From Premed to Attending Physician – Showing You the Path

Session 248

Have you ever wondered what the whole path to becoming a doc looks like? I'm breaking down every step of the premed & med student journey to give you an idea!

We are celebrating five years of The Premed Years Podcast at the end of November. And I realized I haven't really covered this topic in depth and in totality on the podcast. It's that whole journey, from starting off as a premed and finishing as an attending physician. So I'm walking you through that journey and will fill in the gaps to give you a general overview of everything and what to expect along the way.

As humans, the biggest fear is the unknown. Hopefully, this episode sheds light on the whole process and it makes it easier for you to understand. Therefore, it will be a lot less scary. This is actually the first time that we've put all together in one. Also please check out all our other podcasts on the MedEd Media Network.

[03:15] Start of the Journey

You start off your journey as a premed. There's a lot of you that use premed for pre-PA or pre-NP or pre-Nursing. But the standard use of premed is if you're someone who decided to become a physician, whether a traditional premed or a nontrad. Whether you're in high school, in college, or after college; wherever you are on your journey, you're a premed as soon as you decide you want to be a physician. If you're in high school and deciding this, you have a leg up. You know what you want, hopefully. And just because you know it now as a high school student, it doesn't mean that's what you're going to want. Once you're in college and you're on that path, you may decide to change your mind. And that's okay.

[04:30] High School

As a high school student, you have a couple of options. You can go to a four-year undergrad university. Major in whatever you want as long as you take the prereqs for most schools. Those are usually English, Physics, Chemistry, Biology, Organic Chemistry. Some schools are adding in some Psychology, Sociology for the MCAT. Those are the general things you need to look at. You can major in theater. You can major in Spanish.

A lot of students mix up premeds with being the major. There are few, if any left, colleges that have a “premed” major. Most of them will have a premed track. Some will flag you as a premed in their system so the advisors can track you. So they know who you are and offer you advice along the way. As a high school student, you can go down that path. Even as a nontraditional student, you can go down that path.

You can also go to a two-year your university or a community college. There's a lot of myths around community colleges and some negative stigma around it. But the truth is, if you go to a community college, you're going to have to transfer to a four-year school. You have to do well throughout. And you're going to be fine. Most medical schools will accept community college credits. That is okay.

You can also apply for a BS/MD program so you can go straight into college knowing you're already accepted into medical school. Sometimes, they're six years or seven years. Sometimes they're full eight years. It all depends on the specific program you're applying to.

[06:38] Freshman Year

Once you've figured out where you're going to go, you start off in college. The biggest thing you need to do when starting in college is respect the transition to being a college student. A lot of students try to take on way too much stuff. They go on and read stories of students with 3,000 hours of shadowing and ten publications. They think they need to start right now or they won't get into medical school.

You don't have to start right now! Your job when you start college is to get A's or as close to A as you can get. Just be a college student where you are not told what you need to do everyday. You're given a syllabus. You're given dates of tests. And you're left on your own to figure it out. You can go to classes if you want. You don't have to go to classes if you don't want. Some colleges will have mandatory attendance. But you just need to get on to campus and figure out how to be a college student.

You need to start to get to know your premed advisors. They know the in's and out's, hopefully, of your college. They're going to know all of the classes that match up the best with medical school prereqs. They're going to know the best classes that match up with MCAT prep. They're going to be your champion, hopefully, along the way. They're going to push you and coach you and be there for you along the way. Don't show up at the very end of college and say you're a premed and you're asking a letter of recommendation from them. Again, this is first year of college and you're just dipping your toes in the water learning how to be a student. You're getting good grades and easing into that transition.

[08:55] Sophomore Year

Once your sophomore year hits, then you can start piling in some things in a step-wise fashion. You're learning how to take on more and more responsibilities, more organizational skills. You're going to be getting better study skills. Those are going to be needed along the way. So you're just building up on each step of the way.

Once your sophomore year hits, now you can start looking into research if you want to. Research is not mandatory but I recommend you try it out to see if you like it. You'd be surprised. This is the time to start to get into clinical volunteering. This is the time to start to do some shadowing. Shadowing can also be done on your first year since it doesn't take a lot of resources. You're just there hanging out. You can do it once a month or once every couple of weeks for a couple of hours here and there. It's not going to take a lot of time. The first year is to see for yourself and continue to prove to yourself and reinforce that you're on the right path and you still want to be a physician. So that's what shadowing is for.

Then start doing clinical volunteering on your second year. Start to get in front and interact with patients. There are many ways to do this such as the hospice, as an EMT, a CNA, and an ER volunteer. You can be any loads of different things. You can be a certified phlebotomist.

Answer for yourself what counts as clinical experience. Were you close enough to smell the patient? That's the general saying in the admissions world. Being a scribe is a great experience. Most scribe physicians will allow you to have some interaction with the patient. You're going to need to interact with them. They will fill out the chart. Make sure you have everything down properly. If you're interacting with the patient, even if it's not in a specific clinical environment, and you're like a home health aide, that counts as clinical experience. You need to do some non clinical volunteering as well. Just go out there and show you can spread your time out and you can handle the workload. Show that you can still go out and contribute to the community.

Leadership is very important as well. You need to be able to show you're a leader. You don't have to start three different clubs on campus or run for class president. But you need to have some leadership experience.

So as a sophomore, continue to be a great student and adding in these extracurriculars – research, clinical experience, nonclinical volunteering, leadership experience, and shadowing. Additionally, you can start prepping for the MCAT too. You don't need to, but a lot of students like to do it at this time. They buy MCAT books and take them to their classes. Then they look through the MCAT books and start to prep for the MCAT along the way.

[12:35] Junior Year

This is where things start to get exciting! Junior year, especially the end of junior year, is typically the time you're going to take the MCAT. Let's say 2020 is the year you want to apply to medical school. I recommend you take the MCAT in March or April 2019. So that's the tail end of your junior year. Along the same timeline, you're also prepping your application, which starts around May and June of 2019 (again assuming you want to start medical school in 2020). So at the end of your junior year, things start to get even busier.

So basically you're adding more on top of all you've done during your sophomore year. As I've said, you're adding more every step of the way. And by the end of your junior year, add MCAT prep. Get down into the ditches of the MCAT world.

Check out Next Step Test Prep and use the promo code MSHQ and save 10% off their full-length practice test packs. It takes eight hours to sit there and take take a full-length practice test. That's how long the MCAT takes. So you need to do six or eight of them leading up to your exam. That's a lot of time you need to prepare for. And you can't just stop all of your clinical experience otherwise you will have this big gap.

As you're ramping up to your MCAT date, a lot of students think they've got all their hours in for clinical experience or for shadowing. So now they need to go prep for the MCAT. This is a big red flag for the admissions committee. They see that gap and they will question whether you're really interested in being a physicians. If you're really interested in being a physician then you would have continued to be around patients the whole time.

Again, say, for a 2020 start date. Application happens in May or June of 2019. You need to start writing your personal statements around January. You need to start asking for letters of recommendation around March, April, or May. You need to start preparing for your interviews. You need to start asking for transcripts. You need to write all of your extracurriculars down.

[16:33] Keep a Journal

Let's rewind back to sophomore year when you're doing all of your curriculars. Make sure to keep a journal. So that when it comes to application time, you don't have to remember everything, it's all right there in front of you.

[17:00] Apply Early

At this time, let's hope you've already taken the MCAT; otherwise, you will also be prepping and doing your applications at the same time. And what usually happens is applications suffer and you'll apply later and later.

The earlier your application is in, the earlier that they will consider you as an applicant and the earlier that you will be invited for an interview. This means the earlier that you can get an acceptance. The later you apply, the less seats that are available. Then it becomes a giant game of musical chairs. Later in the game, there are more people with less seats. Your chances go down the later it takes for you to apply to medical school. So you need to apply early. Even if you don't have your MCAT score yet, you still have to submit your application. So you can go through the verification process. The application services are looking at your application and looking at all of the grades that you've entered. They will compare that one by one to the transcripts you have submitted. So it takes a long time since it's a human doing that.

[18:21] Senior Year

In your transition from junior to senior year, you submit in June. In July, there comes a lot of secondary applications. The medical school application is broken down into a primary application and then secondary applications. They are more essays. They take a lot of time to write. The suggestion is to submit your application early June. Start writing your secondary essays for as many schools as you can. And as soon as your application gets sent out, you will get a secondary and turn that around as soon as possible. There's this magical two-week window for submitting secondaries. Some schools will give you deadlines, some schools won't.

Again assuming you're applying early, August to April is interview season. It's a long interview season. So be prepared to get an interview at any point in there. When a school sends an invite, they'll send it through email or through their portal. You will be given a date or you log on and select the date. Again, the earlier the better because most schools have rolling admissions.

Depending on the school it's usually mid-October, at least for the MD schools. The AAMC has asked for MD schools not to release their acceptances until mid-October. The DO schools don't have the same rules, so acceptance can go out earlier than that. So you have all the way up until March or April for interview and acceptances. Then if you're accepted, you're going to start medical school typically around August 2020 (for this example).

[20:42] First Year Medical School

So you're finally a medical student. You start off with your white coat ceremony. Everybody is excited. Then reality hits and you realize that life is completely different now. There's that analogy of drinking out of a fire hose and it's so true. It's test after test after test. There is a ton of material to learn. You just need to hit the ground running and go.

A lot of students ask how to prepare. What do you do in the summer before? What classes should be taken in undergrad? The answer is to just really enjoy your life up until medical school. Then start in medical school and just go.

So you start in August and in most schools, everything is nonclinical. It's all classes. Some schools will have some clinical-like experiences where you start to shadow and get around patients. You start to interview patients and learn those skills. They'll throw in some little bit of exam skills as well. First year of medical school is a lot of testing and a lot of fun.

Most schools still have a summer in between first and second year. You're free to go do some shadowing and some research. Take a break. Go do whatever you need to do during that summer. Some schools are dropping that summer and just going straight from first year to second and starting their clinical rotations even earlier. So you get more clinical rotations. You get more clinical experience. This is something to look at when you're evaluating medical schools. Ask whether they still have that summer. I personally recommend to still have that summer. I would not be a fan of not having that summer. Because it's a good break between all of the classes you're taking.

[22:55] Board Exams

Around the end of your second year, you're going to take the boards, Step 1 or Level 1 depending on whether you're an allopathic student or an osteopathic student. An osteopathic student is a DO student and allopathic student is an MD student. At the end of the day, you're a physician when you graduate. DO's have an extra skill of osteopathic manipulative treatment osteopathic manipulative medicine. The history is that DO students treat patients more holistically. I don't believe in that. There has to be more than that when you're looking at osteopathic schools.

So you take Step 1 and Level 1. Being an MD, I took Step 1. I didn't take Level 1 or COMLEx. If you're a DO student, you can take the COMLEX and USMLE. If you're an MD student, you can only take USMLE.

Step 1/Level 1 is a lot of just basic science knowledge. It's straightforward. It involves a lot of memorization, a lot of just knowing facts. I didn't do well in Step 1 because that's not how I'd like to be tested.

[24:27] Third Year and Fourth Year of Medical School

Once you finish Step 1 and pass it, you go into your clinical rotations during your third year and fourth year. A lot of it is just going to be whatever the mandatory clinical rotations are that your school has set up. A lot of DO students, especially, will have to travel a bunch to go to different sites to do their rotations. Fourth year, you start to do some more electives. You start narrowing down what you're interested in doing as a specialty or what you want to apply to for your residency. You set it up then you go for, say a month, and you spend your time there. You will hopefully do well so that when you apply, you'll match.

Near the end of fourth year, you need to take Step 2, which is the second part of the boards. COMLEX Level 2 for DO and USMLE Step 2 for MD. I believe this test is more useful, because it's testing you based on not just the knowledge or the memorization. It's actually giving you some more scenarios, more treatment-based things, and a little bit more real life. So I had more fun on that test. Step 2 has CK or clinical knowledge which is the written test and the CS or clinical skills. For the CS, you have to go to a site and there's only a handful of sites in the U.S. It's a very expensive test. You have to fly there and stay for a night. You go to the testing center with standardized patients. You have to interact with the patients. Take history. Do a physical. Write a note. And you're tested on that.

All around the same time, you're also interviewing. You're applying to residencies. You're interviewing at residency programs. Then you submit your rank list for the match.

[26:58] The Match

The match is a very fancy algorithm. Its creators actually won the Nobel Prize for it. The algorithm takes your rank list where you rank from one to however many programs where you want to go to. On the other hand, the programs rank from one to however many students they want to accept into their program. Then the algorithm does its magic and you get to have Match Day in mid-March. That's when you open up an envelope and see where you match. You'll find out about it a week before whether you matched or not. And if you don't match, you go through what's called the SOAP process (Supplemental Offer and Acceptance Program). You will find out what programs aren't full and you call them up and ask them to take you. Match Day is a huge day in the medical student's life. It's something I won't ever forget. Most students graduate around May, sometimes later into early June. Then you start residency.

[28:20] Residency

Once you finish medical school, you go into residency. A lot students get confused with internship and residency. Internship is just your first year of residency. For your internship, you have a prelim year or a categorical year. In my case, I did a prelim internship. I did a transitional year. It was a mix of medicine and surgery. You can do prelim internal medicine or prelim surgery.

Some specialties don't have their internship built into the main program. They include dermatology, ophthalmology, neurology, and others. They're changing a lot all the time. So depending on the program, you may have to apply to a separate internship. Assuming you don't apply to a separate internship. You're just applying to internal medicine and you apply to your categorical three-year program and matched. When you are applying to residencies, there is a wide spectrum. Three years is the minimum, like internal medicine, pediatrics, and family medicine. Up to seven years for neurosurgery, plastic surgery, and other programs. You are doing your first year as an intern and residency for the rest of the time.

At this point, you are getting paid. It's about $47,000 the last time I checked but it may be more now. But it's the average across the whole country. It depends on where you live, cost of living, etc. But you don't want to calculate your hourly wage. If you look at the hours, you're going to be very sad because it's a lot of work. The last time I looked, it was 80 hours a week on average. 16 hours for first year residents, 24 hours for second and third year residents. Although this is constantly changing. There's a lot of stuff in the news recently with regard to work hour regulations in interns. It may go back to a 28-hour straight shift. So be prepared to work a lot as a resident. Moreover, realize that once you become an attending, there are no work hour regulations. So you can work a lot more than that. A hospitalist is working seven days on and seven days off. Those seven days they're on, they're on completely the whole time. They're sleeping but they're on call. Some hospitals now have nocturnists where they cover the nighttime hours to give the hospitalists some break at night.

Somewhere in your internship year, you're taking Step 3 or Level 3 of the boards. This is needed to get your license to practice independently. It's very important to finish that out strongly.

[32:44] Fellowship and Attending

Once you finish residency, you can go and practice and be a general pediatrician or a general internist, whatever you are. Or you can go do a fellowship depending on what you're doing. It can be one year or three years or maybe more than that. The three years is the maximum that I've seen but it could be more. If you want to learn more about this side of things, go listen to Specialty Stories Podcast. I talk to specialists and listen to their path to medicine and what they're practicing. It”s very interesting to know all the different paths you can take once you get into fellowship and subspecialize in a lot of other things.

Finally, once you finish your fellowship, you are considered an attending. Whether you're in academic practice or community practice, you are an attending. Once you're out of training, you are an attending physician. Then you worry about your board exams so you can be board-certified in whatever you trained in. You also have to worry about continuing medical education to keep up your license and so much more. So it's never-ending once you become an attending. But don't let this scare you away because it's worth it once you get there. Not to mention you've been working a long time to get there.

[34:15] Final Thoughts

There are a lot of nuances along the way such as MD/PhD or some of the three year MD/DO programs out there. There are some deviations to what I talked about. But hopefully, this gives you a good long-term overview of what to expect. Let's assume four years of college, four years of medical school. That's eight years. Let's assume a three-year residency. That's now a total of eleven years. Plus one year of fellowship, now it's twelve years before you're an attending and making the big bucks. But along the way, you also have all your loans during your training. Most of those loans are accruing interest because you're not paying back a lot. They're deferred loans and a lot of other issues along the way. You have kids along the way. You get married along the way. If you're still out there wondering if this is what you want, now you understand how this works. Hopefully, that will give you enough confidence to jump in with both feet.

Check out the Hangout Group and go to our Facebook page. I go live almost everyday that I'm at home and in the office around 3 pm eastern time. I've been pre-arranging my schedule and the calls I have with students and other things I need to do throughout the day. I do a Facebook Live video and I will be putting them out as a new podcast called Ask Dr.Gray, Premed Q&A.

Links:

MedEd Media Network

Next Step Test Prep (Use the promo code MSHQ and save 10% off their full-length practice test packs.)

Specialty Stories Podcast

Hangout Group

Facebook page

Ask Dr.Gray, Premed Q&A

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