Interlude: Dinner at the United Nations last night. Healthcare Reform

I had dinner at a friends house last night, at one of the missions to the United Nations. Turns out the whole Heme/Onc fellowship and more were there from a hospital in NYC. I do not want to tell you the country, so my story does not seem about a particular group.

I ask “What do you think of what is going on in healthcare reform?”

“Those people do not work, why should they get insurance?”

“They are bums!!!  I do not want my tax dollars supporting them”

“Socialized medicine is bad!! It is a failure in every country it is used”

“Why should we help them? Let them get a job and make money and pay for it themselves”

Most of these people are doctors. they are all immigrants. My tax dollars pay for their fellowships.

I am extremely angry upset and angry. I expect better.  Here are people who will all be very comfortable.  The decision for healthcare reform will take NOTHING from them, but they have bought a line of crap from some third party.

All objective measures show BETTER medicine in the countries that guarantee insurance in Europe .
Again, the basic issue: Is healthcare a right or a privilege?

Last night’s event was VERY useful for me. It convinced me that some people, even the ones you expect to care about sick people: the doctors, only care about any possible RISK to their own paycheck.
It is not even a fact, it is just a ‘fear” and yet it brought out the very worst in human beings.

I was embarrassed that half of them were former students.

Part 3: The Transcript

The transcript is VERY difficult to interpret between schools.

The scoring systems are highly variable. Even between the 128 US schools, you cannot tell who has a difficult scoring system and who has an easy one.

Also, it is better if you have a school where only a few people get honors that the transcript SAY “5% get honors” .

If you have a school where the clinical grades are automatically upgraded, you won’t want people knowing 90% get an A or B in clinicals.

Also, if your school requires an exam to get honors, that is a BETTER school and you should make sure people know.

In international schools, transcripts are virtually unreadable. I have seen people come in and say “I am an excellent student!! My average grade was 678!!!”

This is like a person from another galaxy saying “I will give you 3 ounces of Strontium as payment!!! ”

I can’t relate. The transcript are like the Period Table of Elements. For those who understand, it is REALLY valuable. For everyone else, it is a letter or number.

If your are special on your transcript you have to do something to make it clear.

If your grades are terrible on your transcipt……. That’s why we have USMLE!!! so you can make it up!!

Happy hunting.

write to me.

Warmly,
The Fisch

What program directors look for: Part II. USMLE scores

* Please post your comments/questions. Keep it short*

USMLE scores are critically important because they are the only uniform measure in the world of student/physician quality.

They compensate for the variability between transcripts and grading systems between schools.

Some places have cutoffs, some don’t and like money, more and higher is better.

1. You CANNOT hide previous attempts at taking the test.

2. If you feeling weak and your Qbank averages are low. it is MUCH better to delay your test.

3. Yes, the later the application, the harder it is to get interview spots, but a failing or low grade is something you will not be able to repair later. That goes for everyone. If you are applying in Ophtho, a delay makes it harder, but a score that is low can eliminate you altogether

4. Good scores are based on what you are applying in.

Average score to get pediatrics is  205 but the average for OB/GYn is 220 and the average for orthopedics is 245.

5. Now is the time to obsess on studying. You are going to live with the resulty for a long time. Do more prep.

the average score on USMLE has been going up more than a point a year.

in 1992 the average score was 200,

in 2008 the average score was 221

Visa holders need higher scores than non visa holders.

If you have a good step 1 score (>90) then apply with JUST the step 1 score and take more time to prep step 2.

IF you have a poor step 1 score (<80) do not apply. YOu may have your application inactivated.

Send in your questions/comments.

CFisch

Getting a residency: Part 1: Your School continued

You must put yourself in the mind of the program director. Again, if you do not know a person, how do you assess quality?

It is best perhaps for people to be honest. Do you REALLY think there is a need for FIFTY FOUR caribean schools? Many have no real quality control. A few are super-excellent.

Again, these posts are to be an HONEST assessment of what is going on.

How are the schools in BURMA (Myanmar)? How would you know?

There are >600 schools in India. Which is numer 89? and which is number 589?

for US grads how would you assess the difference between SUNY Downstate, Buffalo, Syracuse or Stonybrook?

But…. you have heard of Cornell University, yes?

It is the same with the program directors.

Also, when IMGs come to interview the FIRST thing people say is “That must be a GREAT place!!! I was the ONLY IMG interviewing there today. Everyone else was a US graduate.”

You see, it is the FIRST thing everyone sees.

Also, I have heard this a million time!! “That place can’t be too good.” says the IMG. “Why?”I ask.  

“Nothing but IMG’s there”

Sorry, it is not a value judgement. It is just how people think. I am am to educate you not pass judgement

Post your comments and questions.

The Fisch

How to get a residency Part 1: The School

Please post your comments and questions

Program directors do not know who you are.  How are they supposed to assess your quality?

The name of the school for U.S.  graduates.

What country you came from for International Graduates

What I am writing about here is NOT my personal opinion. I am writing this to help you get insight into how the mind of the program director works. I am not always agreeing.

For instance, I recently spoke to a surgical program director who did NOT want to take anyone graduating from a Caribbean med school. His reasoning was anyone in a caribbean school was someone who could not get into school in the US.

I do not agree with the attitude, but it must be addressed.

US schools are considered better because there is a more uniform ‘product’. US schools have a rigorous accreditation process that is identifiable and measurable. Most international schools do not.

Recently a student from a caribbean school got very upset with me about this. He said “Our school is just as good” Then he admitted that with >1,000 students in a single year and the fact that most of the 3rd and 4th year had to be virtually self-arranged by the student, that, perhaps this might lead to some quality issues.

Here is the rank order

1. US grads

2. Americans who went to international schools

3 Internationals in international schools

4. Internationals with Visas

Before you start getting upset, or feeling ‘discriminated’ against, this works at EVERY level.  In New York there are a lot of 1st class schools. A student applying from Stonybrook or Buffalo will have a harder time in getting an interview that the students from Columbia, NYU or Cornell.

I was at Boston University last year. You might think they would feel relaxed and at an advantage.

they don’t. Why?

“We are in the city with Tufts and Harvard”

Remember, it is like an arranged marriage. They do not know who you are at first. They know the name of the family.

Please post your comments and questions.

What Program Directors look for

I have been getting a lot of emails this week, as well as questions in classes about what program directors look for and how to get into residency. I will do a series this week about what the majority of program directors look for. I invite your comments and I will respond to them as often as I can.

The first thing is:

1. Where did you go to school

2. USMLE Scores

3. Transcripts

4. Research

5. Personal statements

6 Letters of Recomendation

7. Visa status

8. Other languages spoken

These are the things that get you the interview. At the end, I will try to cover what to do in interview.

CF

Internship is SUPPOSED to be hard!!

I am walking in my gym and a recently graduated, extremely intelligent 4th year student runs up to share her experience of Internship. “It is REALLY hard!!!” She says, with the look of burden and an unpaid blood donation.  “I am so slow and inefficient.  ”

It is the end of July and she has just become a doctor about 20 minutes ago

“It is SUPPOSED to be hard. That’s why it is an internship. You are experiencing pain because you expect to have your usual life. Your usual endeavors.

Just forget having a life for a few months and you will feel better. Once you completely give up the idea that you are to have any form of personal life, any amusements or social life, then you will feel better. It is only because you are trying to have outside interests that you are uncomfortable. ”

I did not think of this for a long time until she said it. How can anyone expect to have an outside life during internship? That is not how it works.

The Internship is one of the purest, cleanest, truest endeavors in the sphere of human existence because it is a time of 100% immersion in your art. At the end, if you want, your regular life will return back to you. But at least you will know what you are capable of. ON the plane when they say “Is there a doctor on the plane?” you will be able to raise your hand.

You will look back on this time as one of the most pristineand sacred time of your life. It does NOT last forever. Surrender to your training.

Internship is a process of beautification. Is not a cooked eggplant more useful than an raw one? Is not a statue more beautiful than a rock?

Internship is the person being made into a lovely sculpture. Light will shine off you and relieve pain in others.

Knowledge transforms from information, into action.

Internship. Expect to disappear. See your friends in six months. Dissolve

And you will be happy. And pure.

A working man with metastatic colon cancer

I was on  rounds with the subinterns recently and I met a man admitted for GI bleeding and anemia.  He has a relatively straightforward presentation. On colonoscopy he had a mass found that was biopsied. Since I was not the attending of record, I was careful not to overstep how much I revealed to him.

The man saves me the trouble by volunteering “So, it looks like I have cancer, isn’t that so Doc?”

Colonoscopy reports are so efficient. You can, with a color printer, place a report with actual pictures of the patient’s lesion directly into the chart as a routine matter of care. The lesion was almost certainly cancer and he had lesions in his liver as well.

I ask the intern and students taking care of him where he will follow up after being discharged . they had not thought it through. In-patient care is very intense. Fill the tank with blood. Get a diagnosis. Discharge.

Key issue: “Does he have insurance?”  NO

“How will he come here for chemotherapy without insurance to pay his visits?”

THe man works full time as a carpenter. unfortunately, he works for a small business that could not possibly afford $15,000 a year per family plan for insurance. Full time work. Just enough to render him ineligible for medicaid, but not enough to afford ANYTHING we were doing for him today.

And…”How old is the patient?”  …..”54″

“So, at what age does screening begin?”   it’s an easy question. Colonoscopy is to begin at age 50. Time enough to have detected and removed the cancerous polyp long before it invaded his colon, and now his liver.

A working man. Just enough to live. Not enough to get him the colonoscopy that would have saved his life had he been screened at age 50 like all the patients with insurance get.

Why did we do this in the first place?

The raging debate of the day is ‘Healthcare reform’. Let’s take a minute to remember why we went into this in the first place.

I believe that most everyone who went into medicine was at the beginning, driven by a sincere desire to make life better for others. Let’s cleave to that.

We know, for sure, that those without coverage will suffer, and die this year.

We know that nearly a third of bankruptcies have a medical cost link.

Let us invoke our higher order thinking, and with the confidence of the power of our calling, insist that the benefits of our art be extended to all Americans.

Will our concern for the suffering be beaten by loud negative voices of fear?

Doctors will be the MOST anxious about healthcare reform

The sad fact is that physicians may often be the most vocal of the opponents of healthcare reform. Again, nervous and anxious about the future. I do NOT believe that physician income will be touched in this endeavor. I think it is just the anxiety of financially conservative people trying to preserve their turf

For students and residents, this is the time to often disregard the negativity of those who are supposed to be your leaders and role models. 

This is the fundamental idea at the center of “Routine Miracles”  which is to get our older physicians and faculty to take a good, hard look at the negative attitudes that they are passing on to students. The worst of which is: fear healthcare reform!! expanding coverage will damage our incomes”

Guard your mind.