How I decided on a combined medicine/psychiatry residency

The third-year medical student has three jobs: 1) To learn how to take a good history and do a good physical exam; 2) To learn how to present patients, both written and orally; and 3) To figure out what field of medicine to specialize in. I found this last job to be the most difficult.

Pre-med and the pre-clinical years

To provide some context, I came into medical school having worked for four years researching the neurobiology of eating disorders. I very much enjoyed and valued my pre-med experience in psychiatry, but I also wanted to keep an open mind when it came to other possible specialties and career paths. This translated into me looking practically everywhere except at psychiatry.

During the first two years, when I was just in the classroom and didn't yet have any practical clinical experience, I investigated various specialties: emergency medicine, neurology, neuroradiology, interventional radiology, surgery.

The third year

Over this past year, as I've gained clinical experience in various fields, I have tried to be purposeful and methodical about how I evaluate each specialty as a possible career. This process of elimination is pretty typical for third-year medical students. I had all but ruled out many possible specialties before third year, but I also tried to keep an open mind. I liked most of my clinical rotations and seriously thought about careers in those specialties.

• I was very interested in emergency medicine, ever since my first year, but eventually nixed it because I want to have continuity of care and to treat the whole patient rather than one acute problem at a time.
• I seriously considered surgery but reluctantly decided against it because of lifestyle issues.
• I got excited about anesthesiology but vetoed it because I want more significant patient interaction.
• I loved pediatric neurology and only recently crossed it off the list because I decided that I don't like general pediatrics enough to do the training. Also, even though I figured out that I could probably handle the sad stories and poor outcomes, I decided that it's just not what I want.

Then there were my internal medicine and psychiatry clerkships. I loved them both.

Internal Medicine

Last Summer, on a warm evening after a long day at the hospital, I was lying underneath a tree in the park talking on the phone with my sister. She asked me how I was liking internal medicine, and my immediate response was that I love the puzzle. I have a patient with a given set of symptoms and a unique history, and based on both of those, I have to decide on what labs and studies to order to figure out what is causing that particular constellation of symptoms and how to treat it. I told my sister that the inpatient setting gives me more time to sit down and really talk with my patients, as well as to thoroughly think through the differential diagnosis. I like internal medicine because it involves both thinking and doing.

Looking back, my most memorable and favorite medicine patients all had psychiatric comorbidities. After awhile, my medicine residents were giving me the "difficult" psychiatric patients because they knew that I was drawn to those patients.

Psychiatry

Then there was my psychiatry clerkship. I looked forward to it with excitement but also some trepidation. What if I liked it? Could I really become a psychiatrist? I worried about that because there truly is a distinction between the practice of medicine and the practice of psychiatry.

It turned out that I did very much like psychiatry. I found that reading for psychiatry was easy because I was so interested in the subject matter... I spent much longer talking with my patients than I needed to... I wrote much longer notes than I should have because I had so much to say and was so fascinated by my patients... I jumped into psychotherapy with some of my patients even though that's way beyond the scope of a third-year medical student....

Discovering med/psych

Liking psychiatry so much posed a problem because I held a mental block against it. Much of that mental block likely came from my desire to practice medicine, not solely treat mental illness. About midway through my psychiatry clerkship, responding to what I recognized as ambiguous reservations against psychiatry, I started researching various psychiatry fellowships. That's when I "discovered" combined medicine and psychiatry residency training programs.

I hadn't even known that such programs existed. Thinking back to my internal medicine clerkship and how much I enjoyed it, I immediately started daydreaming about what I could do with training in both internal medicine and psychiatry. I stayed up way too late that night researching med/psych programs.


The more I thought about med/psych as a training path, the more excited I got. I could continue my work in anorexia and bulimia or focus on binge eating and obesity. I could do geriatrics. I could do palliative care. I could do international and refugee medicine. So many possibilities! I'm the type of person who likes to keep my options open. Med/psych training could give me the best of both worlds; I could have my cake and eat it too!

I realized, though, that I was getting all excited about med/psych with a very limited amount of information, only what was available on the various program websites and the Association of Medicine and Psychiatry website. I needed more information, better information.

Talking with med/psych program directors

A few of the med/psych programs stood out to me, both because of the quality of the integrated curriculum and the general feel of the institutional culture. The directors of these programs wrote open letters describing med/psych, promoting their respective program, and inviting those interested in med/psych to contact them with any questions. Recognizing that contacting these program directors could potentially be self-defeating, I decided that it was worth the risk because I needed to talk with someone - multiple people - in the med/psych world.

I e-mailed three program directors and actually talked on the phone with two of them. I was blown away by how open and friendly and helpful they were, that they would set aside time from their lives to talk with me about med/psych. They answered my myriad questions, settling two major concerns about pursuing both medicine and psychiatry.

• Concern #1: You'd just end up choosing one or the other eventually, so why waste time training for both? Response: We actively encourage our graduates to establish a practice that incorporates both medicine and psychiatry, and most of them do find a niche for themselves. Even if your practice ends up being predominantly medicine or predominantly psychiatry, you will draw upon your training in the other and be a better doctor for it. I doubt that you'll ever regret your training. Both program directors said essentially the same thing in different ways, and I agree with them.
• Concern #2: A combined program would leave you less well trained in both medicine and psychiatry than if you completed a pure residency in one or the other. Response: Our pass rate is 100% for both the medicine and psychiatry boards. Our graduates report feeling very well prepared for both boards and for the responsibilities of being an attending physician. That speaks for itself.

Talking with current med/psych residents

I asked those program directors to put me in touch with current med/psych residents. Being in the middle of this stressful decision-making process, I wanted to talk with someone whose memories of that process are more fresh in the mind. How did you discover med/psych? Did you seriously consider other specialties, or medicine alone, or psychiatry alone? Why did you end up deciding on med/psych? Did you know what you wanted to do with med/psych before residency? I felt that these questions needed to be addressed now as opposed to during an externship or on the interview trail.

One resident answered that he decided on med/psych simply because he wanted to treat the whole patient, not just a set of symptoms. This struck a chord with me. I thought back to my medicine rotation and remembered how frustrated I felt when the psychiatry consult service swooped in to evaluate patients with psychiatric concerns: I wanted to be a part of that aspect of my patient's care. I also thought back to my psychiatry rotation and my frustrations when the smallest medical issue was outsourced to internal medicine. I want to treat the whole patient, too.

Enthusiasm flowed freely from every resident I talked with. Everyone was happy. Everyone was 100% satisfied with their career choice. Everyone would do it over again the same way in a heartbeat. And talking with each successive resident, that enthusiasm rubbed off on me. The vague intuitive sense of rightness I originally felt when I discovered med/psych crystallized into certainty that a combined medicine and psychiatry training is perfect for me.

Trying on med/psych for size

I can't count how many times I've been asked, "What are you going into?" or "Do you know yet what you're specializing in?" It's especially bad toward the end of third-year and even worse when I start a new rotation. So pediatrics and OB/Gyn have offered me numerous opportunities to see how med/psych fits. Rather than hedging, I started answering decisively, "I am going to do a combined medicine and psychiatry residency program."

Reactions have been interesting, ranging from "Oh, what a waste of talent," to probing my reasons for choosing a less traditional training path, to "Wow, that's awesome!" The negative reactions didn't get me down, and the positive ones only stoked my excitement for med/psych further. These self-observations are incredibly helpful in making the final leap to a decision that without overstatement will profoundly shape the rest of my life.

So I've taken that leap. I will apply to combined medicine/psychiatry residency programs.

Fourth year: What lies ahead

With just three more clerkships left in my third year (psychiatry, pediatrics, and OB/GYN), the time is quickly approaching when I will have to start making some serious decisions about my future.

The fourth year schedule is by design flexible, allowing me the freedom to choose those courses that I'm interested in and are relevant to my future career. The problem I'm faced with is figuring out my fourth year schedule when I still have more than a few possible career paths before me. Although we sign up for fourth year classes in February (so soon!), a friend told me that it's usually pretty easy to change the schedule in the middle of fourth year. That's comforting.

But it's more complicated than that. By the end of August, I will want to have completed all fourth year coursework required for applying to whatever field I choose. The Dean's Letter is written in September; residency applications are submitted in October; and I'm interviewing November-January. That means I have a short four months to play around with in my fourth year before I start working on my residency applications. Yikes!

As it stands now, my top interests (in no particular order) include: adult neurology, pediatric neurology, and internal medicine. In order to prepare myself for all of these eventualities, I would need to do the following: 1) internal medicine sub-internship (sub-I), 2) adult neurology elective, 3) pediatrics sub-I, and 4) pediatric neurology elective. Four months right there. Plus, with psychiatry in the back of my mind, I could end up wanting to do a psychiatry elective, as well.

Regardless of what I end up deciding, there will be a period of dead time between my last interviews in January 2013 and Match Day on the third Friday of March 2013, when I find out where I will be doing my residency training. Then more dead time between Match Day and graduation in June 2013, eighteen months from now.

Why I decided against anesthesiology

Over the past few weeks, I have been "trying on" anesthesiology as a career. I started collating a list of anesthesiology programs I would be interested in, I attended an anesthesiology information session during the clinical interlude week, and I networked with some anesthesiologists.

Specifically, I talked with a neuroanesthesiologist, since concentrating in neuroanesthesiology is the direction in which I would want to take my new career. He was very encouraging, in fact excited, about my neuroanesthesiology interest and strong research background. We talked about a scholarship program designed for anesthesiology residents interested in research, and he helped me sketch out a plan for applying and getting accepted to the Colorado program. Wow, things couldn't be better!

I left that meeting with the neuroanesthesiologist, my spirits high, to complete a standardized patient encounter. The purpose of this exercise was to hold a family meeting about a patient at the end of her life. Although these conversations can be especially difficult and emotionally taxing, the patient-actor gave me remarkably positive feedback: "I am glad that you're going to be a doctor. No matter what field you go into, you're going to need to use these skills to talk with patients, and you're a natural at it." These words meant all the more to me because patient-actors are known to be very liberal in their criticisms.

Through the flush of receiving such high praise, I noted with a pang in my stomach that I wouldn't need to use these skills often, if ever, as an anesthesiologist.

More confusion, bred from conflict of what I wanted anesthesiology to be versus its reality. When thinking about the prospect of following through with applying to anesthesiology residency programs, which all of a sudden seemed much more real, I felt a heaviness in my shoulders, a shortness of breath, a quickened heart rate. All of these symptoms were so slight, subliminal, easy to dismiss as a normal reaction to thinking about an uncertain future.

A good friend and classmate, sensing this inner conflict, asked me a simple question: "Why wouldn't you want to be an anesthesiologist?" He kept quiet and listened, allowing me to verbalize thoughts that until then I wasn't ready to consciously recognize.

When you get down to it, anesthesiologists have a different kind of relationship with their patients. It's condensed down to 5-10 minutes during which the anesthesiologist obtains informed consent and reassures the patient about the upcoming procedure. Sure, there's a little room there to insert your personality, but that's about the extent of the relationship. Talking to patients is something that I both enjoy and am actually good at; plus, it is something that can make a lasting difference in people's lives. It would be a shame to waste that talent in a field with minimal patient interaction.

Relief. Having finally verbalized my concerns about anesthesiology, it was impossible to ignore the fact that lack of meaningful long-term doctor-patient relationships is a deal-breaker for me.

Why I decided against surgery

Over the past 8 weeks, I have been giving serious consideration to surgery as a career. I love it. I love the OR environment, the immediate gratification of doing something tangible to fix a physical problem, and I think that I would be good at it. I've watched my surgery residents, imagining myself in their shoes a few years from now, jealous that they actually get to do the surgeries rather than watch from the sidelines. They work hard, really hard. All that hard work would be worth it, though, to do something that I truly love.

But I have other considerations in deciding on a career. A lot of introspection has led me to understand that I need to find a balance between my career as a physician and the rest of my life. I'm speaking mostly about a hypothetical family. This may be just an abstract concept right now, but I know that the importance I place on family now will only magnify when there's an actual flesh-and-blood family to care for.

It's an unfortunate reality that surgeons must sacrifice more in terms of family life than do most other medical specialties. However, most of the surgeons at my community hospital seemed to be able to find a balance between their professional and personal lives. My surgery mentor, for example, has six children! Even the surgery residents at this community program seemed relatively sane and well-adjusted. But the bottom line is that, even if I chose a community versus academic program (usually a more stressful and toxic environment), going into surgery would still require too much sacrifice from other areas of my life that I value.

This reasoning felt like a cop-out when I was first coming to terms with the realization that surgery is not the career for me. My wise older sister picked up on this sentiment, which I hadn't quite consciously expressed, offering me this advice: "Don't feel apologetic for choosing a career that allows you to find balance in your life. There's a difference between wanting to find a career that makes you happy in all areas of your life and being lazy."

At the beginning of this rotation, I laid out three questions to ask myself to help me decide if surgery is right for me:

• Do I absolutely love being in the OR? Yes.
• Can I see myself happy doing surgery when I'm 60 years old? Possibly, but the chances are slim.
• Can I see myself happy in any specialty other than surgery? Yes, I think so. Before this rotation, I felt pretty optimistic that that specialty could be pediatric neurology. It's still high on my list, but this rotation has made me a little less certain. I learned that I like doing things, that I do well with a mix of action and cogitation. I hadn't seriously considered anesthesia as a career until this rotation, but from my one-week exposure to anesthesia, it provides both action and cogitation.

Anesthesiology

The Surgical Care clerkship includes a one-week exposure to anesthesiology. Admittedly, I entered this week with considerable bias against anesthesiology. It's boring... All anesthesiologists do is put patients to sleep before surgery and wake them up after it's over... There's not much patient interaction... It turns out, though, that my prejudices against anesthesiology were wrong.


The primary job of anesthesiologists, medically speaking, is to keep the patient alive and stable, numb, asleep, and motionless, so the surgeons can do their job.

Anesthesiology is mostly applied physiology and pharmacology. It's the application that interests me. Anesthesiologists use drugs and the ventilator machine to micromanage a patient's vital signs for the duration of the surgery and immediately afterward. Physiologic changes take place right before your eyes. Push propofol and watch the patient fall asleep, completely unarousable. Push rocuronium and watch them stop breathing. Push phenylephrine and watch their blood pressure rise and their heart rate drop. Instant gratification.

Minor procedures are another component of the anesthesiologist's job description: placement of arterial lines and central lines, epidurals, spinals, and of course endotracheal intubations.

I couldn't get enough of the procedures. Over the past week, I placed my first arterial line (after one failed attempt), and my entrotracheal intubation record was 6 successful placements for 13 attempts. Pretty good for a third-year medical student, I was told by my anesthesiology mentor, but he was probably just trying to encourage me. An actual anesthesiologist needs to have a perfect record.

I was also struck by how happy and well adjusted everyone seemed to me. One anesthesiologist just got back from a trip to the Galopagos Islands, and another partners with a team of surgeons on regular missions to Africa. At lunch one day, we determined that all six anesthesiologists at the table were runners. My anesthesiology mentor actually runs 5 miles to and from the hospital a few times per week! I felt like I fit in.


Now, I'm left feeling more confused about my future than ever. I had to write out a list of pros and cons for anesthesiology:

Pros:

• Optimal lifestyle
• Lots of procedures
• Taking away pain makes people happy
• Instant gratification
• No rounds
• Work in the OR, get to wear scrubs to work
• Happy, interesting, and active colleagues
• Good compensation

Cons:

• Does not fit the archetype of a physician that I have carried in my mind since childhood
• No longitudinal patient contact and minimal face-time with patients
• Not the star of the show

Pediatric neurology as a possible career path

I enjoyed pediatric neurology much more than I thought I would. Since I have a background in neuroscience, and hold a special curiosity for the workings of the nervous system, neurology has always seemed a logical career choice. But "logical career choice" doesn't necessarily mean that it's the right one for me.

My hesitancy with respect to neurology dates back more than 10 years when I watched my grandfather slowly deteriorate from Parkinson's Disease. Like a teenager's epiphany that Mom and Dad are just human beings, too, I realized that neurology couldn't cure my grandfather. This disillusionment with neurology in part steered me toward neuroscience research instead of medicine. At the time, I didn't appreciate that, through levodopa and other wonder drugs, neurology had given my grandfather and me a full decade of time together during which I didn't even know he had Parkinson's disease.

The pain of his passing dissipated, and so too did the grudge I held against neurology. This freed me emotionally to choose medicine as a career, late as I did, and now, to even seriously consider neurology as a possible career path.

Regardless, the extent to which I as a neurologist could "cure" a patient, versus treating symptoms or improving quality of life, is a real concern at this point in my education when I am deciding to what specialty I will devote my career in medicine. A close family friend who is a physician strongly urged me to keep in mind the emotional toll of caring for patients who will not get better despite all medical interventions. My colleagues on the Student Doctor Network neurology forums have grappled with this issue before me. One perspective that I find especially helpful comes from Dr. Rodger Elble, Neurology Professor and Department Chair at Southern Illinois University School of Medicine, in a June 2006 department newsletter (I love the internet!):

People become neurologists because they are fascinated by the nervous system, and they are not intimidated by disabling diseases that have no cure. Like Sherlock Holmes, neurologists love to use careful systematic investigation and deductive reasoning to tackle problems that are mysterious to others. Most importantly, neurologists understand that they can help people even when there is no cure. [PDF]

This will be the crux of my decision of whether to pursue a career in neurology. Can I find a fulfilling career caring for patients who have diseases with no quick fix, who will deteriorate and sometimes die despite my best efforts to treat them?

This is a particular concern if I go into pediatric neurology because the patients are even more heart-wrenching. I went into my neurology clerkship at Children's skeptical that the emotional burden of caring for such sick children would be too much for me; I left my neurology clerkship reasonably well assured that I could handle such a burden. Moreover, given my neuroscience background and my INTJ personality with a twist of goofiness, I think that I'm well suited to the task and that I'd be good at it.

What I like about pediatric neurology:

• First and most importantly, I enjoyed working with children. This surprised me. Those who know me know that I like children, but it's another matter entirely to do a physical exam on a sick kiddo.
• I like the challenge of figuring out how to get a good physical exam on children of various ages. For example, you can't ask a 6 month-old to touch your finger then its nose and back again to test for dysmetria, so instead I get the baby to reach for a toy. Examining a three year-old, I will bust out a tennis ball and play catch; toss the ball down the hallway to observe gait. Tons of fun.
• I like the observational and intuitive nature of pediatric neurology.
• I enjoyed working with all of my attendings and residents. This counts for a lot. Many doctors who I've talked with have said that they chose their specialty based heavily on where they felt they fit in best.

Having just a hair more than half of my third year of medical school under my belt, I'm still reluctant to pigeonhole myself into a specialty. At this point, though, I'm comfortable saying that neurology, possibly pediatric neurology, is at the top of The List.

Pros and cons of emergency medicine

Pros:

• I like fixing acute problems and seeing immediate results.
• The idea has always appealed to me of being a doctor who can ring the call button when the flight attendants ask if there's a doctor on board.
• I like the fast-paced ADHD environment.
• I like doing procedures.
• I get to wear pajamas (scrubs) to work everyday.
• I would be doing shift work, which would allow for a life outside of medicine.

Cons:

• I don't like dealing with the drunks and drug addicts; I can easily see myself getting disheartened by humanity at its worst.
• I've already decided that I don't want to do primary care, but too many people use the Emergency Department as their primary care physician.
• As a resident and attending, I would have to work a lot of overnight shifts. I can handle disruptions to my circadian rhythm, but I don't like it.
• I value the long-term physician-patient relationship, which Emergency Medicine lacks (except for the frequent flyers).

Some thoughts on specialties

Over Thanksgiving break, a number of people asked me what kind of specialties I'm interested in and whether I know yet what I want to be when I grow up. Although some enter medical school knowing exactly what they want to do - and end up doing it - a sizable majority of medical students have absolutely no idea until they're practically forced to make a decision at the beginning of fourth-year.

"That's what third-year clinical rotations are for," is my short answer when people ask me about specialties. I want to keep an open mind and not close any doors until I have experience-based reasons to do so. That said, there's also a long answer; but it should be kept in mind that this long answer is time-sensitive as it will necessarily change as I'm exposed to new material and new experiences.

So, without further ado, here is my specialty differential (at this moment, in no particular order):

1) Neurology: I have a background in neuroscience, so I obviously find the brain a fascinating subject intellectually. How that translates into day-to-day clinical practice, I'm not yet sure. I have shadowed several neurologists, including my Mentored Scholarly Activity adviser, but I won't get a full picture until my third-year neurology clinical rotation. I am interested in movement disorders, seizure disorders, and perhaps interventional or pediatric sub-specialties.

2) Emergency Medicine: I have been working for the past year in the Emergency Department with my Foundations of Doctoring preceptor. I like the pace of the job. I like that I'm (usually) presented with an acute problem that needs to be fixed immediately. I like the fact that I'd be doing procedures (e.g. lumbar puncture, joint aspirations) in addition to medicine. I like that I'm helping people who typically do not otherwise have access to medical care. I like that I would be working shifts and could leave my work at the hospital. That's especially important to me as I'd like to eventually have a family and be more than a nominal presence at home. I also like that my skill set could be put to good use in volunteering for organizations that provide medical care abroad.

3) Surgery: I like doing things with my hands - I have good manual dexterity from all those years of playing video games, and I'm good visuospatially. But, I know nothing of what surgery is actually like and how good I actually am with my hands. I'm also skeptical about the surgery lifestyle. My interest in surgery will come down to my third-year rotation experience.

4) Nutrition/Metabolism: It turns out that I really enjoyed the nutrition/metabolism unit that we just finished. I found it surprisingly interesting and applicable to everyday health. I'm a strong believer in preventative medicine, and specializing in nutrition or metabolism would be consistent with that value. Plus, with the obesity epidemic, the need for such physicians will only increase. I worked for four years in an eating disorder clinic, and my very first job in high school and college was chart review and data entry for a bariatric surgeon who performed laparoscopic gastric bypass surgeries. A career path in nutrition/metabolism would be consistent with what I've done in the past; still, I know very little about it in terms of clinical practice options and need to do some homework.

After the dust has settled

It's been a week or so since I learned that I would be heading to Colorado for medical school. My excitement for what's to come has only grown stronger over the past week as the disappointment of UCSD's rejection fades.

I decided on a tentative Last Day of Work: Friday, July 24. I contacted the admissions office and told them that I was "most likely" going to be matriculating. The 2009-2010 academic calendar isn't ready yet, but I did find out that the White Coat Ceremony will be held on my birthday (!), information that my parents needed so they could make plans to attend. I started the craigslist search for housing and have booked airfare to check out different neighborhoods in person to see how safe they are. A bunch of people I met during the open house have been very helpful in pointing me in the right direction or steering me away from bad areas.

Each of these steps have made the fact that I'm about to start medical school feel all the more real, even as I am literally fulfilling a dream. It's a wonderful feeling.

My future classmates have set up a group on Facebook for the Colorado University School of Medicine, Class of 2013. They seem like a great group, and I'm looking forward to getting to know them better. One guy who lives in Denver was kind enough to post a map of restaurants, bars, and things to do in Denver.

More silver lining than cloud

UCSD rejected me:

I regret to inform you of the decision not to consider your application further. The Committee feels that applicants who do not have any possible chance of hearing of an acceptance from us during the summer should be encouraged to pursue other opportunities for acceptance.

My first reaction was a visceral flash of disappointment. But almost in the same moment, a wave of relief washed away all of the anxiety that surrounded the uncertainty of my medical education and my life, as well as the looming decision between UCSD and Colorado.

I finally have some measure of certainty in my life, now. I can look forward to going to medical school at Colorado and actually envision myself studying and living there. I can make plans for housing. I can tell my friends who I met during the open house last weekend that I will definitely be seeing them in August.

More importantly, I am genuinely excited about going to Colorado. Numerous people have commented on my animation and enthusiasm when I talk about both my interview and open house experiences at Colorado. "You came away with such a positive gut-level feeling," my mom said, and she's right. In spite of the negativity of being rejected, I see more silver lining than cloud in this situation.

Colorado open house: impressions

My distilled impressions of Colorado after the open house:

I really like it here. I like the program, I like the people, and I like the environment. I can see myself being happy here for the next four years - at least, as happy as one can expect to be while going through medical school.

However, I feel that my experience this weekend was to some extent hampered by the uncertainty in my situation, not knowing whether I will end up here or at UCSD. The majority of my potential classmates are definitely coming to Colorado, but I did meet a significant number of people who are in the same boat as me, who either have multiple acceptances and are here to get a second look, or are on a waiting list at a school that they may very well choose over Colorado.

Aside from getting a second look at the program itself, meeting my potential classmates was one of my primary goals of attending the open house. I was struck by how many people are "non-traditional" candidates like me, not straight out of college but with some real life experiences. A lot of them have advanced degrees, are in committed relationships, and some even have children. As part of the program, a panel of students addressed issues such as housing, living on a budget, balancing work and play, and having a family during medical school. It was helpful to hear directly from current students how they are coping with the pressures of school.

There was a barbecue after the scheduled presentations and panels, and after the barbecue, a big group of us went to the Rockies game downtown. That was when I felt I made some meaningful connections with the people who I might be going to school with for the next four years.

That was also when I realized that Colorado is beer country. Being a wine guy, this revelation was cause for concern (said tongue-in-cheek). "We're sitting in Coors Field," one person told me. "Of course we like our beer!" At a bar later that night, I took a beer taste test of sorts. "That one tastes fine, I guess," and wouldn't you know, it turned out to be Coors!

I came away from the Colorado Open House with overwhelmingly positive feelings about the prospect of going to medical school here. Despite the drastic difference of tuition between UCSD and Colorado, should I be given the opportunity to go to UCSD, deciding between UCSD and Colorado would be difficult.

Colorado open house

Around this time of year, medical schools hold open houses to give accepted applicants a "second look" at their program. I was invited to the Colorado open house this coming Friday, April 24. Regardless of my current state of flux (I won't hear back from UCSD for weeks, yet, if not months), I am moving forward with the assumption that I will be going to Colorado for medical school. I am very excited about this open house to meet my future classmates and professors and to get a better feel for the program. Here are some of the highlights of the day:

• Faculty Panel on Tracks/Program Opportunities related to the Mentored Scholarly Activity (MSA)
• Global Health Track
• Rural Track
• Research Track
• Leads Program
• Financing your medical education
• Student panel topics: Maintaining Relationships, Choosing a Track and enjoying it, Managing Debt with good planning, surviving academic and personal challenges as a medical student.
• Student barbecue and ice cream social
• Rockies versus Dodgers game with current medical students

Drexel: Wait List

Well, I finally heard back from Drexel in a snail mail letter dated April 8. This is a week and a half longer than the long estimate they gave me of 6-8 weeks. It would have felt good knowing that I got into Drexel, but the reality is that I decided almost immediately after getting into Colorado that I would prefer Colorado over Drexel.

Interestingly, Drexel requested that I confirm my continued interest in writing:

• I choose to accept your offer to be placed on the "Wait List."
• I choose to decline your offer to be placed on the "Wait List."

They of course need this information to help them shape their incoming class. The flip side, though, is that I now get the puerile satisfaction of turning down Drexel without even having been admitted.

Jefferson: Rejected

Knew it was coming. Would take Colorado over Jefferson, anyways. No more needs to be said.

UCSD: "Acceptable Pool"

I got an e-mail rather than a phone call from UCSD this morning, which means that I was placed in what they call the "Acceptable Pool" of applicants.

This pool is essentially an unranked waiting list. As the admissions season continues, individual applicants within the Acceptable Pool will be selected for admission – we anticipate that the first acceptances from this pool will occur in early May 2009.

What this means for me is that I have quite a bit more waiting and uncertainty ahead. Although I am obviously disappointed in the immediate outcome, I cannot say that I am all that surprised. It's a tricky business balancing hope and positive thinking with the pragmatism of acknowledging that the odds of acceptance are long in such a competitive process. Regardless of the final outcome, I feel comfortable knowing that I had my fair chance at getting into UCSD and that I did everything in my power to maximize that chance.

Still, though, the game is not over. UCSD will be admitting applicants from the Acceptable Pool starting early May and even up through July. Given that I will be preparing for a move to Colorado in the absence of a UCSD acceptance, I have to consider: At what point do I write off UCSD? Early June? Mid-June? July? Right up until the first day of classes at Colorado?

UC Davis: Rejected

Like Irvine, UC Davis sent me a rejection e-mail (with a typo, even). They probably send e-mails rather than real letters to save costs, which is understandable, but it still comes off as cheap.

At this late stage in the game, I am only waiting to hear back from four more schools: UCSD should notify me on Tuesday (!); Drexel told me 6 to 8 weeks from the interview date, which was January 30; and I expect rejections from both Temple and Jefferson, schools that never invited me to interview.

Tel Aviv: Accepted!

It is with great pleasure that, upon the recommendation of the Admissions Committee, the Tel Aviv University Sackler School of Medicine - New York State/American Program wishes to offer you a place in the Class of 2013

Very exciting!!!

I knew that I would choose Colorado over Tel Aviv even before I got this letter. Regardless, it feels good to have the "right of refusal," as one friend put it, as well as confidence from knowing that I had options, as another friend framed my admittedly enviable position.

My interview with Dr. XXX, an alumnus of Tel Aviv practicing in San Diego County, was even more relaxed than my UCSD interviews. The most probing questions he asked were related to how serious I was in applying to Tel Aviv and how likely I was to complete the program should I matriculate. Can I handle the language barrier and culture shock? Do I have a support network in Israel, or could I function well half a world away from home?

Dr. XXX stated outright, in fact, that the admissions committee understands that Sackler is a backup school for many if not most applicants, and that those who are accepted to a program in the United States tend to stay in the country. Knowing this makes it a bit easier to turn down Tel Aviv. But, if I had not been accepted into any program in America, I would have been thrilled to go to Tel Aviv for medical school.

UC Irvine: Rejected

On the same day as my UCSD interview, UC Irvine sent me their rejection. It was waiting for me in my inbox when I returned from the interview. Yes, my e-mail inbox. It struck me as cheap and unprofessional that, after pouring so much time and energy into my application, they didn't even have the common courtesy to send me a formal letter of rejection through regular mail. I hope that other medical schools don't follow their poor example.

George Washington: Rejected

Another rejection. Though I'm used to it by now, and less fazed because I have already gotten into a good program, I am rather disappointed that I won't at least have the option to live in DC close to my older sister. It would've been a fun city to live in while going to medical school.

Oregon Health & Science University: Rejected

I got the thin envelope from Oregon this afternoon. I knew it was coming:

[I]t is the admissions policy of the School of Medicine to give preference to... residents of Oregon, WICHE-certified residents of Montana and Wyoming, MD/PhD and MD/MPH candidates, non-resident applicants with superior achievements in academics and other related experiences and non-resident applicants from diverse backgrounds. This year the number of qualified applicants in the aforementioned groups significantly exceeded the available placements.

Honestly, though, I feel more a sense of relief from finally knowing than dejection from being turned down. Of course, that may have something to do with the fact that I've already been accepted to a good medical school where I know I can be happy.