State of the Med Student: The Road to Residency Edition

Sunday, January 14, 2018

Photo by Glenn Carstens-Peters on Unsplash

As the interview season begins to wind down for me, I find myself with a lot of thoughts rolling around in my head. There are so many things to think about, and as I prepare to make my rank list, the gravity of the entire process looms large. This is the last part of this experience over which I will have some kind of control. After this, my rank list goes into a computer, gets fed into an algorithm, and on the other end, hopefully a match pops out, and that's where I'm going for 3 years. Craziness. So, as a way to try and organize my thoughts, as well as give you all some insight into the residency matching process, here's what I'm thinking about when I'm making my mental rank list.

Size of the Program

I've interviewed at teeny programs that take 6 residents a year, and programs that take 21 residents a year, as well as everything in between. The programs always ask what about their program made you apply, and since you can't say, "I literally applied to 100 programs because for the love of God, I just want a job," you have to come up with something. I usually went for the size of the program as one of my reasons, as it's low-hanging fruit. Also, it was true. I see good and bad things to having both small and larger programs. I like the idea of the closeness of a small program, but it makes me nervous about covering all the work with just 6 people. What if someone gets sick? Or goes on maternity leave? Also, what if I really don't like one of my co-residents? With only 6 of you, there's nowhere to go to get away from someone with whom you don't really get along. I like the idea of a larger program because there's more people to spread the work between, more people for coverage, more people with whom to make friends. But it's also potentially less personal and a little more likely for cliques to form. In the end, I'm coming down on wanting a slightly larger program than a teeny one, probably in the 12-21 range.

Call Schedule and Nights

Regardless of where I go, there's going to be call and it's going to suck. With the change in duty hour restrictions, interns can now take 24 hour call, which they used to not be able to do. I have mixed feelings about it, mainly, "Ugh, working 24 hours is going to blow," and "At least I'll get used to it?" and "Continuity of patient care is really important!" (Mostly that first one, though.) I'm also going to have to work nights. Fortunately, most of my programs have switched to a night float system, where you do 3 weeks of days and 1 week of nights, as opposed to taking a night every 4 days or something. I definitely prefer the night float situation, so that's a mark in the plus column for programs that have that.

Resident Education and Teaching

Every program is going to have resident education, because let's be real, the whole point of residency is to learn as much as you can so you can pass your boards. A lot of places still do noon conferences, which is nice because then you can eat your lunch (theoretically) while listening to a lecture. The downside is that it's hard to get off the floors to go to noon conference on time, and even though the time is supposed to be protected (which means no one gets paged or called), there's still a lot of phones going off and interruptions happening. Because of this, some places have switched to an academic half-day, where for 4-5 hours once a week, the residents go to educational lectures, seminars, workshops, etc. The time is easier to protect, because it's longer, and it's easier to block off an entire afternoon where the attendings or NP's and PA's take your phone, rather than an hour every day. But.... 4-5 hours is a LONG time to sit and be lectured at, so hopefully, more places will start doing case-based learning. I prefer the academic half day, myself. Also, places that have dedicated board prep education score higher on my list. Another thing to investigate is whether the attendings actually like teaching. The residents are the best source of information for this, and so far, I've heard both the positives and the negatives about the teaching faculty. I've also been fortunate enough to see some of the teaching in action, which is nice. Residency is where you truly learn to be a physician, so having teachers who are invested in that goal is really important.

Research Opportunities

While I know I want to do mainly clinical medicine, I do want the opportunity to use my MPH and actually do some research during my residency. More importantly, I'm going to need research to apply for fellowships after residency, and I want to be in a place that has good support for that. All programs require a Quality Improvement project as part of the residency, and some require further research beyond that. There are some programs on my list that have a lot of financial support for research, like paying for you to attend conferences if your research is accepted, which is a nice bonus. Other places provide a research mentor from the start, where some programs leave it on the resident to seek out a mentor. I definitely prefer a program with more research support, so looking at how many residents have had research published or accepted at conferences, as well as what kind of financial and institutional support is already in place, is a good way for me to stratify my programs.

Fellowship Success

I'm 99% sure that I'm going to do a fellowship after residency, so I want a program that has good success matching their residents into fellowships, especially at large, academic, centers. I also look at what specialties residents have matched into for fellowship, as (at least right now), I'm interested in heme-onc. All of my programs seem to be 50/50 split with residents going into primary practice versus those going into a specialty, so that is a good sign to me that the program is well-rounded and has support for both options.

Resident Wellness

No one is ever going to lie and say that residency is easy. I'm sure I'm not prepared for how hard it's going to be. (Maybe I am, because I'm convinced it's going to be the worst experience of my life, so anything that doesn't make me want to die every day will be a pleasant surprise...? This might not be the best approach here.) Anyway, knowing my own mental health journey, I know that I need a program that takes resident wellness seriously. This isn't just knowing that a program has random yoga classes, but that the administration is committed to combating resident burnout and that there is mental health support available through the health insurance. I'm pleased to say that most programs I've seen do take this seriously, which is definitely a tick in the plus column.

Benefits 

This is pretty straight-forward. Salary and insurance are pretty standard, but things like daycare on campus, money for books and technology, a moving allowance, and free parking are highly variable between programs. For some of my programs, I like one just as much as another, so the little "creature comforts" like those can make a real difference.

Location

This is admittedly not very high on my priority list, which is kind of nice in a way because I'm not beholden to stay in one area or another. It's becoming increasingly evident that regardless of where I match, we're going to be moving to a place where Ken will need to find a new job. (There is one program that is local, but I am not in love with it thus far.) Even if I did match locally, we want to move houses, so we're going to be packing up and going somewhere. There's a part of me that wants to stay in NJ, even if that means moving to northern NJ, because it means Ken can stay in the state pension system. There's also part of me that wants to go somewhere new, though. I've lived in NJ for my entire life (except for a few months here and there in college and then in med school the first time), and I feel like my "new family" and I need a new start somewhere else. Maybe now is the time to do that? It's so hard to tell!

Intangibles

There's a culture and a feeling to every program, and there's no way to quantify it. At least for me, there's always been an initial vibe for each place and it begins when I get into the town or city where the program is located. From the minute you meet the residents, you can get a sense for how happy they are. Even if they're exhausted, you can tell whether they're run into the ground or just regular residency tired. There was one program where I interviewed where it was 100% obvious that the residents were beaten down and were barely keeping it together. That, among many other reasons, is why I'm choosing not to rank that particular program. There have definitely been programs where I've fit in with the residents a lot more easily than others, and that definitely matters. The programs where I felt like I had known the residents for awhile within the first few minutes of meeting them score higher on my list than those where that didn't happen.

At the end of the day, all of the ACGME accredited programs have to have certain things. The training will essentially be the same. What will vary is how diverse the patient population is, how much pathology you see and how varied that pathology is, and perhaps most importantly, the people. The best advice I've gotten so far is to think about who you want to be in the trenches with when everything goes sideways. That is definitely something I've been able to get a feel for, and it's the hardest attribute to try and explain to other people. 

So, that's just a few of the things in my head as I mentally make and re-make my rank list. It certainly isn't all of them, and in fact, I have a spreadsheet that details everything. Of course, every time I look at it, I get slightly nauseated and close the file, so I'm not sure how much the spreadsheet is actually helping. My AP English teacher used to joke that she would take our papers and throw them down the stairs, and the ones that went the farthest got the A's. I'm thinking of doing that with all of the folders full of information from all of my interviews.

There are 38 days until the rank list is due, and 61 days until Match Day, so I guess I'll be freaking out about this until then. At least after the rank list is due, there's nothing to do but wait 23 days for my fate to be handed to me.

Until then, I'll be here, clutching my spreadsheet and probably throwing folders down the stairs. You know, normal things.

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