The Student Doctor Network is teaming with the Princeton Review to provide the chance to win one of three scholarship prize packages:

• First Prize Package ($2,100+ total value) – One full-length Hyperlearning® MCAT classroom course + Set of Princeton Review Med School Books – Best 168 Medical Schools, Planning a Life in Medicine, Medical School Essays that Made a Difference, Anatomy Coloring Workbook, etc.

• Second Prize Package ($1,899 total value) – One full-length Hyperlearning MCAT classroom course.

• Third Prize Package ($200 total value) – Set of Princeton Review Med School Books – Best 168 Medical Schools, Planning a Life in Medicine, Medical School Essays that Made a Difference, Anatomy Coloring Workbook, etc.

Winners will be announced on the SDN website on August 22, 2009. For complete scholarship requirements click here.

Click here to enter: http://inquiry.princetonreview.com/mcat/scholarship/

Good luck!

“Boutique” or “retainer” medical practices have been steadily growing since 2005.  In this practice model, patients pay an annual retainer fee outside of insurance to gain greater access to their physician. (1)

While it is growing in popularity, some physicians, ethicists, and policy makers are concerned about the trend. (2)

“Concierge care…is like a new country club for the rich,” Representative Pete Stark, Democrat of California, said at an economic committee hearing to Congress in April 2004. “The wealthy will pay for exclusive access to quality care, and everyone else will continue to have inferior access to primary care physicians, specialists, and basic medical advice.” (3)

Proponents of concierge medicine, on the other hand, say that it enables doctors to provide the best possible care and remain in a clinical setting.  Dr. Bernard Kaminetsky, an internal medicine physician in Florida, told the New York Times he would be working for a pharmaceutical company if he hadn’t been able to move to a concierge model.  “I’m really helping a lot of people.  I feel good about what I do,” he stated. (2)

To learn more about this growing trend, the Student Doctor Network spoke with Arney Benson of SignatureMD located in Santa Monica, California.  SignatureMD helps primary care physicians transition their practice to a retainer medicine model.  He is a graduate of the Massachusetts College of Pharmacy & Allied Health, and has over 25 years of healthcare consulting experience. He currently serves as President of AB Consulting and Senior Vice-President for Physician Development for SignatureMD.

How do you define “concierge” or “retainer medicine”?

Retainer medicine, sometimes referred to as “concierge” or “boutique” medicine, is a different type of care delivery experience in which physicians limit the size of their patient panel in order to provide more proactive health care services and greater convenience and access to their patients.  Patients pay a defined fee to experience this type of care, the specifics of which vary among physician practices.

How do retainer practices fit into the current health care structure (i.e., Medicare, insurance companies, etc.)?

A retainer practice focuses on patients in a proactive continuum of care.  You get to know your patients well and help them to coordinate their healthcare.  Instead of building your practice up to a panel with thousands of patients, you will have a panel between 300-500 patients.  While you can still accept insurance, you will also assess a yearly membership fee from your patients.

This retainer model typically requires fewer supporting personnel because of the lower patient load.  Therefore, you will have fewer patients and fewer staff to manage.

The retainer practice also offers a different service level that might include cell phone and/or e-mail access, same day appointments, longer physicals and routine appointments, coordination with fitness and nutrition providers and 24/7 access.

However, any practice continuing to participate in insurance plans must take into consideration the view of retainer fees by those insurance providers.  When the legality of retainer medicine comes into question, it’s typically because an insurance provider has a provision that does not allow the patient to be billed a fee for such management.  It is wise to work with a team of legal advisors, or a company like SignatureMD, to mitigate your risk.

One needs to always remember that a retainer fee is for non-covered services. If you stick to that, there should be no added issues for the current carriers.

Arney Benson

What do you see as the benefits of the retainer medicine model for patients?

Many patients complain today that by the time they get in to see their primary care physician, they have 10 to 15 minutes to explain their concerns before the physician is exiting the exam room.  Your patients need a relationship and a physician that knows them and thinks about the bigger picture.  A retainer practice allows for more time and more questioning.  A retainer practices focuses on prevention and the overall continuum of care.  Many physicians who practice in this manner also include their patient in the process in a more educational manner so they work on wellness plans together and discuss options in an informed (and un-rushed) manner.  If you were the patient, wouldn’t this type of care be what you prefer?

What do you see as the benefits of the retainer medicine model for physicians?

Here are the benefits we find:

• Increased income
• More time to spend with patients:  This increased time available to spend with each patient will allow you to address all of their problems, rather than just one or two. It also gives you the luxury of having the time to truly explain their diagnosis and treatment, which will enhance the patient’s trust, education, compliance, and satisfaction.
• More compliant patients
• Patients who value and respect their physician
• Less time at the office

Our company, and others like it, also provide help with practice management, such as:

• Secure online electronic medical records (EMR)
• Ongoing patient marketing
• Help with business operations
• Help with regulatory and legal issues

What types of personalities enjoy a retainer practice versus a more traditional structure – do your doctors tend to be more entrepreneurial, for example?

Not necessarily more entrepreneurial … but what that physician is: a forward thinking healthcare service provider that wants to deliver a quality of care model, and not the run of the mill reimbursement model (which is) stealing the only commodity necessary to function well in medicine, and that is the time factor.

The typical physician, if there is such a thing, that would do well has to have a driving force to change the status quo and deliver the kind of medicine and diagnostics as he or she sees fit and not be buried under the bureaucracy of the reimbursement model of short time diagnostics and paperwork equal to the time, and sometime more, than the treatments the physician delivers.

Is this a model that a physician could enter immediately out of residency?

Typically no. However, one could start a retainer practice, advertise the concept and build it from there. Realistically, that would take the better part of 24 months to 36 months to get to a reasonable patient enrollment to support the overhead of an office and earn a living. However, a better suggestion would be to seek out a retainer medical clinic for employment to build a relationship with patients so in 3-5 years, once your “affinity” relationship is such to support a retainer model, you can consider a boutique or concierge model.  By the affinity relationship I mean, would the patient be willing to pay a retainer to keep you as their primary care physician.  We find that a good professional relationship takes between 3 to 5 years to establish.

How would you anticipate retainer medicine changing if universal healthcare is implemented?

I think that’s it’s not a matter of if universal healthcare were to be implemented but a matter of when.

That being said, the retainer practice model will continue to gain popularity, as it has, as an example, in Massachusetts where healthcare for all has been implemented for the last two years. The reasons are many, but the driving force for many patients is that they are already frustrated with the existing system, including the wait times and care they receive from a 5 to 10 minute appointment.

The system will be a tiered system where everyone will have healthcare and those that wish a different service offering will seek out an alternatives, i.e. retainer model or a different delivery option for their primary healthcare needs.

Footnotes:

1)    Jeff Levine, “Boutique Medicine: For Your Well-Being?  Or the Doctor’s?”, AARP Bulletin Today, April 18, 2008 (http://bulletin.aarp.org/yourhealth/policy/articles/boutique_medicine.html)

2)    Abigail Zuger, “For a Retainer, Lavish Care by ‘Boutique Doctors’”, New York Times, October 30, 2005 (http://www.nytimes.com/2005/10/30/health/30patient.html)

3)    Congress of the United States – Joint Economic Committee Hearing, Opening Statement, Representative Pete Stark, April 28, 2004 (http://www.jec.senate.gov/archive/Documents/Releases/starkopenstate28april2004.pdf)

As an active member and advisor on the Student Doctor Network forums, I’ve received countless questions from medical students (and recent graduates) about jobs and opportunities in the non-clinical world of medicine. There are many medical students who are seriously asking themselves whether clinical medicine is really the “right fit” and they want to learn more about the various types of non-clinical opportunities available. Some may choose radiology or pathology to avoid patient contact. Others pursue non-clinical jobs in healthcare industries that avoid the clinical setting completely.

Why Consider Non-Clinical Options?

Why look at non-clinical opportunities?  Some medical students were pressured into attending medical school. I personally know some who went to medical school because it was an expectation while they were growing up. Now, they’re looking for other opportunities because they never really wanted to pursue a medical career.

Do you see yourself enjoying a lifelong career in medicine based on your unique strengths, talents, interests, and personal qualities? Some may feel like they’re stuck in medicine because they can’t imagine any other type of career. After all, where can you go to learn about non-clinical opportunities? Plus, if you have significant student loans, then you may feel like you have to find a high-paying job so you can make loan payments and still survive.

Additionally, academia tends to look down on non-clinical opportunities.  When I was a medical student, one of our attending physicians left the world of academia to work for a pharmaceutical company. This individual was criticized by others for moving over to the “dark side.” You’ve probably heard that euphemism before, even if you’ve never watched Star Wars.

Residency and Non-Clinical Jobs

Let me start with the most common question I get from medical students who don’t see themselves practicing medicine: “Should I do a residency?” Residents often ask: “Should I complete my residency?”

I generally try to encourage every medical student to pursue residency because I’ve found that physicians have many more non-clinical opportunities if they complete a residency and become board certified in a specialty. At a minimum, complete an internship so that you can gain some clinical experience. This way, you won’t look back and wonder “what if I had done a residency?”

I realize that some students are completely convinced that they want to get out of medicine. They have no plans of pursuing a residency. As a result, they often approach me with questions about non-clinical opportunities for medical school graduates who lack residency experience.

In this article, I will focus on opportunities in the world of medical writing.

Medical Writing 101

What is medical writing? This field is so broad that I could write several articles about it. In a nutshell, the world of medical writing can be many things at once. It can be: flexible, lucrative, enjoyable, boring, stressful, and mundane. If you’re confused, you should be. Most people don’t understand what medical writers do.

If you enjoy writing and you consider yourself to be a strong writer, then you may wish to pursue this career.  I recommend starting by joining the American Medical Writers Association (AMWA) and learning more about the field of medical writing. Keep in mind that most medical writers are not physicians. However, physicians make some of the strongest medical writers, especially when it comes to projects that involve a heavy amount of clinical science and first-hand patient experience.

Allow me to expand on this a bit further by providing you with a few examples of medical writing opportunities.

• Professional medical communications and medical education: There are many small, medium, and large companies that focus on medical communications. Some are large print publishers. Others like WebMD are mainly online publishers. There are also many private companies that develop medical education activities. It’s important to clearly delineate between promotional medical education and certified medical education.
  • Promotional medical education: This is also commonly known as marketing, but promotional sounds better though, doesn’t it? This ranges from content presented at promotional “dinner meetings” (which are not occurring as frequently due to budgetary constraints), journal advertisements, to direct-to-consumer (DTC) television advertisements. Companies may be called “promotional medical education companies” or even “ad agencies.” Publishers also get involved in this space.
  • Certified medical education, also called Continuing Medical Education or CME: In the past, CME was a loose term that people threw around when they were talking about any type of formal or informal education that took place after residency completion. Today, CME specifically refers to certified education that meets the criteria set forth by the ACCME (Accreditation Council for Continuing Medical Education). CME dinner meetings still occur and they are clearly labeled “CME” or even “certified CME.” Private companies that develop CME activities are not allowed to develop promotional activities. The only exception to that rule applies to entities that declare themselves to be “publishers.” You’ll still find CME in medical journals like JAMA along with full-page drug advertisements (but they won’t be on the same pages as the CME activity). Universities and professional medical societies produce a large amount of CME, so you may find some opportunities there as well.
• Consumer-level health education: WebMD is well-known for educating patients about health topics. These types of companies rely on medical writers and reviewers for content that is written on a consumer level. This can sometimes mean a fourth to sixth grade reading level. There are many other companies that offer similar services and most jobs in this area would fall under the “medical writing” category.
• Clinical research: Research opportunities for medical school graduates are abundant in university settings. In fact, this is how many foreign medical graduates enter the U.S. if they are unable to secure a residency. Research can obviously also occur in academia or in government institutions. Be prepared to write grants, research papers, abstracts, posters, and more. You can also find opportunities within Contract Research Organizations (also known as CROs). Medical writing in the world of research often involves regulatory writing, drug safety reports, protocols, etc. Once you gain some experience in this space, you may have the chance to work in pharma/biotech.
• Freelance/contract medical writing: Many successful medical writers work from home or telecommute. In fact, a large number of writers have a busy freelance business that keeps them busy all-year long. The nice thing about freelancing is that it gives you tremendous flexibility. The major downside is the potential for unsteady income. However, if you want to work on various types of writing projects, you may enjoy the life of a freelance writer.
• Market research and survey writing: I actually meet medical students who don’t know what the term “market research” means, so if you happen to be one of them, you’re not alone. These types of students typically have no business training prior to medical school. Market research is often performed through surveys that are written by clinicians or medical writers. If you have an analytical mind, then you may enjoy writing market research survey questions and analyzing the data for marketing purposes.
• Medical blogging: Yes, you can be hired to write for medical blogs (or even non-medical blogs). You don’t have to be a professional writer, but it helps if you have a unique communication style. You may have read the NY Times article about a nephrologist who left clinical medicine to go into full-time blogging (about Apple rumors).

Other Non-Clinical Opportunities

If you don’t enjoy writing, then keep in mind that there are other non-clinical opportunities in industries such as public health, venture capital, executive search, health information technology, public health, consulting, pharma/biotech, and more. You can learn more about these types of opportunities by visiting www.NonClinicalJobs.com.

Preparing For Non-Clinical Work

Finally, let me provide a few tips for those medical students who don’t plan to go into residency (or if you’re thinking about quitting in the middle of your residency – which I do not recommend to anyone):

• It’s critical that you grow your social network if you plan to look for non-clinical jobs immediately upon graduation. This may be the most important step in determining what type of position you land.
• Connect with executive recruiters. You may have heard of them as “head hunters.” These individuals can be very helpful in providing you with job leads and they are eager to help you. They shouldn’t charge you anything since they get their commission from the hiring company.
• There are many positions that may be considered “springboard” jobs. In essence, these jobs will provide you with the necessary corporate experience to then “jump” you into another career or industry. You may gain tremendous experience by working in a “springboard” position for 2-3 years before making a major move. Consider the gains if you’re willing to make such a sacrifice (sounds like residency).
• As you work in the non-clinical setting, you’ll meet more and more people who may become invaluable leads and contacts for the future. Continue to grow and maintain your social network because you never know when you may to find a new job.
• Enhance your computer and technical skills. You’ll be expected to be very proficient and productive on the computer. You’ll be working in Microsoft Outlook, Word, Excel, and PowerPoint. You probably won’t carry a pager, but you may be expected to use a mobile e-mail device like a smartphone.

Have specific questions? I’m a volunteer advisor on the SDN forums and I welcome your questions and comments. Please note that this article is not meant to discourage medical students from pursuing a career in clinical medicine. This article is also not meant to encourage residents to leave residency. Rather, the purpose of this article is to provide some education about non-clinical options so that students can make informed decisions about their career path.

About Joseph Kim, MD, MPH

Dr. Joseph Kim is an active physician blogger and he blogs daily about non-clinical issues at www.NonClinicalJobs.com. He is a strong proponent of strategic social networking and he has used his personal network in various situations to help people find non-clinical opportunities in different healthcare industries.

Roy Ziegelstein, MD

Dr. Roy Ziegelstein is the Executive Vice-Chairman of the Department of Medicine at the Johns Hopkins Bayview Medical Center and a professor of medicine at the Johns Hopkins University School of Medicine. For many years, he served as the program director of the internal medicine residency program at Johns Hopkins Bayview Medical Center. Presently, he is one of the associate residency program directors there.

In 2007, his article ”Rocking the Match” was published. In the article, he offers sage advice “from the perspective of someone who regularly mentors students through this process and as someone with years of experience as a residency program director evaluating prospective interns.”¹ Recently, Dr. Ziegelstein was able to share with us some of the wisdom gained from his extensive experience mentoring students.

Studies have shown that, while medical students recognize the importance of mentors, many students don’t have one.² In your article, you write about the importance of finding a mentor and describe ways to initiate a mentor-mentee relationship. Once established, what can students do to make the most of this relationship as it relates to the residency application process?

I think that there are several things that can be done by students to ensure productive mentor-mentee relationships with respect to the residency application process.  The most important thing is to try to get to know your mentor(s) and vice versa.  People have limits on their time, so you may want to use e-mail for much of your communication; most faculty read e-mail regularly.  You should also schedule quarterly meetings – even if only for 15-20 min at a time – so that your mentor knows how you’re doing, what your goals are, and how he or she can help.  About six months before the whole application process starts, schedule a longer meeting to discuss specifics: what field you’re going to apply in; whether your mentor feels there are others on faculty you should also meet with; what programs you should consider applying to; whom to ask for letters of recommendation; and how to approach your personal statement.  As interviews get closer, schedule time with your mentor(s) for practice interviews.

In a recent survey of 71 internal medicine residency program directors inquiring about the importance of applicant selection criteria, grades in required clerkships were the # 1 academic selection criterion.³ Some have questioned the appropriateness of using clerkship grades in residency selection, citing the significant variability that exists in grading from one institution to another. How do you view clerkship grades and their role in the selection process?

I think clerkship grades are very important.  Whether or not I agree, I believe the findings of the study you refer to are absolutely correct.  Many program directors recognize that the grading system of some schools is much harsher than the system used in other schools, but not all program directors do.  Most faculty who evaluate applicants rely heavily on the Dean’s Letter, now known as the Medical Student Performance Evaluation (MSPE).  Often, the MSPE contains figures or charts that provide information on how the grades were distributed in the applicant’s class.  Sometimes, the MSPE indicates a class rank, or if the applicant just missed an Honors grade, it may indicate “near Honors” and indicate why.

It is often said that audition electives are not necessary for students applying to internal medicine. Under what circumstances should students consider doing an audition elective?

I think by “audition elective” you mean an elective at the program the student is applying to.  I think these are unnecessary, but they may be helpful if the applicant wants to learn more about the program or if the applicant is confident that his or her clinical performance will be impressive enough that it either reinforces an already strong application or demonstrates strengths that may not be apparent from the application alone.  I have heard it said by some students that they were advised NOT to do an elective at an institution they were particularly interested in because it might detract from their application. I disagree.  I have seldom seen an applicant hurt by an “audition elective” but I have seen many applicants helped.  I do want to emphasize that I think that the most helpful “audition elective” is a subinternship.  It allows you to really see what it would be like as a house officer at the program and it allows the program to get some sense of what you would be like as an intern or resident there.

In reviewing residency applications over the years, we’ve found that some letters written on behalf of excellent candidates were brief or vague. Is there anything that students can do to help their professors write effective letters that are most useful to residency programs?

I would focus on three things: First, when an applicant asks for a letter, I think it’s best to say “Do you feel you know me well enough to write a strong letter of recommendation in support of my application?”  Brief or vague letters are often written because the professor doesn’t really know the applicant.  In fact, I think they are often the result of a student asking a professor at his or her school who has a well-recognized name to write a letter of recommendation thinking that it will be of great help, even though the professor really doesn’t know the applicant. I think these letters are often viewed as “prizes” by applicants, but they may, in reality, hurt the applicant rather than help.

Second, when a student asks for a letter of recommendation, he or she should come prepared with a complete and up-to-date CV and, if possible, with a personal statement.  Also, the student should ask the professor for a letter in a formal meeting rather than in a chance meeting in the hallway or cafeteria.  In the more formal meeting, the student can tell the professor something about his or her goals, objectives, background, etc., if the professor doesn’t already know the student well.

Finally, the student could offer to compose a few paragraphs about his or her background, goals, objectives, interests, etc., for the professor.  The student is not really offering to “write the letter for the professor,” but by writing a few paragraphs like this, the student may make it easier for the professor to put things in the letter that are important.  I think these “tips” should help avoid the perils of the brief or vague letter of recommendation.

For many students, the personal statement is often the most dreaded aspect of the residency application. As someone who has read thousands of statements, what makes a statement memorable to you?

I can’t for the life of me understand why the personal statement is so dreaded, but I certainly know it’s true for most students.  Remember, no one is asking you to write an essay on how the principles of the Gettysburg Address influenced politics in the Eisenhower era, and you’re not being asked to solve a complex mathematical equation.  You are being asked to write about yourself, and you should be able to do that relatively easily.  In fact, you should relish the opportunity; this is your chance to tell people something about you before they meet you and to make them look forward to getting to know you better.  If you can communicate what is special about you (without sounding overly self-promoting or arrogant) that is not already evident in your application, you have created an effective personal statement.

Why should I want to meet you?  Let me know in the personal statement.  Remember that the personal statement is also often used as the basis for your faculty interviews, so make it something interesting.  One important point though: a “memorable” personal statement (the word you used in your question) is not necessarily the goal.  I can tell you of many personal statements that were “memorable” because they seemed outlandish or silly or because they made the applicant appear “scary” or weird.  Please show your personal statement to others (e.g., a faculty advisor who has experience reading them and evaluating applicants) before sending it out.

Many surveys of program directors have shown that the interview is the most important factor used in the ranking of applicants. You’ve had considerable experience conducting interviews. Why do some applicants stand out?

Applicants who stand out in the interview are able to communicate confidence without arrogance; sincere interest in the program that does not appear disingenuous; good speaking and also good listening skills; and an enthusiasm for medicine.  Applicants stand out when they make me feel that the interview flew by rather than dragged.  Applicants stand out if I can envision them taking care of my patients when they need to be hospitalized and/or if the interview leaves me feeling eager to teach and work with them.  As I mentioned above with respect to the personal statement, I would advise practicing interviewing with a faculty member who has experience interviewing and evaluating applicants.

The quality of questions asked by an applicant is important to many interviewers. In your experience, how often are you impressed with questions asked by candidates? How can applicants learn to ask meaningful questions?

To me, “meaningful questions” are those that seem “meaningful” to the applicant.    Just be yourself.  Don’t ask questions because someone told you that those are the questions you should ask.  Ask the questions that are important or relevant to you.  Also, come prepared – read about the program before your interview and try not to ask a lot of questions whose answers should be known to you before you visit the program.

References

¹Ziegelstein RC. “Rocking the match”: applying and getting into residency. J Natl Med Assoc 2007; 99(9): 994-9.

²Aagaard EM, Hauer KE. A cross-sectional descriptive study of mentoring relationships formed by medical students. J Gen Intern Med 2003; 18: 298-302.

³Green M, Jones P, Thomas JX Jr. Selection criteria for residency: results of a national program directors survey. Acad Med 2009; 84(3): 362-7.

By Laura Turner
SDN Staff Writer

The Student Doctor Network, in coordination with the Student Osteopathic Medical Association (SOMA), is pleased to announce the winner of the first annual SDN Scholarship in Community and Preventive Medicine. The inaugural winner is Tamar Nazerian, a first year medical student at Western University College of Osteopathic Medicine.

Scholarship Winner Tamar Nazerian

The scholarship was launched earlier this year to provide support for 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 the greater community.  Our goal with the scholarship is to provide support to a student that also feels that sense of community responsibility. Tamar Nazerian has worked extensively in the area of preventative care. It is wonderful that she is the first recipient of this scholarship.”

Prior to matriculating at Western University, Ms. Nazerian served as the Project Coordinator for the University of Southern California/Childrens Hospital Los Angeles University Center for Excellence in Developmental Disabilities, working on two federally grant supported projects. The first was called Project Access for Pediatric Epilepsy, which used telemedicine to bridge the communication gap between pediatric primary care physicians and pediatric subspecialists in rural areas. The second project focused on providing children with special health care needs who are transitioning into adulthood with information to enable them to find appropriate medical care. She also worked at the UCLA Lili Claire Family Resource Center as a Program Coordinator.

Ms. Nazerian completed a Masters in Public Health at the University of Southern California, with a focus on Child and Family Health. She received her Bachelors of Science in Physiological Science from the University of California, Los Angeles, with a Public Affairs minor with a Social Welfare emphasis.

“I am thrilled and humbled to be the first recipient of this scholarship,” Tamar Nazerian said. “As I wrote in my application essay, I have found that the strategies that are most effective at improving the overall health of a community are not those that rely on individual behaviors or access, but instead focus on improving society’s collective health and wellness. My goal is to serve as a Pediatrician and focus on early intervention to improve the health and well being of children and society as a whole.”

A complete text of Tamar Nazerian’s application essay is available here.

“We look forward continuing to support students that are focused on community and preventive medicine with this and other scholarships in the future,” said Lee Burnett.  The annual SDN Preventive Medicine Scholarship was offered as two awards, one for SOMA and the other for the AMA-MSS.  SOMA chose to start the scholarship with the 2009 academic year.  In 2010, annual scholarships are planned for additional healthcare professions.

by Laura Turner
SDN Staff Writer

U.S. health care reform is shaping up to be a key activity for lawmakers in 2009. The Obama administration is mobilizing its volunteer base from the campaign to lobby Congress for change. Politicians on both sides of the spectrum are putting forth their vision for the future of medicine.

In order to provide our membership of future health care providers with the latest reform ideas, the Student Doctor Network will be publishing a series of articles on health care policy. These articles will include interviews from policy makers and details on technical and structural innovations aimed at reducing costs and improving outcomes.

Previously, SDN interviewed Dr. John Geyman, author of Do Not Resuscitate, who espoused a need for a single payer nationalized health care system.

Additional articles in the series, to be published in the coming months, will include the following:

• Interview with Dr. David Sundwall, who served as President Reagan’s Director of the Health Resources and Services Administration at the U. S. Department of Health and Human Services
• The role of health information exchanges in improving health care delivery

We invite our membership to submit ideas for other articles in this area. Please provide your comments below.

Setting the Goal:  A Journey Toward Innovation in Medicine

The Student Doctor Network is pleased to announce the following online presentation to our membership:

Dr. Maria Siemionow

Kaplan Publishing in conjunction with Kaplan Medical is proud to present an evening with Dr. Maria Siemionow, a medical pioneer in facial transplant surgery.

When Dr. Siemionow announced in December 2005 that she had been granted approval to perform this revolutionary surgery, she was bombarded with media attention and moving requests from people wanting to know who would be eligible for the operation. In December 2008, it was announced that she had completed the nation’s first face transplant.

Please join us for an evening with Dr. Siemionow as she discusses her journey toward innovation in the medical field through setting goals and determination.

Event Information

Date: June 3, 2009
Time: 7:00 p.m. EST

This event will take place exclusively online. Registration for this event is mandatory.  Click to register:http://kaptest.acrobat.com/face_to_face/event/registration.html

Special Offer: The first fifty registrants will receive a free copy of Dr. Siemionow’s upcoming book Face to Face: My Quest to Perform the First Full Face Transplant.

About Dr. Siemionow

Maria Siemionow, MD, PhD, was awarded her medical degree by Poznan University of Medical Sciences in 1974, after which she completed her residency in orthopedics, and then earned a PhD in microsurgery. In 1985, she completed a hand surgery fellowship at the Christine Kleinert Institute for Hand and Microsurgery in Louisville, Kentucky.

Today she is director of Plastic Surgery Research and the head of Microsurgery Training in the Plastic Surgery Department of Cleveland Clinic. She is on staff at the Clinic’s Transplantation Center and in the orthopedic surgery and immunology departments. For her research on facial transplant, she received the 2004 and 2007 James Barrett Brown Awards from the American Association of Plastic Surgeons. Dr. Siemionow has been featured in the media including ABC News, CNN, BBC and the New York Times.

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.

by Tony Guerra, Pharm.D.

We have a hiring freeze. Call us in a couple of months. We have a position, but it’s in a small town. Do you need benefits? How much experience do you have? Did you do a residency?

These aren’t supposed to be answers to our interview questions as pharmacists. We’re supposed to be able to fog a mirror and get a job. We should get to negotiate for a higher salary with a nice sign on bonus where and when we want. What happened to the good old days? You know, last year.

Supply and Demand

As the United States population has grown older and heavier, the demand for prescription medications has skyrocketed. Working to fill the need, chain pharmacies have gobbled up independents and kept their doors open later (many overnight), requiring greater levels of staff. As HMO’s, hospitals, clinics, universities, mail-order services, and the military all need pharmacists, they have been willing to pay handsomely for them.

At the same time, women have entered pharmacy in far greater numbers than ever before, many opting for part time positions or taking extended leaves to raise children. Complicating things further, when bachelor’s programs were phased out in favor of Pharm.D. programs, a year’s worth of graduates were lost.

All of this created an historic shortage of labor. State pharmacy schools could not keep up with demand, so the private schools started adding pharmacy programs at a rate of almost two per year (up from one every three years). In 1990, there were 74 pharmacy schools operating in the United States. Today, there are 103 with an additional nine in pre-candidate status. As salaries begin to stagnate or worse—drop, this may end up as a game of musical chairs, forcing a number of pharmacy programs to close their doors as quickly as they opened.

Tony Guerra, Pharm.D.

What does any of this have to do with finding a job you’re passionate about? To put it simply, you must work smarter to get it. If a PGY1 could have landed you a faculty spot before, then now you may need a PGY2 to get that same position. You may need to know a couple of people at the college or at the place you want to work. You may need to take a job that you don’t like as much so that you can build the skills and relationships to get exactly what you want.

But I want it now!

I understand. The truth is you can have it now, if you are willing to go outside the box.

I ask residents, “What are you going to do after your graduation or residency?” Nine times out of 10, the answer is, “I don’t know.”  Like being an Olympic athlete who has worked their entire life to win a gold medal, you will stand at the graduation platform thinking about the moment rather than what might satisfy you in the future. But there are actionable steps to arrive where you want to be.

Step One – Decide what you love to do on the most basic level.

Do you want to teach? Lead? Write? Advise? Manage? Whom do you love to help? Kids? Adults? Students? When you close your eyes, where do you see yourself smiling at work? By answering these questions, you can start moving in the right direction.

A pharmacist herself, my wife loves being the trusted advisor. Whether with family or patients, she loves to sit down and help people because she is a talented listener. With this in mind, she focused on becoming a diabetes expert through a program at Drake and in her practice. After showing a local free clinic how she could help them, they offered to create a 16-hour position due to the great work she had accomplished with diabetic patients. Because her passion was in line with her work, an opportunity was made.

Step Two – Volunteer.

Too many people ask for something then expect to get it, as if getting the career of your dreams is a one step process. The real order of service is to give, then ask, then receive. Since I wanted to teach and didn’t care if I got paid, I volunteered in a middle school math program. Later, I got paid to tutor, proctor, and teach test prep at Kaplan. It wasn’t a pharmacist’s salary, but their training program was great. After that, I volunteered to teach in pharmacy courses at the University of Iowa.

Each succeeding experience has made me more confident and more able. When the opportunity finally arose to teach a full-time course at a local community college, I was accepted right away. Yet, all of this began in a public school classroom with the willingness to give.

Step Three – Build your own practice.

The job you make for yourself is the job you’ll love. The day I left retail and started my own business, I was scared. But once I bought my own health insurance, I realized it wasn’t that bad and the freedom is amazing.

While I certainly had responsibilities to my customers, I could schedule them around other things in my life. I could coach in the afternoons, take trips with my family, and spend evenings at home. I was there for people when they needed me while building deep relationships one-on-one instead of trying to do the same through a plate glass drive-through window.

Building your own practice is life changing. It’s like going to a restaurant and ordering from the à la carte menu and getting exactly what you want.

Step Four – Start Now.

If you haven’t already, soon you will see the real impact of this economy. There are likely to be two kinds of responses. The first: you can cling to a job that you may not like out of fear of the unknown. The second: you can go forward, today, and start building a practice that you love. Involve the friends you missed while you were on that lonely pharmacy island.

Entrepreneurship is back in a big way. It can be your ticket to the work you love. Take the smallest step right now by writing down what you want. My own mission is to “build a service business so I can train in the mornings, teach during the day, coach in the afternoon, and be with my family and friends nights and weekends.” Write yours out, and it will become a reality.

A key component of the successful match is a full understanding of the residency selection process, and the factors that influence it. Program directors are key decision-makers in this process, and their insights and experience are invaluable. In future columns of The Successful Match, we will present conversations with program directors and other key decision-makers across the different specialties.

We would like to preface these upcoming columns by highlighting the results of an important study done by Dr. Marianne Green. Dr. Green is the Associate Dean for Medical Education at the Northwestern University Feinberg School of Medicine. She is the former associate program director of the internal medicine residency program at Northwestern. Dr. Green is the recipient of multiple teaching awards, and her peers have recognized her as one of the “Best Doctors in America.”

In March 2009, her article ”Selection Criteria for Residency: Results of a National Program Directors Survey” was published in Academic Medicine.¹ The study findings were based on questionnaires submitted to 2,528 program directors across 21 medical specialties in 2006. Dr. Green and her colleagues sought to determine the relative importance of various residency selection criteria. Recently, we had the opportunity to talk with Dr. Green about the study’s results.

Before your study was published in March, deans, residency advisors, and applicants relied primarily on the results of a similar survey published in 1999 by Dr. Norma Wagoner, former dean of students at the University of Chicago Pritzker School of Medicine. What were the factors that led you to revisit this area now?

As I became increasingly involved in residency advising for our students, I felt uncomfortable relying on older data, and realized it needed updating. My colleagues and I approached Dr. Wagoner and she graciously let us modify her survey for this updated study. In addition, several specialties were not represented in the 99 study, the competiveness of specialties had changed, and new data (CSE, MSPE etc) were now available.  Charting Outcomes in the Match has a lot of detailed information that is very valuable, but several domains (e.g. clinical grades, preclinical grades) are not included and this information becomes important when advising students.²

What are the key findings that residency advisors and students should take away from your study?

Clinical performance as measured by clerkship grades is the most important thing that program directors look for across all specialties.  Letters of recommendation are extremely important in most specialties with the exception of Internal Medicine, Family Medicine and Radiology.  USMLE step 1 scores remain very important, but USMLE step 2 scores may even be more important in the primary care specialties.

In the article, you wrote that you hope to “highlight possible misperceptions that may affect student advising for residency application.” What do you believe are the more common misperceptions?

Many medical students believe that research is an essential part of their application to residency. With the exception of Radiation Oncology and Plastic Surgery, program directors in other specialties ranked published research among the lowest of the available selection criteria.  (see below for more on this)

Many students believe that their grades in the preclinical years are very important.  With the exception of a course failure, preclinical grades are not important.

Students should consider taking USMLE step 2 in time for residency application especially if they are looking at the primary care specialties like Pediatrics, Internal Medicine or Family Medicine; many of the less competitive specialties are putting increasing emphasis on Step 2 scores.

In Dr. Wagoner’s study, grades in required clerkships received top ranking from both competitive and less competitive specialties. In your study, grades in required clerkships were once again found to be the most important academic selection criteria. Students are often surprised to learn that grades in required clerkships are so important, ranked ahead of other criteria such as USMLE step 1 score and grades in senior electives in the chosen specialty. Why do program directors place so much emphasis on core clerkship grades?

Our study did not address the question of “why” for any of the selection criteria. I can only answer this as a practicing internist responsible for supervising residents and former associate program director.  Program directors and selection committees are looking for people who are going to become excellent physicians with the primary emphasis on patient care and teamwork.  A student’s performance on a clinical team in the direct care of patients is perceived to be the best assessment of these skills.  It is the job of the medical schools and faculty to insure that clerkship assessments are an actual representation of the achievement of competence.

You found that the USMLE step 1 score was the second most important criteria. Many students who seek residency positions in competitive specialties are concerned that their USMLE step 1 score is too low. What advice would you offer to these applicants?

The NRMP’s Charting Outcomes in the Match provides excellent data for the percentage of students with certain USMLE Step 1 scores matching in a given specialty.  I would certainly refer students to this source.  This can provide some realistic information for students.  I would never discourage a student from applying to a specialty that he/she is passionate about.  I would however, be sure that the student understands his/ her chances with whatever data is available.  Often schools track the success of their own students, and that data can be a very valuable tool for an individual student.  If a student’s chances of receiving an interview are low, he/she needs a “back up plan” and this often includes application to a less competitive specialty as well.

Overall, published medical school research and research experience were ranked next to last and last, respectively, in importance among academic selection criteria. However, you did note that some specialties highly value research, particularly competitive specialties. Students are often told that research experience and being published can strengthen their residency application. In light of your study’s findings, how should we advise students in this area?

Only Radiation Oncology and Plastic Surgery program directors ranked research highly; however even among some of the less competitive specialties, research may be an important part of the student’s application.  In my experience advising students, those that are looking at the top 5 programs in a certain specialty are competing with other highly qualified students across the country. Scores and grades are all outstanding, so something else may be needed to highlight the student as a competitive candidate.  Personally I believe that depth in any area (not necessarily research) can make a student stand out.  Extensive international experience or experience in patient safety & quality outcomes are two examples from our own institutions.  Certain residency programs are looking to train research scientists. Clearly a background in research will be a necessary qualification for these programs.

The medical school performance evaluation (MSPE), previously known as the Dean’s letter, is a standard component of the residency application. Critics of the MSPE maintain that these letters are often lacking in key information that programs need to assess and compare applicants. In an effort to make the MSPE more effective and useful, the AAMC has made efforts to standardize and improve the quality of these letters. In your study, program directors ranked the MSPE lowest of all criteria. Did you find that surprising given the AAMC’s efforts in recent years?

There are a few possible explanations for this finding.  The November 1^st deadline may be too late for program directors to use the MSPE extensively in decision making regarding the granting of interviews.  Students can begin applying on September 1^st and many interview offers start going out as soon as applications are received.

More importantly, most of the information contained in the MSPE is available elsewhere.  The grades and narratives for courses and clerkships may be on the transcript.  USMLE Scores are available directly. The ERAS application contains a lot of the “extracurricular information” about a student and so the MSPE is not necessary to view this information.

Probably the most important piece of the MSPE is the students “rank” in comparison to his/her classmates.  Although the AAMC has attempted more standardization in the reporting of class rank, many medical schools do not comply with this request and residency selection committees are faced with interpreting a student’s rank using vague terminology.

Your study did not address the importance of the interview in the residency selection process. As someone who has interviewed many residency applicants, what recommendations can you offer students preparing for interviews?

Relax and be yourself!  Most interviews are not high stress situations. Faculty are looking to see if you can interact effectively with others and would “fit in”. Certain specialties and programs may have some unique interview questions, but these are not common.  Departmental advisors can shed some light on the idiosyncrasies of certain specialties. (One year, some of the ENT programs were asking students to carve a bar of soap while they answered questions!) If you are someone who gets very nervous in an interview, I would recommend practicing a mock interview with a faculty member, advisor or dean.  Be prepared to talk about your interest in the field and why you would be a good addition to the program.  Know something about the program you are applying to.

References

¹Green M, Jones P, Thomas JX Jr. Selection criteria for residency: results of a national program directors survey. Acad Med 2009; 84(3): 362-367.

²Charting outcomes in the match: characteristics of applicants who matched to their preferred specialty in the 2007 NRMP Main Residency Match. Available at www.nrmp.org.