Game. Set. MATCH!

“The last class of 48”- TAMUHSC MD grads, 1998


Here in the U.S. it’s Match Day, that annual event when students find out where they’re headed this summer for the next stage of their training.

The envelope, please!

For some of us, it seems we find out where we’re headed for more years than that.  When I opened that fateful envelope in 1998, I knew I was coming to Utah for 6 years for my general surgery training.  I honestly thought once I was done with that + fellowship that I would land back in Texas.  Some 18 years later, here I still am (admittedly with that one year back in Texas for fellowship).

For me, this is a day to look forward to the new family members who will join us this summer.  It’s also a day to reflect on adventures, unexpected roads taken, and remembering just how far I’ve come in these 18 years.  It’s been a wicked twisted road, and I wouldn’t trade most of it.


So if you’re matching today? Buckle up and hold on.  It may be bumpy sometimes, and it will all be okay.

‘Tis the season…

…for residency applications.  Somehow this process keeps moving forward in a recurrent fashion even when I’m certain I’m not any older than I was when I first started as faculty 10 years ago.  Of course, I’ll do things every once in a while (see “run half marathon”) that remind me I am indeed 10 years older now, mostly because I’m slower and more sore the next day.

For those who are working on their residency applications, this time last year I provided some tips about writing personal statements.  That guidance all still applies.  I also left “have as many people as possible read your personal statement” off of the list, and that is also true.

However, there are other important pieces of the application packet, letters of recommendation being the one that often serves as the greatest differentiator between the many excellent applicants.

For students, here are things to think about when selecting your letter writers:

  • They will ideally be faculty who have worked with you closely in a clinical setting and can therefore speak to your clinical knowledge and skills.  When I am reviewing applications, I always slow down when someone can tell me that they directly worked with a student, particularly if they had fairly extensive contact in the clinical arena.
  •  A letter from a less-known junior faculty member who has worked with you extensively and can speak to that will usually hold more weight than a letter from a very famous senior faculty member who damns you with faint praise because they don’t actually know who you are.  There are some senior surgeons whose letters I almost uniformly ignore because they write the SAME LETTER for every student from their institution.  I scan to make sure it’s the same letter again (I have yet to be disappointed by this) then move on to the next letter.
  • You have a responsibility to ask someone if they can write you a “strong” letter of recommendation. If you were clinically mediocre and ask me if I will write you a letter of recommendation without clarifying that point, I may agree but you may not get the letter you would want.
  • Things to have ready when you want someone to write you a letter:  Your CV.  Your personal statement.  And I now always ask, “What do you want me to highlight in your letter about our time working together?”  That insures that I won’t miss the mark of how you are “marketing” yourself for residency.
  • Please give us plenty of lead time.  While I almost invariably get letters turned around within a week, I assure you that is rare!

Faculty members, don’t think you’re getting away without some advice as well.  Thoughts for you, from someone who reads many letters every year:

  • Please be very specific about how long and in what capacity you worked with the student in the clinical arena.  It helps if I know that they worked one-on-one with you every day for three weeks and that they had the opportunity to first assist with you in the OR; that letter provides me with far more meaningful information than one about a student who came to your clinic for two afternoons.
  • A comparator can be helpful.  Is this the best student you worked with this year?  In the last 5 years?  In the last 10 years?  Having a benchmark like this, recognizing that it is something you have constructed, can still be very helpful.
  • Is this student someone who you want as a resident?  If yes, say so!  If no, navigate this wisely (“I anticipate that Bob will excel in surgical residency and have a great career in academic surgery.” tells me that you think Bob is a great guy who will succeed, but he’s not necessarily the guy you always want on your team).
  • Don’t lie to try to “help” your student in the process.  When you do that and we get a resident who can’t perform anything like the student you described to us, you lose credibility.  In other words, don’t help the one at the expense of all of the future ones.  There are individuals whose letters I skip completely based upon historical experiences with people they recommended.  This also means that when you see me three weeks after Match Day, I do not want to hear, “Sally may struggle with you all…” after you wrote her a glowing, flawless letter.  Again, credibility.
  • If your student really is a superstar and has a blemish on his or her record, your letter can help me get your perspective on why we shouldn’t be worried about it as a long-term issue for them.  I don’t expect you to violate confidentiality, but it’s one way you can support a student who may have had a personal or professional rough spell and subsequently pulled it together to excel.

If you have other tips about LORs, I hope you’ll share them in the comments (or, of course, on Twitter!).




Leavin’ on your mind

This multi-instiutitonal study published in September was a piece that caught my eye for a few reasons.

First and foremost, as a faculty member who has a love for tilting at windmills and fighting for the underdog, I’m always trying to figure out how to best support our residents who are great doctors but struggle with some aspect or another of surgical training.  The truth is that surgical residency, even in the “new world order” of the 80-hour-workweek, is hard.  Granted, there are times that it is harder than others, particularly during high-stress rotations or on rotations with particularly challenging faculty members, but even at it’s best it’s never easy.  While lots of work continues to look at who leaves- or who thinks about leaving and will admit to it- what we’re capturing less-well so far is the why.  As someone who loves stories and has fallen in love with quantitative research, I want the long version of the why in all of its messiness.  Sure, there is a subpopulation of folks who get into surgery residency and discover that the “fit” of the profession is off for them.  My observations, though, lead me to believe that this is indeed a subpopulation and that the stories, particularly those from “high attrition” programs (as identified in the Gifford study), are more rich than a simple statement of, “It wasn’t working for me.”

As usual, there is also a personal angle to my interest in this study’s findings.  I was very nearly part of those attrition statistics.

The last part of internship was great.  The first few months of second year?  Far less great.  I struggled with my role as someone who still felt responsibility for running the floor but who was also expected to be in the OR more.  Technical skills didn’t come as quickly and easily to me as they do to some.  My rotation schedule for the year would likely have worked well for someone with more innate technical prowess or who didn’t feel the same call to making sure the patients were getting ideal care, but for me it was a near-disaster.  Then, in the depths of the winter, I descended into every-other-night call in the ICU.  Remember, this was pre-work hours, when not only was every-other-night call okay, but you weren’t out by Noon the next day either.  While I loved the intellectual challenges of the ICU and didn’t mind the hours (most of the time- if your co-resident took vacation you got to move in for the week), I also didn’t see the sun for more than very limited time periods for 10 weeks.  December and January days in Utah remain tough for me even with control over my schedule, and then…well, in hindsight I would say I was clinically depressed.  I also knew that I was incredibly unhappy and the only logical way to fix the unhappy was to pick a new specialty.

So I did.  I went back to my “Plan A” from medical school, and started talking to our Pediatrics folks about a switch into pediatrics to be followed by a critical care fellowship.  The trouble was that the time of year- January- wasn’t conducive to a major specialty switch anytime soon, likely not for another whole academic year.  I had gone to my program director in surgery and told him that I was leaving, but that I would finish the year. He was either wise or foolish enough to not believe me.

Then I got out of the ICU and the days got longer.  I went to services where I had a handful of faculty members who were able to engage on technical skills in a way that worked for me.  Surgery became fun again.  By April, I had decided that I wanted to stay and I had great support from some faculty who had been patiently getting me up to speed.  And, fortunately, there was that issue of the program director suspecting things would work themselves out at some point.

Had one of any number of factors been any different, I might well be writing my blog from the perspective of a pediatric intensivist.  But I do believe that I am where I am supposed to be, doing what I am supposed to be, and so while in January of 2000 it felt a bit like all forces were aligned against me, I no longer believe that was true.  If anything, it proved the need to sustain when things are hard because things ultimately unfold like they should.

I understand why people leave surgery.  I’ve supported and stayed friends with more than a few who have done so.  I’m also really glad to have failed- miserably- at leaving.

*(With a nod to Patsy Cline’s song of the same title)

Is funding physician training part of the social contract?

I’ve been sitting on a couple of items about residency funding and physician workforce for a few months.  On Saturday, there came this piece in the New York Times, compliments of Uwe Reinhardt, whom many of us would posit is the premiere health economist of our time.  His proposal?  The burden of paying for residency training should not necessarily be funded through tax dollars.

My response?  Yes.  And no.

For those not familiar with the funding of graduate medical education, this great primer on the “how” of Medicare funding for residency positions will give you the backstory far better than I can.  She also nicely highlights the fact that in 1997 residency positions were capped by the federal government so that growth wouldn’t continue in a haphazard fashion.  In the last decade, the number of U.S. medical students has increased at a rapid rate…with virtually no expansion in residency positions.  Within the next 2 years, we are likely to have more medical school graduates than residency positions in the U.S. on an annual basis.  Simple translation?  Young Americans will have huge amounts of debt and not be able to practice because you can’t practice without a residency.

The historical argument behind the Graduate Medical Education (GME) subsidies has been that there are inefficiencies associated with training new physicians, and that teaching hospitals by definition lose money through the activities of education.  Teaching hospitals also serve as a “safety net” in healthcare, with many of them caring for patients who otherwise would not receive care.  They serve as sites for innovation and research in a way that non-teaching hospitals simply can’t, as well as specialized care; my own bias becomes apparent if I confess here that 96% of burn patients in 2007 received care at teaching hospitals.  The relevance of innovation, research, and specialty services to GME funding lies in the fact that patients with private insurance benefit from these things every bit as much as the other patients, yet the private insurers do not contribute to the financing of residency education.  That is the basis for my agreement that the burden of paying for resident education should not fall entirely on the taxpayers’ shoulders.

However, we simply can’t withdraw federal subsidies from the picture either.  This pathway would likely spell collapse for the academic medical centers (AMCs), which would be catastrophic for the reasons I have alluded to above as the unique benefits of teaching hospitals.  I also dispute the following statement from Dr. Reinhardt:

“Although teaching hospitals do incur added costs to train physicians in residency programs, they are already reimbursed for those costs by the residents themselves, which obviates the need for government funding.”

The logical fallacy here is that residents do not pay the teaching hospitals- it’s not clear to me what money they would use to do so between their limited salary and their often exorbitant student loan debt.  If anything, residents are a good deal for the AMCs because they provide high-quality labor relatively inexpensively and (unlike NPs and PAs) really can’t opt out of nights and weekends.  I’m not saying that AMCs are making money off of residents, simply that residents help the AMC to make ends meet.

Do I have the answer to this problem?  No, I don’t, other than acknowledging that we need more physicians and that we fund GME in an irrational, inefficient, and inequitable manner.  It makes me feel a bit better to realize that brilliant minds don’t seem to have a good answer to the dilemma either, but a solution must be found- and soon.