On a Preliminary Medicine Training

As residency applicants stream into our conference rooms and as my friends, some former classmates who took a year to engage in research or seek other meaningful pursuits, pepper my email account with questions on what questions to ask, I find myself unsure as to whether I can offer any truly helpful strategies. The residency interview process, much like the medical school interview process preceding it, is filled with misgivings, misdirection, insecurities, and arbitrary decisions characterizing the behavior of all parties involved, interviewers and interviewees alike. I have observed that the residency application cycle is more collegial: most applicants find positions somewhere, whereas a high percentage of medical school applicants are held at the gates and are diverted to other fields. I would like to say that this encourages honesty and forthcoming gestures: in some cases it does, but this is by no means a universal standard. To this end, I would like to offer these words of advice to applicants for Preliminary Medicine training positions who seek a strong foundation in Internal Medicine prior to pursuing their advanced residencies in other fields:

1. Find a program that values the education of its interns, not just its residents. – Many Medicine programs view interns as the workhorses of the hospital: you are there to get things done, not to learn. There is so much “busy work” in medicine – documentation, orders, phone calls, basic task management – that interns are thought to not have enough time to read or attend conferences aimed at teaching the residents the finer details of medicine. Furthermore, it is assumed that interns do not want to engage in these activities because they just want to get their jobs done and go home. “Attending rounds” often interfere with the daily workflow of interns and are without exception interrupted by “urgent” pages. In some ways, this desire to disengage is true, but it is a self-fulfilling prophecy: a program that does not prioritize and protect time for its interns to learn does not inspire interns to be anything more than simple automatons. Frankly, I want to learn more about medicine than the ideal bowel regimen or how to order a PET scan, but how often do I have the luxury to attend morning report?

2. Find a program that values Preliminary interns. – This is a near impossible task, because most programs who want preliminary interns (whether to use and abuse or for truly idealistic training goals) will talk the talk: “Preliminary interns here do not have a different experience from the categoricals. There is no “P” branded on your shoulder. You do not take care of different patients or have different rotations. Everyone is treated the same.” The only way to find the truth is to talk to the Preliminary interns directly: do they feel valued? Are they having a comparable experience to the Categoricals? What are their values, and do they match yours? Are those values being upheld by the programs? Some Medicine programs advertise to their Categoricals the absence of Preliminary interns as an advantage of their programs. Again, this is a self-fulfilling prophecy: if you expect Preliminary interns to be inferior in quality, they likely will perform to those expectations. From my experience and observation, some of my co-Preliminary interns are truly excellent physicians that outperform some Categorical interns in practicing Internal Medicine, and this is not an observation unique to my program.

3. Find a program that values your chosen field. – The single question I asked most often of my interviewers was “How is your department’s relationship with the (Medicine/Neurology) department?” Most of my interviewers actually fumbled this question or gave a generic “quite good, we’re collegial” reply, but the value of this question revealed itself in the responses of residents in the program: at the resident level where departments intersect on an hourly basis through consults and collaboration, frank impressions are easier to elicit. I personally find it important to find a program where the residents respect their colleagues in your future field because excellence inspires excellence: the Medicine residents will be inspired to know more and connect more with that field, thus providing an excellent bridge in your training.

Unfortunately, there isn’t necessarily a straightforward way to acquire the answers to these questions during the interview process. Nonetheless, knowing what is important to you and to your training experience ahead of time can heighten your senses to both inconsistencies and genuine expressions. Best of luck, applicants.

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