As an early third year medical student, I had a few attending physicians tell me that MD stands for “make decisions.” I find myself subject to these sorts of pep talks when I answer their clinical questions with a response influenced by a high pitched vocal inflection that suggests that I’m uncertain.
For example, while being pimped on the next step in managing a patient, I might have responded with a statement that morphed into a question because my fear of making a mistake betrayed the confidence I had in my training.
“We should check her glucose?” or, “I think we should send her for a chest x-ray?” I’d reply. “You think … or you know?” They would often retort. “Umm … I know?” I’d reply.
Throughout the course of that year, I learned to back up my responses with supporting evidence. I trained myself to say things like: “Given her current vital signs, presenting symptoms and history of sickle cell, I think we should send her for a chest x-ray because I’m concerned for ACS.” This often was enough to earn me some praise, or at least, divert the pimping attention to another student.
In medicine, we often make decisions that we need to be confident in. Some of the hardest decisions, however, are the ones that hit closest to home. We decide to become doctors, decide what type of doctors we want to be, and decide what training program to help bring that decade-long dream to fruition. Unfortunately, the evidence backing up these decisions is not always clear or easily accessible on UpToDate. I think Doximity summarizes it best, “While nothing trumps an applicant’s perception of a program’s ‘gestalt’ after spending a few days on campus, few resources exist to help students discover and compare options throughout the application process.”
Residency is “only” three to seven years in duration, but its effects last a lifetime. Each training program exerts a huge impact on a young doctor’s mentors, influences, professional network, and career trajectory. Selecting a program is one of the biggest decisions an aspiring doctor can make and the process, as I’ve experienced it, can be both financially and emotionally taxing.
Over the past few months, I felt the weight of this decision sharpening my spidey senses, as I traveled from program to program, critically analyzing whether or not each institution would be the place I would call home. I’m incredibly blessed to have been offered the opportunity to visit a number of amazing residency programs, but with each passing interview, I felt increasingly burdened by the prospect of making a decision that seems like Sophie’s Choice.
While the match algorithm, like the Harry Potter Sorting Hat, favors the applicant’s preferences, you never really know whether you will be contractually bound to your first preference, or your last. The National Resident Matching Program reported that in 2015, 78.4 percent of MD-seeking students enrolled in a U.S. medical school matched to one of their top three choices for training. So instead of putting all eggs in one basket, fourth-year medical students need to think carefully about putting most of their eggs into three.
How does each soon-to-be-MD decide which program wins gold, which wins silver, and which wins bronze? According to Dr. James Colletti, the program director of the Mayo Clinic’s emergency medicine residency, a review of the literature on this subject reveals that trainees take a number of factors into account when ranking each residency. I like to think of these factors fitting into three general categories: the people, the place and the program.
When evaluating the people, prospective residents often wonder how happy, satisfied and supported the residents seemed during their visit. They also take note of how well the current residents seem to work together. Other influential elements in this category include the reputation of the program director and whether or not the faculty demonstrates enthusiasm and commitment to resident education. The opinions of spouses and significant others also carry weight in this category too.
In terms of evaluating the place, geographic location and the availability of recreational opportunities are often important considerations. Some applicants even take the quality of the hospital facilities into account. Perhaps this is why so many of my resident tour guides apologized for the creepy or notoriously slow elevators and sometimes avoided showing us the call rooms altogether.
Last but certainly not least, senior medical students tend to examine the quality of clinical training and measure the balance between faculty supervision and resident management of patient care. Many of us recognize that the diversity of the patient population the hospital serves can impact the nature and quality of training too.
As we transition to this next phase of professional development, how do medical students discover which factors are key to personal happiness in residency? In order to give meaning and the appropriate weight to each of these potential factors, it is important for trainees to have a good grasp of their own priorities. According to the Family Medicine Revolution, between today and the day you matriculated at medical school, “your priorities have inevitably shifted, and will continue to shift as you move forward with your training. That’s OK. The big picture, your big picture, might now include family responsibilities, a spouse, and even a child. You have student debt to account for over the next ten years, and the health care environment into which we are starting our careers has become even more dynamic. It’s OK to take these factors into account before you submit your rank list.”
While talking to a fourth-year psychiatry resident about assembling my own rank list, she gave me the following advice: “Write down your top three priorities and focus on the programs that allow you to actively live them. After that, just go with your gut.” Even though this resident seems incredibly happy with her life choices, I’m convinced that she’s right only because Blake Lively, my animal spirit guide, echoed something very similar in a magazine interview. “I feel like I’ve figured out the most important thing to me, and everything supports that.”
I’m in the process of figuring out the most important things and embracing what makes me happy. It’s an exercise that not only has direct implications on the programs I will put at the top of my list, but also have downstream effects on the rest of my life. I recognize that no program is perfect, but I do believe there are a few places that allow me to live my priorities and personality wise, feel like a great it.
Throughout this journey, in times of crisis or procrastination, I’ve relied on the fictional wisdom of Shonda Rhimes and lived vicariously through her characters on Grey’s Anatomy. At this pivotal moment, I find myself reflecting on the words of Dr. Meredith Grey: “There’s the school of thought that says the family you’re born into is simply a starting point. They feed you, and clothe you, and take care of you, until you’re ready to go out into the world and find your tribe.”
Medical school has taken care of me and given me the tools to be advocate. I’m not only leaving the nest with an M.D., but also with the ability to make important decisions for my future patients and for myself. Even though I was not offered an interview at Seattle Grace Mercy West, I hope I am able find my tribe in the upcoming match. My list is almost complete, and before the rank order list deadline, I am certain I will go from “certified?” to certified. Wish me luck!
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