Tuesday, August 26, 2014

The Ask (part 2)

More on asking for and obtaining stellar letters of recommendation.... (see "The Ask" part 1 here) 

Remember, every pediatrician at some point needed a letter of recommendation to get where he/she is now (note: Dr Seuss is not actually a physician). And we want to help. Just ask. We'll take a sincere approach to help enhance your success. And what if you learn that a program of your liking needs a "departmental/clerkship director" letter? Your clerkship director is happy to assist you in this way (with a letter highlighting your strengths) and throughout the match process to help make it indeed that, a proper match. 

Students sometimes wonder whether their letter writers need fancy titles (Founder of the Pediatric Universe, etc). If Don Berwick actually knows you well, ask him.*  Otherwise, go for a faculty member, can also be a private practitioner who you worked with (who would likely have a faculty appointment with your school anyway). Preferably someone who has worked with students before. Perhaps someone who can honestly write that you are one of the top 5 students he or she has worked with in 5, 10, 20+ years on faculty. Would not ask a resident or fellow - though of course we value their skills and contributions to medical education highly! Almost always should be someone with an MD/DO or PhD.... and maybe some writing skilss-- that is, skills.

Your prospective pediatric program director or residency selection committee chair will wonder if you have NO letters from pediatricians. It would be concerning, if not just downright improbable, if not a single pediatrician got to know you and thought highly enough of you and your performance to write a letter of recommendation on your behalf.

But 1 or even 2 of your letters can certainly be from other fields... it's ultimately all inter-related. So, for example, a letter from someone in internal medicine, OB-GYN, surgery, primary care, or family practice would be okay and still speak to your skills as a comprehensive, cool under pressure, clinical reasoner who goes that extra mile for his/her patients. Even geriatrics has its similarities to pediatrics if you think about it (hmmm, sounds like a future blog post in the making). These non-pediatric letters could show your breadth and other strengths.
Ultimately, ask people who know you well (or could get to know you even better this summer with 1 or 2 additional meetings) and can attest to the qualities in you that would make pediatric residencies want you in their program.

Not all your letters need to be in at the precise moment that you submit your ERAS application (for pediatrics that's usually mid-September nowadays). You might have 1 or 2 in at that time, and the others can follow shortly thereafter.

Special circumstances:
  • A possible 4th letter (if the prospective program allows more than 3) could come from a non-clinician /non-researcher, if this person can add something meaningful about you as a person and your skills as a future pediatrician.
  • Could include a letter that "balances out" some difficult academic experience that you have had. Example, you performed poorly on the outpatient portion of the pediatrics clerkship but there were extenuating circumstances that one of your preceptors or other faculty member can attest to.
  • Do meet with your dean/mentor/clerkship director for individual advice about these and other special circumstances.
Of course, you will also have a personal statement to allow the residency selection committee get to know your strengths and unique qualities... where you get to play "show and tell" about yourself. Better to show than tell though, as you help them understand what makes you the outstanding person you are. And aim to make both the statement and your recommendation letters say more than a mere recitation of the items listed on your CV.

*Unless he's your uncle. No aunts/uncles/relatives/best friend letter writers please.
Comment below or email PediatricCareer@childrensnational.org with additional questions or tips

Tuesday, August 5, 2014

Tip Tuesday: Do you have any questions? Or, instead...

As an esteemed pediatric colleague of mine suggests, instead of asking (patients, parents, students), "Do you have any questions?"

we should instead say,  "What questions do you have?"

A subtle but very important difference.  Try it.

There may be unanswered questions, and unlistened to answers.   But let's avoid unasked questions, if they should be asked, and could benefit our patients, our learners, our profession, our society...

So tell me, what questions do you have?

Tuesday, July 22, 2014

The Ask

"I was wondering if (or hoping that) you would...

A) ...be interested in writing a letter of recommendation."
B) ...have time to write me a letter of recommendation."
C) ...have time to write me a strong letter of recommendation."

Ah yes, you are used to taking multiple choice tests. All of the above might be acceptable, but of those choices, which is the
best answer?

Let's make it
boldly clear (don't you wish all tests did that?).

"I was wondering if you would have time to write me a strong letter of recommendation."  Why choice C when A and B are also fine? Asking if they have time gives them an "out" if need be (you'd rather they not write it if it isn't going to good). And they might even effusively say I will make time to write you a glowing letter! Add the word strong so they get that this is not just any random letter, but one to get you in the door of your favorite hospital for a pediatric residency. And again, you'd rather they not write it if it's not going to really sing your praises. 

What else might be part of the ask?An offer to update the prospective letter writer on what you've been up to. That you are indeed applying for a residency in pediatrics. A hello, hope you have been well. A question or two to pick their brain about pediatric residency programs. A thank you... perhaps for past teaching or for possibly writing you this recommendation letter. Logistically, have those materials that they'll need readily available (essentially, the LoR cover sheet with your AAMC ID number and the FERPA waiver that you waive the right to see the letter, and the address of your dean's office) to make it easy for them to submit the letter. 

How to ask?
A) text message
B) a tweet
C) email
D) phone
E) in person
F) via STAT page
G) don't ask, just assume they will offer

A?  Have you ever texted each other before? Assume you need something more formal, more official, more... old school.
You don't need to make it so public and recorded by the National Library of Congress, for that matter.
C or D? 
Sure, either by email or phone would be appropriate, if you have in fact emailed before, that would be a fine choice. And when calling or emailing, do at least offer to set up an in person meeting to follow up.
Sure, in person would work, but you might have to schedule the in person ask, unless you just happen to come upon your prospective letter writer or are seeing him/her anyway. However, in person you aren't really able to give the prospective letter writer an easy "out" if it isn't going to be a strong letter. On the other hand, at least in person you can remind them who you are!
It's not urgent, would be better to use a different method, as you might be paging them in the middle of a code or other important patient encounter.
Perhaps if someone has offered, during your research or advocacy time together or at the close of your clinical experience during 3rd (or early 4th) year, then yes that is a really good sign. But don't assume! Ask.
For your pediatric residency application, do all your letters need to be from pediatricians?
No!  See "The Ask part II" coming soon...

Monday, July 7, 2014

GUEST POST: Imaginations Wanted: Big and Small

Dr Jessica Lazerov, wrote and imagined the following:

When I first chose medicine as a career, I envisioned my future self as many things:

A scientist.  An advocate.  A teacher.  A healer. 

My imagination ran wild with the possibilities.
  • I imagined myself as a super-hero of sorts with endless energy and insight into what needed to be done for my patients and my community, and I imagined I could do it.  
  • I imagined a caring, practical clinician with endless patience and a great sense of humor.
  • I imagined providing comfort to my patients and their families during difficult times.  
  • I imagined myself being able to reach kids from rough upbringings and help to convince them that they were important and could succeed.  
  • I imagined giving strength to new mothers as they learn to cope with the difficulties of their new role.
  • I imagined that I would learn something new every day, from my colleagues, my students, and from my patients. 
  • I imagined that I would become a voice in my community, advocating for things that will improve the lives of kids everywhere.  
  • I imagined becoming a role model for other little girls who may think that becoming a doctor seems out of reach. 
  • I imagined being able to share what I have learned with students and residents. 
  • I imagined myself looking for answers to unanswered questions in medicine.  
  • I imagined leading the fight to ensure that every child could rely on quality health care.
  • Most of all, I imagined that my efforts would in some way, touch the life of another that could give them some measure of comfort, understanding, or hope.

A pretty wild imagination? Maybe.  Some advisors said I should focus my efforts. “Don’t think too big,” they argued.  “Pick one thing and run with that,” others advised.  Now over a decade later I would have to respectfully disagree.

Just like we all benefit from encouraging a child who dreams up their future career as an astronaut, a firefighter, an entrepreneur, or the President of the United States, a wild imagination can often lead to pretty big things…and smaller things too.  And at the end of the day, sometimes the smaller things are what can actually bring a huge sense of purpose to your life, and help just as many.

Some of us may speak on Capitol Hill as an advocate for child safety, while another may kindly and patiently explain to a family that:Yes, the proper car seat is really, really important, and No, immunizations do not cause autism.

One may find satisfaction in investigating the science and epidemiology behind the obesity epidemic, while countless others are more than content to fight obesity at the smallest scale, one family at a time.  Some become leaders in teaching while others teach one student at a time.

Some of us may lead the national fight for teen’s access to contraceptives, while another will spend extra time really getting to know at-risk teens in their practice in order to build trust, educate, and hopefully have a positive impact on the choices they make. 

Whether we head up a landmark scientific study, or spend 40 years treating a generation of children into adulthood, our career is what we make of it.  We can engage in research and still have clinical time to treat the under served populations that sparked that interest in research. We can be an advocate for our patients on a local or even national scale and still be regarded as some family’s favorite doctor. 

One should point out that we can also, at any point in our career, to decide to change course.  We can become more involved in one aspect of pediatrics while we dial back another. Our interests and circumstances may change. 

We may have aspirations of grandeur or many “mini-goals,” but the fact is that each one of us is a piece in a greater puzzle, a movement to improve the health of all children.  We can be whatever part of the puzzle we choose. 

Which puzzle piece will you be?

ABOUT OUR GUEST POST CONTRIBUTOR: Jessica Lazerov received her MD from the University of Maryland where she also completed her Pediatrics Residency.  She is now an Assistant Professor of Pediatrics at The George Washington School of Medicine and works in the Southeast DC Children’s Health Centers.  She is interested in health care disparities and working with underserved populations in addition to understanding and treating childhood and adolescent obesity.  She enjoys traveling and spending time with her husband and two “spirited” children.  Read another post by Dr Lazerov here

Tuesday, June 17, 2014

Tip Tuesday: How to be helpful

Hospitalist Jeffrey Winer (pictured here!) writes: 
Dr Winer, always lending a helping hand

One of the things I wish I had known as a medical student which I now try to impart to my own students is how best to be helpful to a medical team. I have found over time that one rule can govern this effectiveness: NEVER ASK AN INTERN IF YOU CAN BE HELPFUL.

Bear with me, I know this is the core of a medical student's repertoire. I am sure that most MS3s in their first month have had the experience of asking this question and having the intern busy with hundreds of tasks, respond that no, there isn't anything that he or she needs help with. That intern was too busy to stop and figure out what to tell you to help do.

The better thing to ask an intern is "I NOTICED X NEEDS TO HAPPEN. IS IT OK IF I DO IT?" Here, the answer will almost always be yes. The intern will appreciate it, and the intern will have more time to teach you later!

The exception to the rule, and repeat this to yourself, is the following: "IS THERE ANYTHING ELSE I CAN DO TO BE HELPFUL TODAY?" This question is reserved for times after 4:30PM when the intern is busy and is forgetting to send you home. It's not that they want to keep you in the hospital, necessarily. It's usually that in their busy day they have forgotten to look out for getting you home. Asking "IS THERE ANYTHING ELSE I CAN DO TO BE HELPFUL TODAY" has two possible answers: 1) Yes, can you help me with X, or 2) No, you should go home.

Try these out, I think you'll like them!

ABOUT OUR GUEST POST CONTRIBUTOR: Jeffrey Winer, MD is a faculty pediatric hospitalist here at Children’s National Health System.  Dr. Winer is a graduate of Yale School of Medicine and Massachusetts General Hospital pediatric residency.  All he wishes for in his career is his own eponym.  Preferably some test or treatment, but he would definitely settle for Winer’s Disease.

Tuesday, June 3, 2014

GUEST POST: Palpable, pediatric, public health

Medical and MBA student Ashley Landicho (pictured here) writes:


“Pal….pal-puh-bul. That means that you can touch it. Is that right?”

I slowly smiled, and said “yes.”

Across from me, was a second year law student whose furrowed eyebrows had suddenly faded. A room full of public health, law, and medical students looked back at me—some who nodded in agreement, some who still retained wrinkled foreheads, but earnestly leaned in to listen.

This is an ordinary snapshot at one of the many meetings at Roundtable of American Health Delivery (RAHD), one of Drexel’s first graduate student organizations for interdisciplinary healthcare collaboration. I have co-founded this with MPH student Alexander Krengel, and founded a similar seminar series, Recharting the Borders, during my time in medical school.

My impetus to initiate collaborative efforts began early in my third year pediatric rotations at our home site’s GROW Clinic for patients with “failure to thrive.” After seeing a patient with the pediatrician, I was surprised to walk to a table with the staff nurse, nutritionist, psychologist, and social worker actively working to create the final treatment plan. Although each provider had different perspectives and opinions, each maintained a mutual respect for one another.

I was taken aback.

I had been long accustomed to drafting H&Ps and SOAP notes by myself in medical school.  This was truly my first glimpse at the working world, where one person did not drive patient-centered decisions—a team did. The reality is that my educational training is not much different than that of most medical students in the United States. Health care provider curricula focus on creating the “optimal physician” or the “optimal nurse,” which essentially creates educational silos and areas of functional specialization.

The Institute of Medicine (IOM) identifies lack of coordination and communication as the leading culprits to hampering our healthcare system today. Fragmented care and disjointed responsibility lead to readmissions, duplicative diagnostic testing, and poor center-to-center patient transitioning. This drives to upwards of $130 billion dollars in what the IOM considers “waste” due to coordination problems alone. Their solution? Improve transition and coordination processes across organizations to ensure seamless patient care.

For us medical students, the transition to 3rd and 4th year clinical team care is inherently bumpy because a lot is simply foreign. But one area that doesn’t have to be unfamiliar is experience in team-based and coordinated decision-making. The “optimal physicians” are not islands. They work effectively with pharmacists, nurses, physician assistants, physical therapists, lawyers, and public health partners.  The idea behind interdisciplinary collaboration in classrooms is to provide a safe learning setting for correcting mistakes and building confidence. Earlier introduction of this concept in educational training not only helps medical students develop further as professionals, but also provides grassroots solutions to some of our health system’s biggest challenges.

As I get ready to attend another roundtable meeting of RAHD today, I make sure to highlight the medical jargon in our reading that might need explaining. But for every pink highlight I make for medicine, comes a blue highlight for law, and green for public health. I know this slow, but valuable process in learning different disciplines will translate into my clinical practice as a future pediatrician. From it, I hope to see better patient outcomes, or in pediatric terms—a lot more kids smiling. And this itself, will be the most tangible…most palpable success of all.

ABOUT OUR GUEST POST CONTRIBUTOR: Ashley Landicho graduated from Drexel University with a B.S. in Biological Science and is completing her M.B.A. from Drexel Lebow College of Business. She will soon be a fourth-year medical student at Drexel University and plans to pursue a career in pediatrics. She has a strong interest in healthcare policy, child advocacy, and community outreach.

Wednesday, May 21, 2014

You're almost 4. That is, a 4th year...

The hospital seems a little emptier. The line at the coffee bar may even be shorter. And there are more computers available in the library. Why? The 4th year medical students have graduated, or they will do so any day now. Congratulations to them!

And what does that mean for the current 3rd year medical students? These are essentially the senior-most students currently enrolled in the school, almost entering year 4. But you still have a bit more of year 3 yet to complete. Take a moment to think back on how far along you've come. What do you know now that you didn't know ~10 months ago? How have you changed? Compared to "you" last July, how do you now conduct yourself with patients and families? With peers, colleagues, residents, attendings, nurses? With significant other, spouse, children?

And, what can you offer the incoming (rising) 3rd year students? You will soon (or "again" for those who were teachers before med school) experience the joy of teaching, sharing what you know with those soon to be in your shoes. Helping them find their way around the hospital, present, write notes, provide clinical care. Even while you hone your skills further. It will become readily apparent how far you've come (but of course there is always more to learn!).

How will you spend the remaining weeks or months of this academic year? Are you fully immersed in your current clinical clerkship? Or perhaps you are having trouble focusing, only looking ahead to your future residency?

Some of you may be in the final clerkship of the year, only to find this (pediatrics) is the field for you. No, it is not too late! You can likely still modify your 4th year schedule if need be. Why? If you want to gain more information before making your decision about what field to choose, which type of residency to apply to. If you want to confirm or test out some things. For pediatrics, you need not do an acting internship (sub-internship) early in the year. Anything meaningful that you do early on will lay the groundwork for subsequent rotations. You don't need to obtain a letter or recommendation during your AI. These letters can come from the first 3 years of medical school, from electives, from fields other than pediatrics (just try to have at least 1 or 2 from pediatrics), from a research mentor, and/or an advisor on an advocacy project. There are plenty of pediatric faculty interested in advising you through the application process and there are always clerkship directors (!) who can help you find success.

Make the most of these final days of third year. You might get inspired as to what to write in your ERAS personal statement (look for future posts on this). Maybe you have just one more exam during 3rd year. Then Step 2 with it's CK's and CS's.  With each passing day (get it, passing?) comes more and more responsibility as you become "more" of a professional. And while there are orientations and transitions and ceremonies along the way to becoming one, there's no compelling reason to hold back on holding yourselves to the highest degree of professionalism. You can be a model to others.