MINDFUL OF MEDICINE

As a follow up to my previous post about the traditional interview format, I'll be discussing the multiple mini interview format and some advice for those who have been invited to an MMI. I’ll be going over a few points of advice as well as anecdotes from my own MMI experiences.

The MMI was developed initially by the Michael DeGroote School of Medicine at McMaster University in Canada in order to increase the reliability that the interview is an accurate indicator in evaluating a candidate, and to address two problems:  

1. The critique that the traditional interview format was a poor predictor for performance in med school.


2. The candidate’s ability to demonstrate non-academic skills like professionalism, ethical and moral judgment, as well as social skills.

The MMI process goes something like this: You will have a set number of mini interviews, though the number varies by institution. Before entering the room you will get a question/scenario and approximately 2 minutes to prepare an approach or response to the prompt. Once inside, you will have a short exchange with the interviewer (could be a med student, professor, actor, other) for 8 minutes. Sometimes you will be in a room with just the assessor, or in a room with an assessor and an actor, or sometimes a second assessor will be behind a partition like a double-sided mirror or video feed. I know this sounds stressful, but don't worry because it will go by so fast you will only have time to think about your response and not really anything else. Once the 8 minutes is over, the assessor will evaluate your performance while you wait at the next station. The entire cycle is repeated until all the stations are complete, which usually takes about 2 hours give or take. You will also have at least one "rest" station where there will be water, snacks and a chair to sit in - make sure you drink the water, you'll definitely need it from all the talking.

I participated in two MMI interviews along my interview trail. I was even more nervous about this format than the traditional interviews, especially since the questions are unpredictable. In general the questions touched on ethics, critical thinking, communication skills, and policy affecting health and society.

My first MMI was relatively standard: 9 stations including one rest station, two scenarios with "actors" where I had to solve a communication barrier or counsel a fellow "student," and the rest were either ethics or critical thinking-based. My second MMI was LONG - 18 stations, including 2 rest stations! This was by far the most tired I've ever been after an interview. It was also my most interesting. This one had about 4 traditional questions, 3 "acting" situations with a person watching behind a double-sided mirror, and a medley of other questions that I can't remember. Now I'm no expert on the MMI but I've been through a couple myself and seen many others. Here are a few things I recommend.

1. The one thing you can read to prepare for the MMI is a review of medical ethics, because you will undoubtedly encounter at least one of these questions. These questions will center around the four cardinal tenets of medical ethics: autonomy, justice, beneficence, non-maleficence. Whether you understand the concepts fully or not, it will be in your best interest to at least have an idea. I read this overview by the World Medical Association before my interviews: www.wma.net/en/30publications/30ethicsmanual/pdf/ethics_manual_en.pdf. It's a worthwhile resource that has a few case studies. Plus it's something that you'll use throughout your medical career.

2. Use the two minutes outside the room as efficiently as you can. Use the prompt to pull from your own experiences and opinions because answering the prompt directly will only take up a few minutes, and you’ll need to fill the rest of the time with other talking points.

3. Stay calm and collected. The two minutes while you wait outside the room preparing your answer will feel like an eternity and the shortest two minutes of your life all at the same time. The other eight minutes will feel the same. The worst part, for me at least, was that the assessor/interviewer won't give you any clues on how you're doing - they will maintain relatively the same composure and tone. So you have to find ways to speak confidently while remaining calm.

4. Be prepared for odd prompts or scenarios. I had two unexpected scenarios. The first was a an actor that played the part of a mentally disabled teen that needed me to teach him how to tie his shoelaces. It was pretty challenging especially because the actor’s role was to get very frustrated and verbally upset during the process. I couldn’t have prepared for this scenario at all other than remembering to stay calm, act with kindness and do my best to keep “teaching” him how to tie his shoes. The other odd scenario was a biostats question. The worst part was that halfway through the eight minutes the assessor showed up and walked me through my mistakes. The biggest piece of advice when it comes to weird or unexpected prompts is to take it all in stride and make it obvious that you’re trying your best.

5. Be compassionate. The MMI is designed to better predict a candidate’s performance in med school and beyond. This includes being a compassionate physician that embodies the spirit of empathy and service. If a prompt suggest something along those lines, go with it - show them how human you are.

6. Be absolutely genuine. I suppose the fast pace of the MMI probably does a better job of “weeding out” most of the false personas that the traditional interview can’t. Even if it is through prompts and scenarios, the MMI is the place for you to sell yourself and show why you will make a good fit for the school so why not be yourself?

Good luck. :)

Happy med school interview season! There are two types of interviews - traditional vs multiple-mini-interviews. I'll be discussing both types in separate posts.

The traditional interview is definitely the one that I was the most stressed about since it's typically a one-on-one session for roughly 45 minutes. I had a few traditional interviews on the East coast, which is pretty common on that side of the country. I was pretty nervous going into both but felt a lot more comfortable by the end. Here are a few points of advice:

1. Saying hello. The interviews start off with greeting your interviewer. You will usually know who your interviewer in upon arriving for the day or soon after, so remember to address your interviewer properly by name and title.

2. The interviewer will lead you through the conversation. I got asked, "So, tell me about yourself." You're probably thinking: um, well what else can I say about myself that isn't already in my personal statement and CV? There's a LOT you can say about yourself - remember, there's a lot more to you than what's on paper! My advice is to make a list of what makes you unique before you start going on interviews. Start from where you're from, what your upbringing was like and the associated challenges, did you have any exciting experiences that brought you into pursuing medicine, etc. Also, be ready for some interesting situational questions. You won't be able to prepare for these specifically, but you can work on speaking articulately and confidently.

3. Know your application . Make sure you know what you've actually written in your application materials, CV and personal statement. Nothing is worse than being asked about an aspect of your application that you can't recall.

4. Know your weaknesses. You will likely be asked about any weaknesses in your application package, like why you got less than stellar grades one semester or why your MCAT score is lower than average for that particular school. If you've gotten an interview that usually means that your scores are acceptable, but unfortunately there may be other applicants with similar stats. The interview is your chance to set yourself apart from those other applicants. For example, if you had a semester that wasn't perfect be ready to explain why that happened. This isn't an excuse, however. Rather it's a time to show that you grew from the experience and made the necessary changes.

5. Know your strengths. Though explaining the weak points in your application seems like an obvious topic of conversation, your strengths are, too! Be ready to express what you truly excell at. This doesn't mean talk about how great you were at o-chem or other courses. Use this space of conversation to discuss what will make you a great doctor. For example, werer you calm under pressure during a particular experience? Do you strive to keep growing as a person by pushing your own boundaries? Do you give back to your community in some way?

6. Be honest</b>. The truth is always the best approach when it comes to the application process, including the interview. Don't embellish a particular activity or event to make yourself look better. Chances are you will get caught, and no one likes a liar.

7. Be yourself. I think one of the most important things that applicants tend to forget is how to be themselves along the interview trail. Of course you want to be professional and precise in your delivery of interview answers, but you should also remember to be absolutely genuine. An interviewer cannot decide if you're a good fit for their school if you're being an entirely different person. A sincere approach will always yield the best results.

8. Have fun. Interviewing for med school is a prestigious thing in and of itself. So while you're stressing out in the ultimate "hot seat," try to have some fun beause many students don't make it to that stage and would kill to be in your place.

“The good physician treats the disease; the great physician treats the patient who has the disease” - Sir William Osler

I don’t want to be a doctor. I need to be a great doctor.

November 2009: I was sitting on my favorite bench on campus in the middle of fall, just a few weeks shy of my 19th birthday. I was your typical neurotic and flustered premed, but I was happy and excited to conquer undergrad. But there was one little problem: the handfuls of blood I would cough up at night. My roommate at the time (who is still one of my close friends!) threatened to call my mom if I didn’t go to the doctor immediately. So I went.

At my primary care physician visit we reviewed my X-rays. She talked a lot, but the only thing I heard was, “there’s something big there, could be anything even cancer but you’re young.” As you can imagine, there were a few obvious problems with that statement. Even without medical training I knew you couldn’t speculate like that in front of a patient. The way she threw around the “C-word” so nonchalantly and then dismissed it by mentioning my youth still makes me angry. I was offered no assistance in finding a pulmonologist and felt absolutely alone. So there I was, almost 19, thinking I could have cancer. A few months later I found I had coccidioidomycosis, commonly known as ‘Valley Fever” (something my PCP should have thought of since it’s endemic to our area *facepalm*).

Though I was thankful it wasn’t cancer, I could have never imagined the journey my diagnosis would take me on. Starting antifungal therapy was rough. My hair started to fall out, my skin dried out, my nails turned brittle, and just felt ill all the time. The blood didn’t stop though. It seemed there was no escaping that bloody cough: when I laid down to bed, whenever I tried to exercise, whenever I walked a little too fast to class. I had two pulmonologists during those first two years post-diagnosis. One so close to retirement that his approach was almost negligent. The other, too caught up with the fact that I was “young” to treat my infection aggressively. But both taught me that I never wanted to be that doctor: the doctor that doesn’t care.

In 2011 I met Dr. P. He wore a bow tie and had a jaunty walk. He also wore bright, beaded bracelets that his granddaughters had made him. After telling him my story he grabbed my hands, and told me he was going to do everything in his power to make me better. My eyes welled up. He was my first doctor to actually care. Immediately he called his friends: an infectious disease specialist and a cardiothoracic surgeon and personally scheduled appointments for me. He was the helping hand I had needed all along. That December, two days before Christmas, I finally had a chunk of my right lung resected and graduated from the care of Dr. P to my current ID specialist, Dr. N.

It’s been five years since my journey began, and though I'm still on medication it has been such a blessing to learn the struggles of being a patient so intimately. The lessons I learned while being sick in undergrad have carried over into my first years of medical school. It's these lessons that keep me focused on becoming a great doctor through the seemingly endless stream of facts in our pre-clinical years. Being a patient ultimately taught me that the obstacles presented to us in life are a testament to our strength and allow us to develop into a stronger, more focused version of ourselves. What is even more special about these obstacles is that they happen unexpectedly and we must rise to meet them. In order to do my journey justice I have a duty to become the most empathetic doctor I can be. I never want to be the doctor that didn't care, or the one that didn't listen. I want to be the doctor that did her best.

Why do you want to be a doctor?

It was never about a want for me. I always knew I was going to be a doctor - and you better believe I was ready to do whatever it took even if I was in elementary school. Did that mean running unopposed in 4th grade for class treasurer? Yes. Did that mean that I stayed up the night before elections to rehearse my speech and make posters? Yes. Was I a “cool” kid. Haha, no. But I was something: independent.

When I think about it, it’s kind of surprising that I even went to college. I attended elementary school in a lower-income area of the city where most of my classmates came from very poor households. It was clear that most teachers didn’t really push for long-term retainment by their general lack of enthusiasm. Nevertheless, I was lucky to find a few that really nurtured my learning. I didn’t have many friends and realized later that I was bullied pretty bad. I remember not sitting with anyone at lunch, then going out to recess to take a lap around the track. Either I was incredibly independent or I was in denial. I also weirdly remember crying in the bushes furthest away from the school building at lunch and then coming back to class when the bell rang as if nothing had happened. I don’t remember being sad, but the mind is an amazing thing and I’m sure I’ve just blocked it out. I haven’t really decided how to deal with those memories but I know one thing: I didn’t care what others thought. Though some people may take pleasure in watching their “enemies” fail, many of my school bullies didn’t make it through high school and some were teen mothers. It’s sad. I’m lucky that I didn’t become another statistic. I don’t know if it was by my own accord or destiny, but I like to think it was both.

In middle school and high school I switched school districts into a more affluent area. I downloaded and sent in the registration papers by myself - a crazy thing to do at 11 years old. It was here that I met friends that were more like myself. I finally found a space where intellect and academic achievement were not just the norm, they were cool. I really flourished during those years and thus began the mindset of preparing myself for college and what would eventually make me into a suitable med school candidate. Honestly, it is amazing what opportunities are made available to students based on where they come from. I learned a whole new meaning of privilege. But I also felt somewhat behind. Not academically, but rather in the kinds of opportunities afforded to different social classes. While my classmates had parents that guided the way to college and beyond I only had myself. My parents supported my decisions but it was up to me to forge my own path, seek out opportunities, and take them.

From elementary through high school I learned that independence from what others think of you is absolutely priceless. I also learned that in order to take advantage of every opportunity, I had to be proactive. Looking back I’m kind of impressed at how I was able to change my circumstances at such a young age. And even though I didn’t realize it at the time, I was asserting my independence and that's part of what medicine is about: confidence in yourself, your choices, and the ability to step back when you don't have the answers.

I remember the first National Geographic my mom bought me, I must have been around 7. I had seen it at the grocery store and flipped through it until we checked out: it pictured a fetus, curled up in the womb. I was fascinated. It was (*insert Chris Trager voice*) literally the coolest thing I had ever seen. When we got home my mom pulled it out of a shopping bag and I remember freaking out. All I wanted for Christmas or birthdays were baby dolls from that point on. Not the ones where you just get to play mommy. The ones that were anatomically correct and would actually pee so I could see how much water I could feed it and monitor how fast it would come out.

I sometimes wonder where my drive for medicine came from. And until recently I honestly had no clue. But now I know that it was from seeing my parents work so hard to give my sisters and I the best life, and they did an amazing job. Both of my parents immigrated from Mexico. My father was orphaned at age 6 by a mother who died after giving birth and a father who decided raising 5 kids on his own was too much. My mother started working, selling tamales door to door as a young child. My parents tell funny stories about their childhoods but it’s laced with a bit of sadness at how hard they had to work - physically work - to live. Their circumstances are unimaginable. I can’t relate. But I know that I cannot relate because they worked to give me a life much more privileged than theirs. And for that I am grateful.

My parents had such an essential role in making me a lifelong learner, but it was my mother that stressed how important it was to be an educated woman. I was very young when she first told me, “you have to get an education so you don’t depend on anyone and if you’re ever in a bad situation, you can leave without thinking twice.” That’s one of the most important lessons she ever taught me. I was lucky that it was engrained at a young age because it became such a fundamental part of my mentality that still shapes my reality.

My parents gave me drive and a platform from which I could comfortably succeed in school without worrying about things many other children deal with like money, food, water, shelter. And for that I am grateful. My parents taught me about hard work. And though they didn’t push me to become anything specific they made damn sure I knew that “getting an education was my only job.” Where they had to work with their bodies, I had to work at school which is an absolute privilege that many children don’t have. And I am lucky to have parents that reminded me of that.

My shoes were doing that thing again, where they squeak after every step along the sterile hospital floors. This wing of the hospital must have been built so long ago as is evidenced by the unintentional off-white tinge of the paint. There is something so un-glamorous about the scene but at least it's familiar. I pump two squirts of foul-smelling disinfectant into my hands and enter the unit. The nurses look up from their screens, then back down. My ultra-fashionable blue polo, ill-fitting khakis and naive 16-year old smile are my ticket in. I walk into room 3014. "Was it bed A or B?" It must be A since that's the only one occupied.

His turquoise eyes beam up at me, and I can honestly say that I've never looked into eyes as expressive as those. Down his little chest is a scar almost as big as him. There is clear evidence of multiple incisions, and one freshly-healed one lay on top of the pink, firbrosed network. His body riddled in pain, he manages to muster up the biggest toothless smile. I place my hand over his; it's traced by multiple attempts at an IV. He immediately grips at my finger, it's a strong grip and I'm rather impressed. I glance down at his legs which look a little blue - "why isn't he covered with a blanket?" I begin to wonder if the nurses are paying enough attention.

I notice his legs are a bit rigid and I press the nurse call light. The nurse looks tired, and somewhat irritated at the volunteer calling her in. I ask if I can hold him and she situates him in my arms. The rocking chair is uncomfortable but I'm so happy to hold him. The bracelet around his swollen, little ankle says he's only 8 months old. That's a lot of pain to go through so young. Soon a woman walks in and settles in next to bed B, she says she's waiting for her baby to come back from some kind of test. She goes on to tell me that Charlie* is in foster care and never has any visitors. She says Charlie has to have physical therapy every day just so he won't lose mobility from laying in his bed all day. This breaks my heart and I tear up.

Looking down at his chubby little cheeks and beautiful eyes I notice his grip isn't as strong as it was 10 minutes ago and he proceeds to fall asleep in my arms - he must be so tired.

(I started volunteering at the hospital at 15 and did so until starting medical school at age 22. I came to know the hospital very well and truly appreciate all of the lessons "my little patients" taught me. They taught me about suffering, and pain but most of all they taught me what resilience really means. I'll never forget Charlie's little blue eyes and I hope he's out there somewhere smiling a more tooth-filled smile)

*name changed to protect privacy.

As I reflect back on finishing the first half of second year a few important things stand out.

This summer, as I was finishing up my summer research fellowship, it hit me - I was finally going to be an MS2. As a first year the MS2's seemed so wise, so "together." I couldn't believe how much more they knew than us wee, little MS1's - I mean, they had passed some pretty crazy blocks like neuro, cardio, pulm, renal, muscuoloskeletal and even part one of the gargantuan digestion&metabolism block. But, as a freshly-minted MS2, I realized I felt just as lost as I had the year before and significantly more intimidated by the material. That's not to say that I didn't feel like I had mastered a substantial amount of material, but rather that the responsibility of the block content was now paired with even greater responsibility - studying for Step 1. Now before a few of you gunners out there think, "well technically you should be studying for step 1 during first year," I should clarify. You should absolutely study with the thought of step 1 in the back of your mind from day 1. But the passage into second year makes that reality so much more tangible. And, at least for me, the challenge is exciting and terrifying at the same time.

Clinically, we still saw patients once a week on the wards or emergency department. Armed with our iPads or notepads we marched down to our patient's rooms and took an extremely thorough history. We then proceed to take a focused physical exam - a step up from the full PE expected of us in first year. Because now, as full-fledged second years, we know what to focus on. Though the process of walking into a patients room and performing my expected tasks became smoother, the anxiety that I feel walking down the hall is still shocking to me. Even though I truly enjoy talking to each patient I see, the anxiety from the anticipation is something I still have to work on.

It's now winter break, though. And I took a few days to recover from the semester. I had big plans for those first few days but ended up doing absolutely nothing..and it was amazing. I guess you don't really notice how stressed you are until you take a second to breathe. I like to tell myself that I'm not stressed during my busiest times, and to be honest I don't feel stressed. Perhaps I've gotten to an expert level of stress management, or maybe it's denial. Either way I'm on break for three weeks and it's going to be awesome.