Becoming a physician in the US- USMLEKOREA lecture Part 1: Things to consider before residency Part 2: Things to consider during residency

1. Becoming a physician in the U.S
Part 1. Before residency
Joonseok Kim, MD
Internal Medicine Resident PGY2
College of Human Medicine, Michigan State University
January 3, 2013

2. Contents
• Why U.S?
• What are my odds of getting into residency
in U.S?
• What are the ‘handicaps’?
• How can I overcome my ‘handicap’?
• FAQ

3. Reality
• We have to be realistic, and somewhat
pessimistic
• Do not see what you want to see
• You are the one who makes the decision
• Where am I?

4. Reality
• Matching is getting harder and harder
• Will the door be closed in 2015?
• Life in the U.S could be unsatisfactory as
well
• Can be worse than you thought
• You have to give up many things
• Many seniors went back to Korea after
training

5. Why US?
• Most important question
• You will be asked this question more
than 200 times
• If you cannot persuade yourself, you
cannot persuade others
• You need to have a very firm reason to
remind yourself when you are weary

6. Why US?
• 반복되는 일상이 지루하다.
• 나빠져만 가는 한국의 현실
• 안하면 후회할 것 같다.
• 자녀들이 연수를 가는데 나도 가서 뭐라도
했으면.
• Matching and living in the U.S is a long,
long way to go
• Going to the U.S is not the solution for the
dissatisfactions in your life
• Life in US is not easy at all

7. How to decide?
• Prioritize
• What is the most important thing and
what is the least important thing in my
life?
• As a husband/wife, father/mother,
son/daughter and physician

8. Again, why US?
• Lifestyle
• Family
• My education
• Kids’ education
• Life in academia
• Student teaching, resident teaching
• Research
• Clinical, basic
• 미국병
• Refractory disease

9. What are my odds of getting
into residency in US?

10. Specialty
• Internal Medicine
• Family Medicine
• Neurology
• Psychiatry
• Pediatrics
• Pathology
• General surgery

11. Things to consider
• What is the most important thing?
• I don’t know
• Score
• Post Graduate Years
• English
• USCE
• Green card

12. • Desire
• Passion
• Energy
• Right pathway
• Good mentor/advisor
• 지인 who already works as a resident in
the U.S

13. Not very important
• Publications
• Ph.D.
• Research
• May be important for fellowship, but not for
residency
• Unless you are looking for very
prestigious programs

14. Then, Can I ‘calculate’ my
odds?
• No, but we can estimate
• By estimating the number of interviews
that you might be able to get
• Case by case
• If I do match, where can I go?
• Where am I willing to go?
• Best hospital vs. worst hospital
• MGH vs small community hospital vs
NY

15. General rule
• 점수가 깡패
• Not only related to the number of
interviews, but also to the quality of
program that you might go to
• Does not mean that you will get
matched
• 영어는 물귀신
• You might be hopeful that it will not be
hard to ‘pretend’ to speak English well
during the interview
• Not true

16. What are the ‘handicaps’?
• Low score (Less than 220?)
• Failed record (CS)
• Failed record (Step1, CK)
• Old graduate (more than 5
years, especially 10 years)

17. How can I overcome my
‘handicap’?
• First of all, not easy. Handicap is
handicap.
• Can’t compete with ‘넘사벽 applicants.’
• Realize your situation, then set up your
realistic goal.
• Then think about the ‘withdrawal
strategy’ as well.
• You need to have a different strategy from
‘non-handicapped applicants’.

18. How can I overcome my
‘handicap’?
• Reality
• You will get no more than 5
interview invitations
• Mostly 1-2 or none if you have
more than 2 factors
• Your chance of matching to
residency is less than 20%

19. How can I overcome my
‘handicap’?
• Unless you have another extra
strength
• Born in the US
• Fluent English
• Wrote 20 articles, cited more than 200
times
• Excellent, exceptional LOR from very
renowned attending
• Personal call from a mentor in the US
• Many of these are not ‘modifiable risk
factors’

20. Then, impossible?
• No, but needs more effort and sacrifice
• Few interview invitations doesn’t
necessarily mean that you cannot get into
residency.
• Have to have a good strategy to begin
with.
• Do not try without having any strategy
• Ask many residents in the US who
overcame similar handicaps BEFORE
you start studying for USMLE

21. Strategy
• What do you know about US?
• What do you know about US medical
system?
• Do you think you are the best candidate?
• Then, Why do they have to pick you?
• You have to be a candidate that the PD
wants to work with

22. Why IMG/KMGs- Our value?
• Smart
• Ambitious
• Diligent
• Diversity
• Good knowledge base
• Academic background

23. Why IMG/KMGs – our drawback?
• Take time to acclimate to US medical
system
• US clinical experience
• English
• Social skill
• Communication skill
• 어….

24. USCE
• Find observership
• Hard to find?
• The longer, the better
• In order to achieve this goal, the hospital
doesn’t have to be a prestigious hospital; do it
where you might have a chance to match.
• Mixed hospital strategy is also fine.
• Ex. 3 months in University program for good
LORs, 2 months in community.

25. USCE
• DO YOUR BEST
• Not for the LOR, but to impress
attendings so that you can get into
THAT program.
• Not easy to do your best.
• Don’t forget why you are there.
• Show your interest
• Make a connection to that program and
attendings

26. How about mid-handicapped
applicants?
• Not high score (Less than 240?)
• Recent graduate (within 5 years)
• 1 month or no USCE
• No US LOR

27. How about mid-handicapped
applicants?
• You will get 3-12 interview invitations
• Not from very prestigious program unless
you have something else
• If you don’t speak English well enough to
impress your interviewer, your chance of
matching is borderline

28. How about low-handicapped
applicants?
• You will get many interview invitations
• Can get interview invitations from
university-based programs
• Not from very prestigious program
unless you have something else
• If you don’t speak English well enough to
impress your interviewer, however, your
match is not guaranteed

29. Again, USCE
• The only thing you can change in your
spec.
• Be realistic, you may have to sacrifice
many things in your life
• Do I still really want this?
• If yes, go for it

30. One more thing, Applications
• More important than you may think
• This is a modifiable risk factor
• Modify it!
• Many KMGs don’t pay attention to their
documents very much
• Would you give an interview to an
applicant who wrote that personal
statement?
• Korean LORs are important as well

31. Becoming a physician in the U.S
Part 2. During residency
Joonseok Kim, MD
Internal Medicine Resident PGY2
College of Human Medicine, Michigan State University
January 3, 2013

32. Resident Life
• It is totally up to where you are at.
• NY
• East coast vs midwest
• However, ACGME rule protects you
(somewhat…)
• In general, much better than resident
life in Korea in terms of work load
• Cannot generalize, so I will explain
based on what I have experienced
and what I have heard

33. Rotation Schedule
• PGY1
• 6 floor, 2 ICU, 1 night float, 3 electives
• PGY2
• 3 floors, 1 ICU, 1 night float, 7 electives
• Can do up to 2 months of out-of-
hospital rotation
• PGY3
• 1 floor, 1 hospitalist, 2 ICU, 1 night
float, 7 electives
• 3 weeks vacation, 1 week educational
leave per year

34. ACGME regulations
• Interns
• Cannot work more than 16 hours
consecutively
• Have to have at least 10 hours break
before shift
• In reality?
• Residents
• Cannot work more than 30 hours
consecutively
• Have to have at least 10 hours break
before shift
• Fellows
• Yes, but somewhat loose

35. Resident Life: Life in the Hospital
• What kind of work?
• Seeing patients
• Cap?
• Writing progress notes
• EMR?
• Assessment and Plan
• Contact consultants
• Presentation
• Make a plan for the patients
• Dealing with social issues
• Case manager
• Scut work?

36. Work Hour
• Floor
• 6AM – 5PM
• 7AM – 7PM Q8 short call for interns, Q4 or
residents
• 1 day night float per month for interns only
• ICU
• 6AM – 5PM
• 7AM – 7PM Q4 short call for interns and
residents
• 6-7 days night float per month for interns
and residents

37. Typical day
• Floor, ICU
• 6AM - 7:30AM: Pre-round
• 7:30AM - 8:30AM: Morning report and sign
out
• 8:30AM - 9:30AM: Pre-round
• 9:30AM - 12:00PM: Round with attending
and team
• 12:00PM - 1:00PM: Didactics, grand
rounds
• 1:00PM - 5:00PM: Patient care, discharge
• 5:00PM: Sign out to on-call resident

38. Relationship
• No vertical relationship with your senior
• No vertical relationship with your attending
• Yes, sometimes. But not like Korea
• Many 짱돌’s
• Hopefully it is not me

39. Resident Life: Life outside the
Hospital
• Finance
• Salary: USD 45,000 – 55,000 for PGY1
• Rent: USD 1000 – 1800 per month
• Including water, heating, electricity
• Food: USD 500 – 1300 per month
• Etc
• Car insurance, clothes, shopping
• Family
• Daycare: USD 5-10 per hour
• School
• Wife tuition: $$$

40. Resident Life: Life outside the
Hospital
• Generally, you can afford a family of 4 with
a resident’s salary on a tight budget
• Bottom line is, you will not live with that
low salary forever, only 3-6 (7,8,9…) years
• Other options
• 마통
• 부통
• etc

41. How can I become an excellent
resident?
• Be a leader of the team
• If you act like a leader, you will be a
leader
• If you want to act like an intern (or
medical student) in Korea, you can.
• However, your evaluation will reflect
that attitude
You have to speak up when you have to
• An intern can be a leader of the team
• Be proactive

42. How can I become an excellent
resident?
• Read about the case that you are seeing
now, at least 1-2 hours a week
• Not easy
• Critical thinking
• Don’t accept your attending’s words as
the truth
• Ask, ask, ask. WHY
• Research pubmed, textbook,
uptodate…
• Teach your students, interns

43. What can I do to help my
career?
• It depends on why you are doing residency in
US
• Try to find what you truly want to do as early as
possible
• Nothing is more important than focused life
• Don’t have to decide at the beginning of the
intern year
• But no later than at the end of intern year

44. What is my priority?
• Peaceful life with family
• More relaxed life, not too intense
• Internist/hospitalist
• Primary care physician
 Focus on broadening internal medicine
knowledge
 See what your attending is doing
 Try to experience hospitalist/PCP life
before you decide

45. What is my priority?
• Specialist
• More focused patient care
• Then, requires fellowship
• Why?
• When?
• Which specialty?
• What do I truly want to become?
• Private versus Academia
 You may need something to fill out your CV
 You have to have better knowledge base
compared to your colleagues in that area

46. Research?
• It depends on what you want to do after residency
• Find a mentor
• Jump into mentor’s research and learn
• One who can advise on my research idea
• Not always possible
• You can find a mentor out of the hospital
• Always start with small things
• You can’t do it anyway if you have no
experience
• Read, read and read to find research idea
• Again, Idea is the key

47. Research?
• Poster
• Abstract
• Case report
• Case review
• Review article
• Retrospective chart review
• Out of town elective rotation

48. Conclusion
• Matching needs a well constructed plan
• Don’t prepare it alone
• There is no generalized answer to your
situation, do not rely on others’ opinion
• YOU HAVE TO MAKE YOUR OWN
DECISION
• Matching is a whole new start, not the end
of your training
• Think forward, not backward
• If you dream with a concrete plan, it will
come true

49. Thank you
Ten minute break
Joonseok Kim, M.D.
viciousjoon@gmail.com