Enjoying the Milieu of Matching: Reflections from a First Year Intern

The fourth year of medical school is a rather strange mix. You spend much of the months of November to January travelling all over, living completely out of a suitcase, and wearing the same dark suit for days on end. This is followed by whatever method you might choose for ranking the places that you would like to complete residency. Some people make endless lists of pros/cons, others continue to research every possible detail about programs, hospitals, cities, and the like. All of this leads up to filling out the rank list with NRMP (National Resident Matching Program), checking it a few (possibly a dozen) times, submitting the list, and waiting for almost a month.

Then comes Match Week – probably one of the most unusual ways ever to find out about one’s first job (or at least the first as an MD/DO).

The second week of March is filled with a roller-coaster of emotions for fourth-year medical students across the country. There’s the universal anxiety about receiving the email from NRMP on Monday morning – “Did I match?” – followed by a week of anticipation. Medical schools seem to handle Match Day in one of two main ways. Most medical schools convene students (often for the first time in many months) to celebrate the achievements of the class. Some schools (like mine) have students announce where they will spend the next 3-7+ years in training one-by-one in front of a crowd of classmates, families, and friends. Other schools (so I’m told) have students open their match letters all at once, allowing for a bit more private experience. In both situations, the primary motive is to celebrate the achievement of students completing the four years of medical school now embarking on the next part of their training.

As I look back on my own Match Day, I’d encourage those of you reading this to make sure you take the chance to celebrate. Take a little time to reflect on what you have accomplished and to enjoy a day with the people with whom you have worked throughout medical school. In addition, celebrate with attendings, faculty, and mentors alike. Match Day, for many students, will be one of the very last times that you spend with your classmates. Some classes decide to celebrate on the morning before Match Day with a makeshift “tailgate” (caution: rumor has it this can be dangerous), while others host parties afterwards for students and faculty. In whichever way you choose, take the time to enjoy your individual and collective accomplishments. The next few weeks and months will be filled with final rotations, travels to find a new place to live, and hopefully at least a little time to relax. Graduation will find most people in the midst of life changes, marriages, babies, moving, and that day will come and go rather quickly. Take the time on Match Day to realize what you’ve accomplished and to re-connect with the people who were alongside you on the lengthy journey from the anatomy lab, through the classroom, and onto the wards. It’s an exciting week; make the most of it. Good luck!!

- Ross W. Hilliard, MD, Internal Medicine Intern, Rhode Island Hospital and The Miriam Hospital, Brown University/Lifespan

The Excitement, the Nerves, the Uncertainty … it’s Match Day!

Editor’s note: Joshua Liao, a fourth year medical student at Baylor College of Medicine, takes us inside his thought process as he prepares for Match Day or, in his words, one “massive job notification party.”

There is a common theme to the unique experience called Match Day: Unlike every other transition we’ve had as students—from high school to college and from college to medical school—we are forced to consider our options and everything important to us without any reassurance of acceptance. Unlike the college or medical school selection processes in which we could definitively know our options and choose from them, the Match forces us to process our goals using potential scenarios and possibilities (which can be taxing mental exercises). The complexities of this process can be further amplified by well-meaning, but anxiety-inducing, relatives and friends.

If nothing else, Match Day is an extremely unique way to find your first job. As applicants (“soon-to-be physicians”), we start the process off by applying to as many residency programs as we want and then awaiting interviews from all, or a portion, of those programs. We then invest an immense amount of our own time, money, and energy visiting those programs on strictly required, non-negotiable (as I unfortunately found out several times) in-person interviews.

After a brief lull, we rank the programs we visited and enjoyed, and each program, in return, ranks as many of us as they want. This massive collection of lists is then inputted into a central algorithm that pairs students with programs, culminating in a large grid of “matches.” The matches are released all at once, all over the nation, on one morning in mid-March (this year it is on Friday, March 16). The event, or “Match Day,” is essentially a massive job notification party for the majority of medical students.

For many of us around the country, it can be anxiety-laden for a number of reasons:

• For some, elements of their academic records have been questioned during interviews and give them cause for concern
• For others, interview experiences and Match statistics that ought to reassure still don’t
• For others still, specific personal and/or academic reasons can cause anxiety about getting into specific programs

I was determined to avoid all this. I spent a great deal of energy choosing which programs to apply to and then, after doing my best to take stock of my goals and values, selecting which ones to visit on interviews. Afterwards, I resolved to fully engage every program that felt consistent with what I wanted and not to mislead those that were not. I asked increasingly specific questions (including many about the presence of patient safety/quality improvement opportunities!), and gradually, my rank list came together. I revisited it numerous times. I felt consistent and content.

But as we approached the date for final list submission (February 22nd), a few unexpected thoughts formed in my mind:

• Had I ranked everything the right way?
• Was a one- or two-day visit really enough to assess my favorite programs accurately?

In very specific situations, last-minute list changes can sometimes be beneficial for students. But that wasn’t the case for me. As time passed, it quickly became clear that I needed to stand firm in my original convictions, a decision that required much more courage than changing my list. There was an undercurrent threatening to disorient and panic me, but I was determined to resist it. I took a few more long looks at my rankings, calmed the urge to tweak them, and submitted.

Now, I await Match Day with a surprising measure of excitement, and I’m thankful I remained true to my values throughout. On one level, I certainly hope I get my first choice, like every student does. But on another level, I hope that regardless of outcome, I will be content knowing that I handled everything along the way with serious thought, careful reflection, and honesty.

Because while I’m not sure where I’ll be come July, I know one thing beyond a shadow of a doubt: Match Day is an extremely unique way to find your first job, but it’s an even more unique and important way to find out more about yourself.

By Joshua Liao, BA, BS, Baylor College of Medicine jmliao@bcm.edu

Our experience at the Southeast Regional IHI Open School Forum

The Second Annual IHI Open School Southeast Regional Forum in Greenville, SC, was, in short, a fantastic experience. After cramming for—and taking—yet another med school exam, my co-attendee Paras and I drove about five hours down to Greenville for a conference that would remind us once again of the big picture of why we are in medicine.

After we settled in our hotel, we turned to a generous reception the conference offered and I found myself surrounded by other IHI Chapter leaders and experts in patient safety and quality. It was the start of two days of great networking. Just for starters, I learned how payments around patient safety were changing and how other Chapters recruited and raised awareness among their members.

The next day began bright and early, and once again the networking was genuine and extremely useful. HealthSouth founder and former CFO Aaron Beam's presentation was a very relevant cautionary tale about slippery ethics and risk factors. I'm sure I'll recall his story when I'll undoubtedly find myself and my colleagues faced with the temptation to cross ethical lines "just this once."

The presentation by South Carolina Hospital Association that followed delved into how one defines, creates, and maintains a "just culture" around medical errors and their reporting. Only by admitting our mistakes can we learn from them and prevent them from happening to others. I found the case study particularly compelling and useful in solidifying my understanding.

In all, I met some great people, and took away lessons that will help me:

1.       Build a stronger IHI Open School Chapter

2.       Foster a culture of open error-reporting in my career 

Emily Ingram, Ryan Baker & Cassie Besten

University of South Carolina  Columbia College of Nursing , 2012

And

Marisa Dowling

Duke University School of Medicine, 2015

What if hotels billed like hospitals?

Costs of Care put out a a viral video today to help announce a new curriculum being developed to help trainees learn how to make value-based medical decisions. What do you think?

Team: What’s Your Definition?

Writing a job description was not exactly what I imagined myself to be doing in the first week of a clinical immersion. (To many, this might not sound too interesting or even relevant to clinical as a nursing student.) However, it proved to be an extremely valuable experience and inspired a new thought process on defining roles among health care staff.

The task for the meeting was to draft a clear description and distinction for both the nurse and medical assistant. It turned into 2.5 hours of constructive debate about how to word the already understood roles so that they would be concise, clear, and representative of the values of the medical home – a team-based health care delivery model.

What stuck with me the most from participating in the composition of the job descriptions was the meaning of the word “team.” In the medical home model, an interdisciplinary team approach is critical. (In fact, there is even a position for a Team Coordinator.) During the meeting, we were contemplating changing the name of the job title of a Registered Nurse to Team Nurse and from Medical Assistant to Medical Team Assistant. What would be the implications of renaming the role? What does the word “team” really mean?

As I am sure many of you are familiar with, the word “team” is used endlessly in coursework. My field of study, clinical nurse leader, in fact, represents and advocates the importance of an interdisciplinary team. But does everyone think of the word in the same way? This idea was discussed and will be revisited in an upcoming meeting. In the meantime, I asked around at the center, inquired with fellow peers, family, and friends to compile a mix of perspectives on how to define the word “team.” Here are some of the responses I received:

• “A group of individuals working cohesively in order to achieve a common goal”
• “A team is people who make each other better than they can be alone”
• “A group of people working together toward a common goal, sharing resources, skills, and responsibility”
• “A group of individuals working toward a common goal with various different perspectives and approaches to reach that goal”
• “A group of people working for a common purpose”
• “A group of peers working together”

Key words in these definitions were “together,” “achieve,” and “goal.” I was pleased to see how many people chose to use those exact words or something very similar. I think the members of this task force will agree the word “team” will be well received and a positive addition to the job title and description at the center.
I’d love to hear from some of you. What does the word “team” mean to you? Does your clinical site or past sites use the word “team” in everyday practice?

- Jessica Hatch, Clinical Nurse Leader Student, University of New Hampshire

Editor's Notes: Learn more about Jessica—and her clinical nurse leader role—in her interview from the 2011 IHI Open School Student Quality Leadership Academy.

Advice From a Third-Year Medical Student, Part II

Editor’s note: Two weeks ago, Lakshman Swamy, an MD/MBA candidate at Boonshoft School of Medicine at Wright State University, shared some advice for other students that he picked up after his third year of medical school. Not just for medical students, the advice touched on humility and the urge to complain. More than 1,000 readers have viewed the post, which you can see here.

Now Lakshman presents Part II of his advice and, again, wants it to be clear that he has made ALL of these mistakes. No one is perfect, he says, but being conscious of these mistakes – and this advice – helped him grow throughout the year. Take it away, Lakshman:

Here are four more great pieces of advice I picked up during my third year in medical school:

1. Don’t Slander. Don't talk badly about other students or, well, anyone. There will be plenty of opportunities to do so because you will see people violating all sorts of rules and you will be infuriated by it. You’ll see other students slinking away and getting days off to study on flimsy excuses – or coincidentally getting all the best cases and the least of the scut work. Ignore it all. Focus on doing the right thing and creating the best image of you. Be an upstanding citizen, ignore what others do, and have a clear idea of your own expectations and stick to them. In doing so, you will stick out and look fantastic – and deservedly so!

2. Put Yourself Together. Don't look like you slept in the hospital even if you actually did. Take care of yourself because you WILL look unprofessional when you don't – and it is very obvious. You will forget things, drop things, make mistakes that affect your team and your patients, and it all ultimately reflects on you.

3. Be a Great Learner. As difficult as it is, don’t be solely focused on tests and grades. You will have a much better time if you try to learn what you need to know because you see it as your own responsibility, rather than trying to pick out the test questions. If you allow yourself to be geared toward that objective goal (the next test, the boards, etc.), you will cement that way of thinking for your entire career. There are two problems I see with this:

1. You miss out on the depth of the information, and when atypical problems arise, you will be less equipped to deal with them.
2. You’ll be miserable.

You’ll always be looking for some future challenge that needs to be surpassed, and you won’t be able to relax and experience what is happening right now, and to excel in the moment. I’ve personally missed out on things that I would have been so excited to be a part of because I was more concerned about the upcoming quiz or test.

4. Be an Asset. Be dependable to your team. Run to get data for them and really try to know everything about your patients – just trying will pay off. As Eric Greitens said in his keynote address at the IHI National Forum last December, your strength can come from knowing others rely on you. You'll be amazed at your energy and capacity when you feel like you are an important part of the team. Relish the basic chores you have to do – don't consider them beneath you.

As a student, you’re often the first one to meet a patient and gather their story. Long after you present it, knowing those details can really come in handy and make you look fantastically on top of things. One example: Recently on call, the residents were handed a new patient with a surgery. We were walking to the patient and the residents blanked on some of the details of the case. I had done the H&P, knew everything about that patient, and saved them the hassle of logging into the EMR to get the details. Little things go a long way.


- Lakshman Swamy, MD/MBA Candidate, 2013, Boonshoft School of Medicine at Wright State University

The Immunity to Change Health Care in America

Don Berwick, during his time at CMS, had the opportunity to hear about health care from the point of view of consumers. Many times, he noticed the irony that Americans who would benefit most from health care reform were most vehemently against it. The message that health care reform is not only bad, but evil, has aroused the most basic fears – including fear of death – in a distrusting public.

Meanwhile, the message that health care reform is good for our country is falling on deaf and unbelieving ears. Why is that?

IHI staffers recently had the opportunity to hear Robert Kegan speak. In his book Immunity to Change, he points out that there are hidden and powerful assumptions that stymie people from changing habits and attaining stated goals. The inability to reach these goals is due to the reality that our current behaviors are a perfect response to these hidden and powerful assumptions. For example, a child can understand that it's good to share, but if there is an underlying fear that there's not enough, the logical commitment is not to share. It is an emotional response to the assumption of "not enough."

Most people, when asked, would conceptually favor attainment of the Triple Aim – better care for individuals, better health for populations, and lower per capita costs. However, health care in the United States is strongly counterproductive to achieving this: technology and hospitals are overused with resultant waste, access to high quality care is inconsistent at best, and unsafe care remains a problem. What are the hidden assumptions that drive Americans to hang on so dearly to a dysfunctional and unsustainable health care system?

Americans have been led to believe that good health care is a life-giving, but expensive and limited consumer product. The assumption is that health care has to be purchased. It is not a societal right. "Don't take away my Medicare" is a response to the awareness that health care must be purchased. In contrast, we generally expect education to be provided, not purchased. In the United States, people have vastly different expectations of health and education. The assumption is that this is the way it has to be.

How do you think we can alter this assumption? In other words, how can we remove this immunity to change? And how can we create a message for better health care that Americans hear clearly?

- Warren Wong, IHI Fellow