Wischnitzer's Residency Manual: Selecting, Securing, Surviving, Succeeding

by Saul Wischnitzer

Overview

Residency is a defining period in a physician's life because it is the decisive stage for personal growth, intellectual challenge and emotional stress. It is a major transitional period transforming a medical student into a practice-ready physician. This role-change for the physician-in-training usually takes place in a new setting and necessitates coping with conflicting demands, heavy responsibility and long work hours. Adding to the residents' burden is the ongoing need to manage their financial, social and work demands. This manual was designed to help medical students on this final critical segment of their journey to become practicing physicians. It will enhance the students' awareness of the potential obstacles along the way and provide them with guidance on how to avoid them. The book includes: selecting an appropriate specialty, maximizing the chances of being selected, surviving residency and beginning practice.

Product Details

ISBN-13:	9780521675161
Publisher:	Cambridge University Press
Publication date:	06/26/2006
Pages:	394
Product dimensions:	7.01(w) x 10.00(h) x 0.75(d)

About the Author

Saul Wischnitzer is a former Professor in Biology and Pre-Health Profession Adviser at Yeshiva University. He has authored several books on medical careers.

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Cambridge University Press
0521675162 - Wischnitzer's residency manual - selecting, securing, surviving, succeeding - by Saul Wischnitzer and Edith Wischnitzer
Excerpt

PART ONE

SELECTING A SPECIALITY

If you ask college students taking the required premedical science courses and studying for the MCAT exam why they are doing so, the obvious answer that they will give is, “I want to become a physician." The focus of these students’ efforts, justifiably, is on getting into medical school, preferably the one of their choice. They quite naturally must defer the issue of what specialty they wish to work in as physicians for an appropriate later time. Once they are enrolled in medical school, this major issue comes to the foreground all too soon.

   Making the selection of an area for postgraduate training is a key life decision that requires very careful consideration. It is a complex task, for it involves (a) candid self-assessment of your interests, abilities, and lifestyle needs; (b) becoming knowledgeable as to the many specialty options available; and (c) careful execution of the varied components of the timetable relative to securing a residency. (See front matter, Message To the Reader section.)

   Professional activities associated with the practice of medicine are extremely diverse, medicine being a composite of many areas of specialization. Also, there is a wide disparity betweenspecialty activities of, for example, an allergist and a urologist in their approach, skills, and practice (although though they have had a common educational core of knowledge and experience). Complicating the choosing of a specialty is the fact that the exposure of students to specialties and subspecialties during medical school is very brief and limited in scope. Moreover, it takes place essentially in the context of hospital and clinic settings. Although anesthesiologists and pathologists have hospital-based practices, most specialties are primarily office-based or are combined office-based and hospital-based practices. Thus career decisions are commonly made by medical students based on inadequate knowledge of the overall realities of medical practice. This limitation goes as far as not considering some areas for specialization because the prospective resident may not even be aware of their existence.

   It therefore behooves medical students, first of all, to acquaint themselves with the very wide spectrum of specialty opportunities available. If you assess yourself and compare your personal abilities and interests with those that the specialty calls for, making a choice becomes much easier and more realistic. The six chapters of Part One that follow will facilitate becoming knowledgeable as to possible career choices and familiarizing yourself with how best to make a determination as to what area is most suitable for you.

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1   Considering Your Options

Overview

For the greater part of the first half of the 20th century, graduates of U.S. medical schools would automatically complete one of several types of internships. Most of these doctors would then directly enter practice. This was possible because there was a limited amount of medical knowledge available, and physicians could therefore treat patients with a wide variety of illnesses. Specialization was an uncommon path for the bulk of medical school graduates. If undertaken, it frequently involved overseas postgraduate training. This obviously had limited appeal for most graduates.

   The situation changed dramatically in the second half of the century. The internship period was transformed into postgraduate year one (PGY-1). Major and remarkable advances in medical knowledge and technology mandated that graduating physicians secure postgraduate training to acquire the background and skills needed to serve as generalists or specialists. This situation usually requires medical students to make challenging and decisive career choices at some point during their undergraduate medical education. The choice that has to be made is among three fundamental options. Each choice will have its own advantages and liabilities. Furthermore, each path will require subsequent difficult decisions as you narrow your focus. Your basic options are selecting a

• Generalist track or
• Specialist track or
• Transitional year.

Each of these will be discussed separately.

Choosing a generalist track

Over the past several decades, with the onset of radical changes in health care management, the position of the generalist physician has assumed much greater significance in the provision of patient services. This came about because the long-standing, very costly health care system had strongly emphasized specialty and subspecialty treatment. To improve the situation, an ongoing effort exists to establish a more equitable balance between the number of generalists and specialists entering the profession.

   Generalists are viewed as those engaged in primary care specialties, namely, family practice, internal medicine, and general pediatrics. These areas are characterized by

• Treating a wide range of illnesses affecting different body systems.
• Providing ample opportunity to offer continuity of care.
• Commonly providing services in an ambulatory setting.
• Usually treating readily curable illnesses of children or adults.
• Facing simple technological demands in the course of one’s practice.
• Having to treat patients with both medical and psychological problems.
• Serving as community-based practitioners, with local hospital affiliations.
• Responding to the needs of patients with multiple illnesses.

One can decide between the three primary care options noted earlier by a process of elimination. Thus those strongly interested in children will obviously choose pediatrics. Those wishing a wider scope of activity, such as working with adults, will elect internal medicine as a specialty. On the other hand, for those seeking to serve the widest segment of the patient population, entering family practice is the appropriate choice. It should be noted that the three aforementioned specialty areas are discussed in detail in Chapter 3, whereas the basic subject of choosing a specialty is covered in Chapter 2.

   One should be aware that diagnosing problems in primary care specialties is not necessarily straightforward, because a decisive answer is not always readily and clearly available. Thus a tolerance for practicing, at times, in a state of ambiguity is highly desirable for those serving as generalists.

Choosing a specialist track

Specialists are considered experts in their fields. In this book, areas of clinical practice are categorized into (a) major specialties (Chapter 3) and (b) three groups of subspecialties. The latter comprise of medical, surgical, and other subspecialties (Chapters 4, 5, and 6, respectively). It should be recognized that there are also physicians devoting themselves full time to administrative and research activities.

   An alternative, but less clearly defined, classification scheme involves characterizing specialists as secondary, tertiary, and support professionals. In addition to these three areas, the other group is obviously primary care specialists or generalists. In this categorization, both specialists and subspecialists are placed in either secondary or tertiary care categories.

   Secondary care specialists are exemplified by general surgeons and pediatric subspecialists. They secure patients by referral and provide services in treatment or consultation modes, and their practices are largely hospital-based. They usually have an association with their patients for a limited period of time.

   Tertiary care specialists can be exemplified by ophthalmologists who treat only patients with retina problems or orthopedic surgeons who are involved exclusively with joint replacement procedures. These specialists usually have a practice that is restricted to a single structural entity in a limited area of the body. The medical problems they face may be quite challenging, and patients usually are seen by referral for both consultation and treatment. Such practices frequently require a high degree of specific technical expertise.

   Clinically supportive specialists are pathologists, radiologists, and anesthesiologists. They facilitate other physicians in carrying out their diagnostic and treatment responsibilities. Work in these fields may have no or merely short-term patient contact. They work primarily in hospitals, medical centers, or private facilities. Technology usually plays a vital role in their activities.

Choosing a transitional year

A transitional year is a broad-based training period, comparable to the third year of medical school, except that a PGY-1 resident’s level of responsibility is obviously more meaningful than that of a clerkship.

   A little less than one-fourth of medical students make their specialty choices when they are in their preclinical years. Almost half of them do so when they are in their third year of medical school and nearly another fourth do so during their fourth year. Less then 10% defer making a specialty choice until some time after graduation. Uncertainty as to the appropriate selection or a sense of insecurity that an inappropriate decision may result in career failure inhibits some students from making a selection regarding postgraduate training.א

   It should also be recognized that for several specialties, one can apply only during PGY-1 for admission to residency programs. In such a case an internship-type year is needed as a prerequisite. This is the situation for such specialties as anesthesiology, ophthalmology, and radiology. In such cases, deferring a decision in order to undertake a transitional year of postgraduate training may be advisable. Moreover, the clinical experience gained during an interlude when one is genuinely uncertain about future plans can for some prove especially valuable. Thus, a transitional year can provide a suitable alternative under specific circumstances. Should these exist, this option then merits careful consideration.

   There is, however, a negative side to the transitional year. To use this year simply because of a desire to procrastinate in making a career decision can be self-defeating. This is because for most PGY-2 (advanced matches) you need to obtain an appointment before the end of the senior year of medical school. Moreover, many specialties (internal medicine, pediatrics, etc.) do not accept the transitional year as counting toward completion of a PGY-1 residency requirement. Thus, even after gaining enhanced clinical competence during a transitional year, you might be forced to repeat it to gain entrance into a desired residency program. To be forced to serve a second internship year is obviously a very unappealing prospect. Another reason against electing to take a transitional year is that your career goals remain unfocused and your future plans are in a state of limbo, which is psychologically challenging.

   An alternative approach that obviates these difficulties is to seek a preliminary rather than a categorical residency in medicine or surgery. Such programs can meet the PGY-1 requirements in these two areas as well as their many subspecialties. Preliminary residencies are not excessively difficult to secure.

   You should be aware that there is a risk that the intense demands and burdens of a transitional internship can be so excessive as to motivate an individual to accept a residency appointment even in a field of secondary interest. This is done merely because it serves to resolve a burdensome career dilemma, albeit in a far less than ideal way. This approach should be avoided, because the consequences of the wrong choice can very negatively impact an individual’s professional life in terms of work-related satisfaction.

   An additional negative consequence of the transitional year may be induced by trying to resolve the residency problem by seeking to apply to two specialties simultaneously. This has its own inherent risk, namely that your ploy will be uncovered. You may then find that no attractive program in either field seeks your services as a resident and it may therefore prove difficult to secure adequate training.

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2   Selecting Your Specialty

Overview

Medicine as a profession is going through turbulent times. Medical education and patient reimbursement are among issues in a state of flux. Nevertheless, as a medical student, you can exercise considerable control over your personal career. This is because your choice of a specialty will determine (1) how long a training period you will have, (2) how many programs will be accessible to you, and (3) the geographic area of your training site. To achieve a favorable outcome of the specialty selection process, careful planning is essential.

   Medical students, being intensively involved in demanding educational activities, may find themselves pressured into choosing a specialty with undue haste, not giving it the thought that this very important decision deserves. Some elect to choose the specialty of a physician they admire, or of their medical school mentor, trying merely to imitate a person looked upon as a role model. These motivating factors present serious risks, due to the inherent differences that usually exist between individuals, and the sought-after results may not materialize.

   The specifics of choosing a specialty will be discussed later in this chapter, but some generalizations are in order at this point. In seeking to establish a tentative choice of specialty, try to determine what approach to medicine appeals to you most.

• Do you prefer to focus on wellness or on sickness?
• Are you interested in treating adults of varying ages?
• Do you prefer short- or long-term patient relationships?
• Do you favor contact with peers in your profession or with patients?
• Do you prefer a contemplative or decisive approach to solving problems?
• Do you require a professional and personal lifestyle that is organized and orderly?
• Do you prefer the challenges of professional activities that are unpredictable?

Your responses to such basic questions can help you focus on the type of specialty that you will find most satisfying. Some preliminary guidelines that will assist you in your selection process are noted below:

• If the concept of maintaining wellness is appealing, then investigate such fields as family medicine, pediatrics, internal medicine, and obstetrics/gynecology. In these areas long-term patient relationships are a common feature. There is also a special need for being empathetic and providing counseling in such fields.
• Should you prefer long-term patient relationships in the context of holistic treatment and desire a stable lifestyle, then fields such as physical medicine/rehabilitation, psychiatry, or rheumatology can prove satisfying.
• If you seek a well-organized practice with regular hours but also want relatively short-term patient contact, then consider dermatology carefully.
• Some physicians are interested in the concept of wellness, but are not committed to close personal patient relationships. Rather they are more interested in maintaining the health of society as a whole. For these groups, public health, general preventive medicine, and infectious diseases offer an appealing outlet for their interests. In these areas one can work with groups of individuals to help resolve significant medical problems.
• Those who feel they would like the satisfaction provided by the dual aspects of medicine and surgery can benefit from a career in ophthalmology, otolaryngology, or obstetrics/gynecology.
• There are individuals who seek to have a major impact on people without a long-term relationship. For them, such fields as emergency medicine and surgery (including its many subspecialties) will be especially appealing.
• For those who prefer interacting with their peers rather than with patients, specialties such as pathology and radiology are particularly attractive. However, these fields do not have much prestige or power in the medical hierarchy.
• For those who seek intellectual challenge, a field such as neurology is an attractive option.
• For individuals with good manual dexterity for whom creativity is important, plastic surgery can offer personal fulfillment.
• For those who favor procedures and data analysis, gastroenterology will be especially appealing.

Specialties and subspecialties

There are numerous specialties and subspecialties, as will be seen in Table 2.1. New areas are still emerging and some of these are described briefly at the end of Chapter 6. To receive recognized status, a specialty needs to gain recognition by the American Board of Medical Specialties (ABMS). This is the nationally recognized organization that can confer official status allowing certification of MDs who have satisfactorily demonstrated the level of competency established for the field.

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Table 2.1 Specialties and subspecialties
Specialty	Subspecialty
Allergy & immunology	Clinical & laboratory immunology
Anesthesiology	Critical care medicine
	Pain
Colon & rectal surgery	———
Dermatology	Dermatologicpathology
	Clinical laboratory dermatological immunology
	Dermatological pathology
Emergency medicine	Medical toxicology Pediatric emergency medicine Sports medicine
Family practice	Geriatric medicine Sports medicine
Internal medicine	Cardiovascular disease Critical care medicine Endocrinology, diabetes, and metabolism Gastroenterology Geriatric medicine Hematology Infectious diseases Medical oncology Nephrology Pulmonary medicine Rheumatology
Medical genetics	Molecular genetic pathology
Neurological surgery	———
Neurology	Child neurology
Nuclear medicine	———
Obstetrics & gynecology	Critical care medicine Gynecologic oncology Maternal & fetal medicine Reproductive endocrinology
Ophthalmology	Retina-vitreous Glaucoma Pediatric ophthalmology Neuro-ophthalmology
Orthopedic surgery	Hand surgery
Otolaryngology	Otology Pediatric otolaryngology Plastic surgery within the head & neck
Pathology	Blood bank/transfusion medicine Chemical pathology Cytopathology Dermatologic pathology Forensic pathology Immunopathology Medical microbiology Medical genetic pathology Neuropathology Pediatric pathology
Pediatrics	Adolescent medicine Clinical & laboratory immunology Development-behavioral pediatrics Neonatal–perinatal medicine Neurodevelopmental disabilities Pediatric cardiology Pediatric critical care Pediatric emergency medicine Pediatric endocrinology Pediatric gastroenterology Pediatric hematology–oncology Pediatric nephrology Pediatric pulmonology Pediatric rheumatology Sports medicine
Physical medicine & rehabilitation	Pain management Pediatric rehabilitation medicine Spinal cord injury medicine
Plastic surgery	Hand surgery Plastic surgery within the head & neck
Public health and preventive medicine	Occupational medicine
Psychiatry	Addiction psychiatry Child & adolescent psychiatry Forensic psychiatry Geriatric psychiatry Clnical neuropsychiatry Pain management
Radiology	Musculo-skeletal radiology Neuroradiology Nuclear radiology Pediatric radiology Vascular interventional radiology
Surgery	Pediatric surgery Surgical critical care Vascular surgery
Thoracic surgery	———
Urology	———

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   The ABMS is a not-for-profit organization, consisting of 24 distinct medical specialty boards, which is concerned with overseeing certification in the United States. Its mission, for well over half a century, has been to improve the quality of medical care in this country. It does so by assisting member boards in developing and implementing educational standards to evaluate and certify physician specialists. Consequently, the ABMS is recognized by accreditation organizations as the source of board certified specialists for accreditation purposes.

   The 24 specialty boards recognized by the AMBS are identified in Table 2.1 and their associated subspecialties are shown in the adjacent column. These specialties and many of their subspecialties will be discussed in detail in four groupings. These are major specialties, (Chapter 3), medical subspecialties (Chapter 4), surgical subspecialties (Chapter 5), and other specialties (Chapter 6).

General considerations

Five general considerations associated with selecting a specialty need to be considered. Each of these will be briefly discussed.

1. Be realistic. Many medical students set their specialty goals in their youth. For some this desire, after a while, can become a firm inner conviction. It may have been brought on by the favorable contact with a specialist or in response to a serious family illness. In any case, such early plans need to be carefully reevaluated at your current, more mature stage of life, when you are more familiar with your personal assets and limitations. Thus, if you are determined to become, for example, an ophthalmologist and find that your fine motor skills involving hand–eye coordination or your color vision is somewhat impaired, you need to seriously reconsider your plans for entering this field. It behooves medical students to assess their career goals bearing in mind any personal permanent limitations that they currently have. It is essential to evaluate to what extent any significant handicap would limit you in a specific field. What counts is not only the type of work you would like to do, but your capacity for doing such work well.

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© Cambridge University Press

Table of Contents

Preface; Introduction; Part I. Selecting a Specialty: 1. Considering your options; 2. Selecting your specialty; 3. Major specialties; 4. Medical subspecialties; 5. Surgical subspecialties; 6. Other subspecialties; Part II. Securing a Residency: 7. Laying the groundwork; 8. Getting started; 9. Residency program selection; 10. Applying for a residency; 11. The residency interview; 12. Facing the match; Part III. Surviving a Residency: 13. Becoming oriented; 14. Meeting responsibilities; 15. Protecting your assets; 16. Professional challenges facing residents; 17. Personal challenges facing residents; 18. Surviving yet thriving; Part IV. Succeeding in Practice: 19. Securing a position; 20. Practice options; 21. Marketing and operating a successful practice; 22. Monitoring your professional and personal finances; 23. Responding to complementary and alternative medicine (CAM); 24. The Art of medicine; Appendix I. Major professional organizations; Appendix II. Sample resumés; Appendix III. Sample personal statements; Glossary; Abbreviations; Bibliography.