I am in the middle of my 4th year and have had the luxury of traveling all over the country for my rotations. During this time, I have had to explain to many friends, family members, and strangers what exactly it is that I’m doing and why it requires me to travel so much. For the record, it is not required for every medical student to travel as much as I have, it is that I have the flexibility and the opportunity to travel so much and I have taken advantage of it.
Because I feel like a broken record at times, I decided to write about medical school and what exactly it is we do for 4 years (and beyond) and why it is that you don’t see us for years at a time, in many cases. I’m going to go over a lot of terms that we throw around and just expect you to know.
Pre-clinical years refer to 1st and 2nd year of medical school. It is called pre-clinical because 3rd and 4th year are called clinical years haha (I’ll talk more about this later). First and 2nd year of medical school is similar to grad school and college in that medical students attend lectures, take exams, complete projects, participate in small group work, etc. We cover the topics that are necessary to take care of people: anatomy, physiology, biochemistry, immunology, neurology, cardiology, and all the other body systems. We learn about normal anatomy and physiology as well as abnormal/diseased anatomy and physiology. The way the schedule is arranged varies from school to school. Some schools do all normal anatomy and physiology 1st year and then all abnormal anatomy and physiology in the 2nd year. Other schools, like mine, do it in blocks. For instance will cover everything related to neurology from embryology to pharmacology in one block. We repeat that for every body system. The preclinical years provide the knowledge base for the years to come.
During the 1st and 2nd year of medical school, we spend all day everyday in class (almost quite literally). My school for instance, we have lecture, lab, or small group sessions from 8AM-5PM Monday through Friday with 3-4 hour exams every other Monday. For a frame of reference, medical school equates to about 37 credit hours a semester. We finish a semester-long undergraduate class-worth of material in about 2.5 weeks, every 2.5 weeks. Our semesters are 18 and 20 weeks long. If you majored in biochemistry in college, we will finish the material covered by your major in about 3 days. That’s 3 days of a 5-week course!
When your medical student says I’m studying and that’s what they said last night, and the night before, it’s probably true and it’s because they feel like they’re drowning in the material that is being presented to them, as many of us do feel this way many a time in medical school. There’s a saying, that I hate, “medical school is like drinking from a firehouse.” I hate it because it doesn’t really relay the immensity of medical school, especially the first two years. If you find yourself constantly being told by your med student that they can’t hang out or go to dinner because they have to study, please don’t give them a hard time about it because trust me when I say, if they could hang out or go to dinner they would be there in a heartbeat. Hassling us about never being around makes this whole process that much harder. As it is we are sacrificing so much to pursue our dreams.
Clinical years, like I mentioned before, are the 3rd and 4th year of medical school. They are called clinical years because we get to be in clinics and hospitals!!! It’s that golden moment that every medical student is waiting for, seeing a real patient! Consider the clinical years as a series of short internships where we are a part of the care team for patients in hospitals, clinics, and doctor’s offices. We will see patients alone or with other members of the team. We will write notes about our encounters with patients. We will come up with treatment plans. This is where we really learn how to take care of patients, how to talk to patients, and how to interact with other health care professionals.
I will talk about this later, but internship has a different connotation in medicine than in the rest of the world. So keep that in mind when you are talking to your med student. Refer to them as rotations or clerkships. Also, you might here us throw around words like inpatient and outpatient. Just in case you are not clear on what they mean, inpatient = hospital whereas outpatient = clinic/doctor’s office. We will do a mix of both inpatient and outpatient rotations.
Service is another word you might hear. For instance, I am on the heart failure service this month. It is another word for team.
Third year, in particular, is usually spent rotating through many different specialties. The idea is that during 3rd year one will experience as many of the foundational specialties, internal medicine, family medicine, surgery, pediatrics, OB/Gyn, psychiatry, etc, to get an idea of what one likes and doesn’t like because at the end of 3rd year we have to start narrowing down what we want to pursue after medical school. I’ll talk more a little later about this as well.
A few terms you might here while your med student is on rotations (or while you’re watching Chicago Med or whatever medical show is hot these days. I don’t know. I don’t have time for TV haha).
On-Call: Logistically on-call means that we are in the hospital and able to be reached at any time for any reason. Often times it means that we are also admitting people from the ER to the hospital. We are also responsible for assisting in any “Code Blues” (someone’s heart has stopped) that are called. So, we will be sleeping, eating, and constantly listening to the overhead speaker while we are on-call.
Floors: This refers to the floors of the hospitals where the patient rooms are.
Rounds: As a team we meet and discuss each patient, what happened overnight, what tests were done the day before, and what the plan is today.
Attending: This is the big dog. We are all practicing under the license of the attending who is a full-fledged physician (the grown-up of the group). An attending has finished residency and is usually a board-certified physician in the specialty that they are practicing.
Shelf exams are 2.5 hour multiple choice question exams that are taken after a rotation is completed. It is used as a benchmark to see if we learned what we are intended to learn during most rotations. Not every rotation will be followed by a shelf exam, but many are. As long as your med student is reading up on their patients, paying attention on rounds, and during any lectures given throughout the rotation there isn’t a lot of extra studying that has to be done to pass the shelf exam. Grading for shelf exams and rotations vary at every school, but there is a big push to make a Pass/Fail system.
OSCE (Objective Structured Clinical Examination): Many schools have these in the pre-clinical and clinical years. These are mock patient encounters with actors or as we call them standardized patients (SPs). The SPs at my school are really good for the most part. Sometimes you forget they’re acting. These encounters are graded, usually recorded, and reviewed by students and faculty to see what gaps you may have in your history taking or physical exam skills. The bar is pretty low for these encounters often times. First and 2nd year students will have an OSCE every so often and 3rd years will usually have one at the end of each rotation in combination with their shelf exam. The OSCEs are also used as a prep tool for the in-person practical exam portion of boards that I discuss below.
Fourth year is a great year. Fourth year med students tend to do rotations in the specialty we are planning to pursue for residency. During 4th year, students will be applying to residency, taking board exams (see below), and doing away rotations or audition rotations at hospitals that we are interested in doing residency at. Away/audition rotations can be thought of as an extended interview. These rotations are a big deal to those med students that are doing them. I personally seized the opportunity to live in places that I am interested in instead of staying in Southern California and it has been a great experience. Of note, it is NOT required to do aways/auditions. It is an option used if there is any question of the med student’s competitiveness for getting into the residency program (or if you want to travel a little).
While 3rd and 4th year feels more like work, it still isn’t quite like work for most people. We don’t set our schedules as med students, we don’t get vacation time, we don’t have PTO; we abide by the schedule given to us. This schedule rarely takes into account national holidays, birthdays, or illness. We are given a very prescriptive list of reasons that we can take time off and even with that we can only miss 3 days in a month (this may vary from school to school). Like I mentioned earlier, please don’t give your med student a hard time about missing Nana’s 90th birthday because they are on-call. Please don’t ask us to ask for it off, because there is no way for us to actually do that. I promise you it won’t happen. Please help find a different answer than being physically there. I know your med student will appreciate the thought and effort to include them despite not being physically present.
Boards has become a catch-all term for big exams that we have to take along the way to becoming a full fledged physician. Med students have to take 3 licensure exams (USMLE = MD, COMLEX = DO) during medical school and then one during residency. More than not, these are the exams that we are talking about when we say “boards”.
The first installment, USMLE Step 1 or COMLEX Level 1, is taken between 2nd and 3rd year of medical school. It is a 8-9 hour multiple choice question exam. It’s brutal. Board studying is a serious business. If you thought your med student was a hermit before, wait until they start board studying. You might start to wonder if they legitimately are still alive. The second and 3rd installment consist of a 9 hour multiple choice exam (USMLE Step 2 CK or COMLEX Level 2 CE) and in-person practical exam (USMLE Step 2 CS or COMLEX Level 2 PE). Step/Level 2 is usually taken during 4th year. Every school has different requirements on when these have to be taken.
While the USMLE and COMLEX are technically a graduation requirement, the scores are being used more and more by residency programs to sort applicants. USMLE Step 1 or COMLEX Level 1 is rated as THE MOST important part of the application. Med students tend to lose sight of reality and humanity during board studying and this is kind of why. Don’t be afraid to remind them that there is more to life, but also understand the importance of this one exam in determining their future. This one number could either really help or really hinder an applicant’s chances in certain specialties and at certain residency programs.
Residency Application Process:
In June of our last year of medical school the application for residency programs (ERAS = Electronic Residency Application Service) opens and students can start filling it out. It cannot be submitted until July 15th for AOA (DO) residencies and September 15th for ACGME (MD) residencies. The average number of residencies applied to is 36.4 across all specialties. It varies greatly from specialty to specialty. Surgery had the highest average number of residency programs applied to with 58.2 and psychiatry had the least with 21.7. There are a few key aspects of the application that you might hear your med student complaining about: 1) personal statement (the bane of my existence right now), 2) Dean’s letter/MSPE, 3) Letters of rec.
The personal statement is the only part of the application that medical students have FULL control. This is a one page essay where the applicant discusses why they are pursuing the specialty they are, what they are looking for in a residency program, and what the applicant will bring to a residency program. Despite being short, it’s a beast to write. It takes a lot of time and effort, both of which are limited during the end of 3rd year, beginning of 4th year. This is rated as the 5th most important part of a med student’s application.
The Dean’s letter/MSPE (Medical Student Performance Evaluation) is a compilation of all our rotation grades and evaluations. This is rated as the 3rd most important part of a med student’s application. We have no control over this other than rocking each rotation and shelf exam and doing our best to impress our attendings.
Asking for letters of recommendation is always and will always be one of the most awkward encounters that you will have with a human being. Even if you had a great experience with the attending, it is always just weird, but it is a necessary evil. We need 3 letters for the residency application. It is also a really big component of the application. This is rated as the 2nd most important part of a med student’s application. Having good letters as opposed to generic letters will go a really long way for applicants. Attendings are able to compare you to other students, talk about your ability to be a team player, and discuss whether or not they feel you are ready to take on more responsibility. Finding letter writers, good letter writers, is somewhat stressful.
In addition to rotations 4th year med students will be traveling for residency interviews, usually from October to January. A med student MUST have an in-person interview with a residency program to be considered for the program. Skype won’t cut it. Interview days are a production. We usually spend the entire day and the night before, and sometimes the night of, with individuals from the residency program. We, unfortunately, have to foot the bill for the travel related to interviews. Some programs have deals with local hotels and most feed you during the day, but you have to pay for transportation at the very least. The average number of interviews is 12.3. Students will spend on average $3,400 on interview-related costs. This also varies widely from specialty to specialty. Those applying for neurosurgery residencies spent the most on average, $6,900, and those applying to family medicine spent the least on average, $1,900. So if we start pinching our pennies you know why.
Rank Order List (ROL): Once interviews are over, med students have to decide which program is #1, #2, etc down to their last choice. Again, an applicant can only rank programs that they interviewed at. However, one does not have to rank all the programs that one interviewed. If an applicant does not want to go to a program for residency then they should NOT rank that program.
When making the ROL, it is difficult to not let what people have said to you during and after the interview, but in the long run, med students really need to take what people say with a grain of salt. While no program or resident is going to overtly lie to you, you don’t want to get your hopes up for matching at a program. ROL should be made based on the applicants preferences, and those preferences will vary from applicant to applicant.
If they are applying to AOA residencies the ROL is due end of January. If they are applying to ACGME residencies the ROL is due end of February. Once the deadline passes, it cannot be changed. Talk about a scary moment. The residency programs also compile a ROL of the applicants they interviewed. Once the ROL from both parties are submitted, they are put into an algorithm that tries to match the applicant with it’s top choice. If the applicant cannot be matched to their first choice, then their second choice and so on. Here’s an example of the algorithm. An applicant will only be matched with one program. Applicants are NOT given options. The results of this algorithm are then presented on Match Day.
The Match: It turns out that there a number of matches, the Military match (in December), SF match (in January and is for Ophthalmology and Plastic Surgery), Urology match (in January and is also known as AUA Match), DO match (known as NMS Match), MD match (known as NRMP Match). The commonality between all these matches is the applicant will find out where they will be doing their residency training following medical school graduation. I’m going to talk about the NRMP Match since that is the one that most people participate in and the one that most people think of when you say The Match.
The NRMP Match is always the 3rd Friday of March, every year. The Monday preceding Match day, all those participating in the NRMP Match will receive an email that says “Congrats, You Matched” or “I’m sorry, you did not match” and that is it. There are no other details. The details are sealed in an envelope that all (or most) medical students will open at 12PM EST on the third Friday of March. It’s kind of cool that the whole country is doing this at the same time. About 95% of medical students match into their top 3 choices. With that being said, if you’re at the Match Day celebration with your med student, give them some space while they’re opening their envelope. While getting their 3rd choice is still good, it’s not their 1st and that might be a little disappointing in the moment.
What if you don’t match?
The dreaded scenario that every med student hopes they don’t have to deal with. If a med student receives an email saying, “I’m sorry you didn’t,” they will begin the Supplemental Offer and Acceptance Process (SOAP). This used to be called Scramble because an applicant would be scrambling to try and find a residency. The SOAP begins the Monday afternoon of Match Week. Those who received that unfortunate email will submit applications to the programs that did not fill all available positions. Programs will view the applicants applications and create a preference list. The SOAP process gives more power/preference to the program than the applicant. Whereas the Main Match gives more preference to the applicant. Five rounds of offers by the residency program and acceptances/rejections by the applicants. The rounds occur in pretty rapid succession and end the night before Match Day (Friday). This process is SO stressful. Hope for the best for your med student on that Monday.
You may hear someone refer to the Couples Matching. This is for individuals who are in a relationship with someone graduating medical school in the same year and want to live in the same city for residency. The couple does not need to graduate from the same medical school and the couple does not need to match into the same hospital for residency. When the ROL of an applicant is submitted and they indicate they are couples matching, the algorithm will take the partner’s ROL into account when matching the applicant. “A couple will match to the most preferred pair of programs on their rank order lists where each partner has been offered a position.” Unfortunately, this is very difficult to do and many couples end up going through the SOAP. It is not impossible, but it is much more difficult.
Once a med student has matched and graduated, they will continue on to a residency program. Usually they start at the end of June, beginning of July. This is why you might hear people say to avoid the hospital from June to August. There is a whole flock of new physicians that are taking care of you. You can think of residency as an apprenticeship that had a lot of required prior schooling. The specialty your med student is going into will determine the length of the residency program. The primary care residencies (internal medicine, family medicine, pediatrics, OB/Gyn) are all 3 years. The surgical subspecialties (i.e., cardiothoracic surgery) are 5-7 years longs. This is also the first time we will get paid! Residents will on average make $55,000, ranging from $52,000 (family medicine residents) to $65,000 (critical care residents). Salary will depend on the specialty, location, and year of residency. Keep in mind that almost half of med school graduates have over $200,000 in student loan debt!
The first year of residency is always called internship. I honestly don’t know why, but the first year of residency your med student will be called an intern, not always a resident. Technically they are a resident, but most people will refer to them as an intern. Subsequent years they will be referred to as a resident.