By Glenn Laffel, MD, PhD
Senior Vice President, Clinical Affairs
Practice Fusion

Not too long ago, it seemed safe and reasonable to define health information technology (HIT) narrowly as the management of health information and its secure exchange between patients, providers, and insurers.[1]

For many, the definition effectively compartmentalized HIT. It was for someone else, not me.

That began to change when quality initiatives started forcing physicians to deal with performance data and patients began showing up with reprints of journal articles they hadn’t read themselves.

But nothing could have prepared physicians to handle the flood of HIT that inundates them today, a flood that threatens to sweep away established codes of professional conduct and disrupt the very processes by which care is rendered and doctors communicate with patients.

Consider these examples:

1) Dr. Jain, a medical intern[2] receives a friend request on Facebook from Erica Baxter. As a medical student, Jain helped deliver Baxter’s baby. Is Baxter simply a grateful patient interested in sharing news about her child, or does she have other motives? Jain clicks “confirm,” granting Baxter access to his network of friends, his personal photographs and blog, and the scrawls of others on his wall.

2) Dr. Margolis, a middle-aged pulmonologist, receives 120 emails per day. The assortment reflects her busy life. There’s one from her child who needs a lift at 6:30. Her dentist has an opening for her prophylaxis, and her secretary just added a patient to her afternoon schedule.

And then there are emails from her patients, some of which require immediate attention.

Problem is, Dr. Margolis can’t read all her emails. She has a thousand unread messages in her inbox. She worries that some contain time-sensitive information from patients.

3) Dr. Tapscott, nearing the end of his career in family practice, is convinced by office personnel to adopt an electronic health record (EHR).

But the implementation goes poorly. He can’t get the hang of it and believes it puts a barrier between himself and his patients. Five months and $20,000 later, he ditches the system.

Physicians have faced emerging ethical challenges before. Their struggle to develop professional identities is as old as the profession itself. And this isn’t the first time they’ve have had to incorporate new innovations, but the HIT Deluge multiplies these challenges several fold, and creates myriad new ones, many of which remain vexing even to deep thinkers in the field.

The Impact of EHRs on Medical Education

EHRs are a prime example of this. They have begun an inevitable march into the lives of all physicians, stimulated by the American Recovery and Reinvestment Act, which allocated $21 billion to encourage “meaningful use” of such systems[3].

The Fed’s largesse is based on the premise that EHRs will improve quality and reduce the costs of care, but the move will impact the health care system in other ways as well. One such area is medical education.

What kind of impact can we expect? In some ways, EHRs appear to enhance medical education, but in others, the impact appears to be negative.

Benefits
Two studies suggest that EHRs improve documentation[4] by medical students. In the first, Morrow and Dobbie found that first-year students who used an EHR to document a history recorded more features of pain [5]than those using paper charts.

In another survey of third-year students, Rouf and Chumley showed that 72% reported asking more history questions when prompted by an EHR.

These authors also assert that EHRs make it easier for faculty to give feedback to students[6], track the procedures they perform and store records of interesting cases for future use.

Beyond this, EHR speeds access to the medical literature which should facilitate learning and encourage students to rely on medical evidence.

Risks
EHRs have some negative impact as well, particularly relating to the learning environment and patient-physician communication.

EHRs can disrupt the learning environment by creating shortcuts that threaten the time-honored process by which trainees synthesize patient’s symptoms, signs, and lab results into a coherent story and present them to senior clinicians for feedback and discussion.

One example of this is the process by which trainees copy and paste chart notes and other information created by others, and send them to supervisors for feedback. This discourages critical thinking by the trainee[7].

The potential negative impact of EHRs on physician-patient communication is particularly acute for medical students who are just finding their voices as professionals. Inserting a terminal into the middle of a student’s session with a patient adds complexity to the interaction, might reduce eye contact and stilt the conversation, and prevent her from seeing how her words and body language affect her patients.

Tweaking Medical Education to Leverage EHR Benefits

As these issues show, the quality-improving, cost-reducing benefits of EHRs can only be realized by aligning multiple systems and user-based factors. Educators can begin the alignment in three ways:

Begin EHR Education Early
The process should begin in Year 1. Non-science oriented courses like “Introduction to the Patient,” present ideal opportunities to introduce the medium.

If students master EHR skills before their clinical rotations, they can focus the latter time on traditional learning exercises, such as clinical reasoning, diagnosis and so on.

What to Teach
Students should be taught how to use basic EHR functions like order entry, lab look-up, messaging and charting. This exposure should occur away from patients so students can focus on the EHR itself.

They should also be exposed to the nuances of physician–patient communication in the presence of an EHR. Specific communication techniques include:

-        adjusting the spacing between patient, physician and computer so the patient can see what the physician is doing on the computer,

-        encouraging the physician to walk-through data on the screen with patients,

-        spending no more than 30 seconds at a time typing into the computer,

-        making eye contact with the patient; assessing the patient’s emotional status and understanding of the information provided

Don’t Forget Faculty
Most medical school faculty have received no EHR training, yet until they become facile, they can’t be good role models for students. This topic is beyond the scope of this article.

Social Media: Disruptive Force in Medicine

In medicine, social media including Facebook, Twitter, YouTube, blogs and virtual physician communities has grown explosively.

Enterprising providers have deployed sophisticated social media strategies to extend their brand around the world. The Mayo Clinic, for example, maintains several blogs[8], a Facebook fan page[9] (which has 8,800 fans), a library of YouTube videos and a Twitter stream[10] (7,120 followers)[11].

Many physicians also leverage social media to help patients access support networks, a heretofore difficult undertaking for homebound or geographically isolated patients, or those with rare diseases.[12]

But social media also creates challenges for physicians.

In some ways, the challenges are most acute for the youngest physicians, who grew up with Facebook. Unlike their counterparts, they are familiar with social media, but some have become ensnared by it.

Thousands of young physicians have created personal social histories and exposed them on Facebook. Their challenge is to manage this archive while forging identities as professionals.

A study by Thompson and colleagues the University of Florida sheds light on the challenge. They found that of the 44% of students at the UF Medical School who maintained Facebook profiles, only 37% made their entries private. More than half shared information regarding their sexual orientation, while 58% shared their relationship status and half shared political opinions.

A closer inspection of the profiles of 10 randomly-selected medical students revealed that 7 included photos showing them drinking alcohol. Five of these implied excessive drinking. Three students had joined groups that were flagrantly sexist (“Physicians looking for trophy wives in training”) or racially charged (“I should have gone to a blacker college”).[13]

The boundary-blurring effects of social media extend in every direction since medical students, nurses, housestaff, fellows and faculty are linked[14], and the chain is only as strong as its weakest link.

What has been done to mitigate risks associated with social media?

Many have issued warnings. “Caution is recommended,” wrote Jules Dienstag in an email to Harvard medical students. The Dean for Medical Education explained that when “using social networking sites such as Facebook…items that represent unprofessional behavior that are posted by you reflect poorly on you and the medical profession. Such items may become public and could subject you to unintended consequences.”

Similarly, Drexel University College of Medicine warned students that information on social-networking sites can impact decision making regarding their applications to residency programs[15].

Warnings like these are analogous to a “Dangerous Rip-Currents” sign at the beach. By the time people read it, they have arrived in wet suits, having driven an hour to get there.

Some believe the challenges posed by social media are large enough to warrant promulgation of guidelines for its use in health care, modeled after AMIA’s “Guidelines for the Use of Electronic Mail with Patients” which were published just as providers began relying on that medium.[16]

Such an approach begs questions like who has the authority to issue such guidelines, or whether they could impact behavior without an associated means for enforcement. And since no one believes that social media utilization in healthcare should be regulated, the alternative is to modify medical school curricula and beef-up CME.

With social media, the genie is out of the bottle.

Innovations That Make a Difference

Even though EHRs and social media have had a large impact on medicine, it does not necessarily follow that medical education should be modified to account for them.

After all, thousands of technologies have disseminated into the mainstream; medicine accommodates them organically.

To some extent, this is happening with social media. In the Florida study of Facebook utilization for example[17], 64% of medical students were found to have fully public Facebook accounts, whereas only 12% of residents did.

It’s also true that finding space to teach HIT in a packed medical school curriculum means subtracting time from something else.

Still, we argue that the HIT Deluge presents unprecedented challenges to patient-physician communication and while blurring social boundaries in ways that generate ethical challenges and legal risks that cannot be ignored.

Medical schools including Harvard, Stanford, Vanderbilt and UCSF approach the conundrum by offering elective courses in HIT, often in conjunction with other graduate schools.

HST.921, “Information Technology in the Health Care System of the Future,”[18] is an example. The course is open to all graduate students at Harvard and MIT, including those at Harvard Medical School.

In it, students learn how HIT improves health care quality and provides new options for patient education and self-care.

Florida State University College of Medicine, one of the nation’s newest medical schools, has taken a more aggressive approach. Bypassing the above-mentioned incremental approach, its  Internet-age curriculum has HIT woven into its fabric.

FSU students receive laptops upon arrival. Their textbooks are on line. During orientation and first semester, they learn to access library resources on line and gain exposure to decision support tools.

In the second semester, they receive PDAs and learn how to carry out literature reviews and manage bibliographies on line.

In their fourth semester, FSU students learn to use SOAPware, a laptop-supportable EHR. During their third year, they use SOAPWare during supervised patient encounters and receive feedback from supervising physicians.

And what about all the physicians who graduated medical school years ago and have had no HIT education whatsoever? That’s where Russ Cucina, an associate medical director of IT at UCSF plays a vital role. Cucina, you see, teaches a CME class called, “Blogs, Tweets, and Facebook: What the Hospital and Medical Administrator Needs to Know.”

We hear it’s filling up fast.

[2] http://content.nejm.org/cgi/content/full/361/7/649?ijkey=Tarf0DE9052Gc&keytype=ref&siteid=nejm

[3] http://www.ehrbloggers.com/2009/07/meaningful-use-take-ii.html

[4] http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000069

[5] http://www.stfm.org/fmhub/fm2008/July/Heidi462.pdf

[6] http://www.biomedcentral.com/bmcmededuc/

[7] http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000069

[8] http://www.mayoclinic.org/blogs/index.html

[9] http://www.facebook.com/pages/Mayo-Clinic/7673082516

[10] http://twitter.com/mayoclinic

[11] http://www.informationweek.com/news/healthcare/patient/showArticle.jhtml?articleID=219200127

[12] http://www.nytimes.com/2009/06/11/health/11chen.html?_r=1

[13] http://news.ufl.edu/2008/07/10/facebook/

[14] http://content.nejm.org/cgi/content/full/361/7/649?ijkey=Tarf0DE9052Gc&keytype=ref&siteid=nejm

[15] ibid

[16] http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=9452989

[17] http://news.ufl.edu/2008/07/10/facebook/

[18] http://www.hst921.org/home/

Glenn Laffel is Senior Vice President of Clinical Affairs for Practice Fusion.  Practice Fusion addresses the complexities and critical needs of today’s healthcare environment by providing a free, web-based Electronic Health Record (EHR) application to physicians.

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.

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.

Based on a series of polls conducted by the Student Doctor Network, students generally understand the current salaries they can expect to receive as a health professional.

The polls asked SDN users to select the salary range for an occupation “without Googling” to find the correct answer.  The results of the polls are available in the SDN poll archive.

Students were most likely to select the salary range into which the actual mean annual wage falls for all occupations except Dentists and Optometrists.  Actual wages used for comparison were determined by the Bureau of Labor Statistics and are accurate as of May 2007.

The range was underestimated for Optometrists and overestimated for Dentists.  In both cases the mean wage lay very close to a break point for the salary ranges available, and a majority of respondents selected either the correct range or the next closest range.

The table below details these wages:

 

For most occupations, while the answer most likely to be selected was the correct one, incorrect responses skewed higher than the actual wage.  For example, 61% of students overestimated the wage for Occupational Therapists (OTD), versus only 12% underestimating the wage.

“The internet makes it easy for students to identify what they can generally expect for a wage following completion of their degree,” said Michael Magatelli, an employment expert and executive coach with the Magatelli Leadership Group of Sacramento, California.  “No student should invest in a degree without understanding the value they are going to receive from it.”

To gain further insight into wages beyond the average salaries referenced above, Magatelli recommends students conduct four to six “informational” interviews.  These interviews will help illustrate any unique costs or required investments associated with setting up their desired practice model.

“Informational interviews, in addition to internet salary information, will provide a more complete picture of the costs of becoming a practicing health professional in your geographic area,” said Magatelli.

Recognizing the direct and far-reaching value of community and preventive medicine, the Student Doctor Network (SDN) has committed a portion of its 2009 and future revenues to creation of an annual scholarship program for medical and pharmacy students that plan to enter the field of community and preventive medicine.

Lee Burnett, physician and co-founder of SDN explains, “As a nonprofit charitable organization we have a responsibility to our members and the greater community.  Part of our mission is to encourage students to look at those areas of healthcare which provide the most reward, both to their careers and to the world.”

It is hoped that the scholarship will encourage students to take a closer look at the field of community and preventive medicine.  Specialists in this field often have dynamic careers in government, academic or research and make decisions that affect thousands or millions of people.

Details of the scholarship will be available shortly.

Visit Kaptest.com for more information and
SDN Member discounts on Kaplan Courses and Materials.

By Janani Krishnaswami, M.D.
Kaplan Admissions Consultant

The school interview inspires anxiety and anticipation in many applicants. A test of poise and communication skills, the interview is a key component of the school application package.

The process inherently benefits those who are:

• Relaxed
• Sincere
• Articulate
• Aware – of both their own motivations for seeking medicine (i.e., self-awareness) and “externally” aware (i.e., current events, salient healthcare issues)
• Able to comfortably carry on a conversation covering a wide range of topics (which stems from all of the above).

Just as the applicant has tirelessly worked to tackle challenging courses, study for the admissions test, and polish a personal statement, work needs to be done to prepare for the interview.  While school interviews are largely casual and friendly affairs (a far cry from, say, “stress” interviews held in some areas of finance and consulting) it is entirely possible to “tank” the interview by adopting a laissez-faire approach.

The following myths should be dispelled by the informed applicant at once:

• Interviews are mostly a formality; once you are offered an interview you’re at least guaranteed a spot on the wait list.
• Interviews are biased toward extroverts and native English speakers. It’s much harder to get a good score if you’ve got a thick accent, speak softly, or are quiet.
• There is no real way to prepare for medical school interviews, since you won’t know in advance what questions will be asked.

Schools vary regarding how much importance they place on the interview versus the paper application. In general, top-tier schools will lend more importance to the interview – especially as a deciding factor between two exceptional candidates.  Sifting through an abundance of stellar-on-paper applicants, they often turn to the interview to assess honesty, enthusiasm, sincerity and the intangible qualities of personal rapport that come across in the interview.

Getting an Interview

What does receiving the offer of an interview mean?  This, of course, is a complex question varying from school to school. In brief, receiving an interview means one of two things:

1. Based on your grades, test scores and secondary applications, you have passed the initial hurdles of score screening and essay review, making either a numbers-based cutoff process or passing an individual committee member’s screen.
2. Your application was perhaps sub-par or borderline in terms of scores, academic performance, etc., but the committee is intrigued by other aspects of your application and wants to evaluate further via an in-person interview.

The linking factor between scenarios 1 and 2, as the astute applicant might have gathered, is that the interview-invited candidate has an advantage in both cases.   In either case, the applicant has impressed the committee to the point where they would like to know more, where they see a potential fit, a potential acceptance.  In that sense, receiving an interview acceptance represents a very positive development in the applications process – more so than, for example, receiving a secondary.  Drawing from this reality, the conclusion that follows is very important:

Once you have received an interview, the goal of getting an acceptance is within striking distance.

The corollary is that under preparing, underperforming or otherwise botching an interview can essentially lower a stellar “on-paper” candidate to the point where he/she is wait-listed or rejected.   I have reviewed the files of high-scoring MCAT/GPA candidates with a very impressive paper application who were out right rejected by the committee – after painful interviews showed them to be uncertain, haughty or passionless.  Thus, the final conclusion, and the one that applicants should take home:

Acing an interview – and earning an acceptance – is almost entirely within the applicant’s control.

Preparing for the Interview

With that said, here are the top strategies for preparing for a medical school interview:

1. Know thyself. You must have a very clear, convincing, and sincere knowledge of a) why you want to attend school more than anything else and b) what you have done – activities, volunteering, research, etc. – that supports your reasons as evidence.  You get a discrete block of time – 2-3 minutes – to answer the question, “So why do you want to go to (medical, dental, pharmacy…) school?” This is one of the most important questions of the interview. Within that time, you should be able to articulate your true reasons and come across as honest, logical, convincing and real.  Having interviewed hundreds of insincere candidates, admissions committees are quickly able to spot a half-hearted, passionless, or – worst of all – dishonest answer, rendering the applicant to the bottom of the admissions pile.
2. Know why School X is the best place for you. Not surprisingly, admissions committees want to accept candidates who would be likely to accept the acceptance. It looks better for the school and the school’s rankings if, say, 90% of candidates offered acceptances decide to matriculate. Thus, if you come across as someone likely to take that spot if offered, your chances of admissions will increase.  Caution: As in #1, schools will quickly identify candidates who are more hot air than genuine substance.  “Substance”-qualifying reasons include: working with researcher X who is a specialist at the school, curriculum-specific initiatives that are only seen at school X, wanting to pursue a career in an area where school X is renowned or offers unusual opportunities.  Coming up with reasons for attending a school leads to #3:
3. Research the school thoroughly, backwards and forwards. This is more than just a quick glance through the website.  Understand latest developments in the curriculum. What areas were recently changed? How has the school revamped or made innovations in its program recently? What are some of the accomplishments of graduates and current students? What are some areas of ongoing research? The questions are numerous and will be tailored to each applicant’s interest (i.e. service outreach, basic science lab opportunities, international relief efforts, clinical training and simulation, to name a few) . But the key is to spend several hours (yes, hours) analyzing and understanding information to answer them in full.
4. Above all, be humble and sincere. This does not mean downplay your significant accomplishments.  But always remember where they’ve come from: it is rare that a stellar applicant has reached his or her heights without help. Often, there is a mentor, a teacher, a volunteering experience, a parent or patient that has paved the way. It is perfectly fine to describe your outstanding achievements, awards, discoveries, cutting-edge research, critical acclaim, etc. But add that “I-remember-where-I’ve-come-from” angle: how you are thankful to Mentor X or Professor Y for their tireless help, how you are inspired to give back to the community (only if you are, of course!), how you hope to be like Doctor Z, etc.
5. Do. Not. Lie. Under ANY circumstances. Often, the truth has a funny way of revealing itself. And if it is ever found that the applicant lied under any circumstances: it is automatic rejection and a firmly closed door on the application process.

Visit Kaptest.com for more information and discounts on Kaplan Courses and Materials.