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The residency MATCH: a 101 guide to understand it

The match, residency, ERAS. These terms become part of our everyday vocabulary, either as MS4 or IMG applying into residency. A cumbersome, long application process in which oneself that is going through seems lost most of the time. It is no wonder that our family or friends who are not in the medical field get confused about how the process occurs. To alleviate my anxiousness prior to the match and help our loved ones understand better what the process of applying to residency in the USA entails, I will make this quick 101 guide to understand it. And before we start, I will address a very common preconception; passing the steps1 and 2 does not mean we got into residency.

The beginning

Hello! If you are reading this behold, as a friend or family relative is about to embark into a couple of stressful, exciting, doubtful several months starting early June/July until matchday in March, yes, it this long, so please gives us love.

The process starts earlier than you might imagine. Before applying, you should have already decided what specialty you want to go into. Specialties in medicine could be divided in 3 big groups medical specialties (internal medicine, pediatrics,dermatology), surgical (neurosurgery, ophthalmology, plastic surgery), diagnostics (radiology, pathology). Once you have decided what specialty you want to apply to, the process begins.

Around June, ERAS will become the most searched website on your applicants one’s laptops. ERAS stands for Electronic Residency Application Service. This is the website where we will have to do a lot, so I will bullet point all that we have to get done on this website that gets quite stressful even with the calming blue colors of the ERAS banner.

  1. CV: LONG standardized CV format where we will have to write in excruciating detail all our accomplishments, education background, hobbies (yes, super important). This is an essential part of the application because we have to look attractive for programs. Your applicant will spend several hours witting, re writing, and writing again this application for several months.
  2. Letters of recommendation (LOR): It is pretty standard to put references down for a job, right? Well, I wish this was just to put down a name. The LORs are probably one of the most stressful parts of the application since it does not depend entirely on us. Our professors write these letters, mentors that want to support our residency application, and every word they write is taken very seriously by programs one applies to. There are two ways to upload a LOR as they are so important. One is to waive the right to see the letter (which is usually preferred) so that the person can freely write about you or upload the letter yourself (not recommended). So we reach a point where many students are asking the same attendings for LOR’s, that in addition to their busy clinical schedule, they have to write and upload in a platform for which they have to create an account. So you can imagine the stress one could go under while catching our mentors and pressuring them to write the LORs and upload them. Tip for future applicants, do this early in the season if possible.
  3. Personal statement: I think my non-medical readers might be familiar with this part, as you must have read a couple of versions of the personal statement. In less than 28’000 characters, convey who you are, why you want the specialty you are applying to, and seem interesting enough to catch the attention of the selections committee. One goes on and on, and one writes several versions (I think I did about ten versions) and gets inputs from many people. So, brace yourself as you will be receiving personal statements any time soon to revise.
  4. Medical School Performance Evaluation (MSPE): For American graduates, you are blessed; you don’t have to do much here as your medical schools are in charged. For my fellow IMG’s, this is where we go back to our alma mater across the world to ask for our medical school performance, and we all know how slow administrative requests are. Please do so in advance as we need to request them and translate them to English. I enjoyed this part as I got the chance to remember great memories from medical school.
  5. Programs selection: Decision burnout, yeah, it might happen. How do I choose from so many programs? Which ones to apply to? This is where applicants will go over more than > 100 programs and read what each has to offer to decide which ones they want to apply. Usually, the limitans is, yes, you guessed it: money as applications to around 100 programs could cost up to $2000.

Congratulations! Once you have gathered all items on your ERAS application and decided which programs to apply, all is left is to use that plastic to pay thousands of dollars in applications and wait for the next phase of the match season.

The interview invitation season: two rules

  1. ALWAYS HAVE YOUR PHONE TURNED ON WITH NOTIFICATIONS ON
  2. Have a proxy that will be receiving emails when can not

Your application rests now in the people’s computers that might decide your future career. It is only normal that your applicant seems anxious during this time and is waiting impatiently for that NoReply@AAMC.org email at any time for an interview invitation.

Most programs will send out interview invitations at any time during the day, hence you will see your applicant glue to their phones, with an special alarm ready to receive these emails, and in constant cycle of checking to see if the email is working. This tends to become stressful for many reasons, as sometimes programs might send more interview invites than slots to interview, or if you don’t respond fast, you might have scheduling conflicts.

You will hear funny stories such as people jumping out of the shower once they hear an email notification. Thus, having a proxy answering your emails and scheduling your interviews when you won’t be able to be on your phone, like when flying on an airplane or while you are in other interviews. In my case, the funniest story was that I received an interview invitation while in the middle of taking step3, good energy boost but terrible timing. Shout out to my proxy Sebastian Gallo for scheduling that interview for me.

This time is mixed with extreme rushes of energy and enjoyment once you get that email that says you are invited to interview, sadness when a program you liked rejected you, and uncertainty when most of the programs you will apply for will neither invite you nor reject you.

Interviews: Game ON!

While the most stressful part is the first month and a half to receive interview invitations, by this time, your applicant will most likely start to interview. We will all do our interviews virtually as we are going through the COVID-19 pandemic, which makes things somewhat more accessible. Before the pandemic, applicants had to travel all over the United States to interview their desired programs, wild, right?

Before the interview, applicants will carefully study the program, the attendings that will be interviewing them, and reviewing their own application as anything they have written could be asked whether that been a hobby or a paper. This period is full of excitement, they are interviewing for their dream job! You will probably be asked to help them with mock interviews and to practice with them for a few times to be able to shine during the interviews. So be there for them and cheer them through this interview season that will last from October until probably mid-February.

Ranking order and match day

The interviews are over, by this time you probably have a sense of which programs your applicant liked more and you have asked, so when do you get the job offer? Well unfortunately this is not a direct hiring process. After the programs have interviewed the applicants and applicants have interviewed at all of their programs, each one of them well sit down and write something called the Ranking Order List (ROL). This is a list of preferences in descending order of which one is the program they liked the best to the least, or even not rank places they did not like. Programs will do the same to rank in order of preference applicants or not rank them at all if they did not seem like a good fit. Once the lists are done, they will be submitted to the NRMP platform. On this platform, the Gale-Shapley matchmaking algorithm, which earned them the 1995 Economic Nobel Prize, will dictate where you will spend the next 3 to 8 years of your life and be the most crucial part of your training as a physician; an algorithm will be determining our life’s.

So, the best way to explain this is to make an analogy with Tinder or any dating app. You swipe right when you like someone, and if the other person also swipes right, you will both match! It is similar in that if the number 1 ranking in your list is a program that also ranked you first or within the number of positions available, you will have a perfect match and train in your most desired program.

But if that program ranks you in a lower position than there are available slots, things get a bit complicated. So let’s set a fictional hospital, Greys Sloan Memorial, and our two dear applicants, Derek and Meredith.

Let’s say Greys Sloan Memorial has eight spots for General Surgery, and our imaginary applicants Derek ranked Greys Sloan as his number 1 residency program and Meredith as her 4th choice. Derek was ranked in the position 9 and Meredith was ranked as their # 1 out of the 60 people they interviewed. He was certainly ranked high, but for Derek to match in Greys Sloan Memorial, at least 1 of the other applicants that are above him must have either matched elsewhere or not have ranked Greys Sloan. Meredith on the other hand would have directly matched into Grey Sloan, right? They have 8 spots, and she was first! However, Grey Sloan wasn’t her first choice. Since the algorithm favors applicants, the system will first try to match Meredith into her other top 3 hospitals. For Meredith to match into Greys Sloan, she must not have been able to match in her top 3 choices. She would go ahead and match at Greys Sloan.

As you can see, Meredith matching into this program might mean that Derek will not be able to match into his top choice thus the outcome of the match is dependent on the ROL from each of the hundreds of applicants and the programs.

MATCH week: The reveal!

After submitting and editing the ROL endlessly, the second week of March of each year will be a life-defining week for most applicants. On Monday, we will receive an email stating if we were accepted for residency or matched into a program. If so, we will receive another email on Friday, AKA Match Day, that will tell us where we will be doing a residency for the next 3-7 years.

Of note, the match in March occurs only for most specialties, except for urology that happens in January and ophthalmology that happened this past Tuesday.

This was a brief overview of the tumultuous process of applying for residency. It goes without saying that having friends, significant others, and family through this time is paramount, and I take this opportunity to say thank you for the unwilling support anyone has brought me until this point.  I want to specially thank my mentor Dr. Nestor Gonzalez, my family, and my friends (Sebastian Gallo, Sandra Saade, Andy Serrano and Juan Esteban Velez) for putting up with my anxiety through these months.

“The views, opinions, and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness, and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions, or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your health matters. If you think you are having a heart attack, stroke, or another emergency, please call 911 immediately.”

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Residency and Fellowship Interviews During COVID-19

As early-career physicians started residency and many physicians began fellowship training this month, it’s hard to think that recruitment for next year’s residency and fellowship classes is beginning soon. The COVID-19 pandemic has disrupted many of our usual routines and processes. Similarly, this year’s residency and fellowship interviews are going to be different than previous year’s interviews. The Association of American Medical Colleges (AAMC) has now recommended that all interviews for medical school, residency, and fellowship be conducted virtually this year.

There are many potential benefits of virtual interviews, including but not limited to:

  • Lowering the financial burden of traveling and housing during interviews.
  • Not having to spend time traveling and potentially being able to interview at more programs without physical distance complicating scheduling. For example, one can interview at a West Coast program one day and interview at an East Coast program the same or following day.
  • Missing fewer days of work/school/rotations for interviews.
  • Not having to frequently pack and unpack and worry that you forgot to pack something important.
  • Not having to tour a campus during the winter months (especially in heels) or drive in the snow.
  • Sleeping in your own bed before an interview.

For those of you who will be interviewing virtually for residency and fellowship programs this year, I have gathered some advice from my Cardiology fellowship program director (@rhythmkeys) and program coordinators (@UmnCardsfellow). Of course, also ask your mentors and other colleagues for advice. Remember that this is a new experience for both you and the programs so there may be some road bumps and steep learning curves.

  • Be open-minded. Fight the urge to stay at the same training institution because of unfamiliarity with a new city and/or program.
  • Spend time researching the programs and cities that you are interested in. Many programs (including ours) will have virtual tours/videos of our facilities and city. Take advantage of the publicly available information about a program/city (i.e. Google Maps is a great way to explore a campus/city in the comfort of your own home).
  • Ask more questions about a program and environment than you usually would if you were interviewing in person in order to get a feel for the culture/environment of a program since this may be more difficult to determine when interviewing virtually.
  • Try to consider the interview as “normal” as possible. Be professional. Be prepared. Login into your computer and the virtual meeting early in case you encounter technical difficulties.
  • Do not worry too much about technical difficulties. Virtual interviews are also new for the programs. Most programs will have contingency plans in place if there are technical difficulties.
  • Here is some great advice on how to master the art of virtual interviews from fellow AHA early career blogger, Dr. Barinder “Ricky” Hansra (@RickyHansra).
  • Reach out to current or past trainees at a specific program. Most of us are happy to talk about our experience in the program. If any of you are interested in the Internal Medicine or Cardiology fellowship program at the University of Minnesota, please feel free to contact me! Interviewees at our program will be able to still meet with current fellows during their interview days and I assume that this will be a part of interviews at most programs.

Depending on the experience of the programs and applicants this year, perhaps virtual interviewing for medical school, residency, and fellowships will continue in the future. Interviewing virtually may be more convenient and cost-effective. Best of luck to all of you interviewing for medical school, residency, fellowships, or jobs this year and stay safe!

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Why Cardiology?

“Why Cardiology?” is one of the most common questions I have been asked by friends, family, interns, residents, and even the occasional stranger sitting next to me on a flight. Despite being a simple question, the answer is very complex. I initially started residency thinking I would pursue a career in pulmonary/critical care – I loved the acuity, broad differential diagnoses, and the bond created with families. However, after my first month in the unit, I quickly abandoned this career path for multiple reasons. Shortly thereafter, I did my first rotation on the cardiology wards service with Dr. Matthew McGuiness (who is still one of my closest mentors) and I saw the light.

The month on the cardiology wards service is best described as “finding the missing piece of the puzzle.” I loved the anatomy, physiology, patient population, subtle differences in presentations, and my interactions even as an intern with patients. I also loved the depth of cardiology – including both clinical and basic science research opportunities, advanced fellowships options, and the ability to create my niche in cardiology. I learned cardiologists were pursuing careers in preventative cardiology, cardio-oncology, cardiac critical care, and cardio-obstetrics. I was blown away at the possibilities of a career in cardiology and having the ability to create my perfect dream job.

As I mentioned earlier, I was very interested in critical care when I started residency but did not want to be in the medical ICUs. The cardiac intensive care units were much more interesting to me with advanced hemodynamics, malignant arrhythmias, various mechanical circulatory devices, and seeing how quickly the realm of the cardiac ICUs were changing. The CCUs are no longer filled with patients who have had a STEMI requiring a week-long admission, but rather those with decompensated heart failure/cardiogenic shock requiring mechanical circulatory support (MCS) with LVADs, Impella, or ECMO.

I am now combining all of my loves – cardiology, critical care, and obstetrics (yes, I at one point wanted to go into OBGYN) for my job as an attending. With the help of my mentors, I have been able to combine all my passions into one. I will be attending in the cardiac intensive care unit and have a predominantly general cardiology clinic with a focus on cardio-obstetric patients. And the best part, every cardiology fellow can create his/her dream job.

A few key questions to ask yourself are:

  • Do I see myself as someone who enjoys the in-patient or the out-patient setting? This will help focus career options and set the stage for your career.
  • Am I a proceduralist or not? For me, I hate wearing lead, so it was a simple decision to not go into interventional or EP.
  • What type of patients do I get the most joy of taking care of. In my case, it was the critically ill and women who are pregnant with cardiovascular disease.
  • Who is 5-10 years ahead of me career-wise and has my ideal job? This has helped me be more active with research, clinics, conferences, and improve my fund of knowledge. It also gave me a roadmap to follow – no need to reinvent the wheel.

Of course, these are starting points and it’s a vast topic that takes time to explore. My journey of “why cardiology” has been filled with highs and low, but with the help of various mentors I have a clear vision of what I envision for my future career.

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Pursuing Cardiology As a Medical Student/Resident

As an Early Career blogger for the AHA, I wanted to write my final blog post on advice for those interested in pursuing cardiology. My interest in cardiology began during my first year of medical school, and now as I am applying to become a fellow, I wanted to look back at the last 7 years.

 

Medical school

As a medical student, it can be difficult to know what field you would like to pursue. Although some may know from the beginning what they would like to specialize in, the majority of students must use their time during their clinical years to explore different fields. Given this, I would advise students to focus on getting a good background in all aspects of medicine during medical school. Take as much in from your exposure to each field. Do well on your boards, take ownership of the patients you see and read as much as you can.

So as a first or second year how can you know if cardiology is a field you should consider? Well, what made me interested in the field during those years was the physiology behind the mechanics of the heart.  It made intuitive sense. The time I spent reading Lilly’s Pathophysiology of Heart Disease did not feel like studying. This inspired me to sign up for electives in cardiology later on in medical school. During third and fourth year, rotating on a cardiology consult service or a CCU service can help you see the day to day life of cardiologist. It exposes you to the common consults and admissions in the field. It also allows you to get to know the type of personalities in cardiology. If you are interested, get involved in research projects.

 

Internal Medicine Residency

In the beginning of my residency, my advisor told me that before one could become a great cardiologist, they must become a great internist. This is something that I heard echoed by cardiology program directors during this past year’s AHA Scientific Sessions. A passion for patient care and an understanding of the intricacies of internal medicine are paramount in the path of a future cardiology fellow.

Be a good citizen in your program. Complete all your administrative duties on time. Be the one that chiefs can rely on when scheduling difficulties occur. Residency is not just about being smart but being reliable and hardworking. This makes you stand out.

While on the wards, incorporate the use of ultrasound in your daily practice. Try and volunteer for procedure and make it a goal to become comfortable with central and arterial lines.

Depending on your interests in cardiology, as a medicine resident it is worthwhile to get involved in a research project. It is important to truly have a passion for the research topic you decide to study. Whether it is because a patient you saw was affected by what you are researching, or if you have background in that topic, it is important to have a connection with the research topic. This is what drives you to spend your time outside of the hospital working on the research project. Attempting to work on a project in the name of “just having research” is a recipe for burnout and you will likely not complete the project.

Show case your research either through presentations at the AHA Scientific Sessions poster session or the American College of Cardiology meeting. Recognize that the deadline for abstract submission for these conferences are months before the meeting. Besides presenting, networking and sitting in on lectures important topics in cardiology. It is inspiring and will further your aspiration to work hard.

Finally, make sure to begin working on your application, specifically the personal statement early.

 

What was your experience applying to cardiology?

 

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How Does An Intern Become Burnt-Out In Residency?

The transition from medical school to residency is abrupt, yet exciting. We begin the year so eager and enthusiastic. The rush of adrenaline as you place your first order… the validation you feel as the attending physicians agree with your plan… the first time you make the correct diagnosis in the ever-elusive morning report cases… all of it is new and challenging.  The patients refer to you as doctor and ask you questions about their care. The nurses ask if you can evaluate a sick patient because they want your opinion. You spend hours after sign-out making sure your notes are perfect, which your academic mind considers a daily writing assignment that you MUST ace every time. You try your best to read that article on UpToDate before you fall asleep. You are the first one to get to the hospital, and last to leave.

You have been given trust and responsibilities. You want to meet these expectations.

The first few months pass and you find a rhythm. The feelings of excitement fade and you begin to feel efficient. You start to recognize what you need to do to keep your attending physicians and the upper levels happy.  You are finishing your work faster than before.

You start to feel more comfortable, but little day to day things happen that change you without you even realizing it. A patient passing away, a picture of your family together for dinner without you, a burnt-out consultant yelling at you over an improper consult. When these things occur, you ignore them and try to move forward. You feel as though you have easily brushed them away, but in reality, they affect you.

January and February become the hardest months of the year. Burnout can present in many different ways. It can present itself subtly like having difficulty getting up in the morning to go to work. You may think to yourself, “this is normal, tons of people have a difficult time getting up in the morning.” Yet, it is like a stepping stone. Your lack of sleep turns into you finding nursing calls annoying. All of the time spent on documentation, hours spent in front of computers taking away from patient care begin to change how you view your work. The combination of working twelve hours a day and trying to learn more about the pathology you see becomes difficult. You may even find your work uninteresting. And yet, with all of that said, even though you are fully aware of burnout and have heard the term multiple times, you believe that what you are experiencing is normal.

The first step to tackling burnout is to recognize it. Self-reflection is an important aspect of residency, but at times, it is your friends and family that point out the subtleties of burn out. Once you have recognized it, then it is easier to track and find what exactly is causing you to feel stressed.

Have you experienced burnout? If so, how has your experience of burnout affected you?