Residency/Rotation Information session

1. Residency/Rotation Information session TeAMS Program

2. Timeline • Late August (beginning of 3rd year): Finish USMLE Step 1 • November: Provide wish list of rotations to the faculty. • November- December: apply to Canadian electives • February (3rd year): Sign up for usmle step 2CK, usmle step 2CS. Research any interested rotations not on the wish list that you would like to go to • March-May: apply to rotations not on the wish list • June: Take USMLE Step 2CK • July 1st: Obtain ECFMG token for ERAS registration • August: Take USMLE Step 2CS, complete Residency application on ERAS • September 2012: Take MCCEE (Canada) • September 15, 2012: Residency programs can download your application STARTING at 8am EST. Send application today! • September 15 to Early February, 2013: Can receive interviews • Late february, 2013: deadline to submit rank list • Mid March, 2013: Match results are released!!! For Canadian timeline go to: http://www.carms.ca/eng/r1_1stIteration_e.shtml

3. Rotations

4. Rotations • Applying to rotations/where to apply • Dates to complete applications • Sub-I vs. elective? • PUSH PUSH PUSH! • How to prepare for rotations • Order of the rotations • Asking for recommendations • Networking/speaking with the program director

5. List of programs that accepted previous students

9. Rotation checklist • 1) Titers showing immunity against: Measles, Mumps, Rubella, Varicella, and HBV. To obtain this, have a classmate draw your blood into an orange (chem) tube and take the tube immediately to the Rambam virology department (8th floor of the main building). Present yourself to a virologist and they will process your order and prepare an invoice. Currently Rambam charges NIS 200 for the titers. Take the invoice and pay in the old building (Binyan Ha-Yashan – 2 nd left after aroma). Return to virology in a week and get your results.  Ask for it in English. ** keep in mind that some programs want positive titers within 90 days of doing the rotation. So make sure your titer date doesn’t expire. On the other hand make sure you do it early enough so that if you get any negative titers youll have enough time to go the health ministry in the missile building and complete your immunizations. • 2-PHASE PPD test (2 ppd tests 1-3 weeks apart). This may be obtained from the personnel clinic in the "stone building" at Rambam. Also ask for in English. (some programs require it be within 5 months of rotation date and some programs request the IGRA test for persons born outside the US/BCG vaccine or positive history )- Recent X-ray results can also be used to rule out • 3) Letter of good standing for rotations • 4) transcripts if necessary (depends on institution)

10. 5) Insurance: You do this after you get accepted for your rotations, not before. A. malpractice insurance Medical malpractice insurance in the states: http://www.academicins.com/ifmsa.html For Canada: Arnold Cariaga at Hub International. arnold.cariaga@hubinternational.com OR if you are going to UWO contact sheila.ryckman@aon.ca (there is a discount for the rotations at UWO)- MUST PAY FOR ONE FULL YEAR!!!! B. Proof of Medical Insurance 6) HIPAA: http://www.goer.ny.gov/ , OSHAhttp://www.elearnonline.net/coursedesc.aspx?ClassID=463&s= 7) Letter of eligibility: Once accepted to a rotation (specifically in NY but may apply elsewhere), you need to submit this form. To do so, you need 1) a letter of good standing from Technion indicating the hospital, department, and dates of the rotation, 2) A certificate showing you passed the New York infection control course. It costs $30 3) and this form (click the link) to the address listed on it. http://www.mssm.edu/static_files/Test2/06081716/www.mssm.edu/medschool/electives/pdf/nys_letter_of_eligibility.pdf 8) Housing: Rotatingroom.com has some great housing if you are unfamiliar with the area. 9) Passport picture 10) USMLE step I score (MANY PROGRAMS WILL NOT TAKE YOU WITHOUT A STEP 1) 11) copy of immunization records 12) criminal record – (US/Canada)

11. Application Follow up • Most programs do not process applications until May 1st (but this is on an individual basis) • Provide alternative dates for every rotation (some dates are more popular than others, and to ensure you get a rotation, giving them more alternatives helps your application) • Confirm deadlines with every program via email or phone • Persist after applications are complete to make sure they receive the application, that they are processing, and that nothing else is needed • Can take between 2-6 weeks to hear back from a program on your acceptance and scheduling • ALWAYS be sure you get written (letter or e-mail) conformation • Canadians- proper LETTER is necessary to get B1 visa (at border)

12. What is a sub-internship • 1 month rotation that allows you to experience what being in the intern year is like • Sub-I are available on the floors in pediatrics, ob/gyn, internal medicine, and surgery • Managing your own patients • Writing patient notes • Discussing and writing orders under supervision • Presenting patients at rounds • Much more responsibility/stress overall

13. Elective • Allows you the ability to experience subspecialties under a particular field • Easier to apply for • Teaches you to write consults • Much more laid back • Less responsibility

14. All in all, Sub-internships give you more responsibilities, causing you to be more prepared for life as an intern, and if you do well, can impress a program to seriously consider you as part of their house staff • Electives give you a chance to get a taste of a particular subspecialty without the excess work and responsibility ***you should do at least 1 sub-internship (preferably at your 1st choice program) during your 3 months of US/Canadian rotations- IN FIELD OF INTEREST!

15. Preparing for US rotations • Presenting Patients to the staff at rounds and at sign out • Writing patient notes • Familiarity with format of Lab results and abbreviations BE SURE TO PRACTICE DURING YOUR 3RD YEAR CORE ROTATIONS!!!!

16. Things to do to stand out positively • Positive attitude • Hygiene, Professional Dress • Men: Button down with tie, dress pants, white coat (purchase your own plain short white coat) • Women: Conservative dress, pants and button down or dress • Ask for more responsibilities, ask to present patients, ask to do procedures • Volunteer to give presentations • Be the first one there in the morning and the last one there in the evening • Speak with the program director in the first week and in the last week to show your interest in the program • Ask an attending in the department for a recommendation at the end

17. Typical hours/Responsibilities • Specialty-dependent • In general, hours are from 630am-5pm depending on elective vs. sub-i • When the new shift staff decides to sign out, you can leave unless you are on call • If on call, you maintain the same responsibilities. Can range in time from overnight call to an extra 6 hours

18. Presenting the patient • Identifying data (age, name, etc.) • Chief complaints (why are they here? pt’s own words) • Circumstances of presentation (how did they get here?) • Did patient come in unconscious in an ambulance? Did they walk in ER? Are they in for yearly exam

19. o Chief complainto Onset of illnesso Durationo Intensityo Exacerbating factorso Remitting factors (what makes it better)o Symptoms associated with it

20. PMH (Mnemonic: CHAMIS)o Chronic illnesseso Hospitalizationso Allergieso Medicationso Immunizationso Surgeries

21. Where do they live?o What is their living situation?o Do they drink alcohol?o Do they smoke tobacco?o Sexual history – tend to include this in psychiatry, might get “slapped if you include it in surgery or pediatrics”o Developmental history – very important in psychiatry, “slapped again in surgery”

22. • Vitals• Physical Exam (learn the shorthand now – it will help during 3rd year)• Lab data• Radiographic data

23. Summary Statement • Main salient facts of patient• Differential diagnosis in order from the most life threatening to the least• Problem list(Why they came in?What other studies are you recommending? ORWhat is the treatment? • Each problem should include: Differential diagnosis Plan for what you are going to do (working it up and treating i

24. Mock Presentation (new patient) • Mr. M is a 67 yo white male who was brought to the ER last evening at 11 pm by EMS after being discovered unconscious by neighbors. He was easily roused but extremely short of breath so 911 was called. The pt was evaluated by ER physician and admitted to our internal medicine service. PI: At 10:30 pm, Mr. M states that he became “extremely short of breath” to the point that he could not get to the phone to call 911. He describes an increasing productive cough with yellow sputum over the past 3 days. He states that he caught a cold 1 week prior to admission, which included runny nose, dry cough, and shortness of breath with an onset gradually over the course of a day. He states that he felt febrile but did not take his temperature. Pt stated that his cough was relieved somewhat by OTC Robitusin DM which he took as directed 3 times over the course of the next day. He states that his cough became more frequent and more productive with sputum over the next day, which was ~5 days prior to admission. He stopped taking the Robitusin and began to use an albuterol inhaler, which his psychiatrist had prescribed for him. Pt’s cough and SOB worsened over the next few days until he was no longer able to take care of himself last evening. His only relief from SOB was to lie in bed for most of the day. He denies hemoptysis, chest pain, dysphagia, hoarseness, or paroxysmal nocturnal dyspnea (brief focused ROS at the end of HPI). PMH: Pt has history of COPD with which he was diagnosed 2 years ago. He was initially prescribed theophyline by his ophthalmologist but quit taking this after 1 month due to jittery sensation. He then was admitted to this hospital one year ago with similar presentation to current but left the hospital without medical follow-up because he felt better. He denies any problems until some episodes of SOB 6 months ago which were relieved by albuterol inhaler prescribed by his psychiatrist. Pt has a history of non-insulin dependent diabetes mellitus diagnosed 3 yrs ago during a routine screening by his psychiatrist. He took glyburide 5 mg bid for one month but stopped when he felt better. He also has a history of major depressive disorder diagnosed after a period of decreased energy and crying spells 3 years ago. He was prescribed ? 250 mg bd but stopped taking it after a month because he felt better. He has no previous suicide attempts and has never been admitted to a psychiatric facility. Currently takes no other medications other than what we’ve said, has no known allergies, and denies previous surgeries. Social history: Pt lives alone in Lutz. He is a retired glue factory worker. He is widowed – he was married once for 30 years to a schoolteacher who died 3 ½ years ago. He smokes 2 packs of Lucky Strikes per day and has done so for the past 40 years. He used to drink a few beers on the weekend but denies any alcohol consumption for the past 3 years. He was born and raised in Plant City and achieved a high school diploma. ROS (just state what was positive, remember you mentioned pertinent negatives in the opening): ROS was positive for difficulty with night vision, constipation, and tinnitus. Vitals: Temperature 99.9OF. Blood pressure 102/60. Pulse 110. Respiratory rate 38. Physical exam: GENERAL: Alert white male wearing a hospital gown in mild respiratory distress appearing slightly older than stated age (this is especially important in pediatrics, a “sick appearing 3 year old” is very ominous). HENT: PERLA, NCAT (normocephalicatraumatic), MMM (mucous membranes moist), pharynx with moderate erythema. Tympanic membranes intact. Neck supple with no lymphadenopathy or thyromegaly. No bruits. LUNGS: Scattered rales bilaterally. Consolidation and dull to percussion in left lower quadrant. HEART: Regular rate, normal S1 and S2, no MRG (murmurs, rubs, or gallops). ABDOMEN: Nontender, nondistended, bowel sound present. No hepatosplenomegaly. No bruits. GU: Normal male genitalia. No masses. Testes descended bilaterally. RECTAL: Heme negative. Normal sphincter tone. Prostate normal size without nodules. NEURO: DTRs, motor, cerebellar, sensory, and cranial nerves normal (in neuro you would go into detail). Studies: Oxygen saturation 91% on nasal canula at 2 liters of oxygen (these details are very important – DON”T LIE OR GUESS). Arterial blood gases (ABG) normal. CBC white cell count 15,000.I n conclusion, Mr. M, a 67 yo white male admitted for SOB found to have left lower lobe pneumonia and exacerbation of COPD which led to his presenting symptoms. Problem #1: Left lower lobe pneumonia. Will start IV Temni, check sputum cultures, which were obtained last evening, follow-up CBC tomorrow a.m. (Why a CBC? Because it includes white cell count, which is indication of course of infection). Problem #2: COPD exacerbation. Start albuterol nebulizer treatments. 2-4 hours. Problem #3: Fluid and electrolytes. Start IV normal saline at 120 ml/hour. Problem #4: Psychiatric. No evidence of depression at this time.

25. Follow up rounds • Introductory Statement • John is a 32 year old white male who was admitted yesterday for chest pain • Consults/changes in the past 24 hrs • Cardiology was consulted last night and suggest echo/ekg and blood panel, will follow up on this • Subjective/objective findings overnight or over the day • Patient felt better overnight, slept well, ate well, voided and stooled appropriately. Temperature went up to 39C but is now 37 as of 6am • Physical Exam findings • New Labs/Imaging • Summary statement • Problem list (with differential diagnosis) • 1)Chest pain (DD: angina, CHF, musculoskeletal) • Plan: labs, imaging, pain medication, call cardio, and observation • 2)diabetes mellitus type 2 • Plan: maintain insulin medication and metformin, observe clinically

26. Sign out Presentation • Very succinct presentation—updating the next doctor* • Summary Statement • Changes in status or medications over the course of the shift • What to look out for overnight*

27. Writing a Patient Note • Be familiar with admission notes, discharge notes, follow up notes, surgical (post op/pre op), SOAP note • Great Website that summarizes these: http://www.angelfire.com/md3/medstudsanonymous/medsubweb/notes.htm

28. Familiarization with handwritten labs

29. Commonly used abbreviations yo year-old m male f female b black w white L left R right hx history h/o history of c/o complaining of NL normal limits WNL within normal limits Ø without or no + positive - negative Abd abdomen AIDS acquired immune deficiency syndrome AP anteroposterior BUN blood urea nitrogen CABG coronary artery bypass grafting CBC complete blood count CCU cardiac care unit cig cigarettes CHF congestive heart failure COPD chronic obstructive pulmonary disease CPR cardiopulmonary resuscitation CT computed tomography CVA cerebrovascular accident CVP central venous pressure CXR chest x-ray DM diabetes mellitus DTR deep tendon reflexes ECG electrocardiogram ED emergency department EMT emergency medical technician ENT ears, nose, and throat EOM extraocular muscles ETOH alcohol Ext extremities FH family history GI gastrointestinal GU genitourinary HEENT head, eyes, ears, nose, and throat HIV human immunodeficiency virus HTN hypertension IM intramuscularly IV intravenously PRN in the circumstances of Qd every day Qh every hour JVD jugular venous distention KUB kidney, ureter, and bladder LMP last menstrual period LP lumbar puncture MI myocardial infarction MRI magnetic resonance imaging MVA motor vehicle accident Neuro neurologic NIDDM non-insulin-dependent diabetes mellitus NKA no known allergies NKDA no known drug allergy NSR normal sinus rhythm PA posteroanterior PERLA pupils equal, react to light and accommodation po orally PT prothrombin time PTT partial prothrombin time RBC red blood cells SH social history TIA transient ischemic attack U/A urinalysis URI upper respiratory tract infection WBC white blood cells

30. Recommendations/Speaking to the program director • Most programs grant you an interview if you do a rotation there • Constantly express your interest in the program • Attendings are usually enthusiastic and are willing to write a recommendation • You should try to get at least one US recommendation from the state uploaded to ERAS. The attendings are familiar with the protocol and are very willing to do this for you • Schedule a meeting with the program director with the secretary 2 weeks before you finish to ensure you meet them.

31. The USMLE

32. Applying for the USMLE https://secure2.ecfmg.org/emain.asp?app=iwa

34. Step 1 • Take USMLE STEP 1 before the beginning of the third year • You are limiting yourself severely if you do not take (it is very hard to manage time after the beginning of third year)—School is instituting a requirement to take it to proceed on to 3rd year • Programs will see that you took the test later, and it can be held against you when they are ranking students for residency programs • Without passing, You will not have the same knowledge of clinical material compared to someone who has studied and taken it • Taking a year off will also be held against you in residency programs…do not use this as a cushion ***

35. Step 2 • Take USMLE Step 2 CK before your 4th year rotations start. • You need to invest all your time in impressing the programs you are at! If you take off time to study, your chances to get accepted decrease dramatically • Take USMLE Step 2CS AS EARLY AS POSSIBLE—preferably after 1st rotation! • It can take up to 12 weeks to grade • If you fail, it takes time to re-register and find available dates • It is better to take it early on so you miss as little of your rotations as possible

36. All steps (Step 1, Step 2 CK, and Step 2 CS) must be taken AND passed by December 31st, 2012 to be eligible to rank programs and enter the match!!!!

37. USMLE-useful resources • First Aid for the USMLE Step 1 • First Aid for the USMLE Step 2 CK • Crush Step 2 • USMLE Step 2 Secrets • First Aid for the USMLE Step 2 CS • http://csprotocol.blogspot.com/2007/12/usmle-step-2-cs-study-plan-for.html

38. The Residency Application Process

39. ERAS Application • 1)register for your ERAS token on ECFMG • Go to Oasis (ECFMG), ERAS services and request token (available after july, 2012) https://secure2.ecfmg.org/emain.asp?app=oasis • Once you receive token, register token on ERAS under the icon “register token” and afterwards, begin applying for residency programs https://services.aamc.org/eras/myeras2012/

40. 

43. ERAS Application • Complete all the components of the application, including demographics, student activities, research, CV, etc. • Bullets will be present in the same format • Then load documents (shown on next slide)

45. USMLE Transcript • Click on USMLE transcript and click release scores—you can send off in 2 different ways: • 1) It is advisable (according to ECFMG and ERAS) to automatically release your scores…the more honest approach and schools see your scores ASAP if there are time constraints • 2) However, you can also release manually---this is if you are worried about not performing well on STEP 2CS or CK and want to ensure you get interviews • However, it will ultimately come up either way and you want to be as honest as possible throughout the application process

46. Personal Statement • Keep to 1 page single-spaced at 12 point font • Start with an attention grabber • Look at your medical school essay for guidance • Mention positive medical experiences • Speak about your unique experiences in Israel • Do not mention negatives, Do not complain • Avoid cliches, rambling, and do not mention why you want to be a doctor, focus on why you want to be a pediatrician, surgeon, etc. • Creativity is good, but maintain professionalism the entire time • Spell check, proof read, and have your advisor read and check it over!!

47. Sample Personal Statement Doctors are highly respected for their noble spirit in saving lives, as well as giving hope and bringing joy to the patients and their families. To be an effective doctor, one has to be cognizant of and familiar with the process of learning to keep up with the innovations in the medical field through continuing education, research, practical experience and better patient care. My wish to incorporate these realms in my personal and professional life has shaped the wanting to pursue a career in internal medicine.The foundation of my learning started in my family that has been pivotal in my development as a person. [not important to an application for residency. High school was a long time ago] I have chosen a field in medicine based on my long-standing fascination with involving learning of complex and varied nature of disease processes. I experienced the most excitement from my time in Internal medicine. Medicine offered me the opportunity to integrate my basic science knowledge with clinical care. In no other rotation, did I have the hands-on application of basic sciences; every case was a mini-experiment in physiology, pharmacology and pathology. My clinical experiences in medical school were the most rewarding and provided me the ability to connect and spend time learning more about the patient's medical condition and understand their inner feelings. Working with patients of all ages and backgrounds helped me discover that one can almost always do something specific and helpful for each patient, usually leading to an improvement of the patient’s problem, allowing them resume an active lifestyle. The knowledge base and practical experience acquired during medical school helped me gain experiences in a wide range of specialties and show compassion, concern, care to the patients. I found every patient interaction to be something new and enjoyable. I particularly remember a 40 yr old male diabetic patient who suddenly became unconscious in the ward. My initial diagnosis of hypoglycemia was correct and the IV dextrose given to the patient helped the patient recover immediately. The satisfaction one experiences when a patient recovers from a near death to normal state is truly indescribable. The variety of clinical encounters, procedures, and degrees of illness make internal medicine extremely appealing to me. The experience of assisting my attendings in various procedures like pleural fluid aspiration, liver biopsy, lumbar puncture and cardio pulmonary resuscitation continued to challenge me to learn the art and science of medicine.Throughout my medical training, I have enjoyed learning from great teachers who taught me to think, and who made the process of learning challenging as well as fun. On a personal level, I find my time away from medicine rejuvenating as well in spending time traveling, creative preparation and presentation of ethnic foods and being with my husband enables me to return to work refreshed. . I feel blessed to have a husband and family who encourage me and provide support in all walks of my life.I am enthusiastic to train at a program that involves clinical practice, education, and research. It is my sincere hope that I will continue to grow as a physician, not only in my knowledge base and procedural skills, but also in my humanistic attributes: to demonstrate compassion, integrity, and respect to my patients. I perceive the medical education and practice as a place not just to survive, but also to thrive.

48. Letters of Recommendation You must write the name and position of every physician writing your recommendation and “finalize” on ERAS *make sure the name and contact information is correct (verify everything with doctor) **make sure the name and contact information match the name and contact information EXACTLY with what you input on ECFMG or it WILL NOT GET PROCESSED

50. Uploading LORs electronically (through ECFMG website)