Preparing for intern year of residency: words of wisdom, best books to buy, and essential things to get before starting

May 16, 2017

Congratulations! You've graduated or about to graduate and are now facing the biggest turnaround in your medical education since the transition from second to third year.

Biggest word of advice for those starting their intern year: there is little you can do to prepare for intern year apart from the 4 years of medical school you have already completed. Enjoy your time off, spend time with the ones you love, and get your other life things in order. Repair your car, schedule automatic payments for your bills, and start reviewing the different loan repayment options. The 1 month or so that you have off after graduation is the only truly free period you'll have until you are done with your residency and fellowship training.

On the day you start intern year, you'll be faced with a lot of problems that you saw as a medical student but never directly affected your time. These things include but are not limited to coordination of discharge (such as planning and communicating with the case manager and social worker), managing day to day medical issues (such as correcting electrolytes and ordering appropriate labs for the next day), consulting specialty services, updating the team list, and learning a new EMR. These are all things that will come when they come.

What you can do before the start of intern year is to ensure that you have everything in order so that when you do start intern year, you will know where to look for answers and already have what you need in order to survive.. Here are the essential tips and tools to get ready for your intern year of medical residency.

General advice for incoming interns and residents

Never lie

It should go without saying that you shouldn't say that you've examined things when you haven't or make up answers to questions you never asked. It's really never too much of a problem if you forgot to do something or ask something—you can always go back and do what your forgot. You're just starting your true medical training and it comes with the territory. Lying, however, can change medical management and patients can suffer true harm from decision making based on faulty information. Suck it up, admit your forgetfulness, say you'll go back to do it, and move on.

Make checklists

Every morning you will have an updated list of the patients under your purview. Before, during, and after rounds, constantly write down and review the tasks that you have to do for each patient. Check off the tasks you've already completed. In the beginning, when your memory may not be as in tune with patient details, write down your physical exam findings or pertinent facts in a different color on the side. Essentially, write down everything and periodically check throughout the day that you are accomplishing the tasks that you have been assigned to complete.

Ask for help

Your senior is an invaluable resource to asking questions. You're going to have a lot of questions and a lot of it won't be found on UpToDate. Your senior is there to guide you.

Remember how to present

Given that you're coming from fourth year, it's likely been awhile since you rounded/pre-rounded. Take a quick refresher on presenting and pre-rounding here.

Call your consults early

Understand that most specialty services sign out between 5 and 7 PM. If you know you're going to have to call a consult, do it early during the day or immediately after you discuss a patient during rounds.

Eat when you can

You will very unlikely have dedicated meal breaks. Keep a bar or two on hand.

Don't forget to exercise

Walking during rounds doesn't count; make sure you curb your stress and your weight by taking some time a few times a week to go to gym or run outside.

Best books for intern year of residency

Quick, immediate texts for answers to patient problems and medical scenarios

Maxwells Quick Medical Reference

A tiny, spiral bound pamphlet that fits well in the breast pocket of a white coat that has normal lab values, an eye chart, quick algorithms, templates for notes, and a built in ruler that you can refer to when you need it. The best sub-$10 resource you can own.

Pocket Medicine

A small 3-ringed book that easily fits in your white coat pocket that succinctly goes over medical pathology and management. A must have for any medical resident. Even for surgical residents, Pocket Medicine will likely serve you better than its surgical counterpart, Pocket Surgery

Longer texts that help jog your memory and gives you a good framework to looking at clinical problems:

When looking for answers to day to day clinical questions, such as the immediate management of hyperkalemia or what to order for a patient with reduced urinary output, it can be cumbersome to go through a whole UpToDate article or look through your own notes. There a few texts out there that simplify the common questions and scenarios that you will be facing as an intern doing floor work and taking call, the best of which are the Washington Manual Internship Survival Guide as well as On Call Principles and Protocols by Ruedy.

Washington Manual Internship Survival Guide

Essentially second and third year of medical school condensed into an outline-based format, comprehensive text.

On Call Principles and Protocols

A paragraph based text that goes over common call questions and scenarios with the proper questions to ask the nurse and patient, physical exam findings, and the appropriate management for each problem in an easy to read format.

Other essential things to have for intern year

Reliable Pens and Highlighters

Do yourself a favor and buy a large pack of reliable pens. The Pilot G2s are reliable with a clean gel ink that quickly dries and doesn't fade out; it comes in a variety of colors and, when bought in dozens, are quite affordable. As an intern scribbling tiny notes onto your precious list, you will want either the .50 nib or, for the especially precise, the .38 nib. These retractable highlighters will come in handy as well to quickly accent the things to do on your patient list. Keep a stash of pens and highlighters in the glove compartment of your car.

Penlight

After going through a number of different penlights and often being frustrated with standard dim yellow penlights, we recommend the ThruNite Ti3 LED flashlight. Small, light, and incredibly bright — able to shine 120 lumens on the maximum setting — the ThruNite at <$15 is a cheap purchase that will pay in dividends when you are trying to quickly check pupils (on its low setting, of course), doing a skin examination, or illuminating a bedside procedure. Keep it attached to your keychain or your hospital badge.

Headlight

If you're a surgical resident, consider buying a headlight for bedside and emergency room procedures. The GRDE LED Headlamp is remarkably reliable and can shine up to 2000 lumens for only ~$20. You'll never have to strain your eyes or spend 15 minutes looking for a bedside light again before suturing that lac. Light is easily adjustable and focusable and comes with a charger. A bargain and an essential for any proceduralist.

Coffee Machine

To save yourself the trouble of going through the motions of brewing coffee in the morning, purchase a Keurig machine, which runs ~$100. There are a large number of different K-cups you can purchase, including the Original Donut Shop Regular, a popular type which comes out to about 50 cents a cup if you buy 72 of them. Break up the sometime monotonous rounds with a different type of coffee everyday by purchasing this sampler pack. If you're looking for a standard drip coffee maker, the Black & Decker DCM600B can make 5 cups, is an Amazon best-seller, and is reasonably priced at ~$15.

Hospital Shoes

You're going to be rounding and standing a lot. Check out our guide here for the best hospital shoes.

Best of luck during intern year. Until then, enjoy your time off and accomplishments!

General financial principles, investing, and saving for retirement for resident physicians, interns, and medical students who don't know anything about money

March 29, 2017 in Finance

When thirty-somethings are asked about the things they wished they had done in their twenties, many invariably state that they wished they had saved more, or at all. As it takes 3 - 10 years after medical school to become a full-fledged attending physician, residents often put off saving for retirement, reasoning that there will be enough money coming in as an attending to make up for the difference. However, this disregards the effect of compounding has on saving earlier; those 3 - 10 years of PGY training are years that your money has to significantly compound. For example, say you maxed out your 403b (we'll cover this later) at $18,000 for a 5 year residency. If that sat in an investment account with a ~6% return, you would have around $1,000,000 in about 30 years.

Medical school and residency together take at the minimum 7 years and medical training often extends 10+ years after undergraduate education. This equates to lost years of income and saving/compounding ability that those in other professions can take advantage of. To put real numbers to it, an engineer can start working straight out of college at 22 years of age. A doctor, if going straight through school and training, will have to wait until they are at least 29.

Most medical students and residents have science-related bachelor degrees and know very little about finance or personal money management. Many went straight through school, from kindergarten to medical school, with the odd TA or research assistant job and never had to significantly management money. Many have not had any formal education in money management or investing. As such, it is all the more imperative for the young physician to self study.

I didn't know much at all and spent the latter half of my fourth year of medical school reading and learning about saving and investing. I've tried to condense below the key points of what I've learned for those those who know very little about the topic.

Set aside an emergency fund

People recommend setting aside 3 to 6 months of expenses aside to be used if needed for emergencies. Other than your standard savings account, you can consider putting this in a high interest rate savings account such as with Ally bank or in a CD ladder if you feel particularly savvy.

Set up a Roth IRA

This is the single most important thing you can do as a resident to ensure, as much as you can, financial freedom in the future. IRA (Individual Retirement Account) is essentially a retirement account that you can set up, by yourself, to save money for retirement. There are 2 different types of IRAs, traditional IRAs and Roth IRAs. In traditional IRAs, you put in "pre-tax" dollars; in the Roth IRA, "post-tax" dollars. What does this mean to the unknowing resident? It means that in a traditional IRA, you will put money into the account and then get a tax deduction. However, when you withdrawal the money (when you're 59.5 years old), you'll get taxed on it as income in the tax-bracket that you are sitting in. For doctors, this is usually going to be a substantially higher tax bracket than the one you're in as a resident. As such, the Roth IRA is a better option for residents: you'll put in "post-tax" dollars, essentially money from your paycheck, and, when you're 59.5, you won't be taxed on it when you withdraw it. Because you're in a lower tax bracket as a resident, Uncle Sam takes less of your invested money.

The maximum contribution for a Roth IRA is $5,500 a year. You can invest this in one lump sum or every month, however you like. You're not just putting money into this account, however. This is an investment account — you can buy stocks/bonds/funds to put in here. To prevent this article from getting too long, I recommend purchasing low expense ratio index mutual funds. Let's break down what that means.

"Low expense ratios" refers to the amount of money that brokerages take from your account to run your account/manage your funds. These ratios range from as low as 0.03% to more than 1 or 2%. The higher the expense ratio, the more money you lose to managerial costs. You want this number to be low; shoot for expense ratios below .50%.

To understand "index funds," we should briefly talk about mutual funds. Say each different stock is a different pizza topping — Disney is a mushroom, Apple is a pepperoni, and Tesla is a mushroom. Take these toppings and put them together on a slice of pizza; to simply the topic for all intents and purposes, that pizza slice is a fund — it has a bunch of different stocks within it. Each "bite" of that pizza with all of its different toppings can be thought of as a share of that fund. A mutual fund owns a bunch of stocks from different companies within it. When you buy some shares of that fund, you indirectly own a bit of each stock that is within the fund, kind of like how a bite of pizza has a bit of each different topping in it. Hopefully that illustration helped.

Continuing that area, what does "diversifying your portfolio" mean? It means not having everything in one thing—not having all of your money in Apple stock or all in bonds. Index funds are, in and of themselves, diversified — they have a bunch of different stocks or bonds in them and by buying a share of that fund, you own a bit of each stock.

As such, "index funds" are mutual funds that have a composition of stocks within that match different market indexes — things that you may have heard about like the S&P 500. Index funds have very low expense ratios because there really isn't that much management that is needed to take care of an index fund; they just aim to match the market.

Because the market goes up, when looked over many years, about 7% a year, index funds should go up about 7% a year when averaged over long periods of time. This is contrasted to actively managed funds where fund managers cherry pick which individual stocks/bonds they want in their funds. This is riskier, because you're counting on one guy or a bunch of guys to dictate what is in the fund you are buying. Because they are "actively" managed, they also have higher expense ratios. A study done by the S&P Dow Jones Indices showed that, over 10 years, 82% of large-cap managers, 88% of mid-cap managers, and 88% of small-cap managers did worse than their index benchmarks on a relative basis. What does this mean? It means that the vast majority of actively managed funds do worse than their index counterpart. Lesson for young physicians? Stick with index funds and worry about actively learning medicine instead of figuring out which actively managed fund to pick.

So, putting it all together, which funds should a resident put into their Roth IRA? Everyone has their own approach to their "ideal" portfolio. Some people have multiple funds covering different individual sectors of industry. Some endorse a "three-fund portfolio" where you purchase a total market index fund (American stocks), a international total market index fund (international stocks), and a total market bond fund (American bonds) which further diversifies your portfolio by giving you bonds and international stocks. There are others whose whole portfolio consists of just one total market index fund.

It all depends on how "risk-adverse" or not you are. If you're very risk-adverse, as in you want to minimize losses as much as you can, you should consider buying a total market bond mutual fund as well in addition to a total market stock index. To put it simply, bonds fluctuate less with the rise and fall of the market as compared to stocks. To figure out what percentage of your portfolio should be bonds, a general rule of thumb is to subtract your age from 100. That number gives you the percentage to allocate towards bonds.

If you're young and not that risk-adverse, contributing 100% into a total market stock index fund such as Vanguard's VTSMX or Fidelity's FSTMX is reasonable. As time goes on, you can add bonds in there as well.

Which brokerage should you use? If you have $3,000, Vanguard is the way to go as their expense ratios are exceptionally low for their index funds. They have, as noted, a $3,000 minimum on purchasing index funds; if you can't do that, Fidelity is a great second option.

Set up an institutional 403b

A 403b is a 401k for non-profit organizations, such as most academic hospitals. The maximum contribution per year is $18,000. It's the same idea as IRAs — you take money and use it to buy stocks/bonds/funds. There are Roth 403bs and Traditional 403bs which follow the same idea as Roth and Traditional IRAs; the Roth 403b option, is not as prevalent as the traditional 403b and your institution may only have a Traditional 403b option.

403bs work by taking money out of each paycheck that you receive — you can't just dump money that you've had saved up in your savings account into a 403b; figure out what percentage of your income you are able to put aside. Also, fund choices are dictated by the institution you work at so they may be good or terrible. Look for total market index funds; if that fails, look at those with the lowest expense ratios. Again, anything below .50, and preferably under .20, is pretty good. Not all academic hospitals offer 403bs for residents so consider yourself fortunate if you have access to one.

Should you fund your Roth IRA first or your 403b? This is dependent on a number of factors but often requires a longer discussion. To put it briefly, if your institution matches contributions, put enough in to get that match—essentially free money first. If your institution has good quality mutual funds, better than that of your Roth IRA, consider investing in that account. However, because you can only contribute to a Roth IRA if you earn less than $116,000 (single) or $183,000 (married filing jointly), and as most physicians will be earning higher than that number as attendings, you should take full advantage of the Roth IRA option while it is on the table before contributing to a 403b (Traditional 403b here, for the sake of comparison and argument).

Live within your means

This is probably the most important point of this whole article, and something I'm sure you've heard repeatedly. Without living within your means, none of this really matters. As a resident, our paychecks are relatively small and our free time is relatively limited; it shouldn't be too hard, in that regard, to "live like a resident" and limit excessive spending.

For each month, figure out how much money you make and subtract from it your known expenses including your rent, monthly loan repayments, internet/television/telephone/water/electricity bills, average gas usage, food, and insurance payments. Determine how much you want to save and appropriate money for your Roth IRA, institutional 403b, or savings account; just as a ballpark, most experts recommend saving 15%+ of your income when possible. Compare your wanted purchases with the remainder of this final bit of the equation before splurging on that new television.

Understand the overall context

All of this is not to say to bury all of your money into savings and investment accounts and wait until retirement to truly "live." To put it mildly, medical school is rough and residency is challenging. Within the context of cognizant budgeting, take full advantage of your days off and use your spare change to make the most of your time with your friends and family and help facilitate real, memorable experiences for the betterment of yourself and others. Human rights activist Grace Lee Boggs has the following quote which I find ties well within the scope of finance and medicine:

“When you read Marx (or Jesus) this way, you come to see that real wealth is not material wealth and real poverty is not just the lack of food, shelter, and clothing. Real poverty is the belief that the purpose of life is acquiring wealth and owning things. Real wealth is not the possession of property but the recognition that our deepest need, as human beings, is to keep developing our natural and acquired powers to relate to other human beings.”

All the best to your medical training and financial future.

Peter Han, MD
Otolaryngology-Head & Neck Surgery Resident

How to apply to Radiology

February 15, 2017 in MS3, MS4

Overview

True insight into the application and interview process for radiology residency and fellowship is limited for most medical students and residents. The process can be clouded at times by misleading advice and rumors. Only someone on the inside can really understand what you need to know when you are applying for a radiology residency. Thankfully, you have come to the right site. I have looked at thousands of applications and interviewed hundreds of residents for positions in our program during the course of many years as associate program director. I am going to delve into the depths of the radiology residency application process and enumerate what you need to know.

The Application

There’s lots of ways to go through this. But I think the best way is to go through the different parts of the application from most important to least important so you don’t squander your energy on the small stuff!

There are few sections of the application that truly differentiates one applicant from another. Dean’s letters happen to be one of those items. The reason for that: you will actually get comments from attendings, residents, nurses, technologists, and secretaries that may say something negative about an applicant. I can’t tell you how many times we have parsed through an entire application with glowing positives until we arrive at the Dean’s letter. And, then we receive coded messages in the letter such as: was very shy during the rotation, but did see some improvement. Or, this resident was very independent, but did not seek help when presented with a challenging patient care issue. And so on, and so forth.

Additionally, the Dean’s letter may be the only document in the application other than the boards that compares the applicant to his/her classmates. Most medical schools have buzz words indicating the resident’s rank in his/her class. Each one is different, but typically it allows insight into which quartile the resident resides.

Ok, so you have your Dean’s letter written in “stone”. The institution administrators may say there is not much you can do about it. But that is not true. Every medical student applying for residency should check their Dean’s Letter prior to sending out the application. At some institutions, you can look at your letter prior to application time. If that is the case, you should certainly check it for any negative or questionable comments. And if possible, confront the department/person that wrote the comment and ask if they could redact or modify it. Obviously, if the writer is truthful, the person may decide to leave it in there. But an attempt should be made, as this one negative comment often makes the difference between high ranking, low ranking, or no ranking on a program’s rank list. It is not infrequent that an admissions committee will obsess over one questionable comment. In fact, countless painful hours have been spent perseverating over these issues.

Other times, the institution may not allow you to look at the Dean’s letter. But the school may allow your mentor or a faculty member to look at the document and possibly edit it for corrections. I can’t emphasize enough how important it is to do this to increase your odds of being accepted to the residency of your choice.

The Boards/USMLE

The importance of the boards/USMLE for getting accepted to a radiology program is merely to assess the ability of a future resident to pass the radiology certification examinations. We have noticed a strong correlation between lower board scores and difficulty passing the new core exam and the old written/oral boards. Radiology board exams are notoriously difficult compared to many other specialties, so most programs take the USMLE score very seriously. The good news is that it is often used only as a baseline cutoff measure. Once you score higher than that baseline, it doesn’t factor as much into the ranking equations. Failing and low scores, unless there are extenuating circumstances, usually place the application in the deny pile.

For those of you that are D.O medical school applicants, I recommend that you take the USMLE in addition to the COMLEX examination. Many radiology programs are unsure of the significance of COMLEX scores and don’t know how to factor the scores into the ranking equations/cutoffs. Applications with COMLEX scores alone may get thrown out of the interview pile entirely.

All this being said, there is some gamesmanship with the boards. If you have done very well on the step 1 boards, often times you may be able to get away with just sending those scores alone. In fact, you may want to delay taking the step 2 portion because those scores can only hurt you if they are lower. In addition, most programs look for/expect improvement from the step 1 to the step 2 boards, especially if the step 1 boards are borderline. So be careful and take the step 2 boards very seriously. Invest in review course if you need to.

Research

Nowadays, research can be a significant factor for getting an interview in a residency program. What is the reason for that? Simply, the graduation guidelines for ACGME accredited radiology residencies have specific radiology research requirements for each resident prior to graduating. Knowing that a resident has completed multiple quality research projects means that a resident can work more independently to complete research projects within the program, reducing the burdens upon the department. Furthermore, radiology research may demonstrate significant interest in the field and provides an avenue for discussion at the point of the interviews later on in the process. Often times, we will look at an application and we will say, it’s pretty good, but the resident hasn’t completed any research. That may take the application down a few rungs.

Bottom line though. It won’t take you completely out of the running for getting a spot, but can be a big assist in some situations.

Extracurricular activities

There are two big red flags when you are completing this section of your applications. Those people that have participated in every extracurricular activity under the sun and those people that have participated in almost nothing. A resident that participates in everything suggest that the person has a lack of focus, never investigating or accomplishing tasks in depth. On the other hand, a resident that participates in nothing but school, tends not to be well rounded and may not have outlets to disperse their frustrations during their 4 years of training.

So what are some activities that impress the admission committee? Interesting extracurriculars that show leadership potential, activities that demonstrate depth of involvement, and activities that demonstrate an ability to handle stressful situations and function independently. Some of the special extracurriculars that stand out in my mind that meet this criteria would be: a student that started a Subway franchise successfully from scratch and made it into a big business, a student that participated in the Olympics, a student that was heavily involved in the congressional lobbying, etc. These are people that tend to climb the rank list higher because their extracurriculars were memorable.

What are some extracurriculars that don’t really add much to the application? Those activities that everyone else does and do not suggest leadership potential. In radiology, those would include participating in a radiology club (Big deal!), participating in health fairs (Every medical student does it), and teaching inner city kids (We see it all the time as part of medical school curricula!) Not that these activities are bad, but they don’t add much at all to your application. My recommendation is find something you enjoy, hopefully something unique, and stick with it during your 4 years of medical school training!

Recommendations

Admissions committees like to make a big deal about recommendations. You’ll certainly hear that you need a great recommendation to get into a great program. But honestly, if you ask someone for a recommendation, it is unusual that you will find someone who is going to write you a bad letter of recommendation. It is obvious that students are going to ask attending physicians that like them. This statement brings us to the one of the few ways that recommendations change the acceptance equation. It is a rare but major red flag to see a “bad” recommendation. It often means the resident that obtained the recommendation has a poor emotional intelligence quotient or couldn’t find one attending that liked them- both major issues!!!

It is also the rare recommendation that raises the application within the pile to higher rank or from no rank to rank. Usually, this type of recommendation comes from a well known entity that wants the person in their own program or a close colleague that the radiology admissions committee implicitly trusts.

So therefore, recommendation rank fairly low in the application influence equation.

The Personal Statement

Finally, I would like to talk about the thing that medical students often perseverate on but has very little influence in the residency application process- the personal statement. The personal statement almost never helps an applicant and can occasionally hurt an applicant. After having read over a thousand of them, there are very few standouts. And, all of those that stood out were somewhat disconcerting. I still remember an essay that emphasized a dead rabbit and did not have have any correlation to radiology whatsoever. I was concerned about mental illness in that student. That same person had the possibility of a radiology ranking immediately terminated!!!

My basic advice for personal statements is be cohesive and relevant to your future career as a radiologist. Also, watch out for typos because typos suggest an inattentive personality, not a characteristic you want in a radiologist. Other than that, don’t fret too much about this part of the application.

Summary

Applications for radiology are an arduous process with multiple pitfalls. Make sure you concentrate on those items that you give you the most bang for your buck and will send your application higher on the rank list. Make sure to put particular emphasis on the Dean’s letter. Check it if you can. Correct it if need be. Otherwise, make sure your application doesn’t stand out too much. Don’t be that student with marginal board scores, no research, with dull or no extracurriculars, with bad recommendations, and with a personal statement that stands out too much. If you follow these guidelines, you should get into a great residency, hopefully one of your top choices.

Barry Julius, MD
Radiology Attending

This post was written by Barry Julius, MD, the associate radiology residency director at Saint Barnabas Medical Center, and was used with permission. More of his work can be found at his website, Radsresident.