How do you succeed during your third year of medical school? How do you do well in your clinical clerkships? How do you “honor” a rotation (and since when is honor a reverse transitive verb)?

Now, there are entire books dedicated to clerkship success: pages and pages of “pearls,” entire tomes dedicated to helping you earn the gold stars you’ve always wanted. These tend to be painfully repetitive and full of common sense.

Of course, common sense is your most important tool for third year, so don’t discount that out of hand either.

The bare minimum, most essential advice for third year is as follows:

• Be on time
• Don’t be a dick
• Use common sense
• Be flexible

(more…)

Update April 2024:

My book is up-to-date and has remained the go-to resource for taking the physician JP exam since its release.

Update September 2019:

As of 9/1/2019, the TMB has moved the test to be self-administered online, which is great. The price has also decreased to $34 per attempt with unlimited attempts, which is also great.

They are now also offering their own practice materials, which you can rent limited access to until you pass the test for $99. You do not need to buy those pricey materials. Early feedback is that tested material (like the laws) is unchanged and my book (which is revised periodically and currently up-to-date) remains sufficient for preparation. Given the low cost of the exam and the ability to retake endlessly, I personally would suggest applicants buy my book (or something else inexpensive), read it 1-2 times, and immediately take the exam. The exam is short, and a re-take is cheaper than other materials would be.

Update January 2016:

In the years since I took the JP exam, the other resources have gotten older but otherwise haven’t changed in substance or price. The landscape has changed in only one significant way: In order to fill the missing void for a concise but readable up-to-date resource for busy doctors (and broke residents), I wrote one. I’m super biased, but I think it’s overall the best, most affordable, and most palatable study option out there. Thousands of people agree.

You can buy the ebook here:

Buy The Texas Jurisprudence Exam: A Concise Review

My original thoughts remain below.

The Texas jurisprudence exam is an irritating last hurrah on your way to getting your license. As a doctor, you’ve taken USMLE Steps 1, 2CS/CK, and 3. The JP exam is not like those tests, in many ways, but particularly because this one is easy. Somewhere between three and five hours of high-yield review should be sufficient. However, don’t take this relative ease further and attempt the test cold. It’s idiosyncratic enough that you need to give the key information a solid once-over in order to pass.

The test costs $58. For this reason (and the fact that it’s extremely approachable difficulty-wise), I find it amusing that both the “recommended” resources and the major online option are so ridiculously expensive. The UTMB book is $100, the TMA Manual is $145, and the accompanying TMA Self-Study Guide is $105. The online course at texasjurisprudenceprep.com is $210. All cost substantially more than the test itself and are probably overkill for anyone who had the skill to pass the boards. You can attempt the exam up to three times if necessary for one fee.

If the residents in your program have passed around a high-yield packet of the more salient bits, studying that exclusively would almost certainly be enough. There is usually someone who has taken some serious notes over the years. As far as I can tell, the test has not changed in any meaningful way recently. By far the most affordable commercially available book is the Texas Jurisprudence Study Guide, which is quite affordable (the Kindle edition is less than $4). It’s very short: roughly 13k words, which is like 25 legitimate single space pages. The book is question and answer format (lots of white space). The form works better in theory than in practice, and the formatting in the ebook version is especially poor. The book is also awkwardly terse, has a decent number of mostly irrelevant typos, and is downright confusing in several spots. It’s essentially a long list of facts without any particular emphasis. No context, no real explanations. That said, it’s totally sufficient. And much much much more affordable. If you’re going to rely on the study guide, this online PDF from TMLT is helpful.

The other books are longer and will take more of your time. The real test is 50 questions and takes approximately 20 minutes to complete (you have 90 min allotted), so there’s lots of extraneous detail to be had here. They just aren’t worth it.

It seems as though the online course is actually pretty popular. It’s a “video” course in the sense that it’s an online audio-backed powerpoint lecture. The audio quality and voice acting approximate the quality of your very first Skype call. The course is also full of painfully awkward juvenile humor, which I imagine is an attempt to make this very dry subject somewhat more palatable. These cringe-inducing bits actually take up a fair bit of talk time. The course itself takes 163 minutes to finish watching. There are also 6 quizzes (#5 and #6 are considered the most relevant), at least some of which are reportedly appropriated from the back of the UTMB book, and some helpful handout downloads, which are honestly the best part. This is not an elegant resource, but it will absolutely get the job done and will do so more quickly than reading one of the full-length resources (The UTMB book is quite dry). They do now have a free practice quiz demo, which takes a few minutes and is worth doing to get a feel for the questions.

So, ask the residents at your program what they’ve been using. Borrow a copy of whatever they used. If you’re on your own, the cheap kindle book gets the job done. As far as I’m concerned, it doesn’t really matter what you use, so long as you don’t waste too much money on it. In this case, more detail is not better.

As for the test itself, it doesn’t necessarily test things you’d think would matter. A large percentage of questions make sense intuitively. Most questions that require reading test facts that are emphasized in all study resources. There are a few randos, but not enough to seriously jeopardize passing. The question writing is pretty poor. There are plenty of “all of the above” questions as well as the negative “which of the following are NOT…” variety–which you’ll remember were stricken from the boards because negatively-framed question stems are a stupid way to get a proportion of people who actually know the answer to select the wrong choice inadvertently.

Anyway.

Good luck.

Buy The Texas Jurisprudence Exam: A Concise Review

The NBME graciously provides brief practice materials for its USMLE tests, including pdf and software versions. While answers are included, there haven’t been explanations available online (until now).

If you haven’t taken a moment recently to think about how you approach Step-style questions, I might refer you to my discussion of that particular topic, particularly the section on “dealing with irritating clinical science questions” near the end. For general information on how to study for the USMLE Step 2 CK (as well as some free Step 2 resources), I recommend you read this.

From the 2014 official “Step 2 CK content description and general information” booklet (official link is dead, that’s the Archive.org cache version), I’ve listed each question and its answer with a succinct (grossly simplified) take-home message:

The newest set of official questions (2014-2015) has been released. There are only three new questions, but the question order has been entirely changed. My updated explanations can be found here.
(more…)

There is more to the USMLE than the requisite volume of knowledge, and you can take the test efficiently by acknowledging outright the things your subconscious probably already knows. This is a somewhat randomly chosen question from the official 2013 USMLE Step 1 information booklet:

A previously healthy 48-year-old man comes to the physician because of fever and cough for 2 days. He attended a convention 10 days ago, and two of his friends who stayed in the same hotel have similar symptoms. His temperature is 38.3°C (101°F), pulse is 76/min, respirations are 20/min, and blood pressure is 130/70 mmHg. Crackles are heard over the right lung base. A chest x-ray shows a patchy infiltrate in the right lower lobe. A Gram stain of sputum shows segmented neutrophils and small gram-negative rods that stain poorly. A sputum culture grows opal-like colonies on yeast extract. Which of the following is the most likely causal organism?

(A) Campylobacter jejuni
(B) Eikenella corrodens
(C) Legionella pneumophila
(D) Proteus mirabilis
(E) Pseudomonas aeruginosa

Once you’ve done enough Step questions, you will already know the most likely answer at the word “convention” (it’s C). Not every question can come as a knee-jerk reaction, but one key to Step preparation is not just overall knowledge but rather pattern-recognition and memorization.

What separates the massive scores from the excellent scores boils down to intrinsic genius, test-taking voodoo, and tons of studying. The first you can’t change; the third you have to do (and should do efficiently). The second you need to be clever about (and doing questions is key). You can lay a strong foundation by making questions like the one above comically easy. Knowing the key phrases and patterns can allow you to literally “feel” the right answer even without having conscious knowledge. If you can get in the head of the question writer and know the tip-offs, you can often make a reasonable guess even if you don’t actually know the “basic science” details the question is supposedly trying to test. (more…)

Rules for the Rank Order List (ROL)

• Put them in the order you actually want them. There is no reason to change how you will rank programs based on post-interview communications or voodoo. Your number one should be your dream program.
• You must “certify” your ROL when you first make it and whenever you make a change to it.
• Rank every program you interview at unless you absolutely hate the program and would rather not have a job. There is no harm in ranking programs just in case unless you would rather not match and try to scramble for whatever scraps are left.
• The Match algorithm guarantees that you will get the very best job you can get based on your preferences.
• Try to avoid any plan that involves the SOAP. The number of spots in your field of interest cannot be predicted and should not be relied upon. Additionally, if a program has spots in the SOAP, that could be an interview fluke…but it could also be an indication that it might not be the best place to spend 3+ years.

For advanced specialties:

• You must create additional supplemental ROL for internships (PGY1 positions).
• You can create different supplemental ROL for each advanced position you rank, which allows you to coordinate geography appropriately (i.e. you can rank Texas prelims above California prelims for your Texas programs and vice versa).
• You can also list PGY1 programs as backups on your primary rank list in the event you do not match to an advanced position. You will still have the chance to enter the SOAP for an advanced position; you just won’t then need to try to obtain two jobs at once.

For couples:

• You coordinate your ROL on your own (their #1 is your #1 and so on), and the software itself doesn’t confirm that you guys did it right. Double check every single selection to make sure that you did match up your choices correctly.

NRMP Rules concerning correspondence (that are sadly and awkwardly broken all the time):

•  A program may not ask you how you will rank them
•  You may not ask a program how you will be ranked
•  It is perfectly okay and common to tell a program how you feel, and some programs may send you love letters as well.
•  No coercion!

Talking to programs

The amount of contact expected of applicants in order to show interest varies widely across programs. Some programs demand to know that you want to be there (using the words #1), others will flat out inform you that they rank the applicants accordingly to how they want them (with no regard to where they fall on the applicant’s rank list). And of course some may say that and have it be a boldfaced lie. There are egos involved. Be cognizant of program personalities and cater to them when possible.

If you tell a program they are your #1, it’s best to do so late in the season after you are absolutely sure. Do not lie. Don’t be that guy/gal.

If you aren’t sure, you can express “strong” interest but save #1 for your real #1.

Keep in mind however the reality that most seasoned program directors shouldn’t/won’t take these comments at face value. They’ve been lied to so much that they believe no one. Your lies may hurt the chances of future students from your school, however. Likewise, you should continue to doubt even the most sycophantic of praise until it’s confirmed by match day. There are no benefits to being duped.

Thank You Notes

It is customary to send thank you notes, though it is unlikely that this correspondence generally makes a significant difference. It’s simply polite to thank people for taking the time to speak with you. Typically, one should write thank you notes at the very least to the Program Director and Program Coordinator, though it seems most applicants still also write letters to all interviewers. Write them and send them immediately after your interview, as the interactions will be freshest in your mind. And it’s polite.

You may not want to bother. And that would be okay in most circumstances. However, an anesthesia program director once told me he doesn’t rank anyone who doesn’t write him a post-interview thank you letter. He especially likes Christmas cards. This is a dramatic (and ridiculous) example, clearly, but I found that helpful motivation.

To facilitate writing personal thank you notes, it is advisable to jot very brief notes after your interview encounters. By doing so, you can specifically reference interesting (wink wink) conversation topics you had with different people. Most people still write thank you notes by hand, but email is becoming more popular. Some programs will express preferences (follow them).

Hearing from programs

Programs vary widely also in how much (if at all) they contact applicants. You may receive emails or phone calls with warm fuzzy feelings of varying significance.

Some programs will outright tell you are “ranked to match” (take with a grain of salt). Some may tell you that you have a job. Others will vaguely tell you that are “ranked competitively” (double grain of salt alert!). People have been burned by even the most specific and seemingly failproof promises.

Some programs do not contact applicants at all and hate the mind games of the match. Do not take silence the wrong way. Simply rank your programs the way you want them, not the way they want you.

The first question for many students to ask (themselves) is where? Because the majority of physicians practice in the same location they trained, some would argue that residency is about Location, Location, Location.

Using FRIEDA, you can search all accredited programs by field and location to help you find potential residencies.

Are you considering enough programs?
Is there a reasonable mix in the competitiveness of the programs you are looking at?

• Certain locations (California, NYC) tend to be competitive based on location regardless of program quality
• There are three broad types of residencies: big name programs, university-based academic programs, and community programs.
• Depending on how competitive you are for your chosen specialty, it will be important to at have programs in at least two of the three broad categories.

The AAMC provides a lengthy but excellent list of questions to ask residency programs (including “what is the call schedule?” and “how are the residents evaluated?”). Read it early to get an idea of what factors might play into your decision. It will help you make the most of the information you receive over the coming year.

Some things to consider when applying:

• Program setting (urban, rural)
• Program size (large, small: affects both social aspects and call)
• Program location (close to family/friends, climate, sounds good on Facebook)
• Program reputation
• Program benefits

Some things to ask:

• Any upcoming changes? (new chairs, changes in funding, new call responsibilities)
• Any Red flags? (probation, residents leaving, etc)
• Patient population (indigent, community, private)
• Number of program sites/hospitals (will you be commuting across town frequently?)
• Where do residents live? (Is it close to the hospital?)
• Can they afford it? (Or are they budgeting like crazy?)

You can look at:

• Program marketing materials and websites (be wary)
• The internet forums (take with massive grains of salt)
  • studentdoctor.net, urologymatch.com, auntminnie.com (radiology), etc.

You should talk to:

• Recent graduates in your field of interest

Just to be clear:

• Conventional wisdom states you’re most likely to make your Rank-Order List based on location first and reputation second, with gut feeling coloring the whole thing so profoundly that you can rationalize your list seven ways til Sunday.
• You will forget everything else about these programs over the course of the interview season unless you take meticulous notes. Even then, nothing else outside of the big three (location, reputation, “feel”) will really matter. After all, you’re not really going to pick one program over another because they have a bigger book fund; it’s just a factor in your overall impression.

You could read the rest of the interview series:
How to schedule your residency interviews and How to succeed in your residency interviews.

Interviews for residency are generally unlike those you are familiar with. They tend to be more conversational and are at least as much a marketing session for the residency programs as they are an evaluation of you (the applicant). The most common question you will receive on the interview trail is “do you have any questions?” by a country mile.

By receiving an interview, you are qualified academically for that program. It means you have a reasonably good chance of ranking there (on the low end, probably 10%). Just be yourself and see if it’s a good fit. If you had a good interview impression of the program, the converse is probably also true. It’s just as important to strike the right number and balance of interviews as it is to be a charming almost-physician on the big day.

The easiest way to hurt yourself in the interview process is to fulfill a pathological stereotype: the jerk, the know-it-all, the creepshow, etc.

A very brief list of rules to interview by:

• Be on time (or reasonably early)
• Look professional (bathed, clean-shaved if applicable, suited). Your appearance should be generally unremarkable (but well put-together).
• Avoid checking bags (it costs money on most airlines anyway). People show up suit-less every season because of this. They really do. Yes, it actually happens.
• Be warm and pleasant. Be excited. Look people in the eye. Smile frequently (your cheeks will ache, be strong)
• Be someone you would want to work with.
• Don’t be a sycophant, however.
• Do not complain. Ever. Be nice to all residents and ancillary staff. The secretary is one of the most powerful people you will interact with.
• Don’t play on your phone. I know you won’t during an actual interview—because you’re not an idiot—but I encourage you to not pull it out to fill inevitable dead time either.
• Have a repertoire of standard “I am interested” questions. You will be asked for your questions by every person you meet. Don’t be combative in how you ask them.
• Ask nitty-gritties to the residents and not to faculty: call schedules, moon-lighting, benefits, etc.
• Do not ask questions that are answered on the website or in the Powerpoint talk. It means you’re lazy or fell asleep or both.
• When possible, research the program ahead of time and have specific questions/discussion points.
• Go to the dinner the night before (don’t drink too much) if you can. It is an excellent time to meet residents. The residents are what you will probably base your decisions on (along with location and reputation; not the Powerpoint). Do not fail to RSVP to the interview dinner if one is requested, and do not no-show without notification if you then can’t make it. Some applicants do this, and the programs always notice. It’s rude.
• The residents will tell you that the dinner is a safe space. It is not if you’re an ass.
• Trust your gut.

Get Practice

Go over common questions with a loved one or friend to make sure you have solid (but not overly rehearsed). Take feedback seriously. You can also look at my Interview Question Compendium for examples.

If your school has a mock interview night or analogous event, you should go. You may not be aware of interview ticks or nervous habits you’ve developed since your last rodeo.

Further Reading

There are some well-reviewed books on this topic (e.g. The Residency Interview and The Successful Match [which is long, good but repetitive, and pretty exhaustive]) but truthfully, I sincerely doubt most American medical graduates with a reasonable student affairs department and a modicum of common sense have very much to gain from any book-length treatments of this topic. A shorter treatment by the AMA is quite readable, and I largely agree with medfools. A more gunner-like approach is advocated by these folks.

As with all how-to resources, so much of it truly is common sense.