What to do if you don’t get accepted into medical school

Let’s say that you have submitted your application and it’s late in the year. You have received no invitations for interview and since it’s now April, your chances of getting invited for interview and gaining acceptance are getting slimmer and slimmer. What are you going to do now? Since the day that you entered undergraduate studies, you have contemplated the study of medicine but at this point, it’s looking like you are not going to be a member of the upcoming year’s starting medical classes. What are you going to do?

Your current application

The first thing that you need to do is pull out a copy of your current application and take a long and objective look at it. Was your personal statement well-written and an accurate reflection of your goals in medicine? Did you illustrate strong extracurricular activities that showed your interest in your fellow humans? Was your undergraduate GPA competitive within the context of the schools that you applied to? Were your scores on the Medical College Admissions Test competitive within the context of the schools that you applied to?

What can you do about improving your application?

If you contemplate reapplying for next year, the first thing that you have to do is upgrade any and all things that were a liability for you in the current year. This might mean taking a course or re-taking the MCAT and making sure that your score is significantly higher. This means reworking your entire application including revamping your personal statement. If your application didn’t work for this year, it’s not likely that it is going to work for you next year. The major reason that people do not get into medical school is overestimation of their competitiveness within the context of the pool of applicants to the schools that they applied to.

The applicant pool

Every year since I have been working with medical school admissions, two things have been generally true. The undergraduate GPAs/MCAT scores of the applicant pool have been increasing and the number of application to my two schools have been increasing. We attribute the increase in the number of applicants to the generally poor economy and we attribute the increase in academic scores to both grade inflation (at some colleges ) and an increasing number of folks who use test prep companies for the MCAT. We are well versed in the undergraduate schools that practice grade inflation and we look very carefully at the patterns in the MCAT scores.  Larger applicant pool and higher uGPA/MCAT scores mean that we are using much of the entire application to make our decisions as to whom we will invite for interview.

The URM myth

Both of my medical schools have about 1% URM representation in any given class. It is entirely a myth that being an Underrepresented Minority in Medicine is an automatic entry into medical school no matter what is on your application. We just don’t “hand out” seats in our freshman medical class for having a certain ethnicity. One of the prime forces for us is making sure that every student who is admitted will successfully get through four years of a very tough curriculum. The material to be mastered knows no color or ethnicity. In the past, with our admissions formula, we have been pretty fortunate in that our graduation rate in four or five years is greater than 99%. In general, those people who graduate in five rather than four years have some extenuating circumstances that have prevented them for continuing with their class not because they were not well-qualified in the first place.

Feelings that you are somehow inferior

This turns out to be a huge factor in whether or not a re-applicant will be successful on the second try. There are far more applicants than seats in medical school period. If you don’t get in, it is generally because you were not a good “fit” for the year in which you applied or you made some poor decisions in terms of the schools that you applied to again you were not a good “fit”. You can reassess you situation, change the things on your application that you can change and reapply stronger. There is very little difference in a student who is accepted and a student who is not accepted in any given year. You would be quite surprised to learn how close many “rejected” students actually came to an acceptance. Those folks who are wait-listed were definite acceptances but were a bit further down the list in terms of being offered a seat. They are definitly “alternates” but we just felt more strongly about the people who were offered admission.

Graduate school

In general, if you are NOT interested in graduate school, don’t undertake a graduate degree to enhance your application. If you have developed a passionate interest in Public Health or Business and you can complete your degree in one year or so, then obtain an MPH or an MBA but don’t look to these degrees to make you more competitive for medical school if your uGPA/MCAT was low.

If you elect to enter a Special Masters such as the Special Masters in Physiology (offered at many colleges/university), you can definitely enhance your chances of admission if you perform well in this type of a program. In addition, you will have some graduate training that can be used if you don’t enter medical school. These Special Masters generally have you taking the same coursework as medical students and can show that you are capable of handling a tough medical school curriculum. These programs are ideal for candidates who are just a bit below average (3.2-3.5) uGPA range or those who had a great deal of difficulty with the MCAT but higher uGPAs.

Retaking the MCAT

If you scored below that magic “30″ or had a severly lopsided score say 13 in PS, 12 in BS and a 5 in VR, then retaking that exam with solid preparation and remediation in your lower scoring areas might be a good idea. One of the things to consider is that you must shore up your deficiencs and be sure that you have done something major before you re-take this exam. Nothing can tank your application faster than several mediocre MCAT scores. While some schools will take your higher scores at each re-take and use a composite, most schools (includng mine) do NOT do this. If you retake, make sure that you are going to score higher period. Also remember that most people do not accomplish a higher score so you definitely need to do something different in terms of prep in order not to wind up with a lower score.

Timing

It is definitely true that the earlier you apply, the better your chances. Meet and exceed every deadline and in the case of reapplication, be early period. You can’t procrastinate on this one. As soon as you have decided to reapply, start getting your materials together for an early submission of your application. Most of the time, the difference between waitlist and acceptance is the timing of the application. Resolve that you are going to be proactive about getting your application done and that you are going to upgrade everything that you can upgrade within the time frame that you have between application cycles (this is not an infinite amount of time)

Reapplication time is also a good time to explore other career opportunities outside medicine especially if you are well below the averages for accepted students. One has to be realistic about their chances of acceptance if you are sitting on a uGPA of  2.9 or an MCAT score of less than 28. Sure some students in the past have gotten into some schools with those scores but most applicants with these numbers are automatically “screened out” of may medical schools. The other thing is that everyone is NOT going to become a physician no matter how great the desire. There are just too many applicants for seats.

Also do not make the mistake of thinking that you will become a Physician Assistant or enter Nursing as a substitute for medicine. While these are great careers, they are not the “same” as medicine. These careers can be extremely rewarding and satisfying but enter these careers because you have decided that they are a good “fit” for you and that you will enjoy them. Getting into Physician Assistant school is quite competitive and not a stepping stone into medicine. It is far likely that if you were not competitive for medical school, you are not going to be competitive for PA school. 

Above all, if medicine is your dream, you will do whatever it takes to accomplish it but you need to be sure that you are upgrading your application with each reapp and that you are being realistic in terms of you competitiveness. Just reapplying does not increase your chances of acceptance in itself. Most people who reapply do something significant to upgrade their application. Make sure that if you elect to reapply, you do the upgrade.

Physical Diagnosis (You get to play with your toys!)

Most medical students take a Physical Diagnosis class during their second year. This course teaches history taking and the skills necessary for performing a complete physical examination. Back in my second year of medical school, I found this course a bit intimidating in terms of what the syllabus outlined for us to accomplish in a few short weeks. Little did I realize that I had most of the tools that I needed to do well in this class, namely, an insatiable curiosity, a good ear, two good hands and total interest in my patients.

 The first lecturer emphasized that we would get 90% of what we needed to make a diagnosis from a good patient history. “Good” was the operative word here because as one sits and reads the “how-to” of taking a medical history, it seems that there is an abundance of information that we must obtain in the patient interview while writing a couple of notes here and there. How would I remember every detail? What happens if I forget something important? What if the patient lies to me? How am I going to figure out what a comatose patient needs? Those were just a few of my concerns in addition to looking at my opthalmoscope and trying to figure out how I would ever get the “hang” of making this forbidding tool useful in my practice.

One day of the week, we would spend the afternoon in the hospital with our preceptors. My upperclassmen friends looked at the name on my paper and said that I had “hit the jackpot” with my preceptor assignment. My preceptor was a master diagnostician and an excellent teacher too. He was an endocrinologist who specialized in metabolic syndrome, a disorder that runs largely unchecked in most medically under-served populations because of poor diet and lack of physical activity. I was excited to get my practical knowledge underway with  my new preceptor. My preceptor had two medical students assigned to his service at the same time. It turned out later that the other student rotating with me was my rotation partner for all of third year so we were great friends and become even closer.

We met our preceptor in his office and he led us to one of the medicine floors in the hospital. He had made a short list of his patients who were willing to have us use them for our history-taking practice. I entered the room of a middle-aged gentleman who was hospitalized for jaundice. I quickly went thorough my script of questioning this very soft spoken man who lay quietly in bed. I came to find out that he was a physician who had been diagnosed with a biliary disorder that would kill him without a liver transplant in the next two weeks. He was kind and patient as I asked all of those questions about family history, social history, medications and the like. He asked me to stop by later that evening and read my historical write-up back to him. When I stopped by, he helped me organize the information and provided invaluable assistance in thinking about how to question patients. We chatted off and on for a week, until he received the word that he was being transferred for his liver transplant. I saw him three weeks later when he was ready to leave the hospital with a new liver, a new life and such joy!

I practiced with  my stethoscope on my own chest. It became very satisfying to lie in bed at night and listen to my own heart sounds. I listened to each sound appreciating the tones and timing. I also listened to my breath sounds, over the trachea, over the bronchi and over the lung parenchyma. I practiced listening to each heart valve and learned to appreciate the subtle differences between the sounds a the pulmonic site versus the sounds at the mitral site. I appreciated the split in my second heart sound with my respiratory cycle. If I could appreciate the subtleties of my own chest, I would be able to pick out abnormalities on my patients.

That pesky opthalmoscope was the biggest hurdle that I had to cross. The first thing that I did was learn to operate the light and aperture. Since I have no visual defects, I always start with the diopter setting on 0. I also quickly learned the utility of performing this examination in a dim room as bright light makes the patient’s pupils quite constricted. A dilated pupil is easier to examine. The other useful piece of information is to start with the opthalmoscope light dim so that you don’t blind the patient while you are attempting to examine the retina. At first, I could just pick out the “red reflex”. Soon, I found a vessel and later, I learned to focus sharply on those vessels and follow them to the optic disks. In short, there is a learning curve that is most quickly overcome if you force yourself to examine the retinas of every patient that comes into your office. If you don’t practice, you won’t learn to do an adequate examination. I would wager that most physicians out in practice today, other than the ophthalmologists and neurologists, do not perform an adequate retinal exam.

When it came to learning the rectal, pelvic and breast exams, we were taught by professional “patients”. These people knew the exams and used their own bodies to teach medical students. On the pelvic exam demonstrations, one of the demonstrators indicated that she was in the middle of her menstrual cycle. One of the male students in my group, left the room and never returned. I never found out how or if he learned to perform a pelvic examination but those demonstrators were excellent. They allowed us to practice and pointed out landmarks and hints that were invaluable. I found myself thinking about the type of person who is willing to become a professional demonstrator of breast, pelvic and rectal exams. While the job pays well, I would have to cross it off of my list of things to do if I needed loads of money quickly.

The neurological examination is the most fun to perform and write up. I found myself collecting an odd assortment of instruments to test sensations of hot and cold (I used capped test tubes filled with tap water); vibration (tuning fork), smell (alcohol pads, nail polish remover pads); color sensation (photos); light touch (feathers of various colors) and sharp versus dull (paper clip). I had a small bell and a small stuffed kitten as objects for my patients to name. I also collected a tape measure for lesions and an assortment of cotton swabs and tongue blades for cranial nerve testing.

I learned to perform my history while I was performing my physical examination. I would start with the head and ask about problems with headache, earache and vision. I would examine the eyes and nose while asking about sinus problems. I went from head to toe asking questions as I moved along. I always save invasive exams like pelvic and rectal for the end of the exam. While the patient is getting dressed, I would jot down my pertinent positive findings and spend the rest of the time chatting with the patient and explaining my findings. At this point, my preceptor would usually join me and we would discuss the treatment plans for the patient together.

The most important thing that I learned in this class was the value of communicating with your patient. I probably learned more from my patients than they learned from me. I learned to listen to their words and put their words and my physical findings into a cogent clinical plan for treatment. I also learned the importance of just getting to my patient’s fears, concerns, likes and dislikes. When a physician touches a patient, there is a relationship of trust that is begun. Your patient trusts that you will use everything that you have learned in biochemistry, anatomy, pathology, pharmacology and physiology to figure out what you can do to get them healthy and keep them healthy. There is a puzzle and the pieces must be fit together for the good of the patient.

I also came to appreciate the sanctity of the apprentice-mentor relationship that I had developed with my preceptor. In no other profession is that relationship so important than the attending physician/medical student. My preceptor was indeed a master and I was a very willing student. He led me through the maze of various patient encounters and kept me coming back for more. It was truly magical in many ways.

Finally, I mastered that opthalmoscope during the last week of my Physical Diagnosis class. I was quite comfortable with my exam and I appreciate the art of being able to make a diagnosis. While this class seemed to be quite intimidating at first, it became one the the sentinel courses in my medical school experience. After five plus years of practice and thousands of patients later, I wonder if my preceptor knows how many thousands of patients he has touched through all of his students.

Surgical Clerkship 101 (Part 3)

This is the last in my series about surgical clerkship. In this essay, I thought I would address some of the things that can go wrong and present some strategies to fix them or do “damage control”.

Misunderstandings or Miscommunication – Communication in medicine – any specialty- is a key component. Learning to listen carefully to your patients, your colleagues and your teachers is of paramount importance. Sometimes anxiety or time prevents you from actually “hearing” the message. This happens to everyone and especially to people who are trying to juggle several tasks at the same time. If you make a mistake, own up to it, apologize and move on. Don’t internalize and don’t personalize anything on any clinical rotation. It is very easy to miscommunicate when you are under pressure and in unfamiliar territory. When you find that you have misunderstood something or that someone has misunderstood you, acknowledge the mistake and keep moving forward. Forgive yourself, forgive others and move on as misunderstandings/mis-communications are part of being human.

Not telling the Truth – This goes along with miscommunication and mistakes. Don’t lie about anything. If you didn’t check something, acknowledge your mistake and let it go. Make a note to yourself not to repeat the mistake and leave it at that. Many times, especially when you are tired, you will forget something. Again, make notes to yourself if you forget something or did not do something but don’t lie about anything that you did or did not accomplish. Your ”word”  in medicine is golden and your career, your patients’ lives  and you colleagues trust all depend on your word and its truthfulness.

Grave errors – I remember an incident when I was an intern. A fourth-year medical student was attempting to re-wire a central line and made a fatal error that caused the death of a patient. In the defense of the fourth-year student, he/she was not supervised and wasn’t familiar with central line rewiring. In defense of the resident on whose service this student was rotating, he/she did not know that the student had not performed the procedure unsupervised. In this case, the student and resident was reprimanded but both owned up to this grave error. The worst problem is that this student will carry this incident for the rest of his/her life.

In short, never ever perform a task or procedure unsupervised unless you are sure of what you are doing. In any procedure, especially the invasive ones, you should be able to explain the procedure to the person who is supervising you along with any complications that can arise and how you will handle them. When you are learning procedures, learn them from preparation, performance, complications and management of complications. The learning curve for things like central lines is usually 10 supervised before you do the procedure unsupervised.

Personality Conflicts – There will be people on your team (nursing personnel, fellow students, interns, attending physicians) that you will not get along with. In my opinion, personality conflicts have no role in medicine as they are counterproductive to good patient care. When I have encountered a personality conflict, I will defer my feelings as long as the care of my patient is not compromised. In short, my business and my job is to be able to work with each member of the team as professionally as possible for the benefit of the patient. As I have said in other essays, the clock ticks and you will not be around this person for the rest of your life. Be sure that you don’t burn any bridges behind you.

Another rule of mine is that I never discuss my colleagues with anyone except the person that I am having the conflict with. I don’t have time for gossip and I never allow negative comments about my colleagues from nursing or other people. One of my jobs as I have moved through residency has been to evaluate others. In these evaluations, I have readily admitted when I have a personality conflict and tried not to allow this to interfere with my evaluation. If I place something negative on an evaluation, I always cite the reason and what I believe the person can do to improve the situation. I also do not place negative information on an evaluation unless I have warned the person and asked them to correct the behavior which is the object of an evaluation in the first place. In short, check your ego at the door when it comes to patient care.

Time Management – There are 24 hours in a day and you do need rest at some point. Don’t try to ignore your body’s signals when you are tired. Manage your time so that you get some rest (it’s never going to be enough) and take care of your physical needs (eating, hydration). When you start a new rotation, you won’t be as efficient as when you end the rotation because you don’t know the procedures. Pay close attention to your interns and residents and ask for help. Never be too proud or too afraid to admit when you are overwhelmed. Also, avoid drugs to “keep you going” as these often bring on personality changes that can cause problems.

Most chief residents and interns will allow you to rest when there is nothing of educational value going on. If you are told to leave (go home), do what you are told to do. Don’t hang around the hospital but leave. If you are not tired, go to the library and study or go home and study but don’t hang around. You won’t get too many opportunities to “leave early” on most surgery rotations. If something is going on that you want to observe, ask your intern or resident before you go off and observe. Don’t ever leave one service to “hang out” with another without permission from your intern/resident and the agreement of the intern/resident of the service that you are “hanging out” with.

Helping Your Fellow Students – If your are efficient at getting your work done, help your fellow students if they need it. Your fellow students are your colleagues and sometimes they just need a hand at some small chore. If you are able to lend this hand, do so.  Share information with your fellow students if you have something that is useful to the team.  Your fellow students are not your competition at this point. Try to do what you can for the good of everyone. If someone has an emergency, offer to switch their call (let your chief resident know) and do so if you can. You never know when you might need the favor returned.

If one of your fellow students mistakenly keeps trying to manage your patients, show off to the residents and attendings, speak to this person about their behavior. If they continue in this aggressive behavior, let the intern/resident know what is going on. I can tell you from experience that quite often, the chief resident is aware of what is happening and will deal with the problem. Your job on any clerkship is to learn as much as you can. If someone, fellow student or resident, is interfering with this process, the clerkship manager/dean should be made aware of the situation. Ask for a meeting and come prepared with examples of how your education is being compromised. Offer solutions to the problem too. As I said above, personality conflicts have no role in medicine but nothing should interfere with your learning. Make sure that you outline that problem and depersonalize it before you present it. Most of the time, learning interference problems can be solved by good and honest communication as opposed to “running to the clerkship manager/dean”. Reserve going outside the team for things that you cannot solve within the team.

Beware of the fellow student who is “going into surgery” and feels the need to scrub any cases that he/she deems interesting. Do the cases that are assigned to you and don’t let your fellow students take your cases. If this is happening on a regular basis, that is, you have scrubbed 15 hernias and nothing else while your colleagues are getting all of the interesting cases, check with your chief resident. On the other hand, if you are just scrubbing the “easier cases” so that your inpatient list is short, your grade may suffer. Don’t be afraid to tackle a complex patient and a complex case. You will be surprised at how much you can learn by digging in and taking on the assignment.

Attitude – I have said that attitude is everything in clinical medicine. Approach each rotation with the attitude that you will master what you need. You don’t have to “love” everything that you are doing but you do need to be able to give your patients your best work regardless of whether or not you love the rotation or anticipate entering the specialty.

Ask for feedback early and often. No one was born knowing how to perform on a rotation. A five-minute “how am I doing conference” with your intern and resident is not a bad idea early in the rotation. Listen to what they have to say and make notes of what you need to improve. Practice your skills and add to them. Keep a running list of procedures that you have done complete with the names of patients, date of procedure and supervising physician.

Problems in the OR - Don’t get into a ”pissing match” with any of the Operating Room personnel. If a scrub person tells you that you are contaminated, step away from the field and take care of it with a “thanks for pointing this out” attitude. I can tell you from personal experience that some OR personnel will try to ”get to you” because you are male, female, human, and other characteristics. Let this stuff go as long as they are not interfering with your knowledge. As an assigned medical student, you have a role in every case that you scrub. You are not to be ”pushed out of the way” by anyone. If this happens, discuss it with your attending or chief resident after the case but don’t get into a shoving match during a case. This rotation is part of your medical school education and you are paying good money for this experience. Don’t allow anyone to compromise your learning experience.

If you feel “faint” in the OR, step back from the table. You can just say, “I need step back” and everyone knows what is happening. The circulator will usually stick a stool under your before you fall. It also goes without saying that you should never go into a case with a full bladder or an empty stomach. Keep some kind of a snack in your coat pocket and keep hydrated too. If you are feeling ill, don’t scrub especially if you have a fever. Explain the situation to your resident/attending and don’t scrub the case. If you are “sick” for every case, your grade may suffer but on at least one occasion, students DO get sick and should not be in the OR.

Remember that too much caffeine will make your hands shake. I have found from experience that caffeine doesn’t alleviate fatigue and doesn’t make you more alert if you are exhausted. Things that help me fight fatigue are rest, hydration, good physical conditioning and fresh air. A cup or two of coffee/tea is not going to hurt you but downing cases of cola or pots of coffee/tea will not help you and may compromise your health, not to mention the diuretic effect of caffeine. Use this drug with caution and avoid overuse.

Grades – You should know ahead of time, how your grade is going to be calculated for any rotation. Be sure that you are not neglecting the projects and performance objectives of your rotation. Go back and look at your clerkship objectives weekly to be sure that you are accomplishing what you need to accomplish. If you have been assigned to a Cardiothoracic team, be sure that you are not neglecting your reading when it comes to hepatobiliary conditions. Your shelf exam is going to cover all aspects of general surgery, trauma, critical care, orthopedics and cardiothoracic surgery. Be sure that you neglect nothing.

Be sure that you continue to hone your diagnostic skills. Even if you are going into primary care, you need to be thoroughly familiar with the diagnosis and treatment of the acute abdomen. In short, you need to be totally familiar with the instances where you need to “consult” surgery. Every case of abdominal pain does not require a surgical consult and you will quickly lose the respect of your surgical colleagues if you consult them before you have done a complete work-up. Be sure that you know why and what you need from any consultant and are not using them to do your work.

Physical Limitations - If you have physical limitations that do not permit you to scrub the longer cases, the let you chief resident know ahead of time. If you have a chronic condition such as diabetes, multiple sclerosis, cerebral palsy or other physical limitations, these should have been discussed with your clerkship preceptors and the residents should have been made aware of your condition. These should not be done in front of the rest of the team but you should make sure that the people who need to be aware of your condition are aware. This is especially true if you are pregnant and are having complications. If you become pregnant during your surgical rotation, be sure that your preceptors knows what is happening and is made aware of any problems that encounter. Again, this rotation should not place you (or your/your unborn child’s health) in jeopardy. I have had medical students who were physically challenged who contributed more to the success of my surgical team than some students who didn’t have these limitations. In these cases, I didn’t run the stairs with the team or make that person scrub the ten-hour cases without a break.  In the end, it all evens out.

Remember that your chief resident and attending physician preceptor are not your enemies. You need to have a good working relationship with them and good communication with them. You also need to be proactive about your learning by keeping up with your reading and adding to your skills whenever possible. General Surgery often moves very quickly and decisions must be made with incomplete data gathering. If you don’t understand how a decision was reached, ask the resident to go through this with you.

Have the attitude that you are going to be a valued team player because you are. You are not the “scut person” and you are not on a team to be the “butt of jokes” by your residents or fellow students. Pitch in and refuse to be alienated by things like occasional “locker room humor”. Don’t personalize anything and learn from your mistakes.