How to Get Into Medical School

Once in a while, I interview pre-med applicants to my school. While the medical students' evaluations are probably influential as only a low-NPV serial-killer screening test, I still very much enjoy doing them. This is because, if the applicants are eventually admitted, I get profuse thank-yous and friendly hellos for the entire subsequent year. Other than this experience, I have no knowledge whatever on the inner workings of the admissions chambers, so my insights are based on some post-call Gladwellian blinks.

Please note that Numbers 1 and 4 should not actually be followed by anyone, and are akin to obtaining a Golden Ticket by serially eating thousands of candy bars, or harassing hundreds of factory employees to unwrap them. It's just not worth it.

1) Take Physics for Poets.
And Literature for Actuaries. PE for Hobbits. Enroll in the easiest courses that fulfill pre-med requirements, and for which you almost certainly can earn an A- or above. The caveat here would be that you'd have to choose a somewhat traditional-sounding major, so it cannot be Fashion Merchandising, Liberal Studies, or Communications. Slightly newer, but still well-respected (and sometimes difficult, depending on your school- be careful!) majors, such as Women's Studies, as well as many interdisciplinary majors (i.e. Latin-American Studies) are considered fine.

My reasoning here is that, when it comes to course-work, admissions committees care mostly (though not exclusively) about Overall and Science GPAs, as well as a notable absence of Cs. A B- in "Physics for Future Nobel Laureates" is worth less than an A- in your standard Calc-based Mechanics course. Don't take any high-stakes gambles.

(For those now tuning in: Do NOT actually follow this advice. Take 4 years of Russian, a Combinatorics class, and a seminar on James Joyce. Keep your life joyous and a bit irrationally exuberant.)

2) Do your Undergrad at State School.
State school makes sense in general, and especially so if you are pre-med. It's generally easier to get an A in the science classes there. I know this statement may draw some contrarian personal testimonies from people who attended The University of Somewhere. The thing is, I know that many of the kids there are just as smart as the ones in Someone University, and that the teacher quality is likely the exact same. But the same student can often be in the top 10% of his Orgo class in a public school (also improving his chances for getting an excellent recommendation), rather than in the middling middle of an equivalent Ivy course.

3)Sign up for at least one test prep program, but not for any live classes.
Study by simply doing as many sample test questions as possible, starting on day one. Then go over the explanations and the reading material for anything you get wrong. You may get many or most questions wrong in the beginning. Still, do not waste time reading through the review books before you start taking practice tests. Take your MCATs in April, not August. Try to get at least a 30, unless you funded your school's infectious diseases institute (Treating Burmese children suffering from infectious diseases is not an acceptable substitute).

4) If Short on Time, Don't Dedicate a Huge Amount of Time to Clinical Experiences
While you should have some shadowing or hospital volunteering experiences, you do not actually need much of it. An EMT who has transported five patients looks roughly the same on an application as an EMT who has worked since age 16, has delivered a hundred babies, and can already interpret EKGs. The AMCAS does ask you how many hours per week you spend on each activity, but 5 hours vs. 10 hours per week probably doesn't get noticed. If stressed and cynical, think of marginal benefits.

(Repeated disclaimer: This advice is about what gets you into medical school, not about what you should do. To become a good doctor, take advantage of every opportunity you can to gain clinical experience. Some people cut corners without any one else ever noticing, but don't allow your values and ambitions to conform to this strategy).

5)Be Specific in your Essays.
When answering questions for your secondary applications, do not write "I am passionate about..." Have a strong, unique opening, even for those one paragraph answers. When addressing why you want to attend a particular school, refer to specific professors or programs. Don't use generic phrases like "Exceptional academics," "Excellent location," or "Outstanding research." Instead, say that you've always admired the [Insert Name] Free Clinic that Dr. [Insert Name] started, and you would like to volunteer there because he sees a lot of patients with [Insert medical condition], which is a disease you may want to specialize in.

(Don't lie. No one will ever know whether or not you are truly interested in that clinic, but to maintain your dignity, try to identify specific features of a school that you do actually care about.)

I know my take on medical school admissions is a bit cynical. However, even the most caring and mission-minded committee members must focus one eye on the US News rankings. The subsequent diplopia means that the theoretically best choices for pre-meds are not necessarily those that insure a successful application. If you find yourself sacrificing too many opportunities, I'd recommend dropping pre-med, enrolling in PA school, keeping your specialty of choice, and becoming a happy, dedicated, and productive clinician.

Psych Consult

Mr. A is a 40-year old male. After checking in his items with the clerk, and obtaining a full evaluation from the ER doc, the psychiatrist and students begin the interview.

Mr. A: You have to check me into the psychiatric unit. Otherwise, I'm going to hurt somebody! And I'm going to kill myself!

Student: Mr. A., Which do you plan to do first, hurt someone else or kill yourself? [Yes, I know it's a weird question, but we use it to assess the viability of the plan. Some patients take the bait].

Mr. A: Hurt someone else first!

Student: Who do want to hurt?

Mr. A: Anyone who pisses me off! I was already going to hurt at least 5 people today, before I checked in.

Student: How do you plan to harm someone else?

Mr. A.: I'm gonna stab them with a fork!

[After full assessment]

Physician: Mr. A, we're going to admit you into the psychiatric unit of the hospital... students can you please bring over Mr. A's belongings?

Student: Clerk, can you tell us which one's Mr. A's locker?

Clerk: Yeah, it's over here. But he only brought one item with him. I think it was a fork.

The Epistemology of Paranoid Schizophrenia

Note: All details, including names, ages, and specific descriptions of conversations with staff or patients have been considerably changed. Sorry, I know that reality blogging is more fun than fake medical encounters. Additionally, the discussion exclusively concerns people with relatively mild or well-controlled schizophrenic symptoms, with whom I can easily engage in conversation.

When the psychiatry resident asked for an update on Tracy, I glibly responded, "Still very delusional. Thinks the CIA is after her."

"She's not delusional!" the doctor corrected. "The CIA or the FBI or whatever agency really is after her. Tracy used to threaten killing former President Bush numerous times. During her last hospitalization, I had to argue with the authorities for hours, to convince them that she's safe for discharge." Thus, my near-designation on my patient's record as possessing this delusion, or a "fixed, false belief," that is not "widely held within the context of the individual's cultural or religious group" was in error. Tracy's paranoia was based on truth.

The interesting part, however, of working with schizophrenic patients is generally not figuring out what is false; Patients have spoken of receiving commands from their televisions to overthrow the "vitamin pill industry," and of obtaining classified information that their true parents are Liza Minnelli and Bobby Fisher. Many patients insist that a doctor or nurse can gain remote access to the contents of their brains, via some transhumanistic, genetic link-protocol of sorts. False belief, check.

Determining what falls under cultural norms can be a bit trickier. One patient, David, believes that he and fellow schizophrenics have powers in the "sixth dimension," on an "etherical, astral, plane," a belief that I'd brand as delusional, if I 1) Knew what it meant, curvilinear coordinates not being my forte and 2) The International Headquarters of the Theosophy Society weren't right in my hometown, flagging this as a possible local cultural or religious belief.

The main challenge in assessing delusions, however, lies mainly in determining which are considered "fixed," or intransigent to reason and the passage of time. A binary "yes" or "no" to describe the "fixedness" of a belief is inadequate. Many patients come to the hospital voluntarily, desperate to rid themselves of fearsome beliefs or voices that they know, at least in part, aren't true. Thus, they demand anti-psychotics that deny the pleasure of dopamine, and beg for mood-stabilizing drugs that inhibit norepinephrine-fueled arousal. And those are just some of the intended effects. Side effects include dystonia, neuroepileptic malignant syndrome, the frog-tongued gestures of tardive dyskinesia, and the rabbit-mouthed oscillations of EPS. Patients are often desperate to "unlearn" their beliefs, and hope to foster distrust of the voices in their head, which so distrust everyone around them.

Tom, one of my fellow medical students, asks patients an interesting question: "What do you think is the percent probability that your belief is true, and what is the percent probability that it isn't true?" Lillian, who's convinced that President Obama promised her $1 million, so long as she refrains from eating, (the Cult of the Presidency is the only thing both alive and well in the psych ward) said "About 5% of me thinks it's true, and 95% of me thinks it's not true." Five percent is not terribly much. I'm sure there are plenty of beliefs I maintain with a similar level of certainty that would confer me with at least an Axis II diagnosis, if someone could scan my brain for the latest Bayesian updates. Which leads me to wonder if percentages and predictions can adequately capture the credos that serve as the foundation for diagnosing paranoid schizophrenia.

For those of us with homo economicus pretensions, such stated probabilities may even persuade us that schizophrenic biases are simply standard deviants from very irrational mean population thought content. Indeed, critics of psychiatry often insist that people are deemed psychotic, simply because their delusions don't conform to what all the cool kids are fabricating this season. In this view, once norms change (like they did when the medical professions stopped labeling homosexuality as a disease), many schizophrenics will be considered as peers among the unhinged masses, with all our opioidic (agonistic and antagonistic both), nonsensical beliefs unleashed.

Perhaps we can focus on a more qualitative approach to evaluating "fixedness." After all, numbers don't seem to work with a patient named Mark, who contemplates (at least after he's taken his meds) of the instructions he "receives" from the devil via rap songs on the radio, "they're sometimes real...I don't know... it's so hard to separate in my head." Perhaps, we can ask an Isaac Levi-inspired series of questions, checking off what David considers "serious possibilities," out of a "potential corpora of knowledge and evidence." I can ask David, "Do you think that it's physically possible for you to hear the devil speaking to you, and only you, from the radio? Logically possible? Technologically possible? Psychologically possible?

Defenders of psychiatric designations counter their critics by noting that virtually every DSM-IV diagnosis, including schizophrenia, must involve significant impairment in occupational or social functioning. Apparently, in 2003, 20% of Americans affirmed to pollsters that an HIV vaccine already exists, but is being kept a secret. And yet, I don't see many people staging the proper revolt that such a conspiracy, if actually true, would merit. Aberrant thought content alone is not the rate-limiting-step to being diagnosed as schizophrenic. Many people have negative thoughts about the vitamin pill industry, but only Sally (who has Schizoaffective Disorder, Bipolar Type) embraced her mission by roaming in the streets, "recruiting" fellow revolutionaries (i.e. passing cars), and propelling Los Angelenos into traffic-induced hysterics.

So for paranoid schizophrenics who maintain only 5% certainty about their delusions, perhaps they simply act upon this glimmer of confidence more often than others, like the "Deal or No Deal" folks who, knowing basic math, still reject the banker's actuarially outlandish offer, because, what if the million is in my box? According to polls, many Americans claim that our current president is a foreigner, and is thus ineligible for his elected position, according to our country's most sacred national document. Then we go off to do our laundry and water our lawns. However, there are always those few that can't eat, sleep, or tweet, while harboring such persistent ideations of conspiracy.

A behaviorist might say that, Bayesian self-reports not-withstanding, patients' actions exclusively measure their convictions. Skinnerians will believe our stated fidelity to untruth when they see it! All the rest perhaps just falls under the purview of "symbolic belief." In other words, you may take pride in widely professing that Obama is an alien, but watch your shame when a behaviorist calls you out on your pretense! My humble suggestion: To stay out of the psych ward, you're better off holding certain beliefs as insincerely as possible.

Quick Overview of My Intro to Urology Clinic

The first clue about the maturity level of your typical urologist, can be gained from seeing, on the door of the doctors' lounge, a labelled picture of the handsome animal featured above. These urologists strike me as the future incarnations of Kumar, the guy from that White Castle movie.

In contrast to the bawdy behavior of the urologists, one of our patients, Mr. Smith, was the quintessential "gentleman." He thanked us for taking the time to see him. Whenever he referred to any portion of the male anatomy, he said "Sorry, to the ladies, I don't mean to be impolite talking about these things." He was fully aware of his prior condition, and had followed his previous doctors' advice. The juxtaposition becomes especially absurd, however, when you notice the patient's right leg that is cuffed to the bed, and the two police officers sitting in the corner, mindlessly surfing the web, Berreta 92s intimidating from their holsters. The patient has scars on his back and legs, all from multiple previous gun shot wounds. Based on the manners of most of the patients who head over from County Jail, I can only assume that Cotillion is scheduled between recreation and lockdown.

No kid grows up dreaming of becoming a urologist. Even medical students tend to not think of it (I want to work with urine!) The thing is, however, unlike the "stereotypical" image of a surgeon, who might be seen angry and annoyed, the urologists love to make jokes, have fun, and really get along with their patients, all the while doing a cool fusion of medicine and surgery. The two attendings whom my group assisted today are volunteers, who spend one day a week away from their private clinics, just to teach us lowly Second-Year-Know-Nothing-Medical Students. They showed us the procedures for inserting a Foley catheter, doing sonogram assisted prostate biopsies, and performing a cystoscopy. They were all so eager and excited to teach us whatever they could, and we were all having a blast. It's kind of like an old boy's club, but one where young boys and all girls are invited, too.

The Most Dreaded Day in Medical School

Pelvic examination day, where we must perform the full genital exam on a real, live, person. And it was... totally fine. I thought the ophthalmascopic (eye) exam was more difficult, and more uncomfortable ("While you go on in your investigation to find my macula, are you sure this light scorching my eye won't turn me blind?")

Pelvic Examination Training

First, a word of warning to all the women out there:
If you see a male second-year medical student with a speculum in his hand, drop everything and run.

Luckily, our victims this week were vinyl dummies, not-unlike the kind sold to lonely middle-aged men who visit unsafely-searched websites. These unenthusiastic volunteers, come with a set of interchangeable parts (Cervix with endocervical polyp! Cervix with neoplasia!, Pregnant 10 week uterus! Two adnexal masses!). The sneaky doctors mix up Eva's (as she is always called) internal organs, so we can test our abilities to palpate and identify her various pathologies. Eva does not charge by the hour, but her $597 fee ought to be returned if you diagnose her correctly.

I've noticed a bit of a difference in how we are taught to perform the male versus female pelvic exams. The gynecologist gets up, and with a soft, sympathetic voice, talks about how she carefully drapes the patient, and eases her into the examination, by first placing her hand on the patient's knee and then thigh (she recommended that all doctors do this, to comfort the patient, but I insist that any male doctor who cares about retaining his license ignore that advice), before performing the exam. All anatomy is referred to by the most professional sounding jargon we have in our medical toolbox. "Sensitivity" and "comfort" are each mentioned about 12 times during her presentation.

In contrast, the urologist is crass and bawdy, talking about his own and others' mastrubation habits, and joking about how Los Angeles doctors, many of them Jews, are clueless about the fact that patients can get severely edematous retracted foreskin, if the patients fail to put it back where they found it. He seems to imply that the most important thing is to reduce the "unmanly" factor as much as possible when you position the patient during the prostate exam ("I call this the last position any male wants to get into"). He described an inguinal hernia as "Dude, where'd my penis go?"

Of course, we are taught to interact respectfully and professionally with all of our patients. But I do wonder if there is a silent understanding among doctors, that some men prefer to have their discomforts dispelled by bluntness and Adam-Carolla-style humor, while women often prefer to be treated with sensitivity. Of course, the above observations are gross generalizations, but it's the impression I've gotten so far, watching the style and mannerisms of the gynecologists versus the urologists. During the pertinent rotations, I'll report back on whether I still find this to be the case, or if generic "doctor-speak" is employed for all.

Palliative Care

This post is about a patient, approximately my age, whom I visited at the hospital last year. As usual, names and other details have been changed.

The first thing that I noticed about Maria, was not the oxygen mask into which that she desperately breathed, nor the black and blue marks that whirled along her arms ( inflicted by needles, syringes, and other abusive medical equipment), but her carefully painted fingernails. This was clearly a woman whose family lavished attention upon her. We said hello to 28-year-old Maria, who recognized us with her eyes, but could not respond due to the breast cancer, that had metastasized to her brain, bones and liver. As late as yesterday, Maria was able to express that her pain was a “9 out of 10." Today, she just stared at us intensely.

Dr. Stone, who heads the palliative care office at our hospital, felt that it was perhaps time to discuss with the family about increasing the pain medication, and about how the exhaustive poking, prodding, and procedures, should now be reconsidered. She wanted to explain that Maria could perhaps spend her last days without suffering, and with her family by her side.

Surrounding Maria’s bed were pictures of her as a little girl, as well as of the Virgin Mary, and other Catholic Saints. Taped onto Maria’s bedpost was an image of Jesus, toward which I imagined Maria used to pray, long before the drugs diminished her comprehension. Dr. Stone recommended to Maria’s sisters that there be a family meeting with Father Joe, the hospital’s priest. Instantly, Maria’s sisters felt comforted by the idea. They weren’t as religious as they had been growing up, but they knew that their mother, who was grieving in the lobby, would be happy that a pastor could be present, to console them and help them make decisions during this agonizing time.

I knew that Maria’s sisters would remember every detail of this day forever. I came to this understanding because of the experience that morning in Dr. Stone’s office, when each member of our six-member clinical medicine group went through his and her own experiences dealing with death and loss. Even though it was about the fourth time I had heard each person’s personal story, I found that each retelling provided new details and perspectives. Experiencing the last days of a loved one’s life means that little things begin to take on great importance. Do we take her to the bathroom now or later? Should we give her more pain medication? Does she want to be propped up higher on her bed? These seemingly minor concerns can drive families into tortuous doubt and bitter conflict.

This is why I was most impressed with Dr. Stone’s explanation that palliative care was as much for the patient’s families as for the patients’ themselves. Families are given the opportunity to lay on the couch, talk things over with the palliative care staff, and to drink tea in the office upstairs. The program itself allows them to gain reprieve from nurses who visit the home once a day, an opportunity which does not cost the families extra money. If possible, patients and their loved ones have the opportunity to spend the patient’s last days in their home, rather than in a stale, impersonal hospital ward.

That day in the hospital, I saw Maria’s sister, Carmella express denial that her sister was truly going to die soon, hoping she could “stay alive just until after Thanksgiving.” She was angry, saying her death didn’t make sense because “Maria was the smallest of the three sisters.” Carmella bargained with the doctors about attempting other life-extending measures, if not a whole new round of chemotherapy. Ultimately, she started to feel depressed, realizing by the end that Maria's imminent death was inevitable. However, as Dr. Stone, the nurses, and we students gave Carmella hugs, stroked her tears, and stood with her in silence, she began the process of acceptance, breathing easier, returning our hugs, and realizing how her dear sister could live her final days at greater ease, surrounded by the people who love her.

Application Essay Advice for Pre-Meds

Because it's pre-med season in town, I will try to post some advice for applicants trying to get through it unscathed. My first topic is about the AMCAS essay.

My suggestions are:

1) Tell a story

2) Feel free to brag, but be descriptive and specific (Not "I worked closely with patients," but "I held so-and-so's hand when she tearfully told me that she was ready to enter the OR."

3) Avoid phrases like "The experience taught me..." and "It was rewarding because...." Just make those things implicitly clear through your writing.

4) Show, don't tell!

Savvy readers will note that all of the above snippets of advice are basically the same. But that is because pretty much all boring application essays make the same mistake.

Pretend you're trying to impress the hot girl in Italian class. Are you going to pick her up by listing all of your extra-curricular activities, or by just making her feel like she'd have fun going kayaking with you this weekend? In other words, show your personality, not your CV.

And now, for your final viewing pleasure, my AMCAS essay. (All of the names that appear in the essay are names of people I met that summer, but none refer to the actual child being described. I will readily admit that I'm a bit of a braggart in the essay, and I will trust my audience to assume that I don't usually try to come off like I have all my **** together (which I don't). I should also note that, although I did at the time want to do international medicine, I am no longer sure that that is the case):

Exiting the subway in the Brownsville section of Brooklyn to begin my first day as head of a camp infirmary, I conjured up childhood memories of my own camp's infirmary, where scraped knees earned Ninja Turtles band-aids, and sore throats were soothed by a good dose of ice pops. This reminiscence, however, was tempered by recollections of my previous summer as an EMT serving in an economically disadvantaged neighborhood in Israel. The realities of domestic violence, acute physical illness, and emotional dysfunction in a population of Ethiopian and Russian immigrants, Ultra-Orthodox Jews, and Israeli-Arabs had dispelled my naive notions of emergency medical care. Would my experience in East New York also bring unexpected challenges? These musings were cut short by my arrival at a dilapidated public school building on a graffiti-filled block, with throngs of boisterous children running around in Camp ******* T-shirts.

As the individual responsible for the physical well-being of the campers, I felt that my primary task was to secure a safe and healthful camp environment. Thus, after helping to organize game of "Simon Says" until all the counselors arrived, I found an unventilated storage closet to function as a medical office, brought in a fan, and, over time, decorated the space with the children's artwork. Ascertaining that there was only one working water fountain for over 100 campers, I coordinated with the counselors to supervise the ongoing refilling of the children's water bottles. After noticing that soap was absent from the bathrooms, and learning that the facilities staff were too budget-strapped or overloaded with work orders to replace them, I bought and allocated soap myself. Finally, I aimed to make the medical office a safe haven for the kids, often playing games or reading with my visitors.

I soon discovered that, while there were few medical emergencies in the camp, there were plenty of ethical, practical, and cultural challenges confronting me. What should I do if, before breakfast, a child says that she is starving because she did not eat dinner the night before? What was my role if a mother told me that she cannot bring her child to the doctor because she lacks health insurance? What of the child who is afraid because she says that her brother often beats her mother? How do I effectively empathize with a child who suffers from sickle-cell anemia? Many of these problems, such as violence, depressive moods, and general illnesses can be found in any community, rich or poor. However, some issues were disproportionately prevalent as this was an economically disadvantaged community.

When I encountered these complex issues, I often dealt with them by consulting with my supervisors and peers. The counselors were role models for me, as most of them were college students from the neighborhood, and brought a wisdom born of experience. At other times, I relied on my own judgment. As an oldest child in a family whose youngest brother is fifteen years my junior, I have had my share of dealing with interpersonal conflicts, scraped elbows, and negotiated truces. Thus, when it became clear to me that five-year old Bianca was manufacturing the illnesses that required her visiting me during reading session, I proactively offered that she read with me during that time-slot.

What impressed me most of all that summer was the incredible power of a caring community. Despite the difficult realities surrounding them, the children were ambitious, intelligent, friendly, and playful. Many would pass my makeshift office, and announce, somewhat inaccurately, "Hi nurse!" Tafari informed me whenever he won relay races, while Kyana always showed me new stickers, earned for good behavior. The parents were kind and supportive, as evidenced by their filling the auditorium on "performance day," as well as the generous home-cooked soul food that they brought.

This interface of medical practice and real-life ethical and practical challenges draws me to public health, international medicine, and perhaps, specifically epidemiology. I want to address issues such as the Ebola virus or the effects of unsanitized water, but also how to make health care economically efficient and sustainable, and to explore the relationship between doctors and the communities they serve. I hope to listen to patients talk about their lives, their assessment of their illness, and their collaborative thoughts on the healing process.

On the last day of camp, many campers came by my office to sign messages on my staff T-shirt. This included eleven-year old Najee, who, while recovering from a stomach ache, had related to me some difficult emotional issues that she was facing. I had developed a good relationship with her and encouraged her to visit the camp social worker. Najee's note to me summed up my goal for the summer and my future goal as a doctor- to develop a meaningful relationship with each patient: "Dear nurse," she wrote. "Thank you for letting me talk in your office and listening to me.”