March madness ...

“Luck is what happens when preparation meets opportunity.”

~Seneca

I love the NCAA tournament. Every year there is a team who goes further than predicted. I join a poll every year and every year I am high on a team that gets knocked out early. When the brackets come out, all of the analysts put in their 2 cents. Dicky V always has an opinion. "It's march madness baby."

Every year there are teams on the bubble. The "at large" bids are the big question. Which bubble team should be in the tournament? Each year there is a team that has an argument. This year it is Arizona State who missed out while the team they beat twice, Arizona, made it. Dayton may have an argument as well. For the tournament committee, it can't be easy.

Tomorrow is known as Black Monday. The day that all resident applicants find out if they matched or did not match. I remember this day well. I previously posted about how the process had affected me. Black Monday reminds me of tournament Sunday. Teams on the bubble sit waiting to hear if they are in the tournament.

To all of you in the match, good luck.

“Serendipity. Look for something, find something else, and realize that what you've found is more suited to your needs than what you thought you were looking for.”

~Lawrence Block

Good night moon ..... Good night stars

“Do not spoil what you have by desiring what you have not; remember that what you now have was once among the things you only hoped for.”

~ Epicurus

Match day is tomorrow. I feel like it is Christmas and I can't wait to open my gifts. We get a new group of bight eyed new residents egar to save the world, or may be a limb. It excites me.

Unfortunately, all of those who are waiting to find out where they are going to go will probably not sleep tonight or drink themself to sleep. Those who have matched will be should be excited as I am ready to start their new life. I am almost giddy.

I say to you all, welcome. Welcome to the specialty that inspires me and I hope you are also inspired. Do your best to keep that youth and egarness in you. Remember this day. Eventhough you may not get your first choice, you are IN. Make the most of what you have. You will be an orthopaedic surgeon. (Smiley face) So, good night moon and good night star because you are about to find out where the wild things are.

“Limitations live only in our minds. But if we use our imaginations, our possibilities become limitless.”

~Jamie Paolinetti

The match is coming .... the match is coming ....

“"But I don't want to go among mad people," said Alice.”Oh, you can't help that," said the cat. "We're all mad here."”

~Lewis Carrol

For all of those waiting for that magic envelope that will becoming next week, you are probably filled with angst and apprehension. For those of you who match into my chosen specialty, I welcome you; and for those who don't, I wish you well. Regardless of your outcome, remember this is only the beginning of a long journey of learning. Your education has not stopped, it has just begun. You will realize in the coming years that with more understanding come more questions; and more questions lead to reassessing you knowledge. Once you reassess that knowledge, you will realize you don't know as much as you think you do or should.



Young padawan, everyday is a school day. I ask you to aspire to learn at least one new thing a day, always question your reasons why you do things or why others do things, and continue to reevaluate yourself and your knowledge. Although you may have made it through you first level of education, you have a long road ahead of you. Remember, everything in medical school is in the past; you must again prove yourself and show your worth. You have arrived with a clean slate; do with it what you will.

“You know more than you think you know, just as you know less than you want to know.” ~Oscar Wilde

Calls, Lies, and Letters ....

“The truth is rarely pure and never simple.”
~ Oscar Wilde

I was speaking with one of my residents yesterday about match day. We shared our experience. How it was during the interview process. What we were told. We both had expectations based on what we were told by many people during the process. In our own mind, we had expectations based on information given to us from people in positions of importance. Therefore, on match day, we were both surprised at where we ended up. And we both had an ego deflating sensation based on where other people matched, etc. When I submitted my rank list, I submitted it as I saw it. I placed the 12 programs in the order that I like them, not based on the likelihood of me matching there.

I am a purist. I feel that the match should be done the way it was intended. I like these applicants and I rank them as I see them; you like these programs and you rank them as you see them. So, it kind of bothers me when there are people who make calls and send letters saying that you are in a ranked to match or in a position that has matched in previous years. When information is sent out about being ranked to match, it only benefits the program. The more applicants that have ranked you high, the more likely it is that you can report that you program always gets its top applicants. That is an ego thing. Truth is, we all can manipulate our list so that we get our top applicants. Making calls and misleading applicants can be done as long as there are no “verbal or written agreements”. That is why many letters give ambiguous information.

So, what is my point? The point of the match was to prevent programs from influencing/forcing your decision. I say, "stick to your guns." Rank them as you see them, what are they going to do, say “but you promised.”(sad face) Were all big boys and girls, we’ll get over it.

“Integrity is the essence of everything successful.”

~Richard Buckminster Fuller

Nightmares and Dreamscapes ... the match is coming

“I act like sh*t don't phase me, inside it drives me crazy, my insecurities could eat me alive.”
~Eminem

The match is coming. For all those involved, your emotions are probably all over the place. Your stomach is aching. You can’t sleep. I remember this time like yesterday. I just wanted to close my eyes and sleep until the day after match day. For me, it was like Nightmares and Dreamscapes. Welcome to my mind 2 weeks before the match.

This is the year

where hope fails you

The test subjects run the experiment

And the bastards you know is the hero you hate

But cohesion is possible if we try

There's no reason, there's no lesson, no time like the present

Tell me right now, what have you got to lose?

What have you got to lose, except your soul?

Who's with us?!

Slipknot (Pulse of the Maggots)

Please someone make the pain stop.

Why do we

Crucify ourselves

Every day I crucify myself

lf Nothing I do is good enough for you

Crucify myself Every day

And my heart is sick of being in chains

Tori Amos (Crucify)

Phone rings (RING, RING)

Mother mother can you hear me

I’m just calling to say hello

How’s the weather

how’s my father

am I lonely heavens no

Mother mother are listening

just a phone call to ease your mind

Life is perfect never better

distance making the heart grow blind

When you sent me off

to see the world

where you scared that

I might get hurt

Would I try a little tobacco

would I keep on hiking up my skirt

I’m hungry

I’m dirty

I’m losing my mind

Everything’s fine

I’m freezing

I’m starving

I’m bleeding death

Everything fine

Tracy Bonham (Mother Mother)

There are so many applicants that are better than me .... what if ....

Almost there ...... help ... make it stop

My end It justifies my means

All I have to do is delay

I'm given time to evade

The end of the road is my end

It justifies my means

All I have to do is delay

I haven't time to evade

THE END OF THE ROAD!

Slipknot (Before I forget)

...... Is that my name, my eyes .... I can't focus .... WHAT DOES IT SAY .....

May be your 2 weeks will be better than mine. Sleep well .....

“If you want a happy ending, that depends, of course, on where you stop your story.”

~Orson Welles

The residents and medical students now adays are soft .....

5am this morning .... I am out running ... 8 mile run ... training ... marathon training ... it's been cold outside ... today, cold and a fresh coat of snow ... the numbers of runners are far fewer ... several people walking dogs ... very few footprints in the snow .... I run past a older man (grey mustache and hair) ... I've seen him before ... We are the dedicated few ... continuing our training regardless of the weather ... like the postal service .... rain or shine, we will be there .... we smile at each other with a kind of understanding not understood by those still in bed ....

I look at the young doctors coming into medicine now a days and their perception of what is expected of them and what they are willing to do is less. Will they run in a storm. Will they stay until all the work is done or will they say, " my shift is done" and leave.

Times are changing, but the patients are not. The amount of work that is needed to be done does not. Residency programs are now dealing with how do we adapt to the 80hr work week. It has become difficult for most programs to accommodate the restrictions. A number of things within residencies have changed to adapt to the changing hour restrictions. As programs become more accustom to working within the restrictions, so do the young physicians. They become more likely to schedule those hair appointments during the day (4:30pm or so) etc. The medical students leave without even checking out. I say strange. This is a definite change from when I was a medical student or resident. The expectation is different.

You may say, "Well, it is a different time and place. We don't need to do every other night call or stay in the hospital 2 days straight to be a good physician." And I would say, "You are exactly right." I do not think that you should spend countless hours in the hospital doing nothing. I would agree that more time spent reading and not doing busy work is probably better in the long haul. Andrew Palmer, MD, former president of the American society for Surgery of the Hand, made an opening address several years ago making a plea to many young physicians to find other interests outside of medicine. He felt that after many years dedicating his life to medicine, researching, operating, and teaching, he learned that there is a need to develop other interests. A need to develop yourself without medicine. So, I do feel that this is an important.

The problem we have now is the same problem that you get with unions. Yes, being formed is protective, but a certain mentality develops. The mentality developing now is that of a sense of entitlement. A sense that menial work is beneath them and that they should only do meaningful things. They don't need to prove themselves before we let them make decisions or make incisions.

Some may read this and say, "he is full of it. I am not like that." Well, not now, but there is a changing mentality. We had a visiting lecturer from the UK who gave us a lecture of the system in Britain. He was describing their work hour restrictions and how they have adapted. They are now down to, I think, 48 hrs a week. He says now they have more residents, to cover the time; the number of "hand off" errors have increased; and the operative case number is dropping. He reported to us when the restrictions began, the residents there said, "we will stay, regardless of the restrictions." Now, when time is up they just leave, regardless if they are in the middle of a case or in clinic, time is up and they are gone.

This mentality will creep slowly into the mentality of most as it has done in the auto industry. I fear the development of shift workers. I say that the medical students and residents are weak to incite anger in you. I want you to prove me wrong. Prove to me, yourself, that you have the fortitude to weather the storm, the cold, and the snow. Maybe one day when I am old and grey I will see you and we will smile together with an unspoken understanding.

The rank list - a scientific process?

I sit here in my office thinking about the resident applicants that I am about to interview tomorrow, and I realize that this really is not a very scientific process. We have to go through and interview a number of applicants. Everyone sits down in a room and goes back and forth and tried to remember the people form weeks ago. We go back and forth who we like and who we didn't like. I actually think placing people at the bottom is the easiest part of the whole process. Those people that give you the willies are easy to spot, and it is usually a consensus thumbs down. The middle section is extremely difficult, and the top, sometimes, even more difficult.

At our institution, we review all of the applications to select those who we will interview. We split them into 2 piles, and 2 faculty members review half and the other 2 faculty members review the other half. Then we rank the applicants from 1 to whatever. Unlike some institutions, we actually read the applications first and offer interviews based on what we see. Now that is not very scientific. There is no exact formula; no cutoff by board scores. It comes from a gut feeling. Now understand that we don't have 500 applicants to review. We have a 6 year program, which deters some from applying. Most large programs and programs in more desirable cities have a larger number of applicants and therefore use some way of "screening". For most, the USMLE score is probably use in some way shape or form (e.g. cutoff). Smaller programs, like ours, are more likely to look at other factors like where you are from, the school you attend, your aspirations, where you rotated for AI's. These "other" factors come into play.

I sit here trying to think of what factors I am looking for once we have selected you for an interview. What makes me want to choose you? I guess it comes down to a number of things. We are all shaped by our own experiences. We tend to be drawn to things for different reasons. May be it is your alma mater; or may be we know the person who wrote your recommendation; or may be your personal statement brought to light something that is not evident in you application, something that is unique to you. The interview for most is a snapshot of who you are. I guess for me, I can't speak for anyone else, it is a gut feeling. As an attending, I have to trust you, I need to like you, I need to know that you will be a good representative of me to my patients, as well as, a good representative of our program. So we are shaped by our experiences. Bad previous residents or experiences may cloud our judgment of you (not something you can prepare for). If you come unprepared to the interview (don't know your CV or research, don't know about the program, and don’t have answers to the simple questions like why you are going into orthopaedics), I wonder is this how you will be when you enter the program. So, I guess what I would advise be yourself, know who you are, know your strengths and weaknesses, and some how bring that to the interviewers attention. You need to be able to be your own spin doctor.

So, needless to say the whole rank list comes basically out of some gut feelings. People that make us feel like you will be a good representative of our program. I personally feel that the people that I help train are somewhat a representative of me and our program. When they go onto fellowship, into practice, and present at meetings, I want to be like a proud parent and say that was one of ours.

Do I have a chance getting into an orthopaedic residency?

The first question I would like to put out there is:

Do I have a chance getting into an orthopaedic residency?

I personally think this is a very important question. It is a reality check. And this is something that you have to look at without kid gloves. You can ask you parents and friends (unless they are in the field and honest), because that's like asking you mother if she thinks you are pretty/hansom. You need to be brutally honest with yourself and get someone else to review you application who will be honest as well.

Lets look at what "relatively" objective measures you have in your application that will help you get into the door.

USMLE
This is definitely an area that gets a lot of press. Do programs have cutoffs and what are they? etc. Realize this is the only objective measurement that everyone has in common. So, most programs (I can not speak for all) use it in some way, shape or form, to get the numbers of applications down to a reasonable number to review for interview. Every program is different in this initial process. Some do have absolute cutoffs, some relative cutoffs, and others no cutoffs. It depends on the number of applications to the program. If you have 500 applicants, probably more like absolute cutoffs; if only 150, may be relative cutoffs. Regardless, the test will be used in someway, and you will need to do well on it.

This is were honesty and reality comes into play. If you score low (say 200-215 ave is now around 215), please be realistic. You are probably not going to one of the top 10 programs unless are able to pull some strings.

GRADES
This is something that differs from university to university. Some schools are very liberal with the honors, and others not. Regardless, 2 rotations you need concentrate on getting honors in are surgery and orthopaedics. Now, we can be lenient on the surgery honors, but if you don't honor orthopaedics, you are definitely a tougher sell.

AOA
This may be considered by some, but the elections for AOA are not always complete when the applications come out. So it is difficult to use as an evaluation tool for every applicant. It does in general correlate with the number of honors at most institutions.

RESEARCH
This is kind of hit or miss for me personally. Some applicants decide late, so should they take a year off and do research; find a project to tag on; do a month rotation. I think if you do research, you genuinely need to look as if you want to do research. Get a publication out of it, etc. I have review may applications were the research was kind of half ass, done so they can check that box off on the application. If you decide late to go into ortho, I feel it is better to concentrate on you strengths and make contacts who will be an advocate for you. If that means you end up doing research, fine. Make it look real though.

RECOMMENDATIONS
These need to be strong recommendations with key words. Words or statements like:
1. will be ranked high at our institution
2. we are actively recruiting for our program
3. one of the top students we have had this year; (or even better) on of the top students we have ever had.

Things that you don't want with you letter of recommendation.
1. you would not sign the waive to not be able to review you recommendation
2. a statement like " we tried to persuade him to go in to another less competitive area."

PERSONAL STATEMENT
At most institutions, this does not get read until interview time. In general for most it is a none factor. Most of the statements say similar things like
1. the applicant or a family member had some interaction with an orthopaedic surgeon and that is what made them interested in it
2. the applicant was an athlete
3. the applicant likes to work with his/her hands
4. on a rotation, the application had an experience which shaped his/her decision.

so, for me, I read the statement and if I start to see this theme, no bonus points.

Now this personal statement can be a plus or a minus. It is tricky if you decide to go outside of the norm. If it is too artsy and you sound crazy, minus; if you are creative and interesting, plus. But this is tricky and I would only recommend this for the literary inclined.

SUMMARY
In summary, most of these things are common sence. I don't think I am shedding a ton of light on the situation. The most important thing initially is to be realistic. If you don't have the numbers, you may need some other assistance, like an away rotation or people who can be advocates for you.

And is you are a good applicant (after being honest with yourself), you need to then ask yourself what makes you different. Something to set you apart, otherwise you all blend together.

Orthopaedic residency: the attending's perspective - First Post

Welcome to my first post,

I would first like to make the statement that these opinions are my own opinions and not those of my institution or my department.

Introduction:
My name is Aki Puryear. I am a pediatric orthopaedic surgeon in St. Louis, MO.

Background:
College - Case Western Reserve University
Medical School - Case Western Reserve University
Residency - University of Michigan
Fellowship - A.I. duPont Hospital for Children

OK, enough with the formalities. My sole purpose of beginning this blog is to provide a opportunity for medical students and residents to gain information in regards to:
1. getting into residency, the application, and interview process for the medical students;
2. particular residency questions (fellowships etc.) for the residents.

I would like people to feel free to ask questions and provide comments. Please provide these without the fear of repercussions. This is for information gathering and to hopefully dispel myths and untruths passed down from student to student and resident to resident.

Let the fun begin.