We are excited to learn of your interest in Internal Medicine. There are few other specialties that combine the use and interpretation of complex technology with humanism and intellectual curiosity to provide safe, effective, patient centered and equitable care. You can look forward to a lifetime helping patients achieve and maintain good health, developing satisfying collegial relationships with caregivers in every specialty, and challenging yourself to expand your knowledge continuously as diagnostic and therapeutic technology evolves. Every year, the residency program directors, key clinical educators (KCE’s) in the department, and chair meet with many students throughout the year and we are often asked about ways to prepare for the residency interview season and for the PGY1 year. We thought we would compile a set of ideas that we commonly share with the students in a (frequently asked questions) style to help you with your plans.
Early in your fourth year of medical school, the Chairman of Medicine’s office will contact you to arrange a meeting with Dr. Mark Geraci, our Chair of Medicine, and a separate meeting with one of a dozen key medical education faculty in the Department of Medicine. These faculty members have been carefully chosen and have a goal of helping you achieve the best possible training tailored to your career goals. These faculty members will:
- Provide Internal Medicine-specific career advice, even if your are unsure about pursuing Internal Medicine as a career.
- Offer to review your personal statement (this is completely optional)
- Draft a Department of Medicine chairman’s letter of reference which are often requested by many IM residency programs around the country. This letter will be signed by the faculty member and Dr. Geraci.
This letter does not count as one of the (usual) three required by most programs, nor does it serve as your official Medical Student Performance Evaluation (Dean’s Letter). Our Department of Medicine letter may incorporate information out of your performance on your Internal Medicine clerkship and sub-Internship (if available), but the authors do not have access to your school transcript.
Q: How do I notify the Department of Medicine of my interest in Internal Medicine?
Dr. Buckley: At any time during your third year, contact Pam Clinton at email@example.com and let her know of your interest. She will add you to our (list). In addition to this, the school often sends our department results of student surveys where you may have identified Internal Medicine as a possible career choice. We also get a list from the school’s Medicine Student Interest Group, a great way to learn more about the field and get to know people with similar interests.
Q: When to take my Sub-I?
Drs. Hotz and Buckley: Pursue a sub-internship in Internal Medicine early in the year if possible. All Departments of Medicine across the country realize many students will not be able to have an early sub-Internship, so don’t worry if it doesn’t happen. Even with our lottery systems, the school does the best it can to give those with an interest in internal medicine their sub-I as early as possible. The Sub-I is a good time to secure additional letters of recommendation as well.
Q: What about an ICU experience?
Dr. Hotz: Take an ICU month if possible in addition to a ward-based Sub-I. This will be a challenging month; however, when you start your intern year you will be much more capable and comfortable with very ill patients.
Q: What electives should I take?
Dr. Hotz: Concentrate on your weaknesses! Recognize what your weaknesses are and take electives in them! For example, if you are feeling weak in your knowledge of infectious disease or cardiology, take an elective. When you are a resident on-call by yourself, you want to be the person who can help the patient with any condition not just help conditions that pertain to the subspecialty you might be thinking of entering one day! To be as good of a generalist as possible should be your goal first. Remember, you are invested heavily in your education from a financial prospective so you might as well get your money’s worth!
Dr. Buckley: Another approach is to take electives you may never get during an Internal Medicine residency. You’ll have plenty of opportunities to learn infectious diseases and cardiology during your residency, but consider augmenting your education with an elective in anesthesia or dermatology. Each student is different, and it may be your last chance to fill a relative gap in your general medical school training.
Q: What are residency program directors looking for? Do I need to do service projects or research electives? What about additional degrees (M.S., M.B.A., Ph.D.)?
Dr. Goldman: Residency directors are looking for people who have obviously worked hard and done well in the coursework and clinical rotations. Performance in the medicine clerkship, and especially the subinternship, bear obvious parallels to how you might perform as an intern. Your scores on USMLE are evidence of your mastery of the first years of medical school, and we like to see the USMLE 2 CK scores. Programs often set minimum levels of USMLE 1 and/or USMLE 2 scores needed for an interview because they receive thousands of applications and are unable to interview everyone. Letters of recommendation should reflect your hard work, contribution to the evaluation and management of the patients, and eagerness to learn (including evidence that you have developed good habits in reading about your patient’s illnesses during your time away from the hospital). Individual service activities or research electives carry very little weight in comparison to the above. Obviously if you have a passion for service, we appreciate knowing about that, but frankly it doesn’t prepare you for many of the demands of residency, and doesn’t increase your competitiveness if your overall performance is average. We think that induction into the Gold Humanism Society is a real honor, but this is less important than your academic performance. Evidence of serious research involvement (publications, especially as first author) are great and reflect on your intellectual curiosity and abilities. But again, your performance as a medical student, working with patients who have complex illnesses, is more important than your research ability as you enter residency.
If you really are interested in the business side of medicine and can foresee yourself in a business/administrative role, then an MBA may be a good preparation for that career. But if you think that simply adding another degree to your CV will make your application look better, then this is ill-advised. Plus, many physicians later on go back and pursue an MBA degree and their clinical experience can add so much more perspective and meaning to their MBA pursuits than someone who has only the clinical experience of a third year medical student.
Q: What should I look for in a residency program?
Dr. Goldman: You will find that most programs look fairly similar- this is because we are all subject to the same regulations of the accrediting bodies. You will also find many excellent medical educators all over the country. What to pay attention to is (a) the diversity of patient care experiences you will have, (b) the degree of autonomy you will have in overseeing patient care as you grow in your competence, and c) whether the residents are treated with respect and d) whether the program will responsive to their needs and listen to their ideas for improvements.
Programs with multiple linked venues like VA hospitals, public hospitals like our Eskenazi Health System, and referral hospitals naturally provide that kind of experience. Some referral hospitals provide both the tertiary care environment and care for the indigent, so it is important to learn exactly which patient populations are served. You should seek a training program that will challenge your knowledge and skills, thereby giving you the chance to optimize your residency years and grow into a well-prepared physician – regardless of whether you plan to go directly into practice or seek subspecialty training.
What is the difference between university-based vs. community-based training programs? This is a bit hard for us to comment on since we work in the former environment. Aside from the question of patient diversity and autonomy, consider whether there are opportunities to be involved in teaching of medical students, and if you are interested in a fellowship, whether there are fellows at the program to help you understand their role. We suggest you contact IU students in community programs to understand what their experience has been.
Q: Any advice regarding the application process?
Dr. Goldman: How well you prepare your application reflects your ability to manage tasks and articulate your goals. Poorly prepared, incomplete, and late applications may not help. Seek letters of recommendation from your faculty early in the process. Ask them if they can submit a (strong) letter of recommendation, and do so before the due date. Don’t be discouraged if they say (no), because it is better they tell you than share their opinions in a letter of reference. Remember though, the letter writers cannot recommend you more than you have deserved through your own efforts. It is okay to send gentle reminders to the faculty to ensure they submit these letters early. Strongly consider waiving your right to see the letters, as this usually strengthens the comments shared by the faculty (and conversely, not waiving the right may be interpreted to mean you feel the need to screen letters for negative comments- why?).
You should explain all gaps in your training. This is typically done in your personal statement, and shows that you are telling your entire story. Some students avoid awkward issues (e.g., not getting into medical school on their first attempt), but an honest story about adversity and persistence can pay off. Along those lines, a little humility can go a long way even though you are trying to (market) yourself to prospective programs. If you are uncertain of your eventual career goals, that is perfectly okay for this stage of your training. Demonstrating an open mind to a variety of careers is often something program directors seek.
Many students also ask how many programs they should apply to: practically speaking, it is hard (and expensive) to interview at more than 10 places in a month, and you really should try to narrow your choices before going for interviews.
Q: How to get letters of recommendation?
Dr. Hotz: I agree with Dr. Goldman’s stance (please see above) about asking if the person will be able to write you a strong letter of recommendation. Also, do not feel badly if they say no. Just move on to the next person. Some of the best times to get your letters of recommendation are during your sub-I month (if you are able to take it early). Often times, one can get two letters out of this month. When you get done working with a faculty, go ahead and ask them if they would be able to write you a strong letter of recommendation. Every year, the faculty members expect requests for letters of recommendation. It’s part of the job as an academic clinician. Other sources include faculty with whome you have done a project with or spent significant time. For example, your ICM2 preceptor.
Q: What letters of recommendation will I need for my application?
Dr. Buckley: In general, there are three types of letters:
- General Letters of Reference: Most Internal Medicine residency programs will ask for letters of references from faculty members with whom you have directly worked. Typically, you identify these faculty members, and you should ask them if they can write you a strong letter of support. Most students waive their right to review these letters of reference under the 1974 Family Educational Rights and Privacy Act, but that is entirely your choice. It is thought a letter of reference carries much more weight if the subject of the reference does not know its contents. You will want to ask for these letters early in the process, ideally while the faculty member’s experience with you is fresh. If you wait too long, busy faculty members may struggle to submit their letters to ERAS in time. The number of letters required from residency programs varies by institution. To find more information of the particular institutional requirement I recommend going to the website-http://www.ama-assn.org/ama/pub/education-careers/graduate-medical-education/freida-online.page
- Medical Student Performance Evaluation (MSPE): These letters are also known as (Dean’s Letters) and are written by your lead advisor assigned by the school. They follow a template agreed upon by medical schools accredited by the Liaison Committee on Medical Education. You will have an opportunity to contribute to certain portions of this letter and view it prior to its entry into ERAS. The school will contact you and initiate the process with you and your lead advisor.
- Chairman’s Letter: Some Internal Medicine residency programs will want a letter of reference from the Chair of Medicine here at Indiana University, Dr. Mark Geraci. More details are listed above.
Q: Any other advice on interviews?
Dr. Hotz: The interview season is an amazing time for you and the programs you are going to see. You should take time and do the proper work and preparation before your interview in order to maximize the time you spend on your interview day. What I recommend before the interview day-go to http://www.ama-assn.org/ama/pub/education-careers/graduate-medical-education/freida-online.page and research the program before you go there. Go to the program’s website as well. Come up with your questions at that time that you have about the program. It is important to find answers for your basic questions before the interview day so that when you are there, you are asking insightful questions that might affect if you would want to go to the program or not. Dress professionally. You are not going out to a club or a New Year’s Eve party. If the institution offers a dinner, try to attend! This is one of the best ways to get the pulse of the program and get a sense if the residents happy or if the residents people you could see yourself working with? Remember, you really are also being watched during interviews, if you have something negative to say or an off color remark, it could reflect negatively. Programs are looking for good people to work with and they might decide not to rank you if your personality type and actions during the interview are not conducive to a healthy work environment.
If the program provides the names of interviews ahead of time, look these people up and get to know their professional interests (eg. research). If conversation gets dry during the interview, talking about one of their papers is a great way to energize the conversation and leaves a very positive light on you as someone with commitment and can take things to the next level by your preparation. When you are done with the interview, take notes of the benefit and negatives of not only the program but also the city and if applicable what is available for your significant other in the town. Also, comment on your gut feeling at the time. When it comes down to ranking programs, try and rank all the programs you could even remotely consider. The most recent statistics on the traditional American graduates with no extenuating circumstances (not failed boards or repeating years in schools-match at rate in the upper 90 percent. To properly match, the average person will take nearly 12 interviews (applies to 30 schools on average) and as stated above you really should try to rank most or all of these (the number of schools you apply to can flux up or down depending on how competitive of programs you apply to in relation to the level student you are). Also, be realistic with yourself and talk with your advisor. If you are a below average to average candidate and you only apply to the hardest programs, then you will have a lower chance of matching.
Have your application in as early as possible. Interview slots can fill quickly, and many good student miss out, because they are later than others in submitting their application. Do not take any program’s word if they tell you that they will be taking you until you see your name on match day. Programs are not allowed to tell candidates this so do not base your rank list on this bad information. Remember to have fun and bring your A game to each interview. It is a long season but worth the work if you invest the proper time and energy!
Dr. Buckley: Interview days are an opportunity for both you and the program to see if it’s the right place for you. Facts and information are available ahead of time (your application and the program’s website). The real opportunity is for the program to assess your communication & interpersonal skills and assess your emotional intelligence. For you, it is to get a feel of the program, current trainees, and culture.
Q: How should I set up my senior year and interview season?
Dr. Hotz: Create your schedule to have at least a lighter rotation or ideally a vacation during the time when you would want to interview. At IU we generally interview candidates from the beginning of November to the end of January. This is pretty standard across the board. Doing this will facilitate ease of stringing together interviews (making travel cheaper for you!).
Q: When should I take my vacation?
Dr. Hotz In addition to considering using some vacation time for interview, save some vacation time to take just before your residency starts. Residency is a fun and exciting time of your life; however, it will be a more busy time as well. Before residency starts is an excellent time for an adventure or just some peace and quiet!
Q: Should I consider an away rotation?
Dr. Hotz: Internal medicine in general does not put much weight on doing an away at a certain institution. This practice is more important for other specialties. That being said, if you really want to do an away rotation to check out a program or region of the country, then it is still something to consider. If you need match in a specific city (for family or other personal reasons) and your application is not highly competitive, it is appropriate to do an away rotation at an institution that you would like to be. In this situation an away clerkship can allow you to gain experience at that institution and facilitate you in obtaining a letter of recommendation from that institution as programs tend to pay more attention to letters from faculty at their own institution.
Q: How do I perform well in my clerkships?
Dr. Hotz: To perform well on a clerkship, there are no secrets. The formula is to show up earlier than they tell you to be there (for example if you are supposed to be there at 7am get there are 6:45 or 6:50). Be enthusiastic. Try and present on something you read about every day. You should already be reading for the clerkship and the patients you are seeing. The presentation can be easily done each day and it does not need to be a 10 min presentation, 1-5 minutes is fine. The presentation can be given in a variety of ways. For example, embedded in the plan for the patient that day: (Problem number 1-Copd Exacerbation-I would recommend treating with 5 days of oral prednisone based on the 2013 JAMA article on the subject…) This shows the attending you are going to the primary literature and gives a quick learning point as well to the team! You could also do this during a short sit down with the head resident or attending each day. Make sure to have your other medical students on board so everyone is learning and moving forward!
Other key factors to success make sense as well, be a good teammate. Try and anticipate things that need to be done and do them. For example if you work with an attending that likes standing daily standing weights on the patients with heart failure, work with the other medical students to get this done even on the patients that are not you own. Remember, to unify the medical students in these team efforts makes you look better than if you try to outshine another person. Everyone on the team benefits, especially the patients!
Attend all lectures and learning opportunities given during the clerkship. Early in the day, remind your team (and attending) that you would like to attend the scheduled lecture and mention the particular time. Don’t wait until five minutes before you have to leave to remind them. Make sure and ask your interns, residents, and attendings what your role on the team should be, then ask what you can do for the team to maximize everyone’s time and effort. When presenting to your team remember each attending likes a different style; it is best to just ask her or him how you are doing on the oral presentation and what they would like you to change in order to improve. As for your write ups, a good history is always key, but the real money comes in you creating the assessment and plan. These are your patients, so own the plans!
Q: How else can I prepare myself?
Dr. Goldman: Because the work hour regulations limit patient contact time and time in the hospital, you need to anticipate a more active role in your education. One approach is to begin systematic study of a textbook of medicine (we generally like Kelley, Harrison, or Cecil). The review books and board question panels may not get into pathophysiology and etiology in sufficient depth for an internist. It would make sense to read the chapters pertaining to a clinical rotation (e.g., cardiology chapters during a cardiology rotation), and budget time to cover as much of the rest of the book during other parts of your senior year. You probably won’t get through, but you will have an excellent start on reading the rest as a house officer. Cecil has about 2400 pages, meaning you can read it in a year at about 10 pages per day. Not that hard if you break it down. We would also recommend that you re-learn physical exam skills using the JAMA Rational Clinical Exam series (now published as a book with new updates) along with some cardiac auscultation practice using Harvey at the Sim Center. An excellent summary for physical examination is McKee’s (Evidence Based Physical Examination).
Q: What else should I learn from my other clerkships during my fourth year?
Dr. Hotz: Radiology (core) will be lighter than some of your traditional clerkships, but it is a core (required) clerkship with specific learning objectives and an excellent time to lay the framework of going through radiographs. It might be the only time in your career in medicine that you have time to sit down with the attending radiologist. Try and lock down your technique and resources to refer to in the future when you are not on the rotation. Try and see the greatest volume of material you can! Do not be afraid to challenge yourself!
Emergency Medicine (core). This core clerkship provides you a look at a high paced, high turnover type of medical care with a wide spectrum of disease severity and care. What to take away from the rotation is the incredible exposure to pathology you will have. The other is to learn techniques for becoming more efficient in your data gathering as well as presentation speed and decision making. The Emergency department also allows you to see how to treat many common conditions quickly and safely. This is a skill you will need to master as in the future you will have a number of walk style visits. It also gives a nice insight at how patients transition through the medical system safely.
Other electives: https://www.iu.edu/~iusom/electives/electives-2016-2017.php
Good luck! If you have any more questions feel free to contact me!
James (Jimmy) Hotz MD
Ambulatory Medicine Rotation Director-Internal Medicine Residency Indiana University
Key Clinical Educator Indiana University
Staff Physician-VAMC Internal Medicine-Green team outpatient and White team inpatient