Treating a pediatric patient at a mission clinic in Albania (courtesy Joel Mundall)

“In Africa, we wash and re-use the gloves,” said one of our resident physicians who was doing clinic procedures with me.

When he graduates from our Family Medicine Residency Program at Loma Linda University, he is planning to work in the mission field in Africa where he spent time as a medical student. We had been discussing principles of “universal precautions” and discussing the use of medical gloves.

I looked at him as he was wistfully staring at the boxes of gloves that line the exam rooms in our Family Medicine clinic at Loma Linda University in California. Gloves that are ubiquitous here in the United States are so precious in the mission field. I remembered seeing mission photos, from our doctors who went to Africa and Papua New Guinea, showing gloves drying on clotheslines ready to be re-used. All day, I thought about medical gloves and the hands that wear them, the hands that are extensions of the doctors we are training to care for patients in the United States and around the world.

At Loma Linda University School of Medicine, students are encouraged to take elective rotations at mission hospitals and clinics around the world. The program, called Students for International Mission Service (SIMS) exemplifies the university’s commitment to global service. It empowers students to become compassionate, socially responsible health professionals and helps to promote the health of global communities. SIMS offers students opportunities to do mission work of various lengths. There are weekend interdisciplinary trips to mission clinics in Mexico and longer trips to various other countries. Students can also participate in an International Service Learning program (I-Serve) in which they do a month long observational or hands on clinical experience at a mission hospital. There is funding available through the Dean’s office to help defray travel costs. The students are usually housed at the mission site.

Mother with newborn at clinic in Nigeria (courtesy Joel Mundall)

Resident physicians at Loma Linda University (LLU) are also encouraged to do a mission elective either domestically or overseas. Some of our residents have recently returned from mission work in Malawi, Mexico and Nepal.

When resident physicians (at our institution or other institutions) plan an elective rotation, they must consider if their salary, malpractice insurance and benefits such as health insurance will carry over during their elective. At LLU, residents can choose from the “big book” of approved mission clinics around the world which will allow their salary and benefits to be uninterrupted.

Resident physicians and other health professionals often face the dilemma that they want to enter mission service but they are concerned about how to pay their student loans. For non–medical students who wish to serve in the mission field, they can apply for the Global Service Scholarship Program (administered by the Loma Linda University Global Health Institute in conjunction with SIMS) and they can get their student loan indebtedness amortized while they volunteer in an international setting.

At Loma Linda University Family Medicine Residency Program, several of our residents have chosen to participate in the Deferred Mission Appointment (DMA) Program. This program enables medical or dental students to work in overseas mission service with financial stability. During medical school they receive a stipend to cover room and board. After graduation they are placed in one of the Seventh–day Adventist Church’s many health care organizations world wide. In the DMA program, they receive a salary and competitive benefits such as health insurance, licensure fees, one month furlough (vacation time) plus continuing medical education time each year, and a percentage of their student loan indebtedness is amortized each year they serve in the mission field.

“The DMA program was an obvious choice because it makes it possible to work internationally without any delays after residency for repaying my loans,” said Dr. Joel Mundall. “Without this program, if I were to try to work for a little while to repay my loans before going, I would be at risk for never leaving this country or going where God wants me to be.”

The mission hospital in Nepal (courtesy Aaron Sartin)

Most of our residents will serve a six year term in the mission field and they may choose to stay on afterwards. At their mission site, they staff medical clinics or possibly a hospital and train indigenous people to provide health care services. This program is administered by the World headquarters of the Seventh-day Adventist Church in Silver Spring, Maryland.

As Dr. Aaron Sartin, a third-year resident in the DMA program explained: “A large barrier to doing mission service after residency is the enormous medical school debt, which grows exponentially after years of in-school and residency deferments. That barrier is removed with this program as the medical school debt is amortized over a six year mission term overseas. At the time I signed up for the program it seemed like seven years was so far away and would seemingly never arrive. Now in my third year and last year of residency in Family Medicine this reality is less than a year away.”

Although our residents in the DMA program may be placed around the world, most of them will be heading to Asia or Africa. They can request their first choice but they will not know until they complete their residency where they will be going.

“Recently, my wife and I returned from a three week mission elective to Nepal where we witnessed first hand the poverty and great need (physical, emotional and spiritual) as well as the beauty of the people,” continued Dr. Sartin. “We were awakened as never before to how blessed we are in the United States and reminded of our responsibility to use these gifts to be a blessing to others, both here and abroad. Where will we end up? That remains to be seen but as a Christian physician I am confident that God will direct us to the right mission field.”

As I put on my gloves for the next procedure, I couldn’t help but wonder where the skills I was teaching my residents would be used to provide health care around the world.

For more information, access http://www.llu.edu.

Alex Shalman

by Alex Shalman
AlexShalman.com – Practical Personal Development

“The brick walls are there for a reason. The brick walls are not there to keep us out; the brick walls are there to give us a chance to show how badly we want something.”

~Randy Pausch

There are certain goals in your life for which success is a non-negotiable conclusion. It’s inevitable that the bus of your life is going to drive towards a fork in the road.  The trick is to position yourself in the drivers seat.

My most current and biggest obstacle so far has been to get into dental school. If my whole story was simple, that “I applied, I got in, woot!” then it wouldn’t have been very inspirational. Luckily, for the story’s sake, it took me three years of applications, rejections, retaking the DAT, and upping the ante with a master’s degree in order to push my way through.

The whole process really humbled me, and at the same time made me really proud of what I can do when I put everything I’ve got into it. I’ve had the benefit of being very self-aware, and carefully analyzing the mental processes that I went through in order to reach this goal. I could have been depressed at the first rejection. I could have quit and found another line of work…I almost did…but I didn’t, because my brain thinks as follows:

1. Cut Off Unsupportive People
   I’ve long been going through the process of purging negative people from my life. The friends that were just great to party with, the people that were disgustingly pessimistic, and the ones that clearly did not have my best interests in mind. Getting rid of negative people opens you up to meeting new ones with qualities you respect and admire.

   Several months ago I had a friend ask me why am I still trying to get in, and why don’t I just give up and go and get a real job instead of trying for this dental dream. My girlfriend Marina had an awesome response to this onslaught. She said, “How can you live if you stop trying? That’s the formula for regret.” I like it a lot. I have to keep this Marina person around me more!

2. Cut Off Plan B
   I’m very inspired by a story of Julius Caesar that I heard from one of my personal development tapes years back. When Caesar’s ships landed on the enemy beach, he immediately ordered his army to turn around and burn down all of their own ships. This left only one option, plow through the enemy lines, no matter what, and on to victory.

   In my own life, I gave myself only one option, no plan B, no alternatives, and that option was to become the best Dental health professional in the world. Other options and job opportunities were presented to me, quite often, and I always thought of them as the “Serpent’s apple” which I refused to pick.

3. Talk About Your Dream
   Everyone that I encountered knew that my number one goal, the thing that I wanted so much I could taste it, was to get into dental school. I didn’t ask them for help, I presented myself as a passionate individual who has wanted to be a dentist since he was five years old and would stop at nothing to achieve this dream. People respect this form of sincerity.

   In fact, people would often times start trying to think of solutions to how they might help me, or who they knew in a great position to help me. Over three years, I got a lot of contacts, some of which were dead leads, but the sheer volume that was generated from me speaking about my number one goal created some golden opportunities and referrals.

4. Believe In Yourself
   You know those days: When you’re down on yourself, and you’re thinking about quitting. Perhaps you even start to entertain some good reasons for why quitting would be a good idea.

   *SLAP*

   The trick is to give yourself a mental slap.  Take those negative thoughts and nip them in the bud before the weeds overthrow the yard of your mind. Don’t be the kind of person that thinks this way.

   It’s your job, not your friends or your parents, to believe that you’re the best. You must believe, deep in your soul, that whatever you have, whatever you’re selling is absolutely the air that everyone should be breathing. If you don’t believe you’re the best, and don’t do everything in your power to really be the best, then no one else will believe – so believe!

I’ve played a dangerous game my friends. I got a Masters degree, albeit educational and interesting, in a field that I didn’t want to spend my life working in – but I pushed on. I talked to everyone and their dog about my dreams, and encountered some pessimistic backlash – but I pushed on.

I even spent this summer studying to retake the admission test “just in case,” while having a promising spot on the waiting list, when I could have taken a vacation and hoped I’d make it off the list – but I pushed on.

Never stop trying, not while you’re still alive and capable. As I like to say… “If you have a dream, whether you have to go through those doors sideways, backwards, or jump in from the roof… don’t give up.”

Alex Shalman is a Personal Development writer and speaker, and most recently an NYU Dental student. If you enjoyed this article please tweet it and vote for it on StumbleUpon. I’d appreciate it.

It’s a given that there are healthcare professionals out there with substance abuse problems. But, as we prepare to enter practice, many of us find it difficult to imagine that we’ll be working with affected individuals, or that we could become affected ourselves. Few professional programs ask students to consider what they would do if they suspected or knew that someone in their workplace was impaired. And, still fewer programs formally acquaint students with recovery resources.

No one really knows how widespread substance abuse is within the healthcare professions. With their livelihoods at stake, few people are going to admit to having a problem. Additionally, most health professionals are smart people who are relatively good at hiding their problems. A lecture given by Brian Fingerson, the president of the Kentucky Professionals Recovery Network, indicated that the figure is 12-16% for “pharmacists and some other healthcare professionals”¹.  Given that one out of every nine Americans over the age of twelve was found to have a problem with substance use or dependence in the 2007 National Survey on Drug Use and Health², the suggested range seems quite reasonable.

As healthcare professionals, we may be more likely to develop substance abuse problems than members of the general population due to high work-related stress, increased access to controlled substances, and our knowledge of drug effects. Those of us who do become addicted may be shielded from discovery by the trust of our patients and coworkers. Plus, we may work very hard to avoid discovery, fearing harsh professional, social, financial, and legal consequences.

By this point, it should be clear that you should expect to encounter impaired healthcare professionals during the course of your career. What is less clear is what role you will play in the situation and how you will feel about it.  When you aren’t sure about what is going on, it can be hard to take action. You may only suspect that a coworker is coming to work intoxicated. Maybe there are narcotics missing on a regular basis but you aren’t sure who is taking them. It is reasonable to have fears about accusing an innocent person. You may worry about losing rapport with your coworkers if your suspicions aren’t proven true. There are many other reasons that you may feel compelled not to act. Perhaps you are worried about feeling guilty about turning in a close friend, or taking a provider away from a family. Or, maybe you feel like it’s not your place to take action since others are already aware of the situation.

The bottom line is that an impaired colleague is a danger to both themselves and their patients and needs intervention. If you suspect that a coworker is impaired, you need to connect with someone who can investigate and assess the situation or refer you to resources to do so. This could be your employer, the state board, or a representative from a Professional Recovery Network (PRN) or Caduceus group. If you know that a coworker is impaired, they need to be relieved from duty immediately. But, in order to fully do the right thing, you should also make an effort to connect them the unique support, advocacy, treatment, and recovery resources available through a PRN program. It is may be best to shield yourself by giving the PRN their information and letting the program initiate contact. It is not necessary for the affected individual to know who made the referral.

With the advocacy and monitoring offered by PRN programs, many healthcare professionals are able to regain licensure and return to work while in recovery. These individuals are typically required to sign a contract with the PRN organization and are subject to practice restrictions such as not being allowed to work unsupervised or not being able to work more than a specified number of hours per week.³

While employers or partners must know whether or not a healthcare professional is in a PRN program, coworkers may not.³ They often choose not to identify themselves because they don’t want to deal with the stigma, have their work overly scrutinized, or be judged on a daily basis. If you do discover that a coworker is in a PRN program, I encourage you to be supportive. While there is potential for relapse, PRN programs are used because they work. One pharmacy PRN program coordinator at The Utah Conference on Alcoholism and Other Drug Abuses shared that the drug abuse rates in his state’s PRN program were lower than that of the general pharmacists population. So, with proper monitoring, it may be less risky to hire an individual in a PRN than it would be to hire the average applicant.

For students or professionals interested in learning more about substance abuse in the health professions, I recommend attending the University of Utah’s School on Alcoholism and Other Drug Dependencies, now in it’s 58^th year. This annual week-long event is designed to help students and professionals understand and cope with substance abuse and incorporates a mix of speakers, discussions, social events, and open meetings for recovering addicts and families. Exposure to and interaction with recovering health professionals is one of the most valuable aspects of the program. For students and professionals in recovery the school also offers a unique opportunity to connect with a supportive network of people who share similar experiences. The pharmacy section, which I attended this June, is the largest section of the group, with around 300 participants, mostly students. Other healthcare sections included physicians, dentistry, and nursing. Both college and continuing education credit and are available at a reasonable cost. For more information, please visit http://uuhsc.utah.edu/uas/

1) Fingerson, Brian. “Chemical Dependency Among Healthcare Professionals.” Lecture. The University of Utah’s School on Alcoholism and Other Drug Dependencies. Salt Lake City, Utah. 23 June 2009.

2) http://www.drugabusestatistics.samhsa.gov/NSDUH/2k7NSDUH/2k7results.cfm#Ch7

3) Quigley, Michael. “Issues in Relapse Prevention and Monitoring.” Lecture. The University of Utah’s School on Alcoholism and Other Drug Dependencies. Salt Lake City, Utah. 23 June 2009.

by Paul Goleb

You have all certainly heard the expression “good things come to those who wait.”  Since our first days of pre-school, the virtue of patience has been constantly reinforced as a valuable trait.  For years we have stood in lines and waited for our turns.

In the fast paced life of a physician, in which potential decisions must sometimes be made in a matter of seconds, patience is sometimes an undervalued trait. In the realm of medicine, “waiting” almost seems to be a dirty word for both patients and physicians alike.

Nowhere is this more evident than in the life of a medical school applicant, a life in which waiting for days, weeks, and even months at a time is commonplace.  If you have ever applied to medical school, I am confident that you have spent more than your fair share of time waiting.

As pre-med students, we are notorious for our constant worrying and over-analysis of the most minute details and the long gaps in correspondence with medical schools do little to ease these anxieties. Months between application submissions, interview invitations, and potential acceptances often seem like cruel punishments to over-anxious pre-meds like ourselves who interpret no news as bad news.

I, like many other medical school applicants this year, was placed on a wait-list over the course of this past admissions cycle. I, like almost every other applicant placed onto a waitlist reacted to the news with a sense of disappointment, disenchantment, and (at best) a slight sense of hope. I, unlike many others was eventually admitted to the medical school of my dreams in a matter of days following my placement on a waitlist (twice to be exact).

Ironically enough, the only day out of the past eight months in which I did not fervently check my e-mail or anxiously pace to my mailbox since the submission of my primary application was the day I was accepted to medical school. The one day that I stopped trying to find what I was looking for, what I was looking for somehow found me.

The morning before I was accepted off a waitlist, I found myself coming to the realization that I would have to re-start the arduous work associated with the application cycle: re-taking the MCAT and re-submitting my primary application only days after I had graduated from college. The prospect of studying, writing, applying, and traveling for interviews again had been wearing on me over the course of the past several months.

As I usually do, I went to my neighborhood park to play a game of pick-up basketball to clear my head. About twenty minutes later, to my surprise, I saw my mom frantically walk by the court in a pace that suggested she had very good or very bad news (or had to find a bathroom ASAP). My surprise grew when my mom ran onto the court, stopping a game of basketball in its tracks to give me a hug and tell me I had just been accepted to medical school. I stopped, the game stopped, my mom grabbed me and tried her best to hug me (or squeeze the life out of me) and slowly, I realized what I had waited for since this past August had finally arrived, in May, multiple weeks after I had graduated college with no sure-fire post-graduate plans and plenty of anxiety.

The remainder of the day became a blur of congratulatory phone calls, text messages, and visits from neighbors. This euphoria created such a sense of stunned disbelief that I almost forgot to return my paperwork indicating I would actually accept my admission into the class of 2013 (a minor detail). Waking up with plans to begin studying for the MCAT again and eventually going to bed a soon-to-be medical school student made for quite the exciting day. I was honestly astounded by the good news I had almost given up hoping for.

It took nine months to the day for the secondary application I submitted in August to lead to an acceptance in May. The application, interview, and waitlist process certainly made the year seem like an eternity. Also, I like to think I took the longest possible path to my eventual acceptance. My application was put on hold after my initial secondary application submission, I received a post interview hold, and to top that off, I was placed on a waiting list following this marathon year of waiting and hoping.

It is tough to say if I honestly did believe I would get off my waitlist. Based off of anecdotal evidence from peers, friends, and professors, I thought my chances to get accepted off of a waitlist were one in a million (at best). Waitlist statistics are typically not released by medical schools, which are the sole institutions that know exactly how many students (if any) were admitted via waitlist. I have been told that not even AMCAS, the veritable treasure trove of pre-med statistics and semi-pertinent percentages possesses this information.

The entire situation repeated itself two weeks later in a much less dramatic fashion when I eventually received the same good news at the second school where I was wait-listed. I could not believe my good fortune. While I do not know the exact probability of these two independent events occurring, it seems to be a very rare occurrence. The utter surprise I felt in getting accepted off of my initial waitlist became a sense of sheer disbelief when the process repeated itself.

By no means do I intend for this article to sound like a personal pat on the back, congratulating myself on my two, equally miraculous waitlist acceptances. I believe readers can search various SDN acceptance threads for that type of writing.  I find myself writing this for a much different purpose. In writing this, I hope to give a sense of hope to those currently on waitlists or those who may soon find themselves on a waitlist at some point in the application cycle. Additionally, August is an interesting point for applicants in the medical school process. Past year’s applicants who have been wait-listed find themselves still hoping (with good reason) for a last minute acceptance into a medical school class beginning this year while a number of current year applicants are just beginning what could potentially be a very long application cycle. It is a busy, stressful time for applicants both former and current.

Reflecting on the process, our teachers and parents may have been right about this whole waiting thing, as much as it hurts me to admit. I consider myself a habitually impatient and multitasking person, but patience is the key to surviving the medical school application process. In my experience, I have found it is true what they say; good things come to those who wait, or in my case, to those who are wait-listed.

Dr. Talya Miron-Shatz

Talya Miron-Shatz, PhD, is a decision scientist, studying the way people interpret medical information. She teaches consumer behavior at Wharton and is a keen public speaker, advocating the importance of understanding the psychological aspects of medical decision making.

She recently sat down to speak with SDN about how consumers and health care providers make medical decisions.

What is decision science, and how does it apply to health care decisions that consumers make?

Imagine you are designing a sticker promoting flossing. Should you say, “Flossing helps you prevent gum disease,” or should you emphasize the loss of protection that results from neglecting to floss? It turns out that people are more motivated to act when something they have is about to be taken away from them. So, when you’re in the bathroom at night, being aware of the potential risks to your gums might prompt you to dedicate a few extra minutes to the fine art of flossing. This, in a nutshell, is what decision science is about.

Decision scientists make sense of people’s judgment and decisions, even when these seem random, erroneous or irrational. Decision science was developed by Amos Tversky and Daniel Kahneman, Nobel Laureate of Economics, 2002, with whom I had the honor of working closely at Princeton University. This science draws on psychology and, rather than concluding that people are unpredictable, or just plain dumb, helps explain their behavior.

A really cool thing that decision science does is that it incorporates emotions into the equations. After all, the facts don’t change in the flossing example – what matters is how the information is presented. We show that the way alternatives are presented often dictates, or at least influences, how people feel and the choices they make.

Does this apply to every medical setting?

I always tell my students that there is no such thing as a neutral way of presenting information. The beauty of decision science is that the principles apply across the board, even where you least suspect it.

Consider an expectant mother who arrives at a prenatal clinic. The genetic counselor presents her with a list of the available screening tests for the fetus. Some tests are standard at the clinic, while others need to be specifically opted into. This varies across clinics. When a woman receives a list of, say, seven standard tests and five optional ones, adding the optional tests seems unnecessary, perhaps even overly anxious.

Now consider an expectant mother who arrives at a clinic where all 12 tests are standard, and the counselor tells her she can opt out of five of them. Opting out feels different from opting in. The woman may feel that by neglecting to take some of the tests, she is jeopardizing her unborn child. Thus, she will keep all 12 tests.

Most people tend to stick with the standard option or the default, which means that medical students need to be mindful of what they set as the standard.

What trends do you see in health care decisions by consumers that will impact current health professional students?

The emerging trend is patient autonomy – delegation of choice and decision to patients.  The premise is that, given sufficient information, patients will make the health choices that are best for them. This shift poses a huge challenge to doctors, who are trained to treat patients but not to explain treatment options in a way that patients will easily comprehend. Medical students and residents seldom receive training on these types of communication skills.

Nowadays patients have access to online medical information. Does this make a provider’s work any easier?

You would think that greater availability of information should relieve some of the burden off of doctors’ shoulders, but such is not always the case. Medical information is often presented in a way that is confusing and hard to grasp. Probabilities, which are key in risk evaluation, are a particularly tricky concept.

I showed people text from reputable websites that supposedly cater to a wide audience. It is distressing that fifty percent of the participants misinterpreted what lifetime risk probability means – and this concept is broadly applied.

I also inquired about a test for the BRCA 1 or BRCA 2 gene mutations, associated with increased risk of breast cancer. Half the participants knew that the test could not tell them with certainty whether they will develop breast cancer. Yet about a third of the participants expected this kind of certainty from the test. Just imagine how misguided they were.

Doctors cannot assume that their patients are in the know just because there’s more information out there.

Don’t issues of misunderstanding apply only to certain patients?

People with low numeric skills and low health literacy are more prone to misunderstandings. However, doctors are not so good at detecting patients with low health literacy. Moreover, patients are good at hiding their bafflement, because it is embarrassing to tell your doctor you do not know what he or she is talking about.

Recently I heard about a man who had a prostatectomy. Before the surgery the doctor said, “You are going to be impotent,” to which the man replied, “It’s ok. I already have children.” The doctor had assumed that “impotent” is a common term.

The same thing happens when a doctor explains how to titrate medication. The patient nods, then returns weeks later having never increased the dosage.

Are doctors and medical students themselves immune to miscomprehensions and judgment biases?

Not quite.  In one of the most inventive studies, conducted by Gerd Gigerenzer and his colleagues, a healthy heterosexual white male went to a few dozen doctors’ appointments with a positive HIV test result. Almost all of the doctors told him he had HIV. Only a minority remembered that the test is not 100% diagnostic, that there is a 1:10,000 chance of a false positive result. Various ways of presenting probabilities and risk information help medical students and doctors understand those concepts.

How did you become involved in medical decision making?

I was a grad student in psychology, studying decision science, when the mission of making medical information comprehensible snuck up on me.  One of my professors asked if I might be interested in teaching a decision making course to Masters’ students of genetic counseling. I accepted, then realized I had no idea what knowledge would most benefit my future students.  So I sat in on genetic consultations.

I will never forget the first couple I encountered. The father was albino, and both parents were hearing impaired, so they were accompanied by an interpreter. They also brought their two year old, for want of a babysitter. The wife was pregnant, and the couple wanted to know what to expect from the newborn – what were the chances that he or she would also lack pigmentation and/or be deaf. They just wanted to know. They were also curious as to whose “fault” the baby’s condition would be, mom or dad. It mattered to the mother-in-law, who constantly blamed the husband for the first child’s lack of hearing.

The genetic counselor was just the kind of health expert you would want to meet – highly professional, well-prepared, and very caring. She spread out the charts of paternal and maternal heritage, then methodically explained how genetics worked, starting with chromosomes and genes.

None of this was redundant for me despite my education. I did not major in science and had not taken a biology class since, I believe, the 9th or 10th grade – it had been quite a while. Remembering which was the bigger unit, chromosome or gene, was not easy. I had to dig in my memory to figure out that there were 23 pairs of chromosomes and, well, lots of genes.

Meanwhile, the counselor was explaining this to the translator, who would explain it all to the couple. The interpreter seemed no less bewildered than I was. Information just kept coming in, which had to be conveyed to the couple through sign language. I could not help but wonder what they would say if we asked them to translate back what they’ve just been told.

The couple was physically there, but they were not really listening, and it wasn’t because they required hearing aids. They had gotten lost fairly early. You could see it in their faces. Chromosomes, genes, dominant, recessive – lots of terms, but not a lot of meaning.

Of course, the confusion had nothing to do with being hearing-impaired or albino. It had everything to do with being a patient. For all my fancy graduate training, I don’t think I would have fared any better than they did. The added layer of concern for the baby certainly did not make things easier.

Knowledge doesn’t just pour out of the medical system and into the patients’ minds, I realized. It has to be understood, processed, and dealt with emotionally. It was the counselor’s job to explain and the patient’s job to get it. Leaving the medical center that day, I still thought I was just going to teach decision making to genetic counselors. I did not realize that making medical information comprehensible was going to take over my interests to become my vocation. I did not realize it just then, but that was when my mission began.

For more information on medical decision making, please visit “Baffled by Numbers”, Dr. Miron-Shatz’s blog published on the Psychology Today website:

http://www.psychologytoday.com/blog/baffled-numbers

Ahh, simple childhood games. Music playing. Walking around a circle of chairs. I’m eyeing the one closest to me.

*the music stops*
I scramble for a chair.

“I’m sorry, Joe. You can’t sit in a red chair. Those are for people with Outies. Your belly button is an Innie. You need to find a blue chair.”
“But the kindergarteners took most of the blue chairs for their game…”
“I’m sorry. Just see if you can find a left over one.”
I cry.

While this never actually happened, it is a recurring nightmare I have (and may explain my deep seated phobia of blue chairs). This game represents how health professional school admissions, particularly medical school admissions, work.

For medical schools, there are a good number of chairs that are spoken for before you’ve even submitted your AMCAS. How many depends on the types of alternate acceptance programs the school offers, but these programs contribute to the ultimate class size and subsequently are fewer seats available during the AMCAS application cycle.

As an informed applicant, what you can do is realize that you’re only going to be competing for the blue chair.

What alternate acceptance pathways are there?

BS or BA/MD Programs
These programs offer medical school acceptance to exceptional students either directly out of high school or early in their undergraduate careers. After completing their undergraduate and program requirements in anywhere from two to four years, students in these programs join the entering medical school class at the institution affiliated with the program.

Early Acceptance Programs
Similar to the above, some schools will offer early acceptances to students at linked universities or within their home state. This generally occurs sometime following the junior year. These students also matriculate with the entering class.

Special Masters Programs
Many medical schools offer Special Masters Programs. These programs allow students to take classes with M1 students in order to show they can excel at medical school coursework. While the degree of linkage between SMPs and Medical Schools varies from program to program (few, if any, offer a direct acceptance), many will at least interview every SMP student and SMP students will traditionally be accepted to their home institution with a higher rate than the general applicant pool. SMP students do apply through AMCAS, but they are deceptively competitive for the school in question.

Where else do the spots go?

Deferrals
Every year, there are students that are unable to matriculate the year they’ve applied. These students defer and subsequently join the next year’s class. This is a small number of students and this happens each year, so it may be negligible, but these students are already holding acceptances in the application year that the entering class is applying so they may be considered as drawing away from the total number of available seats.

The Innie/Outie Factor
State residency is a large issue at state funded schools. Unless the school is private and state residency is not a factor, there will be separate pools for in state and out of state students. This is a division of seats you’ll need to consider.

A Note on Gender
A false impression exists that schools hold a specific number of seats for males and a specific number of seats for females. While researching this article I was informed by an admissions committee member that the approximate 50/50 ratio of male to female students is not a function of intentional admissions selection, but rather a function of the proportion of male to female applicants.

Applying the Math

Those were some nice observations, but what does it all mean?

Let’s take a hypothetical state medical school trying to fill a class size of 200:

• This school had 5 deferrals from the previous year.
• It accepts 20 students per year from an Early Acceptance program from its Undergrad.
• It accepts 20 out of 30 students per year from its SMP program.
• The In State Acceptance Rate is 70%
• No BS/MD program.

Now let’s pretend you’re an In State applicant applying to the above school. How many seats are you actually applying for?

200 seats
x.7 In State student acceptance rate
140 Seats for In State Students

That doesn’t seem too bad, but wait, the linkage programs and SMP programs are predominantly for in-state students. Deferrals are able to attain IS residency in some states.

140 Seats
-5 Deferrals
-20 Early Acceptances
-20 SMP Acceptances
95

While there is a 70% acceptance rate for in state students, the applicant is only applying for 47.5% of the seats in the class. Out of State applicants are essentially unaffected by these programs.

Below is a table of the make up of that class mentioned above:

Where can I find this information?
One source would be the school’s website. You can search for info regarding any alternate admissions programs or Special Masters Programs. Additionally, the AAMC publishes the Medical School Admission Requirements (MSAR) annually. This gives the best breakdown of admissions stats and class profiles. Check both of these and combine the results to give you the best understanding of what programs are operating and their scope.

What can I do about it?
When looking at a medical school, or any health professional school, it helps to know your odds. A lot of money can be wasted for spots that were filled years ago. A little research can help. Know how many spots a school has open for you. This will tell you if that long-shot application is worth the money.

Prospective professional school applicants are often advised to avoid taking prerequisite classes at community college. Conventional belief among many pre-health students is that prerequisite classes taken at community colleges will be disparaged by admissions committees and could lead to the rejection of the applicant.

Such fears are expressed routinely in threads on the forums at Student Doctor Network; e.g., “Will taking a year of community college hurt my chances?” in the High School Forum and “Retaking at a CC after graduation/Chances?” in the What Are My Chances Forum. But are these fears and assumptions founded on actual admissions practices? Unfortunately, there is no clear consensus on this issue.

One school of thought suggests that students avoid doing prerequisites at community college because admissions committees consider a strong academic background essential to success. Such admissions criteria are supported by the findings of a 2007 study of medical students by Kleshinki, et al.[1]

Using a statistical model to examine the predictive ability of preadmission variables, including college selectivity as determined by the Peterson’s Four Year College selectivity index, on USMLE Step 1 and Step 2 performance, the researchers found that students from the most selective undergraduate institutions scored higher on Step 1 and Step 2 than students from minimally selective-nonselective institutions. College selectivity remained a predictor of USMLE scores even when undergraduate GPA and MCAT scores were included in the model.

Therefore, the stronger the academic institution an applicant attends, the better, says Judy Colwell, a medical school admissions consultant with more than 18 years experience as a premedical advisor and former Assistant Director of Medical Admissions at Stanford University.[2] “Particularly when looking at science prerequisite classes, medical schools want to make sure that an applicant can perform at a rigorous level. Rigor of the courses is very important and reputation of the school is important too.”

Generally, community colleges classes are viewed as being less rigorous than those taken at a four-year institution. According to Colwell, if an admissions committee were hypothetically debating between two nearly identical applicants, one of whom had done prerequisites at a community college and the other at a four-year university, the acceptance would go to the student who fulfilled prerequisites at the university.

While it is true that some community colleges are known by the medical schools in their local region to be strong in particular science disciplines, this reputation may not be known in other parts of the country. “What happens when the applicant who took his or her general science courses at a well-known local community college applies to schools out of state that are not familiar with the program? If they have not taken upper division courses at a university it may well be an issue,” Colwell says. She advises that students at community college focus on general education requirements, fulfill prerequisites in English and mathematics, and plan to take their science courses at a four-year institution.

Of course, this is not always possible given the array of basic and school-specific prerequisites and the limited time of students who need to graduate in four years. For students whose schedules make it imperative that they do prerequisites at the community college, certain cautions are in order.

The Pre-Health Advising Office at Florida State University College of Medicine advises community college students taking their basic science prerequisites at their community college to finish two semester course sequences at the same institution.[3] For example, students should not take first semester physics at a community college and second semester physics at a university after transferring.

The University of Kansas Premedical Advising Service advises community college premedical students to take actual medical school prerequisite courses, like general chemistry, and not biological sciences courses for nursing and allied health majors.[4]

Perhaps the biggest caution of all is that once students transfer to a four-year university, they should take upper division science classes that are not offered at the community college level. This recommendation is seconded by Premedicine Advising at the University of Washington. They advise students transferring from community colleges to take some advanced science coursework at a four-year school to help medical schools evaluate an applicant’s performance in relation to that of other applicants. Their website states: “the level of the coursework at community colleges is certainly comparable… [to] the equivalent courses at the UW. However, grades tend to run higher at community colleges than in comparable courses at the UW.”[5]

This brings us to a second school of thought, as explained by Dr. Amerish Bera, Clinical Professor of Medicine and former Associate Dean of Admissions at the UC Davis School of Medicine. Since medical schools are well aware that differences in grading practices have an effect on the GPAs of applicants, “in the end the MCAT becomes the great equalizer. Admissions committees will look for discrepancies between GPA and MCAT scores. For example, if an applicant has a 4.0 science GPA and 7s on the biological and physical science sections of the MCAT, it suggests that the coursework was not as rigorous as that taken by an applicant from another school with a 4.0 science GPA and 12s on the same MCAT sections.”

Bera advises that students take prerequisite coursework at the institution where they will feel most supported, can build their confidence, and have the best opportunity to learn the material. Whether this is a community college or a four-year institution matters less, in his opinion, than performing well in the classes and on the MCAT. Medical schools receive vast numbers of applications and develop thresholds to screen applications before sending out secondaries. “The initial screen is usually based on MCAT scores and GPA, which is calculated by AMCAS and includes community college classes. It is better to have an A in a class from a community college than a C from a class at a university,” he says. “If an applicant makes it past the initial screen, it is doubtful that committee members will scrutinize every course, given the sheer volume of information there is to review.” The composition of the student body at the UC Davis School of Medicine reflects these screening practices. According to Bera, an internal review of UC Davis’ admissions data in 2005-06 revealed that approximately 20% of current UC Davis medical students had completed one year or more of community college coursework at the time of matriculation.

Admissions practices can have more variation between schools once applicants reach the interview stage. Bera says some schools may assign extra points to applicants based on where their diploma was received or could re-calculate GPAs to put more weight on university classes. In the case of the latter, he agrees that there are benefits in community college students taking upper division science courses once they transfer to a university. “But keep in mind there is a growing recognition that with high tuition costs and cuts to direct university admissions due to state budget shortfalls, more and more students will need to get started at community colleges,” Bera said. “At the end of the day it is most important to have a good GPA that aligns with strong MCAT scores.”

Non-traditional premedical students, many of whom are working full-time in other careers, often ask if the same advice that is given to traditional students about prerequisite courses and MCAT scores applies to them as well. Bera would consider the low tuition and convenient schedule and recommend the nontraditional student choose the community college if the added comfort level will contribute to stronger academic performance in prerequisite classes and on the MCAT. Colwell, whose admissions consulting practice is focused on advising non-traditional applicants, has counseled many students who are considering taking medical school prerequisite classes at community college. The process, Colwell says, is the same for all applicants to both allopathic and osteopathic schools, and she encourages non-traditional students to “jump through as many of the traditional premed hoops as possible.” She advises all premedical students, whether traditional or non-traditional, to take their prerequisites “at the most rigorous four-year institution that time and money will allow,” and to do well on the MCAT in order to have the best chance of admission.

It is clear that among the advising sources noted above there is no clear agreement on the assessment of community college science prerequisites in medical school admissions. Having preparation in the basic sciences that leads to an applicant’s best possible performance on the MCAT is essential to gaining admission to medical school. At this point premedical students have to analyze their own situations and make their own choices. Much as we might wish it otherwise, even the experts are divided in their advice.

[1] Kleshinski, J, Khuder, SA, Shapiro, JI, and Gold, JP. (2007). Impact of preadmission variables on USMLE step 1 and step 2 perforamance. Adv in Health Sci Edu 14: 69-78.

[2] http://www.judycolwell.com/

[3] http://med.fsu.edu/StudentAffairs/advising.asp

[4] http://www.medadvising.ku.edu/prospective.shtml

[5] http://www.washington.edu/students/u…ap/premed.html

Just over a year ago, I stood, heart racing and hands trembling, in front of my mailbox.  Any other Thursday I would have nonchalantly checked my mail as I came home from work, but today was an entirely different story.

A friend had texted me earlier in the day to let me know that decision letters had been delivered by our state school.  I had only been offered two interviews, and the letter which innocently lay in my mailbox represented my highest hope for attending medical school that year.  I paced for a full two minutes in front of my mailbox before I built up the courage to open it.  I probably would have paced longer, but someone came down my hallway, and I felt a bit foolish dancing around in front of the mailboxes.

Four attempts at inserting my key in the lock later, I was holding a too-thin, white, letter-sized envelope in my severely shaking hands.  Suddenly, I desperately needed to know the contents of that letter, and I ripped open the envelope with fervor akin to a starving man diving into a steak dinner.  I never made it past the first line.  The phrase

We regret to inform you…

jumped out of the page.

Panic gripped me, and it seemed that I could barely breathe, but no tears clouded my vision as I stared mindlessly at those dream-shattering words.  I stumbled down the hall to my apartment, where I collapsed in my desk chair.

In an attempt to think of something, anything, else, I opened the browser on my laptop and checked my e-mail.  I immediately noticed that I had received an e-mail from the one other school I had interviewed at, my last chance for the year.  I quickly opened the e-mail, only to discover that I had been waitlisted.

Utterly shocked, I crossed the room and lay down on my bed with one thought on my mind.  What in the world am I going to do now?

As I reflect on my reaction to the news I received that day, I can’t help but see myself as overly dramatic.  But if anyone had accused me of being a drama queen that day or in the weeks that followed, it is likely that they would have received a swift kick in the shin (or at least a scathing glare).

It’s easy to downplay the emotions I felt as I watched my dream disappear when those emotions are set firmly in my past.  Truthfully, up until a few months ago, I was petrified that the exact same thing would happen again this year.  In fact, I must say that I’m proud of myself for having the courage to stick it out, reapply, and dare my fears to make themselves reality again.

So, having been in this position before, I thought it would be beneficial to offer some advice to those who are in the same position now.  Be aware, this advice is heavy on how to handle the emotions that come with being rejected, as opposed to what you can do to improve your application for the next time around (though I do have some ideas where that is concerned as well).

First, allow yourself to freak out a little.  For you, this may mean a very vocal rant to your friends, an embarrassing sob fest, a pavement-pounding run with angry music screaming in your ears, or a trip down to the local pub to take off some of the sting.  Just remember that however you choose to cope with the initial wave of emotion post-rejection, you don’t want to do anything that could damage your chances next cycle.  Therefore, I would not recommend jumping on SDN to bash the schools that rejected you or drowning your sorrows to the point that you end up with a public intoxication.

Second, only talk about it if you want to.  Perhaps the worst part of being rejected last year was when people would ask me what I was doing after graduation.  I hated explaining to people who weren’t familiar with the concept of a waitlist that I was currently on one.  I hated admitting that I hadn’t gotten in.  Each time someone asked it felt like my self-esteem dipped that much lower.  I became a master at avoiding the questions and changing the subject.  It wasn’t until late last summer that I realized that I wasn’t obligated to answer their questions, and a simple “I didn’t get in, but I’d prefer not to talk about it” would have sufficed.  Whether or not you get in is your business, and whether or not you want to talk about it is your decision to make.

Third, don’t stay in the same town unless it is beneficial to you.  I cannot stress this enough.  After being rejected last year, I decided to stay at my undergraduate institution and work on raising my undergraduate GPA.  While this was academically the right choice for me, it was extremely hard emotionally.  Chances are, many of your friends graduated when you did, so not only will you have lost much of your social support system, you will more than likely feel that you are stuck in an enormous rut.  If you have the opportunity, change locations.  If you are reapplying, look for a research or clinical position in a different city, do a Special Masters Program at a different school (many schools guarantee at least an interview for medical school if you complete their post-baccalaureate program), or go on an extended medical trip (if you can afford it).  Do something different that you can add to your application next year and avoid going crazy at the same time.

Next, take this year as an opportunity to grow and mature.  Many of us apply when we are just 21 or 22 years old, with a decidedly undergraduate mindset.  While we may be ready to move on, we may not be mature enough to handle the pressures that come with medical school at this point in our lives.  Admissions Committees may see this and it may be part of the reason an acceptance wasn’t in the cards this year.  When I was interviewing this year, I realized how young and uninformed my answers had sounded last year, and I realized just how much I had matured in the past few months.  Maybe this is a chance to do the same.

Re-evaluate your ultimate goals and make sure this is what you really want to do with your life.  This may be the most important advice I can give.  If you can think of concrete reasons why you want to be a doctor, call the places you applied and ask them why you weren’t admitted.  Most schools are willing to tell you where you were lacking on your application.  Then, act on the information they give you.  Whether this means taking more classes, putting in more volunteer hours, completing a masters, working on your writing skills (darn personal statements), or learning how to present yourself more professionally at an interview, if you KNOW that you want to be a doctor, do whatever it takes to improve your application and get in next year.  If you don’t know why you want it, there’s a good chance you don’t want it enough.

Finally, realize that you are not alone and that this setback is not indicative of how successful you can later become.  Over half the people who apply to medical school each year are not accepted, so even though it feels like you are the only one, recognize that you are actually in the majority.  There are many people in the same situation, and you can believe that while some will decide against reapplying there are others who are going to do everything they can to alter their outcome next year.

Do not expect that just because you are a re-applicant, schools will feel sorry for you and let you in.  Do not be passive about your future.  If medical school is what you want, do not let a single blow to your self-esteem stop you from fulfilling your dreams.

This year, I stood in front of another set of mailboxes.  The same feelings gripped me when I held another white envelope in my hands.  Even though I had been offered seven interviews, I was still terrified that I would not be accepted anywhere.  I carefully opened the envelope and pulled out several sheets of paper.  This time I didn’t make it past the first word, congratulations, before my reaction tore through me and I found myself jumping up and down in my hallway.  Three acceptances later, I still have a hard time believing that this is real, that I’m going to be a doctor.  All I can think is,

What a difference a year makes.

For St. Patrick’s Day 2009, I’m shaving my head.  And so are many of my friends and classmates.

And no, vast quantities of Guinness have nothing to do with it.

We are participating in a St. Baldrick’s Foundation event to raise funds for childhood cancer research.  Participants will either shave their heads or donate their hair to make wigs for a child in need.

Since its inception in 2000, St. Baldrick’s has raised more than $50 million and grown into the world’s largest fundraising event for childhood cancer. Worldwide 160,000 kids are diagnosed with cancer each year and despite tremendous progress, cancer remains the top disease killer of children in the U.S. and Canada.

My medical school class at Tulane University School of Medicine has the goal of beating last year’s event, which raised over $63,000. We’re well on our way, but we need your support.

The Student Doctor Network is currently sponsoring SDN membership for those who donate to the St. Baldrick’s foundation.  To get an SDN subscription, you will need to donate that subscription amount or higher to St. Baldrick’s.  For example, Gold status is $45 for one year or $75 for two years, so if you make a $75 donation to St. Baldrick’s, you will get a two year Gold status membership to SDN.

The link to donate is here (click on photo on the page): http://www.stbaldricks.org/participants/shavee_info.php?ParticipantKey=2009-64188

In order to obtain your SDN membership, please email the receipt you receive from St. Baldrick’s to Anna@studentdoctor.net.  You must request an email receipt at the time of donation.

While battling cancer, children may lose not only their hair, but years of their childhood, and sometimes their lives. In comparison to their struggle, cutting my hair is a small sacrifice, and the money raised will make a difference for children with cancer now and in the future.

Beyond the money raised, my medical school class is banding together for this cause to show solidarity and support for the children and families affected by childhood cancer here in New Orleans and across the country.

So, I am asking you to help me raise as much money and awareness as I can for the foundation to fund as much research as possible!   Please donate now.

Alternative Spring Break Participants

by Bacchus
SDN Moderator

Sunscreen, check.

Flip-flops and toothbrush, check.

Camera, check.

Steel-toed boots, check.

The last item may seem peculiar, but for those of you who are familiar with an Alternative Spring Break (ASB), those boots are a must.

What is an Alternative Spring Break?

Alternative Spring Break trips can take many forms and be completed for numerous causes, but they all stem from one goal: Dedicating as much time as possible helping others.

ASB originated in the 1980’s  as an unconventional vacation from the college semester. By the early 1990’s, the popularity of the “Alternatives” was growing, and was booming by the end of the decade.

Growing curiosity and participation in the new millennium is attributed to the collegiate emphasis on volunteerism and national disasters such as Hurricanes Katrina and Rita. In fact, 36,000 individuals participated in ASB during the spring 2006 semester.

How One Week Can Make a Difference

So you might be asking yourself, “Why should I participate?” I’ll describe my experiences later, but let’s look at this on a large scale.

Most collegiate groups, such as those organized by Habitat for Humanity, follow a strict daily schedule, dedicating between five to seven days from the early morning to late afternoon. So, even though you are only working anywhere from 30 to 60 hours during your spring break, your group is racking up a lot more time on-site and the work completed is remarkable.

In the case of Habitat, a group can erect the frame of a house in a few days and the following week’s group can get it dry-walled. At this pace, the house is finished in relatively little time.

Disaster relief projects also accomplish significant amounts of work because of the volume of volunteers.

My Alternative Spring Break Experiences

I participated in three Alternative Spring Breaks  - my freshman, sophomore, and junior years in college. The experiences were different, but each was rewarding.

The first trip was to Waveland, Mississippi, a small community that suffered tremendous loss after Hurricane Katrina. The town was literally wiped off the map, but Community Collaborations and the Morrell Foundation pledged to help the community.

The following year I participated in a Habitat for Humanity project restoring a home in rural Virginia.

I concluded my ASB experiences with a Habitat project in Sabine Pass, Texas. Sabine Pass was still recovering from Hurricane Rita and I worked to finish a home there.

Of the three amazing experiences, Waveland reconstruction was the most heart-wrenching and life-altering one. A several mile strip of beach had nothing left on it except debris.

iCare Village

The iCare Village, erected and sponsored by the Morrell Foundation, proved pivotal aid work for the area. I stayed in the Village for an entire week, living out of an Army surplus tent from the Korean War. It wasn’t the best accommodations, but it was equivalent to what many residents were living in. Others lived in the infamous FEMA trailers.

The week I spent in Waveland, iCare had roughly 80 to 100 college volunteers. The following week they were expecting more than 300. Our first day, we worked on the iCare Village site preparing for the next week’s volunteers.

Debris from Hurricane Katrina

The following day we cleaned a half-mile stretch of beach. Half a mile doesn’t seem like much, but by the end of the day we had four towering piles of debris, one of which was the remains of a beach bungalow. The work was painstaking, but our spirits stayed high.

The highlight of the week for me was working with Ms. Melanie. She taught us all the importance of a positive attitude. Melanie lost everything she owned, but was the most upbeat person I met the entire week, facing adversity with tenacity and Southern charm.

She was living across the street from her home in what she called the FEMA Palace. Inside, it wasn’t much bigger than a dorm room. Her husband, son, and dog lived with her.

When I arrived on site at what was her home I was speechless. It never fully sunk in that I was standing on top of someone’s life. Her home was destroyed to the foundation with only the fireplace remaining standing.

To this day I am in contact with Melanie. I can still hear her saying, after helping her, “Y’all come back when we have a house here. Thank you so much.”

Luckily for me, I got to visit Melanie on a follow-up trip that summer. I learned on that trip we also helped her sister! It was emotional to know we helped a community that lost it all.

Options for Alternative Spring Breaks

Campfire during an Alternative Spring Break experience

My challenge is for you to volunteer one of your spring breaks through an Alternative Spring Break program. You’ll be helping a deserving community and yourself by opening your eyes to those in need. You’ll also get a chance to meet excellent people.

This isn’t an ordinary volunteer experience. It may even get you the tan you want for the upcoming summer months!

Below are a couple of places for you to get started.

Habitat for Humanity
Habitat doesn’t require a cross country trip nor does it require a large amount of money. For those of you in a major metropolitan area, your city most likely has ongoing Habitat projects or other service group projects to benefit the community. These require less fundraising and planning but allow you to contribute to the community, an activity many people don’t do.
http://www.habitat.org

Community Collaborations International
If fundraising and planning are things you enjoy, the opportunities are endless. Organizations such as Community Collaborations International operate volunteer activities nationally and internationally. International trips include locations such as Costa Rica and China. The amount of planning by the campus organization for trips such as these is immense, but thousands of students each year participate.
http://www.communitycollaborations.org

Morrell Foundation
The Morrell Foundation is dedicated to providing hope and assistance, to people across the world who have been affected by natural disaster, armed conflict or poverty, through a wide variety of programs and volunteer coordination.
http://www.morrellfoundation.org

Break Away
The Break Away website details options for Alternative Spring Break experiences.
http://www.alternativebreaks.org/

If you’re interested in ASB planning, tips, or learning more information about the experiences in this article, contact Bacchus by PM on the Student Doctor Network forums.