The successful match: getting into pediatrics
We recently discussed the pediatric residency selection process with Dr. Su-Ting Li, Program Director of the University of California Davis Pediatrics Residency Program and Vice Chair of Education in the Department of Pediatrics. After graduating from the UCLA School of Medicine, she completed her pediatrics residency at the University of Washington. Following this, she remained at UW as a National Service Research Award Fellow in General Academic Pediatrics and pursued a MPH in Epidemiology. She then joined the Department of Pediatrics at the University of California Davis where she has also held the title of clerkship director.
Dr. Li has been heavily involved in medical student and resident education on local, regional, and national levels. She has also been recognzed for her research contributions. In 2008, her paper "Primary Operative Management for Pediatric Empyema" was recognized as one of the "top 10 articles in pediatric hospital medicine." She has been highly sought after as a journal reviewer and is currently a reviewer for 12 prestigious publications, including Academic Medicine and Pediatrics.
Currently, there are 8,124 total residents training in nearly 200 ACGME-accredited pediatrics training programs (1). Of these, 67% are graduates of U.S. allopathic medical schools, 24.2% are international medical graduates, and 8.5% are osteopathic graduates.
In a recent survey of pediatrics residency program directors, the USMLE Step 1 score was ranked as a highly important residency selection criteria. Low scores lead to concern about an applicant's ability to pass the board exam in pediatrics. Dr. Daniel West, Program Director of the Pediatrics Residency Program at UCSF, writes that "failure to pass the pediatric boards reflects poorly on our program and may cause problems with our residency review committee (3). What do program directors consider a low score, and what can applicants with lower scores do to alleviate any concerns progams may have?
Low USMLE scores concern program directors that the applicant may have difficulty passing Step 3 (which is needed for medical licensure) and may ultimately have difficulty passing the pediatrics board exam (which may reflect poorly on the residency program). USMLE scores lower than 200 are generally considered low scores. Programs are particularly interested in USMLE Step 2 scores. If applicants have a low score on USMLE Step 1, they should plan to take Step 2 earlier and score higher than 200 on Step 2. Better yet would be a Step 2 score higher than 220. If an applicant has previously failed Step 1, it is incredibly important that he/she do well on repeat of Step 1 and do well on Step 2. If failure of Step 1 was due to unusual circumstances (e.g., applicant's parent died immediately prior to Step 1), the applicant should explain the unusual circumstances in their personal statement or during the interview.
Surveys of residency program directors have shown that the pediatric clerkship grade is an important factor in the residency selection process. However, many students begin their pediatrics clerkship with both anticipation and concern. What can students do to excel during the rotation?
Students should come to pediatrics excited to learn. Children have a wonder, joy, and resilience that make caring for them immensely fun and gratifying. In addition, pediatrics is unique in that it allows students thte opportunity to creatively engage children of different ages and have fun with the physical exam. Some of the unique challenges that pediatrics presents to new learners is how to (1) provide family-centered (rather than patient-centered) care, (2) tailor information gathering, physical exam, and information giving to different age and developmental levels, and (3) take into account age when developing differential diagnoses, assessments, and management plans. In order to excel at pediatrics, students need to learn that children are not little adults.
What parts of the history can and should be gathered from the patient versus from the parent and how to gather than information varies depending on age, developmental stage, and what information is needed. How one interacts with and examines an infant (ending with the ears and mouth), a toddler (on parent's lap), a school-age child (ending with the genitourinary exam), and an adolescent (without parents in the room) may be as different as what is incuded in each exam (Ortolani/Barlow in the newborn, cover/uncover in a toddler, back exam in a school-age child, HEADSS exam in an aadolescent).
In order to improve their clinical skills, students should actively observe, practice, and ask for feedback. They should actively observe their resident or attending model information getting, physical exam, information giving, and presentation of patients, paying particular attention to how their approach differs based on the age and developmental stage of the patient, and incorporate the most effective styles and techniques into their own practice. They should practice their skills by seeing as many patients as possible and ask their resident/attending to observe them during patient interactions. Finally, they should seek and incorporate feedback from patients/families and team members.
On Day 1 of their rotation, students should ask their team for their expectations of medical students - including expectations for pre-rounding, writing orders, oral presentations and written notes. Students should read about their patients (and patients on the team) - not just in textbooks, but published guidelines and primary medical literature - and share what they learned with the team. They shouldn't be afraid to be wrong - stick their neck out and offer and assessment and plan for the patients and defend it with their reasoning process (pertinent positives and negatives from the history, exam, studies), and medical literature. Most of all, they should take the time to enjoy their interactions with patients - this is why most of us chose pediatrics and continue to love to come to work every day.
The personal statement is a source of great anxiety and angst for applicants. Dr. Heather Fagan, Program Director of the Pediatrics Residency Program at the University of Chicago, writes that an exceptional statement can help an average file' a very poorly written statement could negatively impact a good file (5). What makes a personal statement exceptional to you?
Personal statements are an opportunity for the applicant to describe the "why" in their application and allows us to better understand them outside of their Curriculum Vitae. For the applicant who struggled during a portion of their medical school (e.g., failed a 1st year course), the personal statement additionally allows the applicant to concisely (in a short paragraph) describe