My First Step

The time has finally come.  There is only one thing on the mind of a second year medical student at this stage in his or her education: USMLE Step I.  Pop your head into any of the few Starbucks coffee shops around Loma Linda sometime this week and I guarantee you’ll see a couple wide-eyed, fear driven students feverishly scribbling in a giant binder or answering practice question #1,532 as the date of their test quickly approaches.

Rewind to about 3 1/2 weeks ago.  There I was sitting in my last lecture of MS2 as Dr. Werner finished up his epic course in pathophysiology by teaching us about complement disorders.  To be honest, my mind was on anything but the immune system.  Over the next two weeks, we would be spending our time taking test after test to wrap up the in-house portion of our medical education, after which we had 2-3 weeks “off” to finish preparing for Step I. It was going to take a lot of discipline and time management to juggle studying and just staying alive! Before I knew it, Dr. Werner was giving his last bits of advice, reassuring our abilities, and ending with a simple, “Well, have a good life!” And so it began. The beginning of the end of the beginning.

The Very Last Lecture…

Dr. Werner Gives Me a Good Sendoff

Flash forward to the present day.  This time around, I survived my in-house exams, and excelled! The relief (and realization that I was crazy enough to do 2nd year TWICE) was only short lived, as I knew I couldn’t celebrate a finish line until I had passed through the final gate of Step I. Onward and forward!

“Now hold on a minute Ryan,” you may be saying to yourself, “What exactly is Step 1?” For those of you who don’t know, the United States Medical Licensing Exam, or USMLE for short, is an intense, three part set of examinations that every MD student must pass in order to become a board-certified physician.  Step 1 is taken after the 2nd year of medical school, Step 2 is taken after your 3^rd year of medical school, and Step 3 is taken after you have your intern year of residency (after being a doctor for a full year).

A Typical Prometric Testing Center

As for Step 1 itself, it is an eight-hour, standardized exam that consists of seven 1-hour blocks of 46 questions, with one hour of break time that can be taken whenever the examinee so desires.  Along with clinical performance, interviews, and letters of recommendation, Step 1 is widely said to be one of the most important factors in determining where a medical student works after medical school.  Score too low and a lot residency programs won’t give you a second glance; score high enough and you will be considered a competitive candidate; what constitutes a “good” score depends on what specialty a medical student wants to pursue after medical school. It takes a score of 188 to pass, with most examinees scoring around a 225.  As you can see, there is a LOT riding on this exam.

I take Step 1 on May 29, so my time to review is growing shorter and shorter. Step 1 could throw anything from the basic medical sciences, from neurology to anatomy to pathology to pharmacology, etc etc etc.  If you think that sounds overwhelming, let me assure you, it is!  Because this test is so expansive, there are many different ways students can review for it.  The majority of medical students stick to one main resource, supplemented by other books that can help areas of deficiency.  Behold, First Aid:

This 600+ page text attempts to take all the most commonly tested material (referred to over and over again as “high yield”) and squish it into one easy to read manual.  But even though it’s very accurate about what should be reviewed, most students choose to supplement their studies with additional resources, just to be thorough.  Other resources I am using include a pathology review text called “Pathoma,” the USMLE World Question Bank, an online course called “Doctors In Training,” and official NBME practice exams.  After I take Step 1, I’ll let you other medical students who may be reading know how well, and hopefully not how poorly, these resources prepared me for Step 1!

An Afternoon of Studying At Starbucks

So as the seconds count down to facing off against this monster of a test, I have been trying to maintain a fairly regular schedule. I’ve been waking up at around the same time every morning, I’ll spend a couple hours doing my online review course, then I’ll do a block of 46 practice questions, review those, go back over my day’s work, go to sleep, rinse and repeat! It’s pretty rigorous work trying to hit all the high points before Step 1, but as my practice exam scores have shown, review is going well so far, and my biggest challenge will be to avoid burning out.  Only 8 days left to go!

Study, Study, Study…

In other news, Loma Linda was recently visited by a representative of the Be the Match bone marrow donation program.  As you probably already know, Be the Match maintains a registry of people who could be used as possible donors to those in need of a transplant.  The need of these patients is highly specific, so only a perfect matching donor can safely donate his or her marrow.  Most who join the registry never match with someone, or if they do it is usually 10-15 years after they have joined. Well to make a long story short, I joined the registry along with a couple of my classmates, and after having been listed as a donor for less than a month, I have already matched with a patient!  My blood was drawn for confirmatory testing to ensure that I am indeed the best match, and if all goes well, I could help out a 71-year-old male with myelodysplastic syndrome! I can’t believe how fast it happened and am feeling incredibly honored that I have the ability to donate for someone.

Ok, back to it! See you on the other side!

My Upgraded White Coat Awaits…

Step 1: One more point.

May is that time where everyone is furiously studying…except for the seniors…  Of note is the proximity of USMLE Step 1, arguably the single most important test in medical education.  For those unfamiliar with USMLE, Step 1 is one of three all-day written exams necessary for licensure in the US.  Step 1 covers comprehensive basic sciences, and is taken at the end of sophomore year.  So for those who are studying for Step 1 or any other exam in any other school, I’d like to offer a bit of encouragement in the form of a personal story.

First, the moral:  every bit of studying counts.

Some of the more competitive residency programs have a threshold Step 1 score (this is a screening method, because they’re competitive and they can).  This threshold varies between institutions.  In researching orthopedic residencies, I recently found out that I’m one point shy.  Just one point too low to even apply to a few certain residency programs.  Sure, I can apply to many others, but it hurts to feel excluded like that, knowing that it’s only my fault.  But would studying a bit more have even made a difference?  In my case, yes.

Step 1 doesn’t have a one-to-one correlation between points and questions, but it’s very close.  There was one fact that I had memorized wrong during that unit in lecture, and I kept getting it incorrect on my USMLE World question bank.  I just didn’t restudy it with enough focus.  Low and behold, that same question (nearly verbatim) showed up on Step 1.  Go figure, I got it incorrect.  What bad luck.  It was the one question I looked up when I got home (don’t do that, by the way).  In the words of my hockey coach when I messed up, “You just didn’t want it bad enough, huh?”  It’s not that I didn’t want it.  I just didn’t do it.

Many people get the post-test regrets of “I wish I had studied just a bit more.”  Instead of a vague feeling, I have a discrete example of why that’s true.  I hope this little anecdote isn’t discouraging (as it was to me as I experienced it).  It would be easy to say “I’m going to make mistakes no matter how much I study,” or “comprehensive over two years? or “last-minute studying will make a difference.”  And I can’t stop you from drawing that conclusion.  In this case, Dr. Werner was correct:  you’re just as likely to get a question from the last lecture of sophomore year as from the first lecture of freshman year.  However, the point of this story is to give you that extra push, that resolution to keep at it when you’re already exhausted.

So keep studying, because every point matters.  Hopefully you won’t learn that the hard way.

Seeing the Sunlight

Over the weekend I visited the Upland Lemon Festival. Lemonade being one of my all-time favorite beverages, I couldn’t pass up the opportunity. Due to long days in the lab and things to do around the house, I haven’t spent all that much time outside lately. I pushed the concerns and worries to the back of my mind and simply enjoyed myself, exploring the various booths and sharing funnel cake with my wife. Sure, it was hot, making the lemonade that much more refreshing.

Perhaps this combination of mental state and vitamin D synthesis explains the near-euphoric feeling I had wandering around the festival in the bright sunlight. I closed my eyes, spread my arms open, and twirled around, feeling the warmth on my skin.

My Secrets to 4th Year Success

Hello!  If you have been following along with my posts, you already know that I am a 4^th year medical student here at Loma Linda University.  I recently matched to Loma Linda University Preliminary Internal Medicine and University of California San Diego Neurology Residency, and I am still super excited!  It feels great knowing that my lifelong dedication has paid off.  Throughout the year, some students have been asking for my advice, and I have been doing my best to share what I know.  Honestly, I’ve gotten overwhelmed by all the questions, so I decided to make a MEGA post to address the topics that I feel are important for success in the 4^th year of medical school.  Anything not on here that you want to know, I suggest you find on official sources.

Note: Please take my words with a grain of salt.  I consider it important to be prepared for worst case scenarios, so I give people practical advice.  These are all my opinions, not necessarily the opinions of Loma Linda University, any particular faculty members, or my classmates, and my opinions may not apply to everyone.  For more of my thoughts, please read my past posts.  What I write may not work specifically for you, but this is what worked for me.

The best thing you can do is figure out your game plan yourself.  Talking to your deans, faculty advisors, and residents is helpful.  However, don’t count on anybody to spoon feed you information about every little thing.  Look at the official NRMP, ERAS, specific program websites, etc. to give you the basics.  If you got into medical school, you are smart enough to find these resources and use them to your advantage.  It will be your personal interactions at the interviews and discussions with your loved ones that will help guide your decisions.  This is your future; grab hold of it.  Now that I’ve successfully matched, I am excited for my upcoming graduation and to start my journey as a medical doctor!

Before 4^th Year

This is a no-brainer, but I suggest you study hard on all your classes and rotations.  You will be amazed how much better you understand clinical care with a strong basic science foundation.  In addition, grades and comments from basic science and clinical years will be on your Dean’s letter that is sent to the programs you apply to.  Your Step 1 score and class rank do matter, especially if your goal is to match to a well-known institution and/or competitive specialty.  It’s not all about scores and grades, but some programs will not know how awesome you are unless you pass their filters.  There are way too many stellar applicants from all over the country vying for the same spots.  Red flags, such as failing a year of medical school, will limit you.  Unfortunately, if you have a red flag, you do not have the luxury of being picky.  Don’t expect to match to a top program if you are not a top student, but of course, you can always dream and apply everywhere to see what happens.  If you can afford it, go for it because it is hard to predict what programs are looking for.  God does work miracles.

Always strive to learn and improve.  Be appreciative of what God has given you.  Not everybody is given the chance, nor the capacity to be a medical student.  While you are in medical school, find some time to give back to others if you can.  Offer whole person care to every patient that comes your way.  It does take more time, but touching a patient’s life in a special way is invaluable.  Being a doctor is not just about having an immense amount of knowledge, but also taking care of people.  At the same time, don’t prioritize extracurricular activities over academic difficulties.  Achieving a balance is difficult, but that is something that you will have to learn to do.  Unlike other professionals, a physician’s job does not end when the clock ticks a certain time.

4^th Year Schedule

What electives should I take?

Honestly, 4th year is your time to do whatever you want, and nobody really cares what you do with your schedule as long as you meet the requirements to graduate.  During your 3^rd year, you will receive an information packet on the requirements you need to meet.  Read that carefully.  Refer to my first blog post, Exciting Choices in 4th Year, if you want to know what electives I chose.  However, my schedule has changed several times, so don’t worry if you are not exactly sure how you want to schedule everything.  I did not finalize my entire schedule until February 2013.  Some of my other posts also detail experiences from electives if you want to know more of what I think.

When should I do sub-internship/specialty of interest rotations?

You should do your rotation early enough to solidify your interest in a particular specialty and get recommendation letters.  The earliest you can submit residency applications is mid-September, so anytime in July or August is good.  Doing it early is also helpful if you are unsure of what specialty you want to go into.

Should I do an away rotation at a program I am interested in?

This is entirely your decision.  It may or may not help.  I have heard stories from both sides.  Some people matched at places they did away rotations.  Some people did not even receive an interview at places they did away rotations.  I didn’t do any away rotations for neurology programs, so I don’t know what it would have done for me.

When should I schedule vacation?

It’s up to you how to schedule.  Interviews can be anywhere between October and February. The majority of interviews are in November, December, and January.  I took off 2 weeks in November and 2 weeks in December.  Most students also take off April or May for traveling or just having fun in general.

When should I schedule tests, Step 2 CK and Step 2 CS?

Schedule them whenever you feel you will be ready.  They just need to be taken by LLU’s deadlines.  Refer to your information packet.  I took Step 2 CK in July to get it over with and so that it would be available before I submitted my residency applications.  I held off until December for Step 2 CS because I needed more time to get ready.  I think I might have written about these tests in a previous post as well.  All the information about these tests are on the official websites.

How should I study for Step 2 CK?

If you already took Step 1 and successfully made it through 3 years of medical school, you should know your study strategy.  What worked for me was practice questions from USMLE World and a review book, Step up to Step 2.

How should I study for Step 2 CS?

The most important thing to do is practice.  Grab a classmate and grab a book with practice case scenarios, such as First Aid to Step 2 CS.  Time yourself through the practice sessions.  You want to be done with the history and physical portion before the 5 minute warning.  After the H&P portion, time yourself writing a physician’s note.  Compare it to the book’s examples.  Another important aspect of Step 2 CS is empathy.  Treat the standardized patients like a real patient that you care about.  If you need more help, talk to the PDX office.  They are great at offering tips and helping you improve.

Applying for Residency

How much money should I save?

Interviews and 4th year in general are expensive. First of all, Step 2 CK and CS are about $2,000. Applying to programs can be about $500. You can check the prices on the ERAS website. I think it’s better to apply to more programs than you need to because it is hard to predict who will offer interviews.  I think it’s reasonable to save at least $5,000 for travel. It’s better to have more money and not use it than to have to cancel an interview at a place you really want to go to.

When should I create my CV?

ASAP.  There are sample CVs in the Dean’s office.  They also give you a sample copy during your 3rd year.  Follow that format.

When should I write my personal statement?

Do it early.  Start before September.  An articulate and well thought out personal statement actually takes longer than you expect.  I gave some advice about personal statements in my previous post, 4th Year Rotations and Residency Applications.

Who should I ask for recommendation letters?

This may vary, depending on your specialty. At least 1 letter must be from your specialty of interest.  1 should be from a core rotation like internal medicine, surgery, peds, etc. if you can get a strong one.  If not a strong letter, then choose whoever can write you a strong letter.  The last can be from any doctor.  Quality is very much more important than quantity of letters.  3 letters is good enough.  My advice would be to ask for them early.  You need to have a CV and personal statement ready by August, so that you can give them to letter writers.  If possible, the goal should be for the letters to be available by the 1st day of submission.

When should I start my application?

Start it before the first day of submission.  It can take at least a few hours to complete.  Make sure you double, triple, etc. check it before you submit.

When should I submit my application?

Submit it on the first day if possible.  I suspect that interviews are given on a rolling basis.  I submitted my application on the day that it opened, September 15, and I got my 1st interview invite on September 18.

What programs should I apply to?

My main advice would be to apply broadly and realistically.  Although I matched to an amazing spot, I didn’t even get interviews at some of the top programs I applied to.  As someone who prepares for worst case scenarios, I think it is extremely important to also apply to non-competitive spots.  That means outside of desirable areas in California, outside of the Ivy League, outside of any place that most people would be impressed with.  What is considered non-competitive also depends on your individual Step 1 score and grades.  This information can be found on the NRMP reports and talking to the experienced deans/faculty advisors.  Some people in my class did not match, and unfortunately, I don’t think that every student found a job in SOAP.  Your goal is to make sure that you apply smartly and go to enough interviews.  Yes, it is all expensive, but if you don’t get a residency position, you won’t have a job.  A job in some random place is much better than no job at all.

How many programs should I apply to?

This depends on what specialty you are applying to and how reputable the programs you apply to are.  For any specialty, I would recommend applying to at least 20 programs.  This is assuming that some of the programs you apply to would impress a layman.  I tend to be more on the cautious side, so I think you should apply to as many programs as you can afford.  If you are applying to well-known places, you need to apply to extra.  As a warning, just know that no matter how competitive an applicant you are, you will inevitably get rejected by programs.  Consult your deans and faculty advisors if you need help.  They have years of experience in helping students succeed.

What do you think about neurology programs?

Well, I think that neurology is the best specialty!  Some programs are categorical with all 4 years.  Some programs are advanced and also need an intern year.  You need to weigh the advantages and disadvantages yourself.  Applying to advanced programs means you have to spend extra time and money interviewing for preliminary spots, so prepare for that if you are planning to do so.  It is all personal preference, and no one can tell you what you should do.  After learning about different neurology programs, I found most programs are more or less the same with differences of prestige and location.  I thought that every neurology program I interviewed at was great in their own ways.  Everybody has different reasons for why they like or dislike something.  This is something that you will have to figure out on your own.

What are my chances of getting an interview and/or matching at a certain program?

I don’t know.  If I could predict the future, I would be rich by now.  The only way you will know is to apply.  The top programs obviously favor applicants with high board scores, above-average class rankings, and no red flags.  If you are not restricted by finances, then apply and leave it up to God.

Interviews

How much money should I expect to spend on interviews?

For local interviews, it will be gas price unless you stay at a nearby hotel, which could be $50-100/night. I think West Coast interviews by plane with hotel/ground transportation is may be about $300 each. Midwest and east coast may be about $500 each. It depends on if you can get some deals. Southwest was usually cheapest for flights, but for flights and hotels, it’s good to shop around. Look at the company’s site, priceline, hotwire, hotels.com, etc. to find the best deals. If possible, you can try to group interviews in the same region but it’s hard and doesn’t usually match up, so don’t count on it.

How many interviews should I go on?

I don’t have a clear answer, but I recommend aiming to go on at least 10 interviews.  The worse of an applicant you are, the more interviews you should go on.  If you get fewer than 10 interview invites, you should go to all of them.

How should I prepare for interviews?

Be yourself.  I wrote about interviews in a previous post, What It’s Like to Go on Interviews.  You can refer to that if you’d like.  There is also a practice interview session offered by LLU.  Go to that.

Should I contact programs after I have interviewed?

It is up to you.  I sent some thank you emails and some thank you cards.  In the end, I don’t know if it made any difference.

Match

How should I rank programs?

This is entirely your decision.  Please read the Match algorithm on the NRMP’s website if you are unfamiliar with how the Match works.  It explains things better than I possibly can.  Pros and cons of each program need to be decided on by you.  Don’t depend on others to spoon feed you their opinions.  Everybody has different personal reasons.  I ranked programs based on my overall feelings and desire to attend them.  This is not something I can describe, but you will have to experience it for yourself.

How does the SOAP work?

I do not know, and I do not want to know.  Luckily, I did not have to know.  I’m sure you can find this information on the NRMP website if you want to know.

What is Match Day like?

Please read my post, Some Thoughts on Match Day! for my thoughts on Match Day.  Also, watch the Match Day 2013 video, which is featured in my last post, Ice, Eyes, and Nice Comments!  Match Day is just simply the best day of medical school for me.

How do you feel about your match?

I am very happy!  I can’t believe I matched to such an awesome place!  I am excited that I get to stay in Southern California and be near my family for all of my residency training.  I feel blessed to match to UCSD’s neurology program.  I also feel blessed to stay at LLU for my intern year.  After 20+ years of nonstop schooling, I will finally start my first job soon, so I am grateful that I get to have my parents around to support me with my transition to the working world.  I know that this is where God wants me to be, and I am thankful for His wonderful plans for me.  I feel great knowing that all my dedication and hard work have paid off and that my dreams of becoming a doctor are coming true.  At the same time, I feel like wherever I matched, I would be a bit sad that it wasn’t one of the other programs because I enjoyed all my interviews and loved meeting people everywhere.  In a way, I’m glad that I’m not the one who makes the tough ultimate decision of where to train next.  Overall, I feel like this is the best time of my young life so far.  I am looking forward to many more special events to come during my lifetime.

My Final Thoughts

Making it to 4^th year of medical school is already an accomplishment.  The first 3 years of medical school are very difficult, and only people who have been through it will understand what it takes.  Be prepared for new challenges in your final year.  Never stop learning.  You still need to give it your best on every rotation.  Treat every patient like they are a VIP.  You will also have more well-deserved free time than in other years of medical school, so spend time with those you love.  This is the last year for a long time in which your time is truly your own.

When seeking residency positions, it is better to play it safe, but reach for the stars if you can afford it.  Even if you think you are a desirable candidate, not everyone will agree.  The money you lose from applications and interview experiences is extremely miniscule compared to the huge disappointment of not matching.  Have fun on interviews.  Be nice to everyone you meet.  Be yourself.  Form your own unbiased opinions.

Enjoy 4^th year.  Have fun.  Do things that make you happy.  Hang out with your family and friends.  Don’t worry about every little thing.  Get comfort from the ones who will be there when no one else cares, your family and God.  Remember that God has brought you this far, and He will be faithful.  No matter where you end up matching and even if it does not work out the way that you want, remember that what God chooses for you is even greater than what you choose for yourself.

…This Past Quarter

Contrary to popular belief.. I am still alive

Sadly this is my first post of the year, but I will quickly attempt to make up for lost time and readers.

So to get some formalities out of the way and to regain the readers that I may have lost.. I would like to wish everyone a Happy Thanksgiving, Merry Christmas, Happy New Year, Happy Valentine’s Day, and Happy (Fill in any holiday I may have missed here)!

This quarter has been… (searches brain for the correct word).. interesting.. Interesting because it was extremely fast paced, everlasting, busy, busy, and oh yeah did I mention busy? It started off with my teachers updating Canvas (our online class portal) with lectures and group projects during the Christmas break. Like every good student, I read the email updates, syllabus, and mentally prepared for the upcoming semester… But I could never have guessed exactly how fast everything would actually happen.

In January alone I had 3 projects and 1 exam, this trend continued into February, and March. Actually… March is quite an exception, since this time I only had 1 exam in addition to projects, daily quizzes for about two weeks, and Finals Week of course (*Insert seemingly ominous music*). Thankfully it all finally came to an end and last week (due to Spring Break *insert Hallelujah Chorus*).

Although the semester may have been difficult at times, I really thank God for leading me and guiding through it. I also would like to thank my professors and research mentors for challenging and creating so many opportunities for me to learn and demonstrate my newfound knowledge.

On an semi-serious note I also would like to thank the school for a week off from classes and serious studying (emphasis on serious.. meaning studying is still occurring). But seriously I am really grateful for this break, because I have time to somewhat rest my mind, prepare for the upcoming quarter (April 1st is right around the corner), actually write posts for the blog, clean my room and do laundry (just kidding) and to re-energize myself for the next semester…

Until Next Time…

Brandon Dixon

P.S.
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