors. At first it's frustrating because it's like 18 vs 19 matters? Yes, it does and get used to it. The reasons will become more apparent as you learn how a small details becomes relevant. If you find that you're barely able to keep afloat, realize that perfect is the enemy of good. For the first few months, everyone should shoot for the highest grade available. If after that time where you've taken care of yourself, gotten help, studied a million different ways, and you find that you ceiling ranges around the average, and you want to do something competitive, accept your best as your best and realize you've lost the battle, but not the war because the alternative is driving yourself insane before the most important stuff (Step 1, 2, Clerkship grades are even in play). There will be chances to shine later and while a less than stellar year 1 performance can be redeemed.
 
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Goro

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Moderators, please sticky!!!!!!!
 
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puahate

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So glad to see number 1. A lot of people keep downplaying prestige. It will be a decent chunk of my choice to go to a school. Going to a public University and then conducting research in top tier institutions have shown me that there really is a difference in resources and recruitment in those places.
 
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Eagleye2

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This is a great write up thanks, referring to point 4-G, what is considered a large class size. Will having a big class size really make that much of an impact when determing rotations and other clinical exposures? Im genuinely curious because some of the schools im interested in have vastly different class sizes
 
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Syncrohnize

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So glad to see number 1. A lot of people keep downplaying prestige. It will be a decent chunk of my choice to go to a school. Going to a public University and then conducting research in top tier institutions have shown me that there really is a difference in resources and recruitment in those places.
The resources for conducting research is probably a thing, but it's also just the hierarchical nature of medicine.

This is a great write up thanks, referring to point 4-G, what is considered a large class size. Will having a big class size really make that much of an impact when determing rotations and other clinical exposures? Im genuinely curious because some of the schools im interested in have vastly different class sizes
I would refrain from looking at definite cut-offs. I think I may have said off-hand in my post 200+/campus, but it really depends on the situation. I would argue having a big class size makes an impact. Quality research opportunities are finite. I know a medical school with a large student body which funds a third of the class to do summer research and pairs them with a mentor who has an IRB. Imagine if they had less students. They could then provide everyone who wanted that with the opportunity. Also, when it comes time to apply for residency, a mentor can be there to go to bat in your corner. They have connections at other institutions they can call to help you land interviews. In order to be on those terms, you need to be close to a mentor and how can you be if there are like 20 other people with the same mentor? Will that person be able to call his or her friend and be like, "Oh yeah, give these 10 people interviews. I got to know them all very well and they're all amazing students". In terms of clerkships quality, it could also make a difference. Find out which sites they own and how many students are at those sites. Ask around and find out if there's an academic/flagship site everyone receives the best learning from. If so, how much time does everyone get at that site vs. other sites? No one is going to admit their weaknesses readily, but you can ask questions to make it more clear and that was the purpose of point #4. It was my attempt at arming you guys with the right questions to ask to determine that.

The more I progress through medical education, the more I realize how easy it is to set up a low quality medical school and get away with it. Things people look for are the name and whether the place will get you your MD at the end of the day. No one looks into these soft factors which sometimes can be important. You guys need to advocate for yourselves and figure out which places will set you up to be the best doctor because your going to be working in this field for 40+ years.
 
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Med Ed

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#1: Tier of a medical school matters if you want to pursue training after residency or a competitive field. As a curious person, I have looked at all sorts of match lists that are none of my business like surgical fellowship rank lists, other medical school match lists, and residency match lists outside my field. The obvious trend is a downsloping trend in prestige from medical school to fellowship (with the unsaid being not obtaining a fellowship because of low residency prestige).
This is a flawed analysis, as you are inferring causation from correlation.

Fundamentally I do not disagree with the premise; I don't think anyone can argue that prestige is a factor in academics. Outside of a few top institutions, however, it's a rather difficult thing to quantify and is heavily confounded by other variables.
 

Reader88

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How common/competitive is fellowship in fields other than IM? I know some of the IM fellowships are competitive (cards, GI) and OB (REI) but I guess I hadn't given much thought to fellowship after other types of residency.
 

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How common/competitive is fellowship in fields other than IM? I know some of the IM fellowships are competitive (cards, GI) and OB (REI) but I guess I hadn't given much thought to fellowship after other types of residency.
Depends totally on the field. There are competitive fellowships in pretty much every specialty. In general (with plenty of exceptions) the more general the specialty overall, the more competitive the fellowships will be. Highly competitive fellowships include cards and GI from IM, peds surg and surg onc from gen surg (arguably two of the most competitive fellowships in all of medicine), MFM from OBGYN, IR from DR, and a whole lot more. Some fellowships in smaller subspecialties have their spots accounted for years before the resident in question finishes residency. But it varies so much that honestly it’s impossible to paint it in broad strokes.
 
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Syncrohnize

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Depends totally on the field. There are competitive fellowships in pretty much every specialty. In general (with plenty of exceptions) the more general the specialty overall, the more competitive the fellowships will be. Highly competitive fellowships include cards and GI from IM, peds surg and surg onc from gen surg (arguably two of the most competitive fellowships in all of medicine), MFM from OBGYN, IR from DR, and a whole lot more. Some fellowships in smaller subspecialties have their spots accounted for years before the resident in question finishes residency. But it varies so much that honestly it’s impossible to paint it in broad strokes.
Completely agree. In smaller fields like surgical sub specialties, the fellowship matches are likely very political with more human factors than say Cardiology which matches 1000 fellows a year. Other than that generalization, it’s very hard to paint broad strokes about the competitiveness for fellowships. The discussion in my original post mainly applies to IM. Hope that helps clarify things.
 

MyOdyssey

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Hey SDN Pre-Med Community,

I'm now a resident physician and would like to type up a bit about some things I wished I'd known when applying. Forgive me if some of this stuff is now obvious. I know the stakes get higher every year and as a result, pre-meds are becoming more and more knowledgeable so the conventional pre-med SDN wisdom may have expanded. To give you some background, I originally joined the SDN community early in pre-med and this stuff wasn't super obvious (or maybe it was and I just ignored it). I'm now a medical resident (please respect privacy). Also, I hope this meant-to-be-advice doesn't offend anyone, but in the event that it does, I think my explanations are thorough enough here and I won't be going back-forth. I also don't like answer Inbox messages because oftentimes I get questions where I can't really help the person or maybe I can but it would betray too much anonymity. If you have questions, I'd prefer them down below where everyone can see so they can help others. Hopefully, this helps some of you! Other medical students and residents are free to jump in as I'm not the authority on any of this.

#1: Tier of a medical school matters if you want to pursue training after residency or a competitive field. As a curious person, I have looked at all sorts of match lists that are none of my business like surgical fellowship rank lists, other medical school match lists, and residency match lists outside my field. The obvious trend is a downsloping trend in prestige from medical school to fellowship (with the unsaid being not obtaining a fellowship because of low residency prestige). There are a significant number of exceptions (maybe a dozen or so per medical school match list), but for the most part, that is how the current flows. I remember debating between my unranked home institution vs. a non-Ivy but very respected medical school that was 25K more per year. I chose the home institution. 4 years later with decent scores, I ended up at a solid residency, but had I gone to the other school like my peers, I would likely have been at a top tier residency which helps for fellowship. 120K extra in loans for tuition+COL vs. a top tier residency? We'll see if that money saved was worth it come fellowship time. Just to reiterate, going where I did didn't limit me and I definitely deserved what I got in the end. Had I stood out in a group of already outstanding people, I could have matched higher but I failed to do so and that was in my control. In general I feel there are 3 general tiers for medical school. There's the non-US MD tier, US-MD tier, top US-MD tier and they are treated significantly different in the residency admission process. The overall point I want to make is if you want to do something competitive, the undergrad -> medical school jump is where you set yourself up for that. A gap year is not the end of the world if you are productive with it.

1b. After some thought, I wanted to write about prestige and what it translates to since I referenced it alot above and don't really explore it fully. Overall, in terms of medical school prestige, I think in order to determine its importance to you, you have to know what you want. If you want to be a leader in a field and have your medical opinion mean something to organizations who set guidelines, journalists, etc. you need to maximize prestige like it's currency as that's how it works. Then, there's a lot of people who want to be just doctors and they're not even picky. Some just want to be trained to be the best primary care physician they can be. In that instance, prestige means very little, but at the same time, understand that there are benefits to higher ranked institutions and there may be roads down the line that open up for you because of your school. For everyone else though, there's no clear consensus. I would venture that the mode of SDN pre-med users (especially males) see themselves doing Ortho, some other surgical specialty, or a procedural IM field, but they don't really care to climb the rungs of academia. For this group, I would say that it's very possible to do that any MD school , (and still a small possibility at DO schools, more so a possibility with IM fields). That said, you make the next 4-7 years (5-10% of your lifespan) spent getting to that point much easier by attending a highly ranked medical school. It is easier (but you still have to work for it) to match a surgical subspecialty if you apply broadly coming from a top medical school than it is coming from a lesser known state school simply because you bring your school's brand name to their lesser-known program. Regarding IM fellowship which is becoming increasingly popular, it's very simple. IM residencies are highly biased to medical school prestige (to be fair, you can make up for it by being top of your class...which is hard, see point 6). Then the most important factor for fellowship selection is where you did your IM residency because there are no more standardized tests fellowships look at.

#2: Medicine is more than just a means to a 6-figure salary job you swipe in and out of. Try to find a unique purpose within medicine and interests outside medicine. Don't just go into this thinking you'll just complete medical school, residency, +/- fellowship but then just forget medicine, get married, and live happily ever after. Everyone burns out at some point. While medicine seems really cool when you're first exposed to it, it becomes very algorithmic and boring the more you go through it. As a physician, you're expected to have the same level of inquisitiveness and enthusiasm for medicine throughout your career as you did when you applied for medical school. There's always more to learn and update yourself on. I've seen so many attendings who are over it at this point and treat medicine as a job they swipe in and out of and are unhappy. There's a term for this and it's called burnout. When people say medicine is a duty/calling some of its BS, but there's also some validity to that. Unlike other jobs, physicians are expected to keep their patients in their mind and take work home (unless you do ED/Hosp. Med). If you're following a patient that's hospitalized, you will get notified and it would be nice to keep track of what happened. When patients are sick after hours, you can keep a reasonable boundary, but most good physicians try to help where they can which takes some sacrifice. Additionally, practices/guidelines/sciences are constantly changing and you have to continuously learn throughout your training and after whether you're in FM or a thoracic surgeon. In order to have the mental desire to continue doing your job, you need to find something within medicine which gets you up every day. Whether it's caring for a unique population, doing research in a specific area, or doing some kind of innovative work to improve how medicine is practiced, you need something to point to that you can say you're adding to medicine. Otherwise, you won't ever feel like your work has meaning and you will do a poor job. Outside of medicine, it's very critical that you don't plan things so that all life stops until you're done with medical school. Medical school is busy, but you need to make time for other important things like dating and maintaining a healthy interest in your hobbies/exercise. I feel like other people have stressed this enough though so I'll leave it to that. .

#3. This ties in well with points #1/#2 . A gap-year is not the end of the world if used appropriately. This may be a by-product of the culture I was brought up in, but getting from undergrad to medical school on time seemed to be the biggest thing in the world to me back then and taking time off was seen as "wasting a year". Looking back, I kinda regret that mindset. There are a lot of skills I could have picked up in the meantime like enhancing my coding experience, exploring research in an area of medicine I was interested in, etc. not to mention the additional qualifications and life perspective that would have boosted my application. For those of you in the middle of unintended gap years who don't have notable academic red flags, if you're depressed because you didn't get accepted, get your depression treated, and then try to develop a skill-set that will give you purpose throughout your medical career instead of wasting time sulking for not getting in.

#4: The medical school curriculums do vary and it may be something worth looking into even though it's hard to find concrete answers. While selecting a medical school, I went in with blinders thinking they're all getting me my medical degree. The match lists (my ROI) look more or less similar, and the curriculums all the school's were talking about seemed like meaningless hype. While in retrospect, I don't think I was too far off on that latter point, I do think there is great variability in the quality of curriculum that is not transparent and I'll try to give some tips here on how to make it more transparent. I'm not saying that the big 3 (location, cost, prestige) shouldn't be main deciding factors. I just think that if you're a very strong candidate with multiple similar offers, it pays to do your research because these other factors (A-H below) aren't necessarily meaningless. For organizational sake, they're listed roughly in order of importance:

A) Clinical Education Quality: I may be biased because I'm a resident so the importance of this is magnified, but this is after all why you uprooted yourself and traveled somewhere else to pay rent, right? You come to learn to function as a doctor seeing patients. You can always learn basic science principles from books and the online market is getting better and better. While many schools do things similarly with basic science, there can be a dramatic difference in clinical education across certain schools that is not always apparent. There is also no real correlation between MD vs. DO either. I have, however, noticed that those from top schools tend to do a great job for the most part for obvious reasons (staff at top places are probably excited about teaching, etc.). Things you need to assess for clinical quality are how well students are prepared knowledge-wise post-Step 1 which can be found with Step 2 CK data. Other than that though, talk to 4th years about the confidence on aways and how their clinical experience has been. Did they feel like their clinical skills translated well and met or exceeded the expectations of the medical centers they traveled to? Ask them if they felt comfortable writing assessments and plans for the typical patient admitted to an academic hospital with minimal supervision. Also, there are some things you can ask about the clinical sites like what the typical responsibility of medical students are. You need to ask multiple people this because you'll get some people who weren't as proactive and others who made the most of their opportunities. For someone who is spouting only good things about the clinical education, ask them what their favorite site was and ask why the others weren't as good. Also, very importantly, ask them if they have a mentor who has guided them through medical school and the application process and try to figure out how close they were to that mentor. This isn't a mentor they were assigned for the sake of fulfilling some wellness requirement or someone who served as a mentor for everyone applying to a field that tour guides will tell you about on interview day. This is someone who took personal interest in a student's well-being and got to know them a bit outside of medical stuff. Again this is going to vary based on a student's proactiveness so ask multiple people. This is important because it basically measures how much faculty care and how accessible they are. Also, ask third years what their roles are in their clinical settings. Don't focus on procedural stuff. A lot of students brag about what they got to do physically as a medical student. Anyone can be guided through a central line. This doesn't tell you much about what they learnt. Procedural stuff is relevant to surgery, but even then knot-tying is 90% learnt on one's own and other things are learnt during specific electives or in residency. Instead, ask 3rd/4th years if they're encouraged to come up with plans or are if they feel they're just given busy-work while the stuff happens in the background. Ask them if they are allowed to complete their presentations from Subjective --> Plan or if they're interrupted. Ask how many students (including students from other schools and other professional students) are on clinical teams and if they feel that impacted their education. Ask them if attendings address them by name, know who they are, and give them reasonable feedback on a daily basis. Lastly, don't listen to a word an M1 or M2 tells you about clinical education because they don't know anything about until they've been through a rotation at their program, yet they seem happy to pretend they do during tour guide sessions.

B) Student Happiness: This is the hardest to figure out and you need to talk to multiple students from multiple classes. First years everywhere will tell you the courses have too much detail because that's the nature of medical school. Second years will complain about the useless activities the school mandates which distracts them from Step 1. Third years will complain about the latest injustice that kept them from receiving honors in a rotation. In general, you want to get in touch with 4th years because they've seen all the ups-downs, have experienced the full mandatory curriculum, and have a good idea of how much work they've put in, and where they're ending up because of it. They also have better insights into the match lists and can explain matches that stand out and have likely talked to people at other schools on interview days. As said before, you need to talk to multiple people and you'll hear things like "there's a competitive/collaborative" environment etc. That's useless information because even if there are grades, studying is 99% your own effort and so-called gunners ripping pages out of books isn't a problem anymore. You should ask more about the student's time to pursue research, other hobbies, etc. I've noticed significant differences across schools. The LCME has mandated that there be free-time for extracurricular work, but some schools apply that more effectively than others and it shows. For example, a school I know has lectures scheduled at 9 am on a Tuesday/Thursday instead of the normal 8 am and that extra time is scheduled for their required research project at home? Right...

C) Match Data: What?!? The ultimate ROI, i.e why I'm going to this medical school is third most important? Yes, it is because again, assuming you've already factored in the Big 3 factors as listed in paragraph 4, if you're looking at two places with similar prestige, their match data shouldn't be far off. That said, there are some hidden gems where faculty really go to bat more so than others in the same tier so you should still check it out. Look at trends, not matches. Don't jump to conclusions because there were no Ortho matches from MGH in 2018 (not true), look at 2017. Don't fall in love with a school because one guy/girl matched at your dream residency. You don't know the circumstances behind that. If He/she stands out, chances are he/she could have take a research year, known someone, etc. Also, there are a bunch of community programs that have Mt. Sinai, Northwestern, Mayo, etc. in their names so if there's a match, make sure it's at the main site and not an affiliate.

D) Latest USMLE Step 1/2CK/2CS data: It's not enough to get a number like "95% passed Step 1". That's the case at every medical school. What about the first time pass-rate (especially for CS)? The average score for Step 1 and CK? I wouldn't hang my hat on those numbers (231 vs. 235 is effectively the same) because they're largely influenced by the scholastic ability of students recruited but if you get an exception with a top 20 school with a lower average than you've seen at other places, it may be worth asking why (but then realize that coming from a top school with an average Step 1 score may not be so bad). Don't forget about CK. This test is truly the one that assesses practical medical knowledge and it can say a decent amount about quality of the clerkship education. CS data can tell you if the school's OSCE system is effective because that's all Step 2 CS is. If the admissions person or tour guides give round-about answers to these straight-forward questions, then ask a 3rd year/4th year student. They're mostly all emailed data on their classes average Step 1 score.

E.) Method of Pre-Clinical Curriculum Delivery: A lot of useless little curriculum gimmicks are advertised to sell the school that should be ignored. No one cares about using Firecracker integration and who cares about a school's cadaver lab? Providing Step 1 resources UWorld, First Aid, and Pathoma is nice, but is $500 really enough to sway you on a school? Don't worry about any unique ideas about the formation of class houses, requiredessays, required scholarly work, etc either. Those were just put in place to fulfill LCME requirements. Instead, focus on how a curriculum is organized. Sorry if this comes off as overly paternal, but the best system is one where there's early clinical integration. The only way this can be established to its fullest potential is if a school has an integrated, systems-based curriculum. What this means is that the school has a brief "foundations" course that throws in all the real prerequisite basic science stuff (biochemical principles like signal transduction, basic anatomy/histo, action potentials) into 2-3 month introductory course alongside a clinical medicine course. Then you jump right into an organ systems like Cardiology (let's say) and go from physiology to pathophysiology to pharmacology all in a month block. This allows for early mastery of clinical material in even M1 so any early clinical exposure you get makes complete sense. You can do OSCEs after each unit, you can allow pre-clinical students on wards as they know the basics regarding managing conditions, and they'll be able to immediately apply the minutiae they learn instead of employing mental acrobatics to apply something they learnt in first year to third year. It also allows you to make use of critical board resources out right from the get go. The contrasting system(ie bad system) is a more "traditional" approach where you cover all the organ systems in a normal human biology context in M1 like biochem/physiology, then visit the same topics but in an abnormal context in M2 like Pharm and Pathophys. Proponents of this system say that it reinforces knowledge of the organ systems (Cardiovascular, Pulmonary, Renal) since you learn them twice. If you look closely though, by going through basic science in an integrated- organ systems approach, you're actually reinforcing the principles as you learn physiology, pathophysiology, etc. each time you do an organ system so there’s repetition regardless.

F) Grading Scheme: This one's actually not the most important, but it's good practice to get the exact details so you know what you have to shoot for. As you all know, there's pre-clerkship and clerkship grades. All you need to know about pre-clerkship grades is how they translate to your dean's letter. If they're used to put you into arbitrary groups (excellent performance, good performance, etc.) your pre-clerkship grades matter. If they're not, they don't. The reason I don't think the grading scheme is that important to consider when choosing a school is because you even haven't gone through a test in medical school yet to know which strategy will benefit you. I for one would have been uncomfortable if someone told me that pre-clerkship was all down to Step 1 with no other numbers, but now looking back that would have been pretty awesome. For clerkship, you actually really want there to be more than just P/F grades (unless there's a recognized top school that does it some different way in which case you're probably alright). The more gradations, the better actually because you don't want to explain why you just passed OB/GYN clerkship when you're going into the field. Having a HP in place makes things a lot safer. I actually have a peer at a school where they did just P/F for clerkships. He recently met the PD for a dream program of his at a national conference who told him they won't even consider people from his school because they have no data outside subjective narrative information on 3rd year performance where every comment states that ABC was the best medical student they’ve worked with. Most schools have AOA which is an honor society where you join a club that then tells us mortals how to study. There's also a checkmark for AOA or Not in the ERAS residency application and program directors can filter for it. If your school doesn't have one, it doesn't really matter because there'll be other ways they have students stand out. Take away points here are that if you're school isn't as well known, make sure they have clerkship grades. I would even go as far to say that if a lesser known school didn't give out more than P/F grades for clerkship, that should be a huge red flag. This is pretty uncommon though. Also, the pre-clerkship grading policy shouldn't be used to make decision on a school (unless both schools are top schools) because you have no idea where you'll be on the curve.

G.) Medical School Class Size: The whole university from undergrad to grad school benefits from having as many medical students as possible to profit from. They make money on you. This isn't 100% set in stone, but generally a large class size in one place should raise eyebrows. Are there enough clinical facilities to give everyone individualized attention? Are there enough mentors for everyone? Will students truly be able to make deep connections with their faculty and peers? This is less likely with too many students per site. Even in pre-clinical education, class size would be a problem as trends are rightfully shifting towards early clinical integration, multiple modes of assessment, and a mix of formative in addition to summative assessment. Could a school hire enough support staff to regularly perform these critical tasks with 200+ students?

H.) LCME probations: The LCME is an imperfect organization, but its goal is to make medical school more effective and it generally tries to do that. Schools don't get placed on probation because they forget to submit a form or something minor or whatever reason the local media is oversimplifying it to be. I have witnessed LCME stuff and there has to a theme or continual pattern of something major that is going wrong in order to place a school on probation. While the school may be reinstated, some underlying problems may still be lingering.


#5: The medical professional will test your mental health. I'm not saying you shouldn't go into medicine and it's a great field, but just prepare yourself by forming good habits. Prior to medical school, I did not even understand mental health. Maybe I was sheltered, I don't know... but I'd never experienced any signs of even depression. That slowly changed throughout medical school as I developed mild depression and anxiety issues that still linger today that I have to remain wary of. The thing is that this is hardly uncommon in medicine. Some people with mild forms are resilient and never address the problem (not the smartest idea), some people do the right thing and get help, some people suffer through a crisis, get thrown off course and (never) come back. Everyone's different, but I bet that almost everyone (I'm sure there are some lucky exceptions) in the medical field has suffered with at least minor mental health issues and burn out at one point or another. I say this just to warn those like me coming in that there's a reason your parents taught you those good habits like sleeping at a regular time, staying physically active, and being social. These are some of the most effective barriers to mental illness in medical school. While you were probably chugging a Red Bull/5-Hour to cram the night before an exam in college, you probably did that once a week and your body could recover. In medical school, you're studying like that every day. I'm not trying to scare any of you or say that it's impossible because medical school when approached correctly is very manageable. If you do it right, you'll probably do very well and realize you still have free time.

#6. I've alluded to this in other posts, but don't get ahead of yourself in the beginning of medical school. You may go in with a set goal and that's great, but acknowledge the level of competition around you. Picture a 20 point quiz you took in undergrad. You'd never score below 16/20 and would be happy with 18/20 or above because it kept you on track for that 4.0. Now take away all those people who wouldn't study and get the 12/20s, etc. Now in medical school, below 16/20 is a fail, 18 is average, and 19+ is honors. At first it's frustrating because it's like 18 vs 19 matters? Yes, it does and get used to it. The reasons will become more apparent as you learn how a small detail becomes relevant. If you find that you're barely able to keep float, realize that perfection is the enemy of good. For the first few months, everyone should shoot for the highest grade available. If after that time where you've tried Anki, gotten help, studied a million different ways, you find that you ceiling ranges around the average with some exceptions and you want to do something competitive, accept your best as your best and realize you've lost the battle, but not the war because the alternative is driving yourself insane before the most important stuff (Step 1, 2, Clerkship grades are even in play).

What are signs of mild depression and anxiety one should watch out for?

If we spot these signs, what kind of treatment should we seek out for ourselves?
 
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Syncrohnize

Syncrohnize

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What are signs of mild depression and anxiety one should watch out for?

If we spot these signs, what kind of treatment should we seek out for ourselves?
I don't know about signs because it's different for everyone. Go see your university's or medical school's mental health services department. They will refer you. Depression is actually really common in medicine and you shouldn't be ashamed of getting help or taking medication if that's what is needed.
 
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MyOdyssey

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I don't know about signs because it's different for everyone. Go see your university's or medical school's mental health services department. They will refer you. Depression is actually really common in medicine and you shouldn't be ashamed of getting help or taking medication if that's what is needed.
I'm not speaking of myself but really am more interested in what low grade depression might look like.
 
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Syncrohnize

Syncrohnize

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I'm not speaking of myself but really am more interested in what low grade depression might look like.
You’ll cross that bridge if you get there.
 
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