What If I don't Match

It is currently the interview season, and I have received inquiries from some friends seeking advice on how to enhance their chances of matching. In my previous attempt, I tried various methods such as sending emails, physical letters, making phone calls, and leaving voicemails to program coordinators, but the outcome was ultimately unsatisfactory.

During this time, I have experienced a considerable amount of internal reflection. Frequently, I find myself pondering the question, "What if I do not match?" The thought of not matching leaves me feeling quite disheartened. Considering the significant investments of time, effort, and finances I have dedicated to this residency pathway, the prospect of not matching carries a substantial cost. Reapplying in the subsequent cycle would require even more commitment to improve my chances of matching. This process can be mentally taxing and emotionally challenging. How can I start my day without the persistent inner voice reminding me that "You have failed, and thus, you are in this situation" or "You could have been working elsewhere as a PGY1"? While I acknowledge that these internal monologues offer no real benefits, I cannot help but project into the future that awaits me if I do not match.

Another concern revolves around how others perceive me. I recognize that this concern may appear superficial, but it has been the primary reason why I have kept my pursuits confidential throughout medical school. Only my closest friend knows about my decision to take the USMLE exams, and I even chose not to notify the school about my USMLE results during registration. Whether I succeed or fail will remain unknown to others. Ultimately, their opinions, views, and gossip hold little significance. However, if somehow these opinions reach me, I anticipate feeling unsettled. Negative comments would only exacerbate my already fragile mental well-being at that point.

If I were to fail to match, I would find myself starting anew and feeling tired internally. Reflecting on my thought patterns from January 2020 to Match Day 2020, I acknowledge that dwelling on these negative thoughts did not contribute positively to my well-being. Perhaps most difficult of all, I would find myself in a profoundly lonely place. None of my friends have shared my experience, and even my parents would struggle to understand why is matters so much to me to match. Somewhere along the way, I have begun to broaden my perspective, allowing myself to consider alternative viewpoints and possibilities.

Every night before going to sleep, I reminded myself to maintain hope. I have a dream of becoming a competent doctor, and I possess the courage to take on this challenge. With adequate preparation, my day will eventually come, perhaps with a stroke of luck. I recall coming across a quote that resonated with me: "If you don't fail greatly, you have not tried anything great." Those who have achieved success understand that failure is an inherent part of the journey. They are not the ones who mock or derive pleasure from seeing others stumble. 

Over time, I have gradually let go of the notion that I must match on my first attempt. I have come to accept that things happen, some of which are beyond my control. I have done everything within my capabilities, and I trust that the universe will take care of the rest. In the meantime, I will continue dedicating myself to personal and professional development. Whether the outcome is a match or not, it does not signify "the end" because there will always be a need to continue putting in hard work and growing. So why not fast-forward to being the best version of myself, starting today?

Lastly, it is crucial to remember that there is a wide array of possibilities out there. I recall discussing with a close friend what would happen if things went wrong. He said, "I will go Norway. Something about the landscape draws me toward it. ... And I will figure it out then."

What other actions can be taken to enrich your life experiences? Additionally, it's worth considering other aspirations/dreams one may have regardless of the circumstances one is in. Reflecting on these inquiries, it is my hope that through an open and adaptable mindset, you will come to realize that life presents countless possibilities, and embracing the journey is a wonderful choice to make for oneself. :)

Internal Medicine Residency Survival Guide

Unknowingly, I have been in residency for 11 weeks.

I have this acute realization that if you are not careful and conscious with your time, it slips away and get blended into amorphous materials in the shape of daily work routines. When a sufficient amount of time accumulated in this dysmorphic form, you wonder where exactly your time went into use? 

pre-rounds, ward rounds, note typing, and working, plus?overthinking.

The point of residency is to educate us further in medicine but paradoxically, some opinions that I amassed from people around me point away from this purpose. It is almost set as a default mode in us to not study and update our knowledge when we devote majority of our waking hours working. Plus, it is convenient to rely on morning reports, noon conference and the likes provided by the hospital to teach us in the course of residency. 

Have you gotten complacent with the current level of knowledge you have? Is the level of learning you are getting right now match up with what you had in medical school? Is this the lack of academic rigors (program's fault) or lack of self-motivation/discipline (your own shortcoming)? 

We are supposed to learn from the patients in the ward by dissecting into their medical conundrums and making assessments and plans through in depth discussions with our attending. However, there is a fine point where things do not work for us residents. When you have too many patients, you do not have the time to read up and think deeply about a clinical problem. When the ward rounds get too long, you are mentally and physically exhausted. You need to save some energy to deal with case manager and social workers too. By the time you know it, sun has already set and you just want to sign out ASAP and slump into the coach. 

Unless you are very motivated, you will not study.

Is this path where we are all going to head down to? How can we at least preserve our neurons in spite of all the perceived tiredness, fatigue, burnouts, etc that we unfortunately are all too familiar with?

I find that being mindful helps tremendously. 

Whatever you are doing, remember to bring your focus into "Now." Have you ever noticed that the washing machine has a internal core that is unperturbed by the surrounding chaos  (your clothes)? Imagine that you have "space" in you, maybe located over your left 4th ICS and it is untouched by the dramas and fast-paced events around you. This sacred headspace is where you can take refuge into and think clearly. In the frenzy of things, you will not lose your cool or get caught up if you can stay mindful this way. Miraculously, mindfulness also helps in decreasing the mental exhaustion you face by minimizing the clutters and unwanted thoughts stem from your mind. 

Besides, you just have to study on-the-go. Whenever you have a "snack" time, hydrate yourself and get onto any educational materials available to you. Simply type in a topic relevant to your patient care and read. It can be just 15 mins before anyone page you, but 15 + 15 = 30mins of learning in a day is a progress. The best part is that you are not able to finish reading and hence you have "unfinished business." When you get home and inertia sets in, you do not have to question yourself "What should I learn now" and battle with your demons that yell "You deserve a rest, go sleep" because you can just resume with whatever topic you left of earlier in the day. 

You can start off my re-reading the topic you went through, so as to get yourself into the "flow" state and then start diving deep into the topic with new information. This spaced repetition will consolidate your memories too! Believe it or not, when you finished reading up, and found some journals that support your current management, it is the best feeling ever. You end your day feeling inspired and you look forward to going to the wards and start this learning process all over again. 

Time flies and it need not to be wasted. A quarter of intern year has already gone, lets seize the rest of the year with more conscientious use of our time. 

Time Management for Medical Students

Today's topic is all about time! I get what Mr. Edison was trying to say, but how to capitalize time???

Over the years in medical school, I tried out different study techniques including using a planner and setting a list of to-dos that fits into multiple time slots throughout the day. I found it hard to accurately figure out how much time you need to dedicate for each to-do. I was alternating between having “too much time” and “too little time” from overestimating and underestimating what I can achieve in the given time period. Besides, it can be counterproductive when you want to dive in deeper on a certain topic but you did not allocate enough time for it, so you skip it just to keep up with your schedule. I always felt the sense of constantly having to keep up with time. Not before long, I burnout and realized I need a change. I eventually got around it and found out what works for me the best till this day, and I am eager to share with you on how.

1. Set your own pace

Put on your watch and just stop everything you are doing right now for 5 minutes. Watch the seconds go by. Internalise that rhythm of a ticking clock. It can feel like it takes a long time before the time is up. Yes, 5 minutes is a lot, when you are undistracted. You have that potential to fill it up with productive deeds by being “present” in the moment. Now, go on to studying, flip the pages as you read through the materials and see how much you can study in 5 minutes. The amount of learning you reap will be your “control.” Next, try to sit down and study for half an hour, maybe reading one new chapter. 

Notice the difference in how much you learn from the 1st and the last 5 mins of that 30 mins period. 

Do you tend to learn more in the 1st than the last 5 mins? Does this difference widen when you stretch out your study period into 2 hours? For how long you can study, before you feel that you are “saturated” and not making full use of your time anymore? 

This practice is essential as in you will get good in setting your own “biological” clock for studying. You will know your baseline (how much you can typically learn) and it is helpful in monitoring for dips in productivity. You will also know your limit, and give yourself a little push to stay close to it for maximum study output. With repeated practice, you will be aware of your “state” of productiveness, and spend your time wisely on focused learning. 

2. Time dimension is context dependent 

As you practice Step 1, you will also realize that the output of 5 minutes in Introduction and Pathophysiology has a huge gap. The former will leave you motivated and energized because there it is a relatively easy learning material. However, understanding intricate, complicated disease mechanisms will take up a lot of your brain power. You will be fuel packed with essential information, even only for time as short as 5 minutes. 

If you were to avoid burnout or fatigue especially while doing long hours revision, keep in mind that the dimension of time is different according to context. Because of the density of 5 minutes on “hard” topics, you might want to alter the dimension by prolonging your time spent on each learning points. Consciously goes back to the previous learning points before moving on to the next, in order to further consolidate your understanding, and to allow your mental faculty some “relaxation phase” to stay agile. 

For example, after you read through the pathophysiology of secondary hypercalcemia in chronic kidney disease (CKD) and started on its treatment, go back to re-reading the pathophysiology when halfway through learning its treatment, and come back again to the next learning point of treatment. So, when you are done reading treatment, you already went through pathophysiology twice or thrice. With full understanding of the fundamental of what went wrong in CKD, you will know what treatments are suitable without depending on memorization.   

 

3. Compartmentalize your time

Time is the f(x) of learning. How much time you put into learning does not compare to how much you learn in a given time. To avoid fatigue and to keep yourself motivated, micromanage your time into various slots for different types of learning. For example, reading Neurology after Nephrology, which is an intrinsically, and some would argue radically different topic. You are much more likely to stay focused on both subjects because they stimulate your brain in different ways. So rather than being overwhelmed by corticospinal and spinothalamic pathways alone, you can master the RAAS feedback loop and neural circuit efficiently. If you have to read a same topic for hours, try to alter the learning modes or materials. For instance, change to lecture videos after textbook, or journal articles after PowerPoint slides. Each change will be like a breather for your brain and a "refresh" button for your mind, so that you can constantly renew your interest in the topic and stay eager to learn more. 

On a meso- level, compartmentalize your day into blocks of hours. Be aware of the times when you are less productive, for example, after lunch; and utilize that as “downtime” by spending it on something recreational that does not demand much of mental capacity. You kill two birds with one stone this way by getting enough rest and feeling energized for the next study session. Besides, make good use of endogenous endorphins too, by slotting in half to an hour of exercise after studying. If you are less of an athletic type, napping can be an alternative as research has shown that sleep consolidates memories. The bottom line is, personalize your study hours with close attention to your physical and psychological needs. Be flexible and take breaks in between. You will last longer, and have more fun along the way studying this way than holing up in a library corner. 

On a macro level, compartmentalize your weeks by putting study break during the weekends. Make your own rituals. I usually clear my desk on Friday night, have some desserts and make plans with family for weekends. These "celebrations" in life are what keep you going, and do not want to lose your momentum in a years long marathon like Medicine. 

It is a long post! 

Long story short: 

Don't just spend time, use it. 

Play it to your strength.

And have fun in MedSchool :) 

H1B for US Residency

One of the most common thread of IMG topics is… H1b or J1 visa? I can be a very personal question, whatever your decision is, I hope that you make an informed one with thorough consideration. 

Crash Course for Newbies

- J1 7 years, H1b 6 years maximum 

- J1 requires you to return to home country and serve for 2 years 

OR

        get a waiver and practice in medically under-served area (MUA)/health professional shortage area (HPSA) for 3 years and do whatever you want with your remaining life

- The process of citizenship goes this direction: J1 ➨ H1b ➨ Green Card ➨ dadada

- So getting a H1b during your residency, you are ahead of the queue, and closer to holding this close to your heart 

- PLUS, the numbers of fellowship sponsoring H1b is LESS than residency, and over the years, hospitals sponsoring H1b are becoming near-extinct species so you better seize it now

- H1b allows moonlighting AKA extra income.

- If you have a family to raise and thinking that H1b allows you to bring more bread home, keep in mind that your spouse is not allowed to work if you hold a H1b, whereas J1 your spouse can get EAD and work 

- Now you are thinking OKAY get H1b, but wait

The Cons: Your choices are limited if you have chosen H1b.

Some fellowships are 4 years, with additional research year/(s). If you want to do Endocrinology at Harvard, it is a 4-year program, and with the limit of H1b (max 6 years) you will be screened out from the applicant pool. 

Besides, some fellowships might not support your H1b status.

 

Case studies

I have my Hollywood dream and I wanted to go Kaiser LA but reality crashed my dream right away

With competitive fellowships like Cardiology, your chances of matching might be jeopardized.You can look up the figure on FREIDA by comparing the number of fellowship programs sponsoring both J1 & H1b vs H1b only. The number drops from 246 to 70 (🔻 71.5%) if you choose H1b. This is prior to taking into account how competitive this specialty is for US IMG (matched 11.1%) and for non US IMG (24.9%)

Source: NRMP Results and Data Specialties Matching Service, 2020 Appointment Year

The number of fellowship programs drop from 150 to 85 (🔻 43%) for Nephro but the unfilled position of Nephro is rising over the years, so it is a calculated risk and potentially manageable one even if you choose H1b.

What if you are aiming for Pulm/Crit or Hemo/Onc? Fellowships popularity goes up and down, we see a spike in Hemo/Onc last few years, and recently, Pulm/Crit. So you might want to weigh the risk & benefits. 

Source: NRMP Results and Data Specialties Matching Service, 2020 Appointment Year

The number of position offered has steadily increased over the years, BUT the extra seats are well-filled and the number of unfilled positions is only 2 in 2020 Match. 

And what if you don’t match? You cannot work as attending out there with J1, whereas H1b even if you don't match, you can work as an attending and you can always re-apply for Match next year.

Long story short: 

☺If you want to be a US citizen 👉 H1b

☺If you want to be cardiologist/gastroenterologist 👉J1 

☺If you are aiming for less competitive ones, like Nephrology or Endocrinology, try H1b.

☺If you don’t know which field you are going into, think if

1. Are you afraid of being jobless? Yes 👉 H1b (so that you can work as an attending if you don't match)

2. Is going back to home country a personally difficult situation for you? Yes 👉 H1b

3. Otherwise, J1 is still a good choice, and many residents I chatted with during the interviews are in the process of waiving the compulsory 2- year home requirement. 

For me I chose H1b, I don’t know if I want to stay forever and my answer changes all the time. So I did not depend on the the vicissitude of my feelings to make this decision.

One thing that will never change is that FREEDOM is the value I prized most in life. If I were to leave US someday, I will do it because I want to, not because I am forced to. 

Freedom in one’s twenties is like food tasting in supermarket. It is free, tasty, but one-time only. In the next 3 years, I can be flexible and practice anywhere, be it Boston or Arizona but in the next 7 years when my age hits thirties, FREEDOM to choose where to practice medicine is goddam expensive. Which school you want your kids to attend, where your spouse booming career can co-exist with yours will come into the picture. I don't want to be the tight position where my choice is tangled with my loved one's future, I rather nip it in the bud now.

Alright hope these help!