Post by Admin on May 9, 2014 4:32:01 GMT -5
Al Salamo Alykom..
I wanted to write this guide long ago, but I was too lazy to start doing so. But alhamd lellah, I finally got together to compile it into a big informative thread. I hope it helps, even if for a little bit, any one of the readers...
During my Sixth year, around May 2009, I started the quest to the electives. I knew about it when someone mentioned the word (USCE). Later on I kind of started gathering information, and eventually I got a comprehensive picture of what I should do by around July 2009. I got into Yale SoM (Heme/Onc) for 4 weeks in April to June 2010, and GWUH (Cardiology, and Heme/Onc) for 8 weeks in January to March 2011.
My Elective experience was ONLY in IM, so I’ll just focus on that...
PS. If anything needs any further details NOT covered in the guide, I’d be gladly helpful if I know it, since what I’ve written here is about 95% of what I know, and I forgot the rest. Find me at www.facebook.com/elkhanany.
This is a link to the "way better, though outdated" formatted PDF file, in case someone wants a printout. Choose "File", then "Download Original" from the top menu. docs.google.com/viewer?a=v&pid=explorer&chrome=true&srcid=0Bx1pctj5tE5XZTM0OTQxYzQtMjJjNS00YTUwLTgxYzEtNDBjYWUwOTlhODUx&hl=en_US
NB. All the books, courses, eBooks and materials mentioned within this document can be purchased and/or acquired easily. Google is your friend (as well as library.nu, Demonoid.com, DocsPedia.org, and BitMe.org)
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I. Why Electives ?
a. To gain US Clinical Experience (USCE). Why is it that the USCE is that important? Why do all Program directors favor it? Simple. They want you to know the SYSTEM. A hospital running on a computer system (they call them Electronic Medical Records) is VERY different from ours. b. USA Electives ARE different from UK and Canada electives, as those last two have National Healthcare systems, and patient care is “rationalized”. But in the USA, since all patients are insured, then tests, procedures, and elective operations are usually done more often than not.
This last point illustrates why a non-US elective isn’t really that remarkable in the CV (Still, better than nothing)
b. Another VERY important point in Electives is to be able to get US Letters of recommendation. More on that later.
c. Also to form contacts during your stay... Again, vide infra.
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II. The Basics
a. You’ll need to understand that our 4th, 5th, and 6th year = the 3rd year of a 4-year system in the US. They call these “Core Clerkships”. As in IM, Surgery, OBGYN, Peds, Core clerkship.
We USUALLY can’t apply to clerkships as IMS (International Medical Students).
b. During US students’ 4th year, they take ELECTIVES. These are “special” month-to-month learning experience, lasting for 12 months. SO, US students take 12-months electives.
We can apply to electives, if we're in a US school 4th year equivalent. That is; in the LAST year of Med school, waiting to receive our Graduation Diploma.
In Egypt, Graduation and Diploma are uncoupled. You'll finish your 6th year exams around Nov. to Dec., exam results are out around Feb. next year, you're approved by University council for the MBBCh title around Apr., and they officially grant it to you around Jul. to Sep. THIS IS when you can apply for your Diploma.
Although technically you're NOT required to do the Internship/Emtyaz year to get your Diploma, you have to wait around a year until it's available. This is where (correlation doesn't mean causation) apply. Note that Emtyaz is ESSENTIAL to get your Medicine Syndicate (ne2aba) membership, and to work in Egypt in general.
For unknown reasons, Graduate affairs INSIST that we graduated (got our MBBCh) on the day we finished exams (Oct. 2009 in my case!), leaving a HUGE gap between the time of Graduation (Oct. 2009), Diploma (Jul. 2010), and Match application.
What this mean to us, is that WE ARE ABLE TO APPLY FOR ELECTIVES during Emtyaz, since our Diplomas aren't out yet. We can "consider" that Emtyaz is "important" for the Diploma, and this is good enough for our application.
Some schools grant the diploma, and the Graduation at the same time. They are graduates, has nothing to do with their med school except through Graduate Affairs, and can't apply for electives.
c. The difference between Clerkship and Elective, is that the latter is usually in a SUB-SPECIALTY field (Cardiology, Infectious Diseases, Plastic Surgery, Trauma), Or in a NON-Core Clerkship field (Ophthalmology, ENT, Pathology).
d. What this means for us, is that a Cardiology elective means that you MUST BE as perfect as you can in Cardiology. At least just to be comfortable as to understand all pharmacology involved. If you depend on what you know from Med School, you aren’t prepared enough.
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III. Before You apply
a. First thing is to decide HOW MUCH $$$ YOU’RE WILLING TO PAY. THIS IS IMPORTANT, as you’ll need to decide between High Tuition fee at a reputable institution vs. Long duration Elective.
b. After putting a financial cap, start looking at schools’ pages.
List of USA MD Medical Schools ( They call them LCME-accredited school) is found here: www.lcme.org/directry.htm
Get the name of the school, go to Google, and type: [School X Medicine Elective], and then the relevant page usually shows up. And I usually do this, as it gives me the most up-to-date URL. Note that in this comprehensive list, many schools DO NOT accept IMGs. If you want a ready made list, then;
AAMC list (46 institutions): Official AAMC database. Outdated in most of its info. services.aamc.org/eec/students/index.cfm
MedEdia List (51 institutions): www.mededia.com/node/18
J. Idrees Blog (26 institutions): slightly less than MedEdia's, but VERY organized, and updated regularly. Here, electives.us/unilistims.html . Credit to Dr. M. Kandeel
Lists like FREIDA online, and ACGME programs are more useful during Match application, or searching for observerships/Externships, and NOT electives.
c. If there’s ANY thing, apart from what I’ll explain later, that you don’t get, contact the school. No problem with that at all.
d. COMPILE A LIST OF COMMON REQUIREMENTS OF THE SCHOOLS YOU’RE INTERESTED INTO.
How to choose the schools you’re interested into? Everyone varies. MOST of the US schools don’t even accept IMGs (non LCME accredited), and many accept only from affiliated schools. Cross those out.
- They all want a good candidate. (Good CV, impressive Personal Statement, and nice school transcript). Prepare to get involved in their preparation.
- In addition, some just ask for $$$$$$.
- Others need iBT TOEFL. (usually the competitive ones, as this means they accept a lot of students, inevitably ending in forcing the TOEFL as a requirement.)
- Some need Step 1 and/or Step 2CK
- Some need PRIOR elective/USCE experience
- Some offer ONLY 4 weeks maximum, while others have up to 24 weeks maximum.
Also, let the US hospital ranking sheds some light on the appropriate hospital <---> specialty choice.
e. Again. Put the financial cap, list your positive points, and start crossing out schools from the lists.
f. Start the QUEST. Your minimum should be FIVE schools – that’s FIVE sets of documents, and in the SPECIALTY YOU WANT TO MATCH IN (If IM, do IM. If ER, do that, and so on).
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III.b. A Subsection on Observerships/Externships.
a. I don't know much about them, but these are all the info I gathered from friends, and by contacting as well.
b. OBSERVERSHIPS ;
These are basically empty positions in certain "programs" in some hospitals. Available positions come and go, as well as hospitals offering them.
You can find these spots via: Directory listing ALL US ACGME-accredited residency programs, to contact the program director/fellowship director directly. These databases; FREIDA online: (https://freida.ama-assn.org/Freida/user/viewProgramSearch.do), and ACGME programs (http://www.acgme.org/adspublic/default.asp) offer such directory. OR you can have a pre-made list here; USCE Observerships (http://observerships.blogspot.com/)
After you find the email of the department head, email a template email in the form of a mini-CV. [Dear Dr.X, My name is ..., I'm from ... School of Medicine. I have a great interest in your program, and I was wondering if you have any vacant training positions, where I can observe/shadow one of the department's physicians to further enhance my education. I'm ECFMG certified in ..., with scores of (...). I have my USA Malpractice insurance, and research experience.... ). I understand that these shaddowing positions will be hands-off training only, and I' will be more than happy to comply. Thank you in advance.]
Here, you just "shadow" a doctor. Go with him mainly to the Out-patient clinics, but not as I'll describe later. Rather, you'll just stick to him. He enters the room, you enter. He exits, you do the same.
The interaction is mainly in the form of discussion about the cases, and the reasonable management for them. Although this might seem like nothing, by one's dedication and enthusiasm, one can get a very strong LoR.
b. EXTERNSHIP is an experience similar to electives, in that it has hands-on training.
BUT UNLIKE electives, it's very informal in nature (no application, guidelines,..), and it has to be approved directly with the department head in the department you'll be working in.
Major problem in externship is the Mal-Practice Insurance, since you won't get accepted without it, and no company would want to insure some random IMG who they have no information on his medical credentials. YET, the sponsoring department can facilitate such a thing if they contacted the insuring company.
For more on Externships, as well as some updated observerships, check here (http://usce.blogspot.com/), and choose by states from the right column.
c. There's now a HUGE industry of helping IMGs get the USCE they need via Externship and Observership coordination.
These companies make deals with private practice clinics/doctors, and rarely with small community hospitals, to allow IMGs to gain experience there. I doubt if any work with teaching hospitals.
Alas, just with anything else, they are pretty expensive, the quality of education isn't optimal, and most important, the LoRs aren't strong at all (writer isn't really known, and the contents might show bias) .
BUT something is better than nothing.
A big discussion, though full of promotion and "fictional member" posts can be found here (http://www.usmle-forums.com/usce-clinical-rotations/1420-paid-externships-imgs.html), as well as links to the most famous companies in the field: (http://www.americlerkships.org/, www.imgprep.com/, and www.fmgportal.com/)
When you contact Americlerkships, they will send you a Clinical Authorization Letter (CAL) application form. It might seem daunting, but it's actually pretty straight forwards, and is similar to most elective applications.. The Sponsor will be your teaching hospital (if you are EITHER a resident, or a student) which is affiliated with the school, which in turn is accredited by Egyp...t's National Authority for Quality Assurance and Accreditation of Education (NAQAAE)... Your core clerkships will be written (4, 5, and 6 years).. And as for the "Program description", just check the things that are NOT marked by two asterisks. Then take it to the vice dean, have it sign and seal it... They do require his email and tel. number. Tell him they might be emailing him.
A sample response of one of these companies; [The location of your Externship will be in an outpatient setting, not hospital-based, which will ensure that you obtain the Hands-On Clinical Experience that is a requirement of almost all Residency Programs. All of our Attending Physicians are board certified in their respective specialties and are affiliated with multiple teaching hospitals.]. Credit goes to Dr. Mohamed Othman.
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IV. Document Quest No. 1. The VISA
a. This is really different from school to school. While most schools (even Harvard and Yale) accept B1, some will ONLY accept F (Mount Sinai) or J (Louisville, UAB). This is important because, while you can finish B1 procedures in roughly 1 month, both F and J visa will TAKE TIME (DS2019 and SEVIS processing).
b. And EVEN in some cases, B1 visas might become “cases”. These are chosen randomly for background security check, and can REALLY slow your B1 visa process. (from a norm of 2 weeks to up to 3 months)
c. So if you are searching in June-July, take an elective NOT before January, just to make sure everything will be fine in shaa Allah.
B1 vs. B2. B1=Business. Doing something productive. Any formal course/education/transaction/certificate/... While B2=Pleasure. Tourist. Going to sight see, explore/shop/fun stuff... Many people do both. Thus B1/B2. You'll do elective/externship (B1) and also visit/sight see, even if for a little while (B2).
Sometimes, you’ll be “Juggling” or changing the VISA type. If you’re in a program needing B1, and then got accepted in a program needing F Visa. Read about this experience here: www.mededia.com/node/131
BE AWARE of staying in NY for more than 90 days, as this might exclude you from getting an NY license for the residency.
If on J short term, do NOT stay more than 6 months with this status, as this will trigger the 12 month bar for obtaining J research,, and might mess with your plans of doing research in the US.
d. In the VISA interview, understand that they look at the REASON THAT WILL MAKE YOU RETURN TO EGYPT, and not primarily the reason why you’re going to the US. Highlight those reasons.
You can apply to the VISA without being accepted in the electives still. Simply print the email correspondence between you and the school, and take it with you. Explain the time constraints that forced you to do so. Be cool, and act with confidence. If you have a Dean's letter of good standing copy, take it with you as well.
More on the Visa interview here: www.immihelp.com/visitor-visa/visitor-visa-interview-guide.html
And here; www.mededia.com/node/138
e. Use IMMI – HELP (http://www.immihelp.com/) for any details on visas.
f. For those with GC/Citizenship
Just to clear a point, chances of US IMGs in the match are slightly similar if not the same to other IMGs, and this is mainly because of their poor CVs (Most of them didn't get proper MCAT scores, and went to study in the Caribbean Medical schools).
However, when they apply to the match, they'll have a "higher number" of available options to choose from, since many southern programs don't sponsor VISAS for IMGs. And although this might look good, most of these programs don't have a competitive residency education system.
But the GC DOES enhance your elective application, as it carries the notion that you're a good English speaker, you have financial support, and you'll definitely be returning to the US for a match.
g. How does the GC help in the match by the way?
Ability to apply to more hospitals (around 50 in total). Although most of these hospitals are weak programs, they all offer prematch and a guaranteed in, especially with good LoRs and scores.
Since most hospitals review IMGs with GC application BEFORE they review other IMGs', you will get early IV invitations, within first 3 weeks after applying to the match, which gives you a higher chance in general of getting IV as the earlier they review your application, the better.
The reason why an IMG with GC is much better than IMG without is the fact that EACH YEAR, many IMGs fail to get their visa by time of residency, and the program risks starting the cycle with incomplete staff. So many PDs shy away from this risk.
Indeed, NRMP says that 49% IMGs who need visa do match as compared with 40% IMGs with GC who do, (http://www.nrmp.org/data/resultsanddata2012.pdf, page 15) you can NOT draw conclusions based on this observation due to a confounding factor: Most IMGs with GC have bad scores/low overall CV, and even sometimes bad English. I can inductively generalize based on my observations here in the US.
In general, an average scoring IMG with GC will get around 5 IV within first month, and around 10 to 15 in total.. A stellar applicant with high scores, USCE AND publications can get a total 30 to 50 IV, with a LOT of university IVs prematch offers.
h. If you applied for the Diversity Visa, and worried about the visitor visa interview;
Rremeber that the DV doesn't ask for a passport number. The data are highly non-dependable. They ONLY go by your last name, DoB, and the confirmation No./Pic.This means, your name can change (letters for example) when you create your passport...... This unreliability won't cut it
But anyhow, In the embassy, you're asking for B visa BECAUSE you want to do something in the USA, and come back. If in the interview he ever mentions the topic (ie, do you plan to be an LPR) simply answer like a US lawyer
, that you'd want to pursue medical career at some point in the USA, and such state will help you immensely. But lack of it won't hinder your goals as well. (and give a nice smile)
The most probable answer to the uestion however is NO, it will never affect your chance, simply because if such a myth was true, then all 11 million applicants would definitely be "denied" entering the US, and the forums will be flooded "literally"
Besides, here's a legal opinion: (http://www.visalaw.com/greencard.html), and see the question : Will applying for the lottery affect one's ability to receive a non-immigrant visa?
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V. Document Quest No. 2. The Army Authorization
a. Rabbena ma3ak. Very unpredictable. But to get it during the first half of Emtyaz you’ll need;
1. The USA university acceptance,
2. A letter from the dean/vice dean, in Arabic, illustrating how this program is essential to your education, and how it will promote the college status (ay kalam)
3. Wasta 7elwa keda (lel2asaf aham 7aga). Anyone knows what "wasta" means in English?
4. Plane ticket (as a provisional ticket, the one you get for free from a booking agency)
Then go to "2edaret elta3be2a weltagneed", and in shaa Allah they will give you the authorization..
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VI. Document Quest No. 3. Documents made by your School
a. School Transcript (kashf daragat IN ENGLISH) from Student affairs.
This is basically all your course grades till last year you’re in, just stating for example: [Anatomy: Excellent, Biochemistry: Good,....]
SOME SCHOOLS require that you PASS ALL YOUR core clerkship, including Surgery and OB/GYN, before applying.
If you’re a 6th year, the transcript won’t have them, thus just tell the vice dean /registrar to sign the following statement: [This student will have finished Surgery and OBGYN clerkship by the time he starts his elective at your school in dd/mm/yy]
Rarely, some school might want the Transcript to be sent directly from your school, ask the Student/Graduate affairs to put it in a sealed Envelope, then the vice-dean/registrar to SIGN AND STAMP IT, and then they mail it directly, or you mail it INDEPENDENT of your application.
b. Courses’ durations (optional) (Kashf 3adad sa3at IN ENGLSIH)
This is the amount of hours you spent per course. Some US schools require for example minimum of 8 weeks per core clerkship, and you need to prove that.
It’s optional, and our schools usually make it along the transcript above. If not, then don’t worry about it.
c. Letter of Good Standing/ Letter of academic standing/ Letter of Support (kashf kayd).
This is basically a letter that mentions: [the student X is enrolled here, and he is in good academic standing, in the last year of a 6-year program] with the dean/vice dean/registrar signature.
d. Letters of Recommendation (LoR) from faculty member.
This is a document that is supposed to give the reader a general “good” description of your previous accomplishments, current endeavors, and future goals, as seen by a faculty member who interacted with you long enough to be able to tell such description.
When doing the LoR, remember that;
- Make sure to “offer help” in writing the LoR so as it doesn’t contain any negative attributes (and it shouldn’t). You can even write it, and ask the staff to sign it, if he was willing.
- Try to add authenticity by getting the letter stamped by the school seal. “Normally, it should be even on school-specific stationary paper”
- Make sure that some contact information of the letter writer are present (email, cell phone, and address)
- Tell the letter writer that they “might” contact him by email.
Some, like Hopkins and Cornell, will ask you for a “Dean’s LoR”. Have a friendly conversation with the dean, tell him your ambitions, give him a CV copy if he asked for one, and in shaa Allah he’ll do it.
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VII. Document Quest No. 4. Documents made by YOU
a. The Application Form of the school you’re applying to. Try to make the name as in the passport.
b. The Health Form from the school as well. Basically, it should be filled by a physician who did a complete physical, and lab tests. Sometimes, they tell you to fill it, but require Immunization/Antibody record to be attached as well. Vide infra.
c. The Curriculum Vitae.
i. There's a very good list of DOs and DON'Ts when writing one's CV, present in First Aid for the Match, along with multiple sample CVs of successful applicants, which can serve as inspirational sources. (http://books.google.com/books?id=fJjJxic4nlkC&lpg=PP1&dq=first+aid+match&pg=PA147#v=onepage&q&f=false)
For Research experience, or presentation, publication, conference, etc, it’s always better and more professional to write it in MLA style. This free website provides intuitive forms that you fill in, and they generate MLA-style citations of your works. EasyBIB.(http://www.easybib.com/)
In the Extra-curricular activity, make sure to list your "Association" if you have any, such as "Medical Student Union", or IFMSA (No alpha Omega alpha lel2asaf ). Clubs and societies are a good asset, particularly if one mentions any community service he did with them. (Vaccination campaigns, donations for new hospital equipment/hospital pharmacy ...)
If anyone has done any undergraduate online degree alongside his Medicine studies (Diploma, Bachelor...), he can put it along with his Education, even if it wasn't in Medicine. (As long as it's a FULL undergraduate degree)
When explaining Clinical experience, it's always good to give a one-liner on your role during it (eg. Participated in consult service, and attended out-patient clinics), as well as your mentors during it (if applicable) . This also applies to your internship year rotations.
d. The Personal Statement/ Letter of Intent/ Admission Essay.
SOME schools want it, others don’t. Usually there is a cut-off limit for number of words, and a standard format (Text type, size, and space) that are requested. ADHERE to them.
First Aid for the Match, 4th Ed. has an AMAZING section on how to prepare your CV, PS, and LoRs. I recommend it to everyone....
There are these websites, which help shaping the PS AFTER you have your blueprint,
- www.indiana.edu/~wts/pamphlets/personal_statement.shtml
- owl.english.purdue.edu/owl/resource/642/01/
- www.studential.com/guide/write_personal_statement.htm
- students.berkeley.edu/apa/personalstatement/index.htm
- www.ucas.com/students/startapplication/apply09/personalstatement/
- www.personalstatement.info/
- www.admissionsessays.com/
And to brush up and polish the overall quality, I suggest using,
- Merriam-Webster Online Dictionary/Thesaurus mainly for thesaurus (instead of using “loving”, use “ardent”), which are ESSENTIAL to buff up your style.
- A Quote dictionary would also come in handy, as it can give you ideas and idioms to use. Check "The Yale Book of Quotations", and "Oxford Dictionary of Quotations"
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VIII. Document Quest No. 5. Documents done at various locations
a. The Immunization and/or vaccination record. This is a record that shows that you’re immunized against some famous communicable diseases (HAV, HBV, MMR, DT, and TB)
Usually, you’ll need a paper, from a local lab, indicating that you had the vaccines in the recent past. You can do this at our Medical Syndicate (elne2aba) or Health office (maktab se77a)
If you don't have past record of vaccination, you can have the vaccination again at our Medical Syndicate. They'll give you a certificate of vaccination. If you aren't keen on getting vaccinated again, you can get an antibody titer. Note that sometimes, the vaccine certificate doesn't replace the need for AB titers.
You do an Antibody Titer for the diseases mentioned in the health form, and when you have “positive” IgGs, this means you’re immune/vaccinated. Some would require qualitative AB. Titre (+ or -), while others require Quantitative (titer in numbers, as in 850 µg/dL), with latter usually required in HbsAg abs.
Where to get these AB titers done? Any local lab can do them. Note though that they are quite expensive.
Details vary by school. If anything is vague, contact them.
b. Health Insurance. Easiest way is to get it from Egypt Air, or Thomas Cook. A 3-months contract from TC would be around L.E. 600.
Some require their own health insurance. Others might need Health insurance from a US based company. Consider www.visitorscoverage.com/index.php , which compares all of the "Visitor Medical Insurance" plans in the USA. Usually a 6 month coverage will be around $200 (from $100 to $350).
c. Mal-Practice Insurance. A lot of discussion can be found over this topic. Best place by far is www.ProLiability.com. Other companies include academicins (http://www.academicins.com/), and HPSO (http://www.hpso.com/). Check on the discussion about pros/cons of each here (http://www.mededia.com/node/16), and here (http://www.mededia.com/node/37#how_much_time_malpractice_coverage).
Note that most programs waive the Mal-Practice till after you get accepted. But some need it right from the start.
Medical Student Insurance can be obtained from Academic Group. The insurance is usually valid independent of the school you're applying at. Contact them with any questions. They are pretty helpful. ALWAYS mention your credentials in full details.
Student Medical Assistant Insurance is directed to "students" of "Medical assistant" careers, such as Physician assistants, and Nurse Practitioner students. HOWEVER, these work pretty well, and most people get those because they're cheaper. Proliability and HPSO sell those, but you need to be "school specific", that means, they're issued for a particular school and for a particular duration. So make sure you got accepted first before applying.
d. If asked for "Criminal background Check", this is the "Feesh we Tashbeeh" done at any Police Station. Address it to the School, translate it, and send the translation along with the photocopy with the rest of the documents.
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IX. Document Quest No. 6. Supporting Documents
a. THEY VARY BY SCHOOL. Most common is of course your USMLE step 1 Score report.
b. iBT TOEFL. Try to do it, and always send a photocopy of the mailed report, even if not required. IELTS as well will be a benefit. No need to send via ETS.
This test is remarkably easy, if you know the right resources (Barron’s, a Pronunciation / speaking guide, and a simulated KAPLAN exam). Work thru Kaplan and Cambridge TOEFL preparations first. Both are great. Then do Barron's stuff. I got 111/120 without taking any courses whatsoever, and I’m from “madrasa 7komeyya” . NB. Official ETS guide is remarkably shallow.
My best advice is to download simulated exams, and practice the test from them. This is simply because this is a STANDARDIZED test, and not an English test. You need to study for it, as you studied for the USMLE. By doing questions.. Learning by doing IS the fastest.
I think if you want to focus on everyone's weakest points (usually speaking, and listening), try to do self-propelled teaching. Start a sound recorder (present in any Windows OS), and start talking about any subject/a subject ur brother chooses at random, for about 5 continuous minutes. Then listen to your recording, and identify your Grammar, Vocabulary, and Pronunciation mistakes... Then re-record and try to correct them...
Use Jason's website for ideas on Speaking/Writing. jasonrenshaw.typepad.com/ibt_speaking_writing/2008/05/40-new-practice.html
Usually 1 week of 2 ~3 hours/day is enough. But again, it depends on how established you are i the Language. Can take up to a month of 3 hours/day if you're "daye3"
...
And forget about books. Barron's book is great, but I think it's a big waste of time.. HOWEVER, you can use this book, 400 words for the TOEFL, to sharpen your vocab... Just memorize these words. www.4shared.com/file/cHgGLdl4/400_Must_have_Words_for_the_TO.html
c. HIPPA Certificate.
Each school has its own course on HIPPA. Just complete it, sign/print the certificate, and send it along your documents.
d. School specific documents (e.g. CORI form in Harvard application)
e. You can also attach a copy of your school’s IMED FAIMER profile (https://imed.faimer.org/). Won’t hurt.
f. If there’s a processing fee involved, there are several ways you can pay for it;
You can use “Traveler checks” from Thomas Cook, or American Express outlets in Egypt. They all accept them. Note however that they aren't fractionated.. They ONLY come as $100 bills. You can't have a $120 bill for example. You'll have to pay $200 for $120 !
OR, the most famous DRAFT way, is to get a decent bank account (HSBC, NSGB, CA, CIB,..), and then ask them to write a DRAFTED CHECK off your savings: They take the $ from your account, and then they write a check to be drawn from THEIR OWN account in a USA bank for the same dollars and then give it to you to mail. The check will have the sentence "Drawn on any US bank" on its back.
Money Order is something you ONLY do at USA Postal Service (USPS). You give them money and an address, and they mail the "USPS check" to recipient. YOU CAN'T do it outside USA.
Wire Transfer = International Inter-...Bank transfer. You transfer funds from one bank to another, and for this, you need the recipient Bank Account Number, AND the routing Number... NOT recommended.
Some schools now ask to have the tuition fees paid electronically, like Yale. The huge amount of money can't be paid by a Credit Card, so I suggest having a Debit Card (linked to your bank account). and pay directly with it.
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X. Send the Documents via Tracked shipping
a. Go to ANY post office, and ask for US shipping via (Elbareed eldawly elsaree3). It will ship via FedEx to the USA for L.E. 155, in roughly 3 business days.
b. Make sure to send the school an email BEFORE sending your documents, just to tell them: [Dear Sir, My name is ...., and you’ll receive my application shortly.]
c. You can add a small cover letter explaining the contents of the package.
d. Keep in touch every now and then with the school. Acceptance is usually granted before the start of the elective by 3 to 1 months.
e. Pray, and make do3a2..
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XI. AFTER Acceptance, before Elective Start
a. Pray again... (VERY IMPORTANT)
b. Start reading on the “department” you got accepted in.
See who the Program Director of the entire program is.
Check the names of the attending physicians in this particular department. Check their PubMed publications, and general clinical interests.
Doing so will help you attaching to some of them, and you’ll be better prepared for them testing you.
c. Start reading on the “Specialty” you got accepted in.
DO NOT USE TEXTBOOKS.
Get Kaplan lectures, and read all the RELEVANT Anatomy, Biochemistry, Physiology, Pathology, Medicine and Surgery related to the subspecialty.
Try to download and read the important landmark papers in the field you’re accepted in. (usually cited in Pocket Medicine, vide infra)
Advanced ABIM review sources, such as MKSAP 15 and MedStudy ABIM board reviews can be overwhelming if you start with them. But, as soon as you build strong foundation, dive right in.
d. If there’s no housing provided, you’ll search for one. Easiest way is Craig’s list.
Make a template email. ATTACHING YOUR ACCEPTANCE LETTER speeds things up by 200%
Example: [My name is ... I’m a medical student from ... I got accepted in x Hospital. Acceptance letter is attached. I saw your listing on Craig’s and I liked the description of the Condo. But I have some inquiries. So is this condo/room close to the hospital? Near Public transportation (VERY IMPORTANT)? How much Deposit do you need? Free Wi-Fi? Separate Bathroom? Who will pay the Electricity/Gas/Cable/Wi-Fi Bills? ]
If replied, try to take his phone No. And call him directly. You can ask him to email you some more photos of the condo.
You want to arrive at least 3 days before your elective start, and leave around 3 days after its end.
Usual rent/month for a ROOM in a house is ($ 400 to 600), and for a Condo/studio apartment ($ 1000 to 1800). Prices vary widely.
NB. Signs of a scams "not real deals" on Craig's list are easy to spot, and they include;
i. UNREALISTIC deal: like a studio for $800/month, with Plasma TV, and 2 bedrooms.
ii. VERY fast response (within an hour or two) to your inquiry
iii. Long reply, that adds much more details to the condo than was previously posted in the ad/
iv. Most important one: ASKING YOU FOR ANY FORM OF ONLINE PAYMENT (eBay, MoneyBookers/PayPal, and the famous bank Wire Transfer). If these words even appear the email, consider it non legit, and search for other postings.
v. Asking you to submit any personal info (he can ask about where I came from, but NOT my national/VISA ID)
vi. A very nice way to rule in scammers, is to search for the condo's description on Google. If you found the same listing being posted under more than one city (sometimes, with the same attached pics!!), then report the posting.
Methods other than Craig's include: Contact the coordinator. He/She usually has a database of some renting options, check local “community” mailing lists. E.g. Yahoo group for Yale students, and note that Youth housing/YMCA/Hostels are NOT a good option. Also, "Easy Roommates" is a nice option. www.easyroommate.com/
e. Get a Bank Account. YOU WILL NEED ONE.
Open an account in a “Real” bank, like CIB, HSBC, NSGB, or Crédit Agricole, and get a VISA or MASTERCARD.
Set up Online Banking options before traveling.
f. Plane Tickets.
Use Online booking IF YOU KNOW EXACTLY WHEN YOU’LL RETURN, and are NOT going to change your US departure date. Pros are it’s cheaper than regular tickets, but usually dates can’t be changed or refunded. Best site is www.Expedia.com and www.southwest.com
Book locally from Egypt Air if you don’t have specific US departure date, as it’s easy to change this date with Egypt Air.
g. Set up a way to contact with your family while away. Any online chat will do. But if you want to be able to call your family, and they call you, at ANY time, with cheapest way, then;
Download MagicTalk (http://www.magictalk.com/). The free application works only for one month, than you have to upgrade it for $20 / YEAR (not month, so L.E. 120 once a year). The upgraded application gives you a free US landline number linked to it, on which you can make/receive calls and voice-mail, as long as Internet connection is present.
Once in the US, get the T-Mobile PrePaid plan: 1500 minutes for $30/month (http://www.t-mobile.com/shop/plans/prepaid-plans.aspx). I honestly don't know if other plans are cheaper, but this one always work for me. Set up an online account to refill easily with credit card. Now the setting you have is: from a mobile phone in US, to MagicTalk in Egypt, and vise versa. This option allows from easy bi-directional calling whenever.
The US number on MagicTalk will help you, before going to the USA, for any direct elective inquiries with the school coordinator, ECFMG, Craig's list posters, ... It also allows them to CALL YOU back, which is a great advantage.
Other options;
i. Skype (on your PC/3G phone/iPhone/iPad), with credit in it to call Egypt landline directly. You can also buy US landline number for skype (called SkypeIn), especially if you have it on your cell phone. It costs around $12/ 3 months.
ii. SmartVoIP, from a computer with Internet to Egypt landline directly (CHEAPEST direct calling service, with 0.8 cents/min, compared to Skype's 2.3 cents/min). SmartVoIP also gives you so called "Free minutes", where you can call some countries' landlines (USA, UK, most of Europe) for free. Amazing service actually.
iii. H2o Wireless is a good alternative (https://www.h2owirelessnow.com/pageControl.php?page=index)
h. Stuff to take with you.
$$$. Although you’ll open a bank account in Egypt, with a credit card, you’ll still need to take $$$ with you, as you’ll usually pay the rent in hard dollars or checks, but not via credit cards. I’d say that for 3-months duration, you should take around $2,000. (About $ 1800 for rent). Take more if you want to open a USA bank account. Generally, the cost of living per month is around $800 to $1200, with ~$600 in rent, and others for food, and transport mainly. If rent will be paid by checks, you'll need to open a US bank account, and get a check book.
White Coat. You actually should get the “short” student coat. Better yet, take the long one, and tell the Elective coordinator that you don’t have “short” ones, and she might give you one for free.
Stethoscope. Very $$ in the US. Take yours with you.
Some Egyptian Souvenirs (Papyrus artwork, or art figurines from Khan Elkhalily for example), will cheer some attendings for sure.
Books and Medical resources:
i. For IM electives, you don’t need that much books to take with you. Maybe “The ONLY EKG Book You’ll Ever Need”, and “Washington Manual of Medical Therapeutics”
ii. Once you arrive in the US, THE MOST IMPORTANT BOOK TO GET, AND NEVER LET GO is “Pocket Medicine, 4th Edition”. A MUST for any IM elective. Get it as soon as you arrive in the US from any local bookstore. Don’t even start the elective without it. This is a sample preview from Google Books: (http://books.google.com/books?id=uLcfBf5bbBcC&lpg=PP1&pg=PP1#v=onepage&q&f=false)
iii. If you have Windows Mobile Phone, iPhone/iPad, or Android, then you can use Skyscape (http://www.skyscape.com/index/home.aspx) “Trial” eBooks on your phone. A great amount of eBooks are available for purchase. There are also some “not-recommended” ways to unlock the trial eBooks on Windows Mobile/iOS. Try to get “A to Z Drug Facts”, “Lab 360”, and “Taber Cyclopedic Dictionary”
iv. If it’s NOT supported in the hospital, and you can afford it, DEFINITELY buy a subscription to UpToDate. A year’s subscription is $200 for students, but it will help you immensely.
v. For US Pharmacopoeia (Drug names), you can either use Skyscape “A to Z Drug Facts”, or if you don’t have Skyscape, the famous book “Tarascon Pocket Pharmacopoeia 2010” from any bookstore will do.
vi. FA for the Wards. A great handbook, for many of the required tasks of a med-student. It helps, but not in the initial (still-know-nothing) stage, at least for us, who never practices in such a system.
vii. A great resource one can use is ECFMG Acculturation Program (http://www.ecfmg.org/acculturation/index.html), which helps IMGs who matched to be able to work smoothly in the first couple of months. Contains many videos in USA healthcare system (http://www.ecfmg.org/acculturation/downloads.html), and a residency survival guide (http://www.ecfmg.org/acculturation/survivalguide.html). All Credit goes to Dr. Karim Mohamed Mady.
viii. For your PDF needs, register a free account here. (http://library.nu/)
i. ONCE YOU’RE IN THE USA, and before the start of your elective, try to;
Familiarize yourself with local stores, and public transportation. Usually you can get a 1-Month pass for an unlimited access to Bus/Subway services for a reasonable price.
Get a US bank account. Not really necessary at this point, unless you want to make a PayPal account, or write a check for the rent.
Go to local grocery. Buy your needs on a Week-to-Week basis. Also make an account on Foodler (http://www.foodler.com/), as it helps in the tougher days.
Get any books you need, as Pocket Medicine, from local bookstores.
Make sure you know how to get to the Hospital in time.
j. The first day of the Elective usually has an orientation session.
This session gives you the hospital ID, the PC system log-on information, and a brief tour on the structure of the Hospital.
Try your best to ask for a PAGER. It's important in the IM rotation, and IS A MUST in surgery rotations.
It's essential to remember: When you're in elective, you ARE A STUDENT in the MEDICAL SCHOOL, spending ONE MONTH in the SCHOOL-AFFILIATED hospital.
This means you have same privileges as any other student belonging to the school, INCLUDING access to different school activities, and access to the school library. Make sure to visit the library, and even borrow books, if you need. Remember this when you're in need of a place to rest/read.
Also, these libraries have librarians in them, obviously. These guys have the job of finding you any book/article/paper you want for your research/project. If you need a paper, and you can't get it, contact the librarian. They're very friendly.
In many schools, the library system is ONLINE. Ask the librarian f ou can have access to it, which will save you time and effort during your paper hunting.
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XII. During the ELECTIVE. Part 1. Introduction
a. Hierarchy in the hospital (in IM programs) goes like: Med Student (usually 4th year.. You'll be in this role), Intern (PGY1), Resident (PGY2), Chief Resident (PGY3), Fellow, then Attending. Others you may encounter include Registered Nurse (RN = a nurse), Nurse Practitioner (NP = an RN nurse who studied graduate masters or doctorate [Advanced Practice (AP) in medicine] and became APRN or NP ), and Physician Assistant (PA) who practices medicine SUPERVISED.
b. The different things you’re REQUIRED to do, as a fourth year student, depend on the nature of the elective. Again, this is IM-Only-experience.
c. A survival guide for ANY elective is FA for the Wards.
d. Your time will be either fully dedicated to one specific component, or distributed among three of them;
The hospital wards component. ( Hospital Wards = 3anaber)
The consultation component.
The out-patient component.
e. These three components DO NOT overlap. Each one has its own time, place, and team. But with proper time management, you can be part of the three, if you have enough endurance. Teams are usually as follows;
The hospital wards: Attending, Fellow, 2 to 3 residents, 2 to 3 students, Nursing staff.
The consultation: Attending, fellow, 1 to 2 students.
The out-patient clinics: Attending, fellow. Residents and students can join at any time.
f. Add to that the conferences, presentations, and teaching sessions, and you’ll have a pretty rough day, that starts from 7:30 am till around 5 pm, 5 days a week.
g. As a general rule, although there’s usually a course description that outlines your BASIC duties, there’s NO LIMIT to what you can do, except how much effort you’re willing to put.
h. The following sections might seem difficult to do in the beginning, but remember: This is the MAX output. You'll have plenty of time to start from scratch, learn how to deal with patients, be comfortable reading journal papers, and finally achieve the top of your performance. So: START LOW, GO SLOW, and remember that Allah will reward you as much as you are willing to give in shaa Allah.
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XIII. During the ELECTIVE. Part 2. Basic Tasks. The Wards Component
a. This component is usually present in electives of Cardiology, GIT/Liver, Heme/Onc., and Pulmonary Services.
b. In a typical Hospital, there’s an Emergency department, where EMTs and Emergency doctors evaluate the case. Decision of Admission is then done by them, and the appropriate IM team is usually contacted to admit the patient in their own wards.
You’ll be part of the “admitting team”. Go with the resident/intern, talk to the patient (take FULL History and perform FULL Physical). Also gather data from patient's companions. Write a provisional “Student Admission note” on the computer system.
Discuss your opinions (Findings, Differential, and management) with the Intern/Resident, and change your note accordingly.
Agree with the admitting team that this “new” patient is now “yours”, and that you’ll present him in the next morning rounds.
If the patient was previously treated at another hospital, try to contact this hospital to make them fax you a copy of his/her records. Also, if he wasn’t able to remember his list of medications, contact his pharmacy for such a list.
c. OK. So I admitted the patient. What next? First, Write his “admission note”. Now this patient is YOUR RESPONSIBILITY. This means that everyday day, starting from the day after he was admitted, you’ll arrive EARLIER THAN THE MORNING ROUNDING, to make “pre-round” on your patient(s)...
1. Go to the PC system, to check for any new Clinical (overnight change of status, or marked change in Vital signs), Laboratory (Morning labs show any change from yesterday), and Imaging (new Xray/CT results...) changes.
2. If anything in his clinical status looks remarkably weird, ASK the nurse responsible for him about it. You should ask the nurse anyways for any noticeable overnight events, and check patient’s charts too.
3. GO SEE THE PATIENT. Greet him again, remind him of yourself. Do a quick review of systems (RoS), and a quick physical YOURSELF. If you aren’t sure about his vitals (BP for example), retake it. DO NOT discuss any future management plans yet, but if the test results were out, discuss them with him. If patient has Telemetry device, interrogate it for any rhythm disturbances.
4. Back to the PC, write your “Daily progress note”. It’s usually in the so-called SOAP Format.
- Subjective: New history since yesterday and new physical from the patient’s mouth and the charts.
- Objective: All the new vital signs, labs, imaging.
- Assessment: What all of these new data mean to the patient condition.
- Plan: What you think should be the next steps in management.
5. When writing the note, you can use abbreviations to your heart content. A useful glossary of medical abbreviations can be found here; www.jdmd.com/glossary/medabbr.pdf, as well as ECFMG Acculturation Program Medicalese (http://www.ecfmg.org/acculturation/glossary.html). Credit to the latter goes to Dr. Karim Mohamed Mady.
6. Print your Progress note, discuss it briefly with any intern/resident who has time (they’re all busy doing the SAME thing you’re doing for their own patients), and take it with you to the morning rounds.
d. In the morning rounds, done each day – INCLUDING WEEKENDS – the residents/interns discuss with the “Morning round Attending” the NEW cases admitted yesterday, and Overnight, as well as the OLD cases that are present 2 days ago or more.
For NEW patients, there will be a FULL description of the case to the attending, including FULL history (From the Chief complaint till Medication list), physical, vitals, pertinent labs/imaging, differential, and management done to the patient since admission.
For OLD patients, it’s just an update of “overnight events” if any had happened, and an update on the general plan of treatment, based on any new lab tests/imaging/family decision...
Each resident/intern/med student has his own list of patients. So DON’T EXPECT an intern to take over your patient. You MUST handle the patient on your own, UNDER GUIDANCE of the intern/resident.
When it’s your turn to talk, simply discuss what you wrote in the Progress note. Make sure to highlight the “reasoning” rather than the result of your management. The way you reached your diagnosis is FAR MORE important than the diagnosis itself.
After finishing your discussion, the attending can ask you ANYTHING related to this particular disease, from definition to Evidence-based management. Make sure you got your knowledge good, as this is YOUR FIRST CHANCE TO SHINE. That’s where Pocket Medicine is very important.
After discussing with the attending, write down his final recommendations on a separate paper, and later on, update the management plan in your note.
e. After the morning rounds, you’ll usually hangout with the admitting team for the day. This is where you usually get to eat/attend Grand rounds/hang out in the Library.
f. In many teams, there will be so-called Sign-Out rounds around 4 to 5 pm. This is similar to Morning rounds, but much shorter. Here, a brief discussion on new patients admitted during noon, and a brief update on patients who had major interventions/imaging at noon as well. And then, students usually call it a day.
g. In some electives, you can ask the elective coordinator to be an “ACTING INTERN”, sometimes called Sub-Internship. Basically, this is where you act like an intern (BUT YOU WILL OFCOURSE be supervised still). This means you’ll actually have to receive calls on patients needing to be admitted from ER, and also that you’ll have Evening, and Night shifts as well. It’s a VERY STRESSFUL job role, but can be manageable.
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XIV. During the ELECTIVE. Part 3. Basic Tasks. The Consult Component
a. This component is present in almost ALL of the IM electives. Some electives, like Infectious Diseases, Endocrine/Diabetes, are usually of this type, with no ward service.
b. When a patient in another service/team/specialty (e.g. A Pediatric patient, or a female patient in OB/GYN, or a pre-surgery patient) gets a medical problem, that is specific to the sub-specialty you’re in, they call the “consultation fellow”, briefly discussing the problem with him on the phone. They will ask him “a question” on what to do.
c. The fellow, in turn, will call you, relaying what he was told. He’ll usually tell you his insight, gives you the name and the MRN of the patient, and asks you to go “see him/her”.
Unlike admitting a new patient, here the patient is already admitted, with a WHOLE amount of notes written about him/her.
Skim through the pile of notes as fast as you can to get a good background of the following,
- Patient’s pre-admission history.
- Patient’s chief complaint (cause of admission).
- Management course since admission.
Go to the patient, introduce yourself as being a part from consult service, and then take a pertinent history, and perform a focused exam. Remember to discuss your impression with the patient.
Go back to the PC system, and start writing your “Initial Consult” note. You’re now looking for answers to “the question” that was asked by the treating primary team. And this should be reflected in all the components of the note (Pertinent History, physical, relevant lab values, Medication list ...). Write your differential, and “recommendations” to the possible “answer”.
Discuss the note with the fellow. He’ll point out the flaws in your reasoning, and you should correct accordingly.
Usually around noon, the consultation rounds start with a “Consultation attending”, different from “wards attending”. This other attending will have an open discussion with you in any aspect of the consult, and the probable diagnosis at hand. This is your SECOND CHANCE TO SHINE.
After the discussion, update your recommendations.
d. Again, once you started the consult, it’s yours. Each day, you’ll see the new updates from the patient’s primary team and whether or not they started the recommendations put by your team. When the rounding with the attending starts, present the patient in a one-liner, and discuss any update to the plan of management you thought of.
e. The consults are usually pretty demanding. You MUST research your findings, and reach a possible differential under limited amount of time and data. JUMP to the Internet.
POCKET MEDICINE. This time, try to get the papers cited within the topic.
If still no luck, then UpToDate. It gives immediate answers to almost any question you might ask. And it has an exhaustive list of citations that you can print out some of them.
Websites like PubMed@Yale, and SCOPUS can be pretty helpful as well, if you have time and mental energy.
- PubMed@Yale (http://www.ncbi.nlm.nih.gov/sites/entrez?otool=yalelib) is just an enhanced version of PubMed, linking ALL entries indexed at PubMed to Journal databases (not just to SciDirect, Elsevier, and Springer as with the plain PubMed)
- SCOPUS (http://www.scopus.com/home.url) is a journal search index, like Google Scholar (http://scholar.google.com/), that can arrange papers by citations, which helps you in getting the “most groundbreaking” articles concerned with your search term.
That is, if you search for “Polycythemia Vera”, and arrange for citations, then make sure that the one with +2000 cites, published in the 30s, IS THE most famous paper on the topic.
- This will allow you to not just know A LOT about the disease, but even know the historical physicians behind it, as well as the history of its understanding.
- Use this mainly with the “elder” attendings, as they appreciate the importance of these pivotal papers.
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XV. During the ELECTIVE. Part 4. Basic Tasks. The Out-Patient Component
a. This is, I think, the most IMPORTANT component.
In the wards, you’ll spend ONLY the morning rounds with the attending, along with the other members of the team. No proper chance for assessment.
In the Consults, you only meet the attending during rounding on the patients. Although it’s a fruitful one-on-one encounter, it’s limited in duration.
At the clinics, it’s usually you and the attending for a good+4 hours. This is where all the actual “judging on YOUR performance” occurs.
b. From the patient’s perspective, the patient usually calls the Clinics around a month before to schedule an appointment. His data are then entered into the Clinic-Specific Computer System, and are linked to ONE attending who will see him.
c. The clinics are either in a separate building from the Hospital, or in a separate self-contained part of the hospital. Their computer system is usually separate from that of the hospital, and may require another log-on ID.
d. The day before the attending’s clinic, inform him of your wish to attend clinics with him, and get his approval. This is because sometimes, they have a fellow, resident, and another med-student with them, and this might be too many.
e. On the clinic day, arrive before its start:
When you look up on the PC, you’ll find that each attending has his own set of patients. Most of them are OLD/Returning patients who he sees regularly, while some are NEW patients, and he’ll see them for the first time.
Try to print out a list of summaries of the Today’s patients’ LAST encounters with the attending, to get a hint of how they were, and what the attending’s plan was, till the very last appointment.
Skim through the cases, read up on the stuff you don’t know. Pay special attention to the NEW patients, as the attending will definitely ask you more questions about them.
Check out UpToDate for any recent major clinical trials/FDA-approved therapies on any of the diseases that you have.
f. When the patient comes into his exam room, the computer system informs you of this. Now what to do?
IF YOU DIDN’T DO THE STEP 2 CS, THEN YOU MUST ACCOMPANY THE ATTENDING/FELLOW FIRST. There are A LOT of things that can go wrong in such an encounter. You must be in the company of an experienced tutor at the beginning.
Once you feel prepared, start going to the exam room ON YOUR OWN.
When the patient arrives, grab his chart, knock on the door, call him by his name, introduce yourself by name, and that you’re a medical student, enter the room, shake hands, then CLOSE THE DOOR BEHIND YOU. Remember to tell him that you’re working with the doctor x he came to see, and that he’ll see him shortly.
If the patient was a NEW patient, take a COMPLETE FULL IN-DEPTH history, emphasizing the presenting complaint [What brought you to the clinic today?], and a complete physical, similar to patient admission. Ask about Social history, Medication list ... Remember to write EVERYTHING down. Finally, discuss your impression with the patient, without mentioning any future plans.
If the patient was a RETURNING patient, take a brief history, then continue by asking [How have you been doing since last time you saw Dr.x?]. Perform a brief physical, inform the patient of any new labs/imaging that came back since last time, and discuss your impression, without mentioning any future plans.
g. Once you finished data collection, thank the patient, tell him that: [Dr.x will be with him shortly], get out of the exam room, and CLOSE THE DOOR. Then go to the attending to discuss the patient with him.
For NEW patients, discuss everything in details. Be prepared for anything. This is why you came in the clinics early in the first place ?.
For RETURNING patients, discuss any progress from last time. Pay special attention to whether the positive symptoms from the last encounter persisted or resolved.
This discussion is your THIRD, AND MOST IMPORTANT, CHANCE TO SHINE.
h. After the discussion is done, start writing your “Student Note”. Make sure the attending checks the notes you write.
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XVI. During the ELECTIVE. Part 5. Advanced Tasks
a. Sometimes, the elective might contain a “Topic Presentation” at the end of the month. You need to start working on that from Day 1.
The fellow will be your friend. Ask him what the attending expects you to present about the topic, and where you can get more information about it (apart from UpToDate and SCOPUS)
The attending KNOWS about the disease. Try to keep the pathophysiology, pathology, and findings brief, unless a recent groundbreaking news came up.
When discussing papers about recent therapies, always try to weigh the evidence. Not all trials are created equal. Some are stronger than others, and a lot of them have “correspondence”, or criticism directed at them.
Be biased to the practice employed at your department.
b. If you’re lucky enough, you can suggest writing a “Case Study”.
Once every while, a very interesting case comes by, and doctors just stand there, unable to come up with any diagnosis. If the case is later diagnosed, and you were an integral part of the service-providers, you can suggest writing a case study about him/her.
It’s actually simple to write. But the main difference is that you NEED TO CITE THE PAPERS that reflect your decision making process.
So, if you ordered a specific test, you should cite the paper linking this test to a possible diagnosis that can match up the patient’s still-unknown disease.
Let the attending and fellow in on this, after drafting a plausible length case, and together you can get it published ?
c. Some electives have ORAL, or even WRITTEN exams. Discuss with the attending the scope of such exams if there are any. Make sure to get your evaluation. It helps immensely in your ERAS application, as you can scan it, and attach it to the LoR. This will allow the program director to link the LoR with actual performance data from the physician who wrote the letter itself. More concrete bonus to your profile.
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XVII. During the ELECTIVE. Part 6. Putting all tasks together
a. You can “juggle” most the tasks together, unless very explicitly said otherwise by the program description, AND the attending physician.
For example, while in the wards, and after Morning rounds, you can go the clinic with the “wards attending “. More interaction time.
Also, the consults can be done right after the morning round. Can take up to 2 hours. From the till the sign-out rounds, you can be at the clinic, or any conference they make.
Try to maximize your clinic time, but try to attend morning rounds as well (most of the teaching is actually in the morning rounds)
b. It will take approximately the first 2 weeks to get to know the Computer system, how everything is timed, who the attendings are, and how you can do your tasks best. Thus, your best week should be THE THIRD ONE. That’s when you’ll do your best.
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XVIII. During the ELECTIVE. Part 7. Gains. How to Get the LoR?
a. Now, the most important thing you can come out with from the elective is an LoR from a US doctor. First, you must understand some basics:
In ERAS application for the Match, you can submit ANY LoR, Programs ask for maximum of 4. That means, you can submit LoRs from Non-US schools, and even your school. Needless to say, the letter then will have near-zero value, UNLESS it’s written by a world-famous expert in the specific specialty you’re applying in.
When ERAS receives an LoR from you for the Match, it’s usually in 2 ways. First way is that either they got it directly from you, or your letter writer ALONE, accompanied with only ECFMG DSF. Either case, it’s considered “non waived”. That means, you SAW the contents of the letter, you knew what’s written in it, and you “approved” its suitability for the Match application.
OR the second way, they get it accompanied by your AAMC ID in ERAS Cover letter, and with a Document Submission Form (DSF) from ECFMG, send directly from the writer’s school mailing address. This is considered “waived”, meaning that you allowed the writer to send it, and you DO NOT know the contents of it.
OBVIOUSLY, YOU NEED TO HAVE ERAS ACCOUNT TO DO THE WHOLE "WAIVED" LETTER ROUTE.
The whole value in the “waived” letter is that the writer will write “honestly” about you, as he sees fit, and won’t be “forced” to write good things knowing beforehand that you’ll see what he wrote later.
The amount of value between a waived vs. Non-waived letter is ALWAYS under debate between IMGs.
From a personal experience with the Program directors, they consider anything, in the IMG profile, other than US-doctor written LoR, and “waived” to be less trustworthy. Note, however, that since MOST programs require that you submit at least ONE LETTER from a Department Head/ Program Director in the specialty you’re applying to, this letter will usually be written by a Non-US doctor, as you rarely get the chance to have an LoR from a US program director.
It’s VERY EASY to get an LoR. But it’s DIFFICULT to get a GOOD LoR. That means, don’t be happy with just an LoR. Try to do your best to ensure a good/productive one.
b. How to ask for an LoR?
BEST TIME to tell the attending that you'll need an LoR is at the End of your SECOND WEEK. This will give him ample time to assess you more intently, give you hints on your performance, and write an honest evaluation about you.
A PERSONAL ADVICE: Create an ERAS Token and account for $90, and print out a cover letter and a DSF. (If your elective is between July to April)
1. WHY? All the people I knew of, well over 20, find it difficult that when the doctor agrees to write an LoR, and then the elective is over, AT LEAST one of the three doctors becomes “hard to find”/”doesn’t answer emails”/”forgot about me”/.....
2. To ensure you get your hard-earned letter, simply tell the writer to write it in the Letter Writer Portal (LWP).
3. Although some doctors may tell you to “email them when you’re ready for the ERAS Match” so that the letter is ‘FRESH”, it’s actually pretty easy to know WHEN the letter was written (either in the body of the letter itself, or from the USCE dates you provide to ERAS in your CV). So this point is illogical, and can again make you worried for the occasional non-responding doctor.
4. Although you will be on ERAS, you won’t apply to any program of course. And you won’t participate in the NRMP. When the season is over, the letters in the ERAS PostOffice will be retained, and once you get a token for the next season, you can retrieve all of them.
Note however that; a. You MUST keep getting tokens each year, so that they are carried over to the next one., and b. IF your letters were non-waived, you can simply ask ERAS for Return of Documents (RoDs) service at ERAS Support. This is NOT applicable for “waived” letters.
Prepare your up-to-date CV and specialty-tailored Personal Statement, Also put in one of those Papyrus papers you got from Egypt. If the elcetive has some "Written evaluation", add it to the package as well. Put all in a nice manila folder, and go to him/her, when he/she is free.
A very important document to prepare is a list of all patient encounters/educational activities you had with the mentor, and how these activities impacted you in your education. This list will help the LoR writer with his task, and will allow you to "steer" him in a specific direction.
Your PS here can be different from that of the match, so customize it according to what you see fit. I suggest discussing red flags here (like a failed CS, low scores,..) so that the LoR writer addresses them on the fly as well...
Simply ask the LoR writer . Then present him with the folder.
In the next two weeks, make sure to improve your weaknesses, so that less of them appear in the LoR. Don’t bring up the topic again, except maybe at the end of the fourth week. Just a friendly reminder.
c. When the letter arrives at ECFMG, you’ll see a note of that in your ECFMG profile. That’s when you send a [Thank you for all the efforts] email.
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XIX. During the ELECTIVE. Part 8. Other Gains
a. Try to get an email with the DNS (domain) of the institution/school you're in.
Go to the Tech. Dept at the school, and ask for an email account. Reason your way with the person in charge. If he refused wholeheartedly, don't push it of course.
This might sound weird. But believe me, when you have an email like a.b@hms.harvard.edu, it opens up opportunities everywhere you go. It will be especially helpful when you contact researchers,either then or later, to work on a specific research project. This domain will ENSURE that your email WILL BE READ...
b. Build contacts with the attending.
This will help later if you want to work on a research program with them.
Especially true if they were same nationality as you. As they have been in your exact shoes once, and know how hard the road was.
c. Build contact with the program director.
You HAVE TO BE in the specialty where the program director is in (e.g. Pulmonary Medicine, Geriatrics)
Attach to him in the clinics.
A program director is just like any other attending, and will notice the hard-working student when he sees one.
A magnificent boost to apply for a residency in the same hospital. At least a guaranteed interview.
d. An opportunity for academic or clinical research, after electives end.
Best if directed at an attending with a reputable PubMed-indexed papers.
From the list of his publications, you get a good sense of his clinical interests, and the fields he is more interested in.
Physicians interested in academic research will probably have a profile at BioMed Experts (http://www.biomedexperts.com/), where you can search for his/her name, and find the spectrum of techniques, methods, and pathology interests he is involved in.
Armed with these bits of information, confront the attending with [how much you admire his work, and that you’re very interested in this particular field, and ask for a possibility in an unpaid open position]
I wanted to write this guide long ago, but I was too lazy to start doing so. But alhamd lellah, I finally got together to compile it into a big informative thread. I hope it helps, even if for a little bit, any one of the readers...
During my Sixth year, around May 2009, I started the quest to the electives. I knew about it when someone mentioned the word (USCE). Later on I kind of started gathering information, and eventually I got a comprehensive picture of what I should do by around July 2009. I got into Yale SoM (Heme/Onc) for 4 weeks in April to June 2010, and GWUH (Cardiology, and Heme/Onc) for 8 weeks in January to March 2011.
My Elective experience was ONLY in IM, so I’ll just focus on that...
PS. If anything needs any further details NOT covered in the guide, I’d be gladly helpful if I know it, since what I’ve written here is about 95% of what I know, and I forgot the rest. Find me at www.facebook.com/elkhanany.
This is a link to the "way better, though outdated" formatted PDF file, in case someone wants a printout. Choose "File", then "Download Original" from the top menu. docs.google.com/viewer?a=v&pid=explorer&chrome=true&srcid=0Bx1pctj5tE5XZTM0OTQxYzQtMjJjNS00YTUwLTgxYzEtNDBjYWUwOTlhODUx&hl=en_US
NB. All the books, courses, eBooks and materials mentioned within this document can be purchased and/or acquired easily. Google is your friend (as well as library.nu, Demonoid.com, DocsPedia.org, and BitMe.org)
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I. Why Electives ?
a. To gain US Clinical Experience (USCE). Why is it that the USCE is that important? Why do all Program directors favor it? Simple. They want you to know the SYSTEM. A hospital running on a computer system (they call them Electronic Medical Records) is VERY different from ours. b. USA Electives ARE different from UK and Canada electives, as those last two have National Healthcare systems, and patient care is “rationalized”. But in the USA, since all patients are insured, then tests, procedures, and elective operations are usually done more often than not.
This last point illustrates why a non-US elective isn’t really that remarkable in the CV (Still, better than nothing)
b. Another VERY important point in Electives is to be able to get US Letters of recommendation. More on that later.
c. Also to form contacts during your stay... Again, vide infra.
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II. The Basics
a. You’ll need to understand that our 4th, 5th, and 6th year = the 3rd year of a 4-year system in the US. They call these “Core Clerkships”. As in IM, Surgery, OBGYN, Peds, Core clerkship.
We USUALLY can’t apply to clerkships as IMS (International Medical Students).
b. During US students’ 4th year, they take ELECTIVES. These are “special” month-to-month learning experience, lasting for 12 months. SO, US students take 12-months electives.
We can apply to electives, if we're in a US school 4th year equivalent. That is; in the LAST year of Med school, waiting to receive our Graduation Diploma.
In Egypt, Graduation and Diploma are uncoupled. You'll finish your 6th year exams around Nov. to Dec., exam results are out around Feb. next year, you're approved by University council for the MBBCh title around Apr., and they officially grant it to you around Jul. to Sep. THIS IS when you can apply for your Diploma.
Although technically you're NOT required to do the Internship/Emtyaz year to get your Diploma, you have to wait around a year until it's available. This is where (correlation doesn't mean causation) apply. Note that Emtyaz is ESSENTIAL to get your Medicine Syndicate (ne2aba) membership, and to work in Egypt in general.
For unknown reasons, Graduate affairs INSIST that we graduated (got our MBBCh) on the day we finished exams (Oct. 2009 in my case!), leaving a HUGE gap between the time of Graduation (Oct. 2009), Diploma (Jul. 2010), and Match application.
What this mean to us, is that WE ARE ABLE TO APPLY FOR ELECTIVES during Emtyaz, since our Diplomas aren't out yet. We can "consider" that Emtyaz is "important" for the Diploma, and this is good enough for our application.
Some schools grant the diploma, and the Graduation at the same time. They are graduates, has nothing to do with their med school except through Graduate Affairs, and can't apply for electives.
c. The difference between Clerkship and Elective, is that the latter is usually in a SUB-SPECIALTY field (Cardiology, Infectious Diseases, Plastic Surgery, Trauma), Or in a NON-Core Clerkship field (Ophthalmology, ENT, Pathology).
d. What this means for us, is that a Cardiology elective means that you MUST BE as perfect as you can in Cardiology. At least just to be comfortable as to understand all pharmacology involved. If you depend on what you know from Med School, you aren’t prepared enough.
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III. Before You apply
a. First thing is to decide HOW MUCH $$$ YOU’RE WILLING TO PAY. THIS IS IMPORTANT, as you’ll need to decide between High Tuition fee at a reputable institution vs. Long duration Elective.
b. After putting a financial cap, start looking at schools’ pages.
List of USA MD Medical Schools ( They call them LCME-accredited school) is found here: www.lcme.org/directry.htm
Get the name of the school, go to Google, and type: [School X Medicine Elective], and then the relevant page usually shows up. And I usually do this, as it gives me the most up-to-date URL. Note that in this comprehensive list, many schools DO NOT accept IMGs. If you want a ready made list, then;
AAMC list (46 institutions): Official AAMC database. Outdated in most of its info. services.aamc.org/eec/students/index.cfm
MedEdia List (51 institutions): www.mededia.com/node/18
J. Idrees Blog (26 institutions): slightly less than MedEdia's, but VERY organized, and updated regularly. Here, electives.us/unilistims.html . Credit to Dr. M. Kandeel
Lists like FREIDA online, and ACGME programs are more useful during Match application, or searching for observerships/Externships, and NOT electives.
c. If there’s ANY thing, apart from what I’ll explain later, that you don’t get, contact the school. No problem with that at all.
d. COMPILE A LIST OF COMMON REQUIREMENTS OF THE SCHOOLS YOU’RE INTERESTED INTO.
How to choose the schools you’re interested into? Everyone varies. MOST of the US schools don’t even accept IMGs (non LCME accredited), and many accept only from affiliated schools. Cross those out.
- They all want a good candidate. (Good CV, impressive Personal Statement, and nice school transcript). Prepare to get involved in their preparation.
- In addition, some just ask for $$$$$$.
- Others need iBT TOEFL. (usually the competitive ones, as this means they accept a lot of students, inevitably ending in forcing the TOEFL as a requirement.)
- Some need Step 1 and/or Step 2CK
- Some need PRIOR elective/USCE experience
- Some offer ONLY 4 weeks maximum, while others have up to 24 weeks maximum.
Also, let the US hospital ranking sheds some light on the appropriate hospital <---> specialty choice.
e. Again. Put the financial cap, list your positive points, and start crossing out schools from the lists.
f. Start the QUEST. Your minimum should be FIVE schools – that’s FIVE sets of documents, and in the SPECIALTY YOU WANT TO MATCH IN (If IM, do IM. If ER, do that, and so on).
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III.b. A Subsection on Observerships/Externships.
a. I don't know much about them, but these are all the info I gathered from friends, and by contacting as well.
b. OBSERVERSHIPS ;
These are basically empty positions in certain "programs" in some hospitals. Available positions come and go, as well as hospitals offering them.
You can find these spots via: Directory listing ALL US ACGME-accredited residency programs, to contact the program director/fellowship director directly. These databases; FREIDA online: (https://freida.ama-assn.org/Freida/user/viewProgramSearch.do), and ACGME programs (http://www.acgme.org/adspublic/default.asp) offer such directory. OR you can have a pre-made list here; USCE Observerships (http://observerships.blogspot.com/)
After you find the email of the department head, email a template email in the form of a mini-CV. [Dear Dr.X, My name is ..., I'm from ... School of Medicine. I have a great interest in your program, and I was wondering if you have any vacant training positions, where I can observe/shadow one of the department's physicians to further enhance my education. I'm ECFMG certified in ..., with scores of (...). I have my USA Malpractice insurance, and research experience.... ). I understand that these shaddowing positions will be hands-off training only, and I' will be more than happy to comply. Thank you in advance.]
Here, you just "shadow" a doctor. Go with him mainly to the Out-patient clinics, but not as I'll describe later. Rather, you'll just stick to him. He enters the room, you enter. He exits, you do the same.
The interaction is mainly in the form of discussion about the cases, and the reasonable management for them. Although this might seem like nothing, by one's dedication and enthusiasm, one can get a very strong LoR.
b. EXTERNSHIP is an experience similar to electives, in that it has hands-on training.
BUT UNLIKE electives, it's very informal in nature (no application, guidelines,..), and it has to be approved directly with the department head in the department you'll be working in.
Major problem in externship is the Mal-Practice Insurance, since you won't get accepted without it, and no company would want to insure some random IMG who they have no information on his medical credentials. YET, the sponsoring department can facilitate such a thing if they contacted the insuring company.
For more on Externships, as well as some updated observerships, check here (http://usce.blogspot.com/), and choose by states from the right column.
c. There's now a HUGE industry of helping IMGs get the USCE they need via Externship and Observership coordination.
These companies make deals with private practice clinics/doctors, and rarely with small community hospitals, to allow IMGs to gain experience there. I doubt if any work with teaching hospitals.
Alas, just with anything else, they are pretty expensive, the quality of education isn't optimal, and most important, the LoRs aren't strong at all (writer isn't really known, and the contents might show bias) .
BUT something is better than nothing.
A big discussion, though full of promotion and "fictional member" posts can be found here (http://www.usmle-forums.com/usce-clinical-rotations/1420-paid-externships-imgs.html), as well as links to the most famous companies in the field: (http://www.americlerkships.org/, www.imgprep.com/, and www.fmgportal.com/)
When you contact Americlerkships, they will send you a Clinical Authorization Letter (CAL) application form. It might seem daunting, but it's actually pretty straight forwards, and is similar to most elective applications.. The Sponsor will be your teaching hospital (if you are EITHER a resident, or a student) which is affiliated with the school, which in turn is accredited by Egyp...t's National Authority for Quality Assurance and Accreditation of Education (NAQAAE)... Your core clerkships will be written (4, 5, and 6 years).. And as for the "Program description", just check the things that are NOT marked by two asterisks. Then take it to the vice dean, have it sign and seal it... They do require his email and tel. number. Tell him they might be emailing him.
A sample response of one of these companies; [The location of your Externship will be in an outpatient setting, not hospital-based, which will ensure that you obtain the Hands-On Clinical Experience that is a requirement of almost all Residency Programs. All of our Attending Physicians are board certified in their respective specialties and are affiliated with multiple teaching hospitals.]. Credit goes to Dr. Mohamed Othman.
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IV. Document Quest No. 1. The VISA
a. This is really different from school to school. While most schools (even Harvard and Yale) accept B1, some will ONLY accept F (Mount Sinai) or J (Louisville, UAB). This is important because, while you can finish B1 procedures in roughly 1 month, both F and J visa will TAKE TIME (DS2019 and SEVIS processing).
b. And EVEN in some cases, B1 visas might become “cases”. These are chosen randomly for background security check, and can REALLY slow your B1 visa process. (from a norm of 2 weeks to up to 3 months)
c. So if you are searching in June-July, take an elective NOT before January, just to make sure everything will be fine in shaa Allah.
B1 vs. B2. B1=Business. Doing something productive. Any formal course/education/transaction/certificate/... While B2=Pleasure. Tourist. Going to sight see, explore/shop/fun stuff... Many people do both. Thus B1/B2. You'll do elective/externship (B1) and also visit/sight see, even if for a little while (B2).
Sometimes, you’ll be “Juggling” or changing the VISA type. If you’re in a program needing B1, and then got accepted in a program needing F Visa. Read about this experience here: www.mededia.com/node/131
BE AWARE of staying in NY for more than 90 days, as this might exclude you from getting an NY license for the residency.
If on J short term, do NOT stay more than 6 months with this status, as this will trigger the 12 month bar for obtaining J research,, and might mess with your plans of doing research in the US.
d. In the VISA interview, understand that they look at the REASON THAT WILL MAKE YOU RETURN TO EGYPT, and not primarily the reason why you’re going to the US. Highlight those reasons.
You can apply to the VISA without being accepted in the electives still. Simply print the email correspondence between you and the school, and take it with you. Explain the time constraints that forced you to do so. Be cool, and act with confidence. If you have a Dean's letter of good standing copy, take it with you as well.
More on the Visa interview here: www.immihelp.com/visitor-visa/visitor-visa-interview-guide.html
And here; www.mededia.com/node/138
e. Use IMMI – HELP (http://www.immihelp.com/) for any details on visas.
f. For those with GC/Citizenship
Just to clear a point, chances of US IMGs in the match are slightly similar if not the same to other IMGs, and this is mainly because of their poor CVs (Most of them didn't get proper MCAT scores, and went to study in the Caribbean Medical schools).
However, when they apply to the match, they'll have a "higher number" of available options to choose from, since many southern programs don't sponsor VISAS for IMGs. And although this might look good, most of these programs don't have a competitive residency education system.
But the GC DOES enhance your elective application, as it carries the notion that you're a good English speaker, you have financial support, and you'll definitely be returning to the US for a match.
g. How does the GC help in the match by the way?
Ability to apply to more hospitals (around 50 in total). Although most of these hospitals are weak programs, they all offer prematch and a guaranteed in, especially with good LoRs and scores.
Since most hospitals review IMGs with GC application BEFORE they review other IMGs', you will get early IV invitations, within first 3 weeks after applying to the match, which gives you a higher chance in general of getting IV as the earlier they review your application, the better.
The reason why an IMG with GC is much better than IMG without is the fact that EACH YEAR, many IMGs fail to get their visa by time of residency, and the program risks starting the cycle with incomplete staff. So many PDs shy away from this risk.
Indeed, NRMP says that 49% IMGs who need visa do match as compared with 40% IMGs with GC who do, (http://www.nrmp.org/data/resultsanddata2012.pdf, page 15) you can NOT draw conclusions based on this observation due to a confounding factor: Most IMGs with GC have bad scores/low overall CV, and even sometimes bad English. I can inductively generalize based on my observations here in the US.
In general, an average scoring IMG with GC will get around 5 IV within first month, and around 10 to 15 in total.. A stellar applicant with high scores, USCE AND publications can get a total 30 to 50 IV, with a LOT of university IVs prematch offers.
h. If you applied for the Diversity Visa, and worried about the visitor visa interview;
Rremeber that the DV doesn't ask for a passport number. The data are highly non-dependable. They ONLY go by your last name, DoB, and the confirmation No./Pic.This means, your name can change (letters for example) when you create your passport...... This unreliability won't cut it
But anyhow, In the embassy, you're asking for B visa BECAUSE you want to do something in the USA, and come back. If in the interview he ever mentions the topic (ie, do you plan to be an LPR) simply answer like a US lawyer
, that you'd want to pursue medical career at some point in the USA, and such state will help you immensely. But lack of it won't hinder your goals as well. (and give a nice smile)The most probable answer to the uestion however is NO, it will never affect your chance, simply because if such a myth was true, then all 11 million applicants would definitely be "denied" entering the US, and the forums will be flooded "literally"
Besides, here's a legal opinion: (http://www.visalaw.com/greencard.html), and see the question : Will applying for the lottery affect one's ability to receive a non-immigrant visa?
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V. Document Quest No. 2. The Army Authorization
a. Rabbena ma3ak. Very unpredictable. But to get it during the first half of Emtyaz you’ll need;
1. The USA university acceptance,
2. A letter from the dean/vice dean, in Arabic, illustrating how this program is essential to your education, and how it will promote the college status (ay kalam)
3. Wasta 7elwa keda (lel2asaf aham 7aga). Anyone knows what "wasta" means in English?
4. Plane ticket (as a provisional ticket, the one you get for free from a booking agency)
Then go to "2edaret elta3be2a weltagneed", and in shaa Allah they will give you the authorization..
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VI. Document Quest No. 3. Documents made by your School
a. School Transcript (kashf daragat IN ENGLISH) from Student affairs.
This is basically all your course grades till last year you’re in, just stating for example: [Anatomy: Excellent, Biochemistry: Good,....]
SOME SCHOOLS require that you PASS ALL YOUR core clerkship, including Surgery and OB/GYN, before applying.
If you’re a 6th year, the transcript won’t have them, thus just tell the vice dean /registrar to sign the following statement: [This student will have finished Surgery and OBGYN clerkship by the time he starts his elective at your school in dd/mm/yy]
Rarely, some school might want the Transcript to be sent directly from your school, ask the Student/Graduate affairs to put it in a sealed Envelope, then the vice-dean/registrar to SIGN AND STAMP IT, and then they mail it directly, or you mail it INDEPENDENT of your application.
b. Courses’ durations (optional) (Kashf 3adad sa3at IN ENGLSIH)
This is the amount of hours you spent per course. Some US schools require for example minimum of 8 weeks per core clerkship, and you need to prove that.
It’s optional, and our schools usually make it along the transcript above. If not, then don’t worry about it.
c. Letter of Good Standing/ Letter of academic standing/ Letter of Support (kashf kayd).
This is basically a letter that mentions: [the student X is enrolled here, and he is in good academic standing, in the last year of a 6-year program] with the dean/vice dean/registrar signature.
d. Letters of Recommendation (LoR) from faculty member.
This is a document that is supposed to give the reader a general “good” description of your previous accomplishments, current endeavors, and future goals, as seen by a faculty member who interacted with you long enough to be able to tell such description.
When doing the LoR, remember that;
- Make sure to “offer help” in writing the LoR so as it doesn’t contain any negative attributes (and it shouldn’t). You can even write it, and ask the staff to sign it, if he was willing.
- Try to add authenticity by getting the letter stamped by the school seal. “Normally, it should be even on school-specific stationary paper”
- Make sure that some contact information of the letter writer are present (email, cell phone, and address)
- Tell the letter writer that they “might” contact him by email.
Some, like Hopkins and Cornell, will ask you for a “Dean’s LoR”. Have a friendly conversation with the dean, tell him your ambitions, give him a CV copy if he asked for one, and in shaa Allah he’ll do it.
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VII. Document Quest No. 4. Documents made by YOU
a. The Application Form of the school you’re applying to. Try to make the name as in the passport.
b. The Health Form from the school as well. Basically, it should be filled by a physician who did a complete physical, and lab tests. Sometimes, they tell you to fill it, but require Immunization/Antibody record to be attached as well. Vide infra.
c. The Curriculum Vitae.
i. There's a very good list of DOs and DON'Ts when writing one's CV, present in First Aid for the Match, along with multiple sample CVs of successful applicants, which can serve as inspirational sources. (http://books.google.com/books?id=fJjJxic4nlkC&lpg=PP1&dq=first+aid+match&pg=PA147#v=onepage&q&f=false)
For Research experience, or presentation, publication, conference, etc, it’s always better and more professional to write it in MLA style. This free website provides intuitive forms that you fill in, and they generate MLA-style citations of your works. EasyBIB.(http://www.easybib.com/)
In the Extra-curricular activity, make sure to list your "Association" if you have any, such as "Medical Student Union", or IFMSA (No alpha Omega alpha lel2asaf
). Clubs and societies are a good asset, particularly if one mentions any community service he did with them. (Vaccination campaigns, donations for new hospital equipment/hospital pharmacy ...)If anyone has done any undergraduate online degree alongside his Medicine studies (Diploma, Bachelor...), he can put it along with his Education, even if it wasn't in Medicine. (As long as it's a FULL undergraduate degree)
When explaining Clinical experience, it's always good to give a one-liner on your role during it (eg. Participated in consult service, and attended out-patient clinics), as well as your mentors during it (if applicable) . This also applies to your internship year rotations.
d. The Personal Statement/ Letter of Intent/ Admission Essay.
SOME schools want it, others don’t. Usually there is a cut-off limit for number of words, and a standard format (Text type, size, and space) that are requested. ADHERE to them.
First Aid for the Match, 4th Ed. has an AMAZING section on how to prepare your CV, PS, and LoRs. I recommend it to everyone....
There are these websites, which help shaping the PS AFTER you have your blueprint,
- www.indiana.edu/~wts/pamphlets/personal_statement.shtml
- owl.english.purdue.edu/owl/resource/642/01/
- www.studential.com/guide/write_personal_statement.htm
- students.berkeley.edu/apa/personalstatement/index.htm
- www.ucas.com/students/startapplication/apply09/personalstatement/
- www.personalstatement.info/
- www.admissionsessays.com/
And to brush up and polish the overall quality, I suggest using,
- Merriam-Webster Online Dictionary/Thesaurus mainly for thesaurus (instead of using “loving”, use “ardent”), which are ESSENTIAL to buff up your style.
- A Quote dictionary would also come in handy, as it can give you ideas and idioms to use. Check "The Yale Book of Quotations", and "Oxford Dictionary of Quotations"
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VIII. Document Quest No. 5. Documents done at various locations
a. The Immunization and/or vaccination record. This is a record that shows that you’re immunized against some famous communicable diseases (HAV, HBV, MMR, DT, and TB)
Usually, you’ll need a paper, from a local lab, indicating that you had the vaccines in the recent past. You can do this at our Medical Syndicate (elne2aba) or Health office (maktab se77a)
If you don't have past record of vaccination, you can have the vaccination again at our Medical Syndicate. They'll give you a certificate of vaccination. If you aren't keen on getting vaccinated again, you can get an antibody titer. Note that sometimes, the vaccine certificate doesn't replace the need for AB titers.
You do an Antibody Titer for the diseases mentioned in the health form, and when you have “positive” IgGs, this means you’re immune/vaccinated. Some would require qualitative AB. Titre (+ or -), while others require Quantitative (titer in numbers, as in 850 µg/dL), with latter usually required in HbsAg abs.
Where to get these AB titers done? Any local lab can do them. Note though that they are quite expensive.
Details vary by school. If anything is vague, contact them.
b. Health Insurance. Easiest way is to get it from Egypt Air, or Thomas Cook. A 3-months contract from TC would be around L.E. 600.
Some require their own health insurance. Others might need Health insurance from a US based company. Consider www.visitorscoverage.com/index.php , which compares all of the "Visitor Medical Insurance" plans in the USA. Usually a 6 month coverage will be around $200 (from $100 to $350).
c. Mal-Practice Insurance. A lot of discussion can be found over this topic. Best place by far is www.ProLiability.com. Other companies include academicins (http://www.academicins.com/), and HPSO (http://www.hpso.com/). Check on the discussion about pros/cons of each here (http://www.mededia.com/node/16), and here (http://www.mededia.com/node/37#how_much_time_malpractice_coverage).
Note that most programs waive the Mal-Practice till after you get accepted. But some need it right from the start.
Medical Student Insurance can be obtained from Academic Group. The insurance is usually valid independent of the school you're applying at. Contact them with any questions. They are pretty helpful. ALWAYS mention your credentials in full details.
Student Medical Assistant Insurance is directed to "students" of "Medical assistant" careers, such as Physician assistants, and Nurse Practitioner students. HOWEVER, these work pretty well, and most people get those because they're cheaper. Proliability and HPSO sell those, but you need to be "school specific", that means, they're issued for a particular school and for a particular duration. So make sure you got accepted first before applying.
d. If asked for "Criminal background Check", this is the "Feesh we Tashbeeh" done at any Police Station. Address it to the School, translate it, and send the translation along with the photocopy with the rest of the documents.
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IX. Document Quest No. 6. Supporting Documents
a. THEY VARY BY SCHOOL. Most common is of course your USMLE step 1 Score report.
b. iBT TOEFL. Try to do it, and always send a photocopy of the mailed report, even if not required. IELTS as well will be a benefit. No need to send via ETS.
This test is remarkably easy, if you know the right resources (Barron’s, a Pronunciation / speaking guide, and a simulated KAPLAN exam). Work thru Kaplan and Cambridge TOEFL preparations first. Both are great. Then do Barron's stuff. I got 111/120 without taking any courses whatsoever, and I’m from “madrasa 7komeyya” . NB. Official ETS guide is remarkably shallow.
My best advice is to download simulated exams, and practice the test from them. This is simply because this is a STANDARDIZED test, and not an English test. You need to study for it, as you studied for the USMLE. By doing questions.. Learning by doing IS the fastest.
I think if you want to focus on everyone's weakest points (usually speaking, and listening), try to do self-propelled teaching. Start a sound recorder (present in any Windows OS), and start talking about any subject/a subject ur brother chooses at random, for about 5 continuous minutes. Then listen to your recording, and identify your Grammar, Vocabulary, and Pronunciation mistakes... Then re-record and try to correct them...
Use Jason's website for ideas on Speaking/Writing. jasonrenshaw.typepad.com/ibt_speaking_writing/2008/05/40-new-practice.html
Usually 1 week of 2 ~3 hours/day is enough. But again, it depends on how established you are i the Language. Can take up to a month of 3 hours/day if you're "daye3"
...And forget about books. Barron's book is great, but I think it's a big waste of time.. HOWEVER, you can use this book, 400 words for the TOEFL, to sharpen your vocab... Just memorize these words. www.4shared.com/file/cHgGLdl4/400_Must_have_Words_for_the_TO.html
c. HIPPA Certificate.
Each school has its own course on HIPPA. Just complete it, sign/print the certificate, and send it along your documents.
d. School specific documents (e.g. CORI form in Harvard application)
e. You can also attach a copy of your school’s IMED FAIMER profile (https://imed.faimer.org/). Won’t hurt.
f. If there’s a processing fee involved, there are several ways you can pay for it;
You can use “Traveler checks” from Thomas Cook, or American Express outlets in Egypt. They all accept them. Note however that they aren't fractionated.. They ONLY come as $100 bills. You can't have a $120 bill for example. You'll have to pay $200 for $120 !
OR, the most famous DRAFT way, is to get a decent bank account (HSBC, NSGB, CA, CIB,..), and then ask them to write a DRAFTED CHECK off your savings: They take the $ from your account, and then they write a check to be drawn from THEIR OWN account in a USA bank for the same dollars and then give it to you to mail. The check will have the sentence "Drawn on any US bank" on its back.
Money Order is something you ONLY do at USA Postal Service (USPS). You give them money and an address, and they mail the "USPS check" to recipient. YOU CAN'T do it outside USA.
Wire Transfer = International Inter-...Bank transfer. You transfer funds from one bank to another, and for this, you need the recipient Bank Account Number, AND the routing Number... NOT recommended.
Some schools now ask to have the tuition fees paid electronically, like Yale. The huge amount of money can't be paid by a Credit Card, so I suggest having a Debit Card (linked to your bank account). and pay directly with it.
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X. Send the Documents via Tracked shipping
a. Go to ANY post office, and ask for US shipping via (Elbareed eldawly elsaree3). It will ship via FedEx to the USA for L.E. 155, in roughly 3 business days.
b. Make sure to send the school an email BEFORE sending your documents, just to tell them: [Dear Sir, My name is ...., and you’ll receive my application shortly.]
c. You can add a small cover letter explaining the contents of the package.
d. Keep in touch every now and then with the school. Acceptance is usually granted before the start of the elective by 3 to 1 months.
e. Pray, and make do3a2..
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XI. AFTER Acceptance, before Elective Start
a. Pray again... (VERY IMPORTANT)
b. Start reading on the “department” you got accepted in.
See who the Program Director of the entire program is.
Check the names of the attending physicians in this particular department. Check their PubMed publications, and general clinical interests.
Doing so will help you attaching to some of them, and you’ll be better prepared for them testing you.
c. Start reading on the “Specialty” you got accepted in.
DO NOT USE TEXTBOOKS.
Get Kaplan lectures, and read all the RELEVANT Anatomy, Biochemistry, Physiology, Pathology, Medicine and Surgery related to the subspecialty.
Try to download and read the important landmark papers in the field you’re accepted in. (usually cited in Pocket Medicine, vide infra)
Advanced ABIM review sources, such as MKSAP 15 and MedStudy ABIM board reviews can be overwhelming if you start with them. But, as soon as you build strong foundation, dive right in.
d. If there’s no housing provided, you’ll search for one. Easiest way is Craig’s list.
Make a template email. ATTACHING YOUR ACCEPTANCE LETTER speeds things up by 200%
Example: [My name is ... I’m a medical student from ... I got accepted in x Hospital. Acceptance letter is attached. I saw your listing on Craig’s and I liked the description of the Condo. But I have some inquiries. So is this condo/room close to the hospital? Near Public transportation (VERY IMPORTANT)? How much Deposit do you need? Free Wi-Fi? Separate Bathroom? Who will pay the Electricity/Gas/Cable/Wi-Fi Bills? ]
If replied, try to take his phone No. And call him directly. You can ask him to email you some more photos of the condo.
You want to arrive at least 3 days before your elective start, and leave around 3 days after its end.
Usual rent/month for a ROOM in a house is ($ 400 to 600), and for a Condo/studio apartment ($ 1000 to 1800). Prices vary widely.
NB. Signs of a scams "not real deals" on Craig's list are easy to spot, and they include;
i. UNREALISTIC deal: like a studio for $800/month, with Plasma TV, and 2 bedrooms.
ii. VERY fast response (within an hour or two) to your inquiry
iii. Long reply, that adds much more details to the condo than was previously posted in the ad/
iv. Most important one: ASKING YOU FOR ANY FORM OF ONLINE PAYMENT (eBay, MoneyBookers/PayPal, and the famous bank Wire Transfer). If these words even appear the email, consider it non legit, and search for other postings.
v. Asking you to submit any personal info (he can ask about where I came from, but NOT my national/VISA ID)
vi. A very nice way to rule in scammers, is to search for the condo's description on Google. If you found the same listing being posted under more than one city (sometimes, with the same attached pics!!), then report the posting.
Methods other than Craig's include: Contact the coordinator. He/She usually has a database of some renting options, check local “community” mailing lists. E.g. Yahoo group for Yale students, and note that Youth housing/YMCA/Hostels are NOT a good option. Also, "Easy Roommates" is a nice option. www.easyroommate.com/
e. Get a Bank Account. YOU WILL NEED ONE.
Open an account in a “Real” bank, like CIB, HSBC, NSGB, or Crédit Agricole, and get a VISA or MASTERCARD.
Set up Online Banking options before traveling.
f. Plane Tickets.
Use Online booking IF YOU KNOW EXACTLY WHEN YOU’LL RETURN, and are NOT going to change your US departure date. Pros are it’s cheaper than regular tickets, but usually dates can’t be changed or refunded. Best site is www.Expedia.com and www.southwest.com
Book locally from Egypt Air if you don’t have specific US departure date, as it’s easy to change this date with Egypt Air.
g. Set up a way to contact with your family while away. Any online chat will do. But if you want to be able to call your family, and they call you, at ANY time, with cheapest way, then;
Download MagicTalk (http://www.magictalk.com/). The free application works only for one month, than you have to upgrade it for $20 / YEAR (not month, so L.E. 120 once a year). The upgraded application gives you a free US landline number linked to it, on which you can make/receive calls and voice-mail, as long as Internet connection is present.
Once in the US, get the T-Mobile PrePaid plan: 1500 minutes for $30/month (http://www.t-mobile.com/shop/plans/prepaid-plans.aspx). I honestly don't know if other plans are cheaper, but this one always work for me. Set up an online account to refill easily with credit card. Now the setting you have is: from a mobile phone in US, to MagicTalk in Egypt, and vise versa. This option allows from easy bi-directional calling whenever.
The US number on MagicTalk will help you, before going to the USA, for any direct elective inquiries with the school coordinator, ECFMG, Craig's list posters, ... It also allows them to CALL YOU back, which is a great advantage.
Other options;
i. Skype (on your PC/3G phone/iPhone/iPad), with credit in it to call Egypt landline directly. You can also buy US landline number for skype (called SkypeIn), especially if you have it on your cell phone. It costs around $12/ 3 months.
ii. SmartVoIP, from a computer with Internet to Egypt landline directly (CHEAPEST direct calling service, with 0.8 cents/min, compared to Skype's 2.3 cents/min). SmartVoIP also gives you so called "Free minutes", where you can call some countries' landlines (USA, UK, most of Europe) for free. Amazing service actually.
iii. H2o Wireless is a good alternative (https://www.h2owirelessnow.com/pageControl.php?page=index)
h. Stuff to take with you.
$$$. Although you’ll open a bank account in Egypt, with a credit card, you’ll still need to take $$$ with you, as you’ll usually pay the rent in hard dollars or checks, but not via credit cards. I’d say that for 3-months duration, you should take around $2,000. (About $ 1800 for rent). Take more if you want to open a USA bank account. Generally, the cost of living per month is around $800 to $1200, with ~$600 in rent, and others for food, and transport mainly. If rent will be paid by checks, you'll need to open a US bank account, and get a check book.
White Coat. You actually should get the “short” student coat. Better yet, take the long one, and tell the Elective coordinator that you don’t have “short” ones, and she might give you one for free.
Stethoscope. Very $$ in the US. Take yours with you.
Some Egyptian Souvenirs (Papyrus artwork, or art figurines from Khan Elkhalily for example), will cheer some attendings for sure.
Books and Medical resources:
i. For IM electives, you don’t need that much books to take with you. Maybe “The ONLY EKG Book You’ll Ever Need”, and “Washington Manual of Medical Therapeutics”
ii. Once you arrive in the US, THE MOST IMPORTANT BOOK TO GET, AND NEVER LET GO is “Pocket Medicine, 4th Edition”. A MUST for any IM elective. Get it as soon as you arrive in the US from any local bookstore. Don’t even start the elective without it. This is a sample preview from Google Books: (http://books.google.com/books?id=uLcfBf5bbBcC&lpg=PP1&pg=PP1#v=onepage&q&f=false)
iii. If you have Windows Mobile Phone, iPhone/iPad, or Android, then you can use Skyscape (http://www.skyscape.com/index/home.aspx) “Trial” eBooks on your phone. A great amount of eBooks are available for purchase. There are also some “not-recommended” ways to unlock the trial eBooks on Windows Mobile/iOS. Try to get “A to Z Drug Facts”, “Lab 360”, and “Taber Cyclopedic Dictionary”
iv. If it’s NOT supported in the hospital, and you can afford it, DEFINITELY buy a subscription to UpToDate. A year’s subscription is $200 for students, but it will help you immensely.
v. For US Pharmacopoeia (Drug names), you can either use Skyscape “A to Z Drug Facts”, or if you don’t have Skyscape, the famous book “Tarascon Pocket Pharmacopoeia 2010” from any bookstore will do.
vi. FA for the Wards. A great handbook, for many of the required tasks of a med-student. It helps, but not in the initial (still-know-nothing) stage, at least for us, who never practices in such a system.
vii. A great resource one can use is ECFMG Acculturation Program (http://www.ecfmg.org/acculturation/index.html), which helps IMGs who matched to be able to work smoothly in the first couple of months. Contains many videos in USA healthcare system (http://www.ecfmg.org/acculturation/downloads.html), and a residency survival guide (http://www.ecfmg.org/acculturation/survivalguide.html). All Credit goes to Dr. Karim Mohamed Mady.
viii. For your PDF needs, register a free account here. (http://library.nu/)
i. ONCE YOU’RE IN THE USA, and before the start of your elective, try to;
Familiarize yourself with local stores, and public transportation. Usually you can get a 1-Month pass for an unlimited access to Bus/Subway services for a reasonable price.
Get a US bank account. Not really necessary at this point, unless you want to make a PayPal account, or write a check for the rent.
Go to local grocery. Buy your needs on a Week-to-Week basis. Also make an account on Foodler (http://www.foodler.com/), as it helps in the tougher days.
Get any books you need, as Pocket Medicine, from local bookstores.
Make sure you know how to get to the Hospital in time.
j. The first day of the Elective usually has an orientation session.
This session gives you the hospital ID, the PC system log-on information, and a brief tour on the structure of the Hospital.
Try your best to ask for a PAGER. It's important in the IM rotation, and IS A MUST in surgery rotations.
It's essential to remember: When you're in elective, you ARE A STUDENT in the MEDICAL SCHOOL, spending ONE MONTH in the SCHOOL-AFFILIATED hospital.
This means you have same privileges as any other student belonging to the school, INCLUDING access to different school activities, and access to the school library. Make sure to visit the library, and even borrow books, if you need. Remember this when you're in need of a place to rest/read.
Also, these libraries have librarians in them, obviously. These guys have the job of finding you any book/article/paper you want for your research/project. If you need a paper, and you can't get it, contact the librarian. They're very friendly.
In many schools, the library system is ONLINE. Ask the librarian f ou can have access to it, which will save you time and effort during your paper hunting.
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XII. During the ELECTIVE. Part 1. Introduction
a. Hierarchy in the hospital (in IM programs) goes like: Med Student (usually 4th year.. You'll be in this role), Intern (PGY1), Resident (PGY2), Chief Resident (PGY3), Fellow, then Attending. Others you may encounter include Registered Nurse (RN = a nurse), Nurse Practitioner (NP = an RN nurse who studied graduate masters or doctorate [Advanced Practice (AP) in medicine] and became APRN or NP ), and Physician Assistant (PA) who practices medicine SUPERVISED.
b. The different things you’re REQUIRED to do, as a fourth year student, depend on the nature of the elective. Again, this is IM-Only-experience.
c. A survival guide for ANY elective is FA for the Wards.
d. Your time will be either fully dedicated to one specific component, or distributed among three of them;
The hospital wards component. ( Hospital Wards = 3anaber)
The consultation component.
The out-patient component.
e. These three components DO NOT overlap. Each one has its own time, place, and team. But with proper time management, you can be part of the three, if you have enough endurance. Teams are usually as follows;
The hospital wards: Attending, Fellow, 2 to 3 residents, 2 to 3 students, Nursing staff.
The consultation: Attending, fellow, 1 to 2 students.
The out-patient clinics: Attending, fellow. Residents and students can join at any time.
f. Add to that the conferences, presentations, and teaching sessions, and you’ll have a pretty rough day, that starts from 7:30 am till around 5 pm, 5 days a week.
g. As a general rule, although there’s usually a course description that outlines your BASIC duties, there’s NO LIMIT to what you can do, except how much effort you’re willing to put.
h. The following sections might seem difficult to do in the beginning, but remember: This is the MAX output. You'll have plenty of time to start from scratch, learn how to deal with patients, be comfortable reading journal papers, and finally achieve the top of your performance. So: START LOW, GO SLOW, and remember that Allah will reward you as much as you are willing to give in shaa Allah.
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XIII. During the ELECTIVE. Part 2. Basic Tasks. The Wards Component
a. This component is usually present in electives of Cardiology, GIT/Liver, Heme/Onc., and Pulmonary Services.
b. In a typical Hospital, there’s an Emergency department, where EMTs and Emergency doctors evaluate the case. Decision of Admission is then done by them, and the appropriate IM team is usually contacted to admit the patient in their own wards.
You’ll be part of the “admitting team”. Go with the resident/intern, talk to the patient (take FULL History and perform FULL Physical). Also gather data from patient's companions. Write a provisional “Student Admission note” on the computer system.
Discuss your opinions (Findings, Differential, and management) with the Intern/Resident, and change your note accordingly.
Agree with the admitting team that this “new” patient is now “yours”, and that you’ll present him in the next morning rounds.
If the patient was previously treated at another hospital, try to contact this hospital to make them fax you a copy of his/her records. Also, if he wasn’t able to remember his list of medications, contact his pharmacy for such a list.
c. OK. So I admitted the patient. What next? First, Write his “admission note”. Now this patient is YOUR RESPONSIBILITY. This means that everyday day, starting from the day after he was admitted, you’ll arrive EARLIER THAN THE MORNING ROUNDING, to make “pre-round” on your patient(s)...
1. Go to the PC system, to check for any new Clinical (overnight change of status, or marked change in Vital signs), Laboratory (Morning labs show any change from yesterday), and Imaging (new Xray/CT results...) changes.
2. If anything in his clinical status looks remarkably weird, ASK the nurse responsible for him about it. You should ask the nurse anyways for any noticeable overnight events, and check patient’s charts too.
3. GO SEE THE PATIENT. Greet him again, remind him of yourself. Do a quick review of systems (RoS), and a quick physical YOURSELF. If you aren’t sure about his vitals (BP for example), retake it. DO NOT discuss any future management plans yet, but if the test results were out, discuss them with him. If patient has Telemetry device, interrogate it for any rhythm disturbances.
4. Back to the PC, write your “Daily progress note”. It’s usually in the so-called SOAP Format.
- Subjective: New history since yesterday and new physical from the patient’s mouth and the charts.
- Objective: All the new vital signs, labs, imaging.
- Assessment: What all of these new data mean to the patient condition.
- Plan: What you think should be the next steps in management.
5. When writing the note, you can use abbreviations to your heart content. A useful glossary of medical abbreviations can be found here; www.jdmd.com/glossary/medabbr.pdf, as well as ECFMG Acculturation Program Medicalese (http://www.ecfmg.org/acculturation/glossary.html). Credit to the latter goes to Dr. Karim Mohamed Mady.
6. Print your Progress note, discuss it briefly with any intern/resident who has time (they’re all busy doing the SAME thing you’re doing for their own patients), and take it with you to the morning rounds.
d. In the morning rounds, done each day – INCLUDING WEEKENDS – the residents/interns discuss with the “Morning round Attending” the NEW cases admitted yesterday, and Overnight, as well as the OLD cases that are present 2 days ago or more.
For NEW patients, there will be a FULL description of the case to the attending, including FULL history (From the Chief complaint till Medication list), physical, vitals, pertinent labs/imaging, differential, and management done to the patient since admission.
For OLD patients, it’s just an update of “overnight events” if any had happened, and an update on the general plan of treatment, based on any new lab tests/imaging/family decision...
Each resident/intern/med student has his own list of patients. So DON’T EXPECT an intern to take over your patient. You MUST handle the patient on your own, UNDER GUIDANCE of the intern/resident.
When it’s your turn to talk, simply discuss what you wrote in the Progress note. Make sure to highlight the “reasoning” rather than the result of your management. The way you reached your diagnosis is FAR MORE important than the diagnosis itself.
After finishing your discussion, the attending can ask you ANYTHING related to this particular disease, from definition to Evidence-based management. Make sure you got your knowledge good, as this is YOUR FIRST CHANCE TO SHINE. That’s where Pocket Medicine is very important.
After discussing with the attending, write down his final recommendations on a separate paper, and later on, update the management plan in your note.
e. After the morning rounds, you’ll usually hangout with the admitting team for the day. This is where you usually get to eat/attend Grand rounds/hang out in the Library.
f. In many teams, there will be so-called Sign-Out rounds around 4 to 5 pm. This is similar to Morning rounds, but much shorter. Here, a brief discussion on new patients admitted during noon, and a brief update on patients who had major interventions/imaging at noon as well. And then, students usually call it a day.
g. In some electives, you can ask the elective coordinator to be an “ACTING INTERN”, sometimes called Sub-Internship. Basically, this is where you act like an intern (BUT YOU WILL OFCOURSE be supervised still). This means you’ll actually have to receive calls on patients needing to be admitted from ER, and also that you’ll have Evening, and Night shifts as well. It’s a VERY STRESSFUL job role, but can be manageable.
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XIV. During the ELECTIVE. Part 3. Basic Tasks. The Consult Component
a. This component is present in almost ALL of the IM electives. Some electives, like Infectious Diseases, Endocrine/Diabetes, are usually of this type, with no ward service.
b. When a patient in another service/team/specialty (e.g. A Pediatric patient, or a female patient in OB/GYN, or a pre-surgery patient) gets a medical problem, that is specific to the sub-specialty you’re in, they call the “consultation fellow”, briefly discussing the problem with him on the phone. They will ask him “a question” on what to do.
c. The fellow, in turn, will call you, relaying what he was told. He’ll usually tell you his insight, gives you the name and the MRN of the patient, and asks you to go “see him/her”.
Unlike admitting a new patient, here the patient is already admitted, with a WHOLE amount of notes written about him/her.
Skim through the pile of notes as fast as you can to get a good background of the following,
- Patient’s pre-admission history.
- Patient’s chief complaint (cause of admission).
- Management course since admission.
Go to the patient, introduce yourself as being a part from consult service, and then take a pertinent history, and perform a focused exam. Remember to discuss your impression with the patient.
Go back to the PC system, and start writing your “Initial Consult” note. You’re now looking for answers to “the question” that was asked by the treating primary team. And this should be reflected in all the components of the note (Pertinent History, physical, relevant lab values, Medication list ...). Write your differential, and “recommendations” to the possible “answer”.
Discuss the note with the fellow. He’ll point out the flaws in your reasoning, and you should correct accordingly.
Usually around noon, the consultation rounds start with a “Consultation attending”, different from “wards attending”. This other attending will have an open discussion with you in any aspect of the consult, and the probable diagnosis at hand. This is your SECOND CHANCE TO SHINE.
After the discussion, update your recommendations.
d. Again, once you started the consult, it’s yours. Each day, you’ll see the new updates from the patient’s primary team and whether or not they started the recommendations put by your team. When the rounding with the attending starts, present the patient in a one-liner, and discuss any update to the plan of management you thought of.
e. The consults are usually pretty demanding. You MUST research your findings, and reach a possible differential under limited amount of time and data. JUMP to the Internet.
POCKET MEDICINE. This time, try to get the papers cited within the topic.
If still no luck, then UpToDate. It gives immediate answers to almost any question you might ask. And it has an exhaustive list of citations that you can print out some of them.
Websites like PubMed@Yale, and SCOPUS can be pretty helpful as well, if you have time and mental energy.
- PubMed@Yale (http://www.ncbi.nlm.nih.gov/sites/entrez?otool=yalelib) is just an enhanced version of PubMed, linking ALL entries indexed at PubMed to Journal databases (not just to SciDirect, Elsevier, and Springer as with the plain PubMed)
- SCOPUS (http://www.scopus.com/home.url) is a journal search index, like Google Scholar (http://scholar.google.com/), that can arrange papers by citations, which helps you in getting the “most groundbreaking” articles concerned with your search term.
That is, if you search for “Polycythemia Vera”, and arrange for citations, then make sure that the one with +2000 cites, published in the 30s, IS THE most famous paper on the topic.
- This will allow you to not just know A LOT about the disease, but even know the historical physicians behind it, as well as the history of its understanding.
- Use this mainly with the “elder” attendings, as they appreciate the importance of these pivotal papers.
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XV. During the ELECTIVE. Part 4. Basic Tasks. The Out-Patient Component
a. This is, I think, the most IMPORTANT component.
In the wards, you’ll spend ONLY the morning rounds with the attending, along with the other members of the team. No proper chance for assessment.
In the Consults, you only meet the attending during rounding on the patients. Although it’s a fruitful one-on-one encounter, it’s limited in duration.
At the clinics, it’s usually you and the attending for a good+4 hours. This is where all the actual “judging on YOUR performance” occurs.
b. From the patient’s perspective, the patient usually calls the Clinics around a month before to schedule an appointment. His data are then entered into the Clinic-Specific Computer System, and are linked to ONE attending who will see him.
c. The clinics are either in a separate building from the Hospital, or in a separate self-contained part of the hospital. Their computer system is usually separate from that of the hospital, and may require another log-on ID.
d. The day before the attending’s clinic, inform him of your wish to attend clinics with him, and get his approval. This is because sometimes, they have a fellow, resident, and another med-student with them, and this might be too many.
e. On the clinic day, arrive before its start:
When you look up on the PC, you’ll find that each attending has his own set of patients. Most of them are OLD/Returning patients who he sees regularly, while some are NEW patients, and he’ll see them for the first time.
Try to print out a list of summaries of the Today’s patients’ LAST encounters with the attending, to get a hint of how they were, and what the attending’s plan was, till the very last appointment.
Skim through the cases, read up on the stuff you don’t know. Pay special attention to the NEW patients, as the attending will definitely ask you more questions about them.
Check out UpToDate for any recent major clinical trials/FDA-approved therapies on any of the diseases that you have.
f. When the patient comes into his exam room, the computer system informs you of this. Now what to do?
IF YOU DIDN’T DO THE STEP 2 CS, THEN YOU MUST ACCOMPANY THE ATTENDING/FELLOW FIRST. There are A LOT of things that can go wrong in such an encounter. You must be in the company of an experienced tutor at the beginning.
Once you feel prepared, start going to the exam room ON YOUR OWN.
When the patient arrives, grab his chart, knock on the door, call him by his name, introduce yourself by name, and that you’re a medical student, enter the room, shake hands, then CLOSE THE DOOR BEHIND YOU. Remember to tell him that you’re working with the doctor x he came to see, and that he’ll see him shortly.
If the patient was a NEW patient, take a COMPLETE FULL IN-DEPTH history, emphasizing the presenting complaint [What brought you to the clinic today?], and a complete physical, similar to patient admission. Ask about Social history, Medication list ... Remember to write EVERYTHING down. Finally, discuss your impression with the patient, without mentioning any future plans.
If the patient was a RETURNING patient, take a brief history, then continue by asking [How have you been doing since last time you saw Dr.x?]. Perform a brief physical, inform the patient of any new labs/imaging that came back since last time, and discuss your impression, without mentioning any future plans.
g. Once you finished data collection, thank the patient, tell him that: [Dr.x will be with him shortly], get out of the exam room, and CLOSE THE DOOR. Then go to the attending to discuss the patient with him.
For NEW patients, discuss everything in details. Be prepared for anything. This is why you came in the clinics early in the first place ?.
For RETURNING patients, discuss any progress from last time. Pay special attention to whether the positive symptoms from the last encounter persisted or resolved.
This discussion is your THIRD, AND MOST IMPORTANT, CHANCE TO SHINE.
h. After the discussion is done, start writing your “Student Note”. Make sure the attending checks the notes you write.
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XVI. During the ELECTIVE. Part 5. Advanced Tasks
a. Sometimes, the elective might contain a “Topic Presentation” at the end of the month. You need to start working on that from Day 1.
The fellow will be your friend. Ask him what the attending expects you to present about the topic, and where you can get more information about it (apart from UpToDate and SCOPUS)
The attending KNOWS about the disease. Try to keep the pathophysiology, pathology, and findings brief, unless a recent groundbreaking news came up.
When discussing papers about recent therapies, always try to weigh the evidence. Not all trials are created equal. Some are stronger than others, and a lot of them have “correspondence”, or criticism directed at them.
Be biased to the practice employed at your department.
b. If you’re lucky enough, you can suggest writing a “Case Study”.
Once every while, a very interesting case comes by, and doctors just stand there, unable to come up with any diagnosis. If the case is later diagnosed, and you were an integral part of the service-providers, you can suggest writing a case study about him/her.
It’s actually simple to write. But the main difference is that you NEED TO CITE THE PAPERS that reflect your decision making process.
So, if you ordered a specific test, you should cite the paper linking this test to a possible diagnosis that can match up the patient’s still-unknown disease.
Let the attending and fellow in on this, after drafting a plausible length case, and together you can get it published ?
c. Some electives have ORAL, or even WRITTEN exams. Discuss with the attending the scope of such exams if there are any. Make sure to get your evaluation. It helps immensely in your ERAS application, as you can scan it, and attach it to the LoR. This will allow the program director to link the LoR with actual performance data from the physician who wrote the letter itself. More concrete bonus to your profile.
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XVII. During the ELECTIVE. Part 6. Putting all tasks together
a. You can “juggle” most the tasks together, unless very explicitly said otherwise by the program description, AND the attending physician.
For example, while in the wards, and after Morning rounds, you can go the clinic with the “wards attending “. More interaction time.
Also, the consults can be done right after the morning round. Can take up to 2 hours. From the till the sign-out rounds, you can be at the clinic, or any conference they make.
Try to maximize your clinic time, but try to attend morning rounds as well (most of the teaching is actually in the morning rounds)
b. It will take approximately the first 2 weeks to get to know the Computer system, how everything is timed, who the attendings are, and how you can do your tasks best. Thus, your best week should be THE THIRD ONE. That’s when you’ll do your best.
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XVIII. During the ELECTIVE. Part 7. Gains. How to Get the LoR?
a. Now, the most important thing you can come out with from the elective is an LoR from a US doctor. First, you must understand some basics:
In ERAS application for the Match, you can submit ANY LoR, Programs ask for maximum of 4. That means, you can submit LoRs from Non-US schools, and even your school. Needless to say, the letter then will have near-zero value, UNLESS it’s written by a world-famous expert in the specific specialty you’re applying in.
When ERAS receives an LoR from you for the Match, it’s usually in 2 ways. First way is that either they got it directly from you, or your letter writer ALONE, accompanied with only ECFMG DSF. Either case, it’s considered “non waived”. That means, you SAW the contents of the letter, you knew what’s written in it, and you “approved” its suitability for the Match application.
OR the second way, they get it accompanied by your AAMC ID in ERAS Cover letter, and with a Document Submission Form (DSF) from ECFMG, send directly from the writer’s school mailing address. This is considered “waived”, meaning that you allowed the writer to send it, and you DO NOT know the contents of it.
OBVIOUSLY, YOU NEED TO HAVE ERAS ACCOUNT TO DO THE WHOLE "WAIVED" LETTER ROUTE.
The whole value in the “waived” letter is that the writer will write “honestly” about you, as he sees fit, and won’t be “forced” to write good things knowing beforehand that you’ll see what he wrote later.
The amount of value between a waived vs. Non-waived letter is ALWAYS under debate between IMGs.
From a personal experience with the Program directors, they consider anything, in the IMG profile, other than US-doctor written LoR, and “waived” to be less trustworthy. Note, however, that since MOST programs require that you submit at least ONE LETTER from a Department Head/ Program Director in the specialty you’re applying to, this letter will usually be written by a Non-US doctor, as you rarely get the chance to have an LoR from a US program director.
It’s VERY EASY to get an LoR. But it’s DIFFICULT to get a GOOD LoR. That means, don’t be happy with just an LoR. Try to do your best to ensure a good/productive one.
b. How to ask for an LoR?
BEST TIME to tell the attending that you'll need an LoR is at the End of your SECOND WEEK. This will give him ample time to assess you more intently, give you hints on your performance, and write an honest evaluation about you.
A PERSONAL ADVICE: Create an ERAS Token and account for $90, and print out a cover letter and a DSF. (If your elective is between July to April)
1. WHY? All the people I knew of, well over 20, find it difficult that when the doctor agrees to write an LoR, and then the elective is over, AT LEAST one of the three doctors becomes “hard to find”/”doesn’t answer emails”/”forgot about me”/.....
2. To ensure you get your hard-earned letter, simply tell the writer to write it in the Letter Writer Portal (LWP).
3. Although some doctors may tell you to “email them when you’re ready for the ERAS Match” so that the letter is ‘FRESH”, it’s actually pretty easy to know WHEN the letter was written (either in the body of the letter itself, or from the USCE dates you provide to ERAS in your CV). So this point is illogical, and can again make you worried for the occasional non-responding doctor.
4. Although you will be on ERAS, you won’t apply to any program of course. And you won’t participate in the NRMP. When the season is over, the letters in the ERAS PostOffice will be retained, and once you get a token for the next season, you can retrieve all of them.
Note however that; a. You MUST keep getting tokens each year, so that they are carried over to the next one., and b. IF your letters were non-waived, you can simply ask ERAS for Return of Documents (RoDs) service at ERAS Support. This is NOT applicable for “waived” letters.
Prepare your up-to-date CV and specialty-tailored Personal Statement, Also put in one of those Papyrus papers you got from Egypt. If the elcetive has some "Written evaluation", add it to the package as well. Put all in a nice manila folder, and go to him/her, when he/she is free.
A very important document to prepare is a list of all patient encounters/educational activities you had with the mentor, and how these activities impacted you in your education. This list will help the LoR writer with his task, and will allow you to "steer" him in a specific direction.
Your PS here can be different from that of the match, so customize it according to what you see fit. I suggest discussing red flags here (like a failed CS, low scores,..) so that the LoR writer addresses them on the fly as well...
Simply ask the LoR writer . Then present him with the folder.
In the next two weeks, make sure to improve your weaknesses, so that less of them appear in the LoR. Don’t bring up the topic again, except maybe at the end of the fourth week. Just a friendly reminder.
c. When the letter arrives at ECFMG, you’ll see a note of that in your ECFMG profile. That’s when you send a [Thank you for all the efforts] email.
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XIX. During the ELECTIVE. Part 8. Other Gains
a. Try to get an email with the DNS (domain) of the institution/school you're in.
Go to the Tech. Dept at the school, and ask for an email account. Reason your way with the person in charge. If he refused wholeheartedly, don't push it of course.
This might sound weird. But believe me, when you have an email like a.b@hms.harvard.edu, it opens up opportunities everywhere you go. It will be especially helpful when you contact researchers,either then or later, to work on a specific research project. This domain will ENSURE that your email WILL BE READ...
b. Build contacts with the attending.
This will help later if you want to work on a research program with them.
Especially true if they were same nationality as you. As they have been in your exact shoes once, and know how hard the road was.
c. Build contact with the program director.
You HAVE TO BE in the specialty where the program director is in (e.g. Pulmonary Medicine, Geriatrics)
Attach to him in the clinics.
A program director is just like any other attending, and will notice the hard-working student when he sees one.
A magnificent boost to apply for a residency in the same hospital. At least a guaranteed interview.
d. An opportunity for academic or clinical research, after electives end.
Best if directed at an attending with a reputable PubMed-indexed papers.
From the list of his publications, you get a good sense of his clinical interests, and the fields he is more interested in.
Physicians interested in academic research will probably have a profile at BioMed Experts (http://www.biomedexperts.com/), where you can search for his/her name, and find the spectrum of techniques, methods, and pathology interests he is involved in.
Armed with these bits of information, confront the attending with [how much you admire his work, and that you’re very interested in this particular field, and ask for a possibility in an unpaid open position]