This is Going to Hurt

From the original UK version of Adam Kay’s This is Going to Hurt: Secret Diaries of a Medical Resident:

Asked to review a patient in labour ward triage and repeat a PV as the midwife is uncertain of her findings. Her findings were of cephalic presentation with cervix 1 cm dilated. My findings are of breech presentation, cervix 6 cm dilated. I explain to mum that baby is bottom-down and the safest thing to do is to deliver by caesarean section. I don’t explain to mum which part of the baby the midwife has just stuck her finger in to 1 cm dilatation.

Good medical humor is rare.

The AAMC on Interview Hoarding

The AAMC recently released an open letter sounding the alarm bells on how the residency interview season is shaping up this year:

We are seeing students in the highest tier receiving a larger number of interviews per person than in past years, leaving other students – including those in the middle of the class – with fewer interviews than we would anticipate based on their qualifications.

Interestingly, interview software purveyor Thalamus is arguing that this year is like last year. Who is right? I don’t know. Perhaps the AAMC’s data tells a different story. Or maybe they’re crying wolf. They do have a vested interest in programs filling and people matching at high rates to stave off growing criticism of their growing ERAS revenues.

They go with this advice to schools:

Discuss any additional steps that students with fewer interview offers than anticipated might take at this point to maximize their likelihood of matching (for example, applying to preliminary positions for which applications are still being accepted).

This could also read: we recommend people give us more money by applying to more programs.

Also, this is terrible advice. There’s a good chance there will be more spots in the SOAP than usual this year. If you’re a typical applicant who would expect to match in years past but are suffering from a dearth of interviews, why would you pass up the chance for a categorical spot in the SOAP for a prelim position that goes nowhere? The kinds of prelims that are accepting new applications in December are probably the kinds of spots that aren’t selling like hotcakes pre-SOAP anyway.

And they offered the following advice for students:

Consider releasing some interviews if you are holding more than needed, allowing your fellow students access to these interview opportunities. If you have fewer interview offers than anticipated, discuss with your student affairs officer or advisor any additional steps you might take at this point to maximize your likelihood of matching (for example, applying to preliminary positions for which applications are still being accepted).

People have largely been going on too many interviews (for years). While some fields have a preponderance of tiny programs, nearly 80% of successful applicants will end up with one of their top 4 and rarely go beyond 7-8.

However, it’s ludicrous to put this back in the students’ hands and argue that they should go against their own interests. Overapplication and–to some extent–interview hoarding are rational choices made to maximize the odds of a successful match. We shouldn’t blame students for playing a poorly designed game as best they can.

The AAMC has the most power to improve this process

This year should serve as a wake-up call because it’s not the n=1 powerless students that have the agency here. It’s the AAMC. The combination of pass/fail Step 1 and increasing graduating medical student numbers was already threatening to send the residency selection process into an application fever death-spiral before the pandemic, and they’re still coming for us.

Though, sure, look at Charting Outcomes and your interview plans. If you’ve been on a bunch of interviews and you have some programs lined up that you aren’t genuinely interested in, you could potentially change a peer’s career by giving up a slot in addition to avoiding another day on Zoom.

But the real take-home point is this:

The AAMC, through its highly-profitable administration of ERAS, is ultimately the entity responsible for the “maldistribution of residency interview invitations.”

The rest of us are just doing the best we can.

Blaming the Algorithm

From a WaPo article discussing protests at Stanford about a vaccine distribution plan that favored remote-working employees over trainees:

The “residents” — medical school graduates who staff the hospital for several years as they learn specialties such as emergency medicine, internal medicine and family medicine — were furious when it became clear that just seven of the more than 1,300 at the medical center were in the first round for vaccinations. Also affected were “fellows,” who work in the hospital as they train further in sub-specialties, nurses and other staff.
An email to pediatrics residents and fellows obtained by The Washington Post said that “the Stanford vaccine algorithm failed to prioritize house staff,” as the early year doctors are known collectively.

Of course “Medical school graduates” should read doctors or physicians.

Stanford blaming the algorithm in its medical version of Silicon Valley doublespeak is such a hand-wavy 2020 way of passing the buck. An algorithm is just a set of rules for carrying out a task.

The algorithm in this case isn’t some artificial intelligence black box. It represents value judgments made by fallible humans. In this case, the folks in charge forgot that it should be a person’s function in the system more than their benefits package that should determine how quickly they receive a vaccine that may not only protect them but hopefully prevent the spread of a potentially deadly disease to patients.

Those in the front line should be at the front of the line (unless we were to otherwise reasonably implement the age-based vaccination program used in many countries). Within a hospital system stratified by job roles, it’s the environmental and food services staff, nurses, CNAs, techs, transport, and all providers directly facing patients who should get it when supplies are constrained.

The idea that leadership could forget a huge class of people working in the hospital because those people aren’t considered normal employees is just another example of trainees being treated as faceless cog-like cheap labor. It’s an unfairness baked into our training system where the only pathway to independent practice as a physician is to be treated as a second-class citizen, which implicitly supports these sorts of slights.

So, when you make a mistake so blatant that you aren’t sure how to respond, don’t blame the algorithm. Blame yourself.

Some Practical Thoughts on the Virtual Interview Season

I’ve done enough Zoom nonsense since March that I thought I’d put down a few thoughts on optimizing your setup during the remaining interview season.

This situation is garbage, and while I’m thrilled that this year’s students won’t have to shoulder the typical fourth-year travel costs, I don’t envy anyone’s decision-making process. Programs can feel more alike than different even when you see them in person, walk the halls, have dinner and lunch and a conference, and talk to tons of people. A breakout session during an informational conference call just isn’t the same.

Let’s start with saying I don’t think anyone would or should consciously judge anyone for their Zoom set up or how they appear on camera. That said, the data on ERAS application photo bias concerns me. How “professional” you look, even outside the usual appropriate dress and grooming that would be true in person, may indeed have an impact.

I personally don’t care if you’re in your closet or at school, if there’s a baby crying (or even a baby in your arms), or if there’s construction just outside. Some landscapers were really going at my neighbor’s yard with the leafblower just this morning. We’re all doing the best we can. Thank you for logging in and making the best of the crazy times we live in.

The vast majority of students I talk to are using their laptop’s crappy webcam (because for some reason all webcams are garbage even though new phones can record 4K video) and sitting in front of blank drywall. So if that’s your jam, I promise that you are in good company.

Without further ado, a few optimizations:

Position & Camera

Raise up your camera. If you set your laptop on your desk or a table, chances are you’re looking down at the screen, which means that the default angle is an upshot of your nostrils or hunting for a double-chin. But more important than the potentially unflattering position is the fact that it’s an unnatural angle for conversation. Unless you’re very tall, you’re probably not used to looking down at people to speak. So get a couple of thick textbooks to prop up your laptop until the camera is at eye level.

If you’re using a separate camera source–like using your phone as a magical webcam with an app like EpocCam or plugging in a fancy camera via an expensive or cheap HDMI capture dongle–try to have it near your screen so that your eyes aren’t constantly looking way down. Lack of eye contact is sad.


If you can be in a room with a large enough window to provide decent natural light, that’s a plus (as long as it’s in front of you or to the side, not behind).

If not, try to get some kind of light source, even a table lamp, in front of you. Strictly overhead lighting casts shadows on your face, which isn’t ideal but can be especially problematic on older computers by triggering over-eager automatic brightness correction when you move your head around. For me, the constant brightness shifts on my webcam depending on the proximity of my face to the sensor was the reason why I stopped using my 2013 laptop for Zoom (and started using my phone, which is new).

So try to get some light. I’ve been using a cheap ring light stand I got on Amazon and it solves the problem of low light in my room of choice but anything that can function as a key light will help. If you wear glasses, try to have the light source elevated or off to the side enough that it’s not reflecting.


It seems like most people have determined that the best quiet spot in their abode for interviews places them in front of empty drywall. If that applies to you, again, you are not alone. Just be aware that if it is possible to artfully arrange something in the background, perhaps some greenery or a print or even some dim accent lighting might be nice. Note that if your artwork has a glass frame that any extra lighting should be arranged to the side enough not to reflect in the shot. And, of course, a blank wall is better than a mess. Virtual backgrounds are fine when necessary.


I almost feel like virtual interviews are to the normal residency interview process what Step 2 CS is to actual patient care. Everything blurs together more because it feels less real.

I am conducting my interviews from home, so we don’t even have the pretense of meeting in my (shared and barely used) office at the hospital.

The interview season has always been tiring, but I think in some ways it may be even easier to let enthusiasm flag this year. The lack of travel and relative brevity of a typical virtual interview day means that some applicants are able to hoard interviews and “visit” programs they otherwise would have been forced to cancel in prior years. Logistics make it easier to waste your and the program’s time.

So, if you are interested, make sure you look interested.

Likewise, I suspect some programs may be showing even more of a regional bias than usual given the unpredictable nature of this year’s process (others may just be over-interviewing for safety). If your top programs haven’t invited you for an interview and your application doesn’t click in an obvious way, it’s not too late to let them know why you love them.

Learning & The Transfer Problem

There’s a classic quote that gets attributed to a whole bunch of people, and it goes like this:

“In theory, there is no difference between theory and practice. But in practice, there is.”

This is the transfer problem, and it’s a real thorn for how we learn (and especially how we learn to perform in high-stakes roles like medicine).

When a medical student says, “I know all the information and can explain it but I just don’t do well on the multiple-choice test,” this is the transfer problem at work.

When someone else can do well on the multiple-choice test but can’t apply their knowledge to actually helping patients, that’s the transfer problem too.

The more different the learning methods are from the evaluation, the harder it can be to succeed. The more different the learning and evaluation methods are from the real-life goal, the less useful they are.

Here are some passages from Ultralearning: Master Hard Skills, Outsmart the Competition, and Accelerate Your Career:

Given a century of research showing the difficulties of transfer along with proposed solutions that have failed to provide lasting results, any student must take seriously the notion that transferring what has been learned between very different contexts and situations will be treacherous.

The answer is that learning directly is hard. It is often more frustrating, challenging, and intense than reading a book or sitting through a lecture. But this very difficulty creates a potent source of competitive advantage.

The best way to prepare for taking a high-stakes multiple-choice exam is to do lots of multiple-choice questions (e.g. How to Study for Step 1). The best to learn to do a procedure (other than actually doing the procedure) is to do a good simulation of said procedure.

If you can judge yourself only on how much you improve at the overall task, it can lead to a situation in which your improvement slows down because you will be getting worse at the overall task while becoming better at a specific component of it.

This is the treacherous problem of stagnant or decreasing qbank performance during dedicated review for some students. More time to trying to memorize low-yield minutia or shore up knowledge gaps doesn’t always yield upfront measurable gains. But, that doesn’t mean that when once again incorporated into a broader approach and after refreshing your core knowledge against the forgetting curve that it won’t ultimately yield results.

This practice of starting too hard and learning prerequisites as they are needed can be frustrating, but it saves a lot of time

Sometimes it’s best to just dive in because you’ll rapidly figure out exactly what you need to know.

I agree with this, and it argues for the early incorporation of question-based learning. This is actually how I learned pathology, by slogging through the question book and largely ignoring the larger text.

Human beings don’t have the ability to know with certainty how well they’ve learned something. Instead, we need to rely on clues from our experience of studying to give us a feeling about how well we’re doing. These so-called judgments of learning (JOLs) are based, in part, on how fluently we can process something. If the learning task feels easy and smooth, we are more likely to believe we’ve learned it. If the task feels like a struggle, we’ll feel we haven’t learned it yet.

No pain, no gain.