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Meet Your Match: USMLE Match 2014 Interview #1 – Houston, you have a Resident!

This is a series in which I post about the confessions of the USMLE matchers this year. I had encouraged people to fill in their responses to a series of questions posted here, in order that I could transcribe them into short narratives for people interested to know more about the match. If you have matched, or know anyone who has matched, please forward this link to them so that they can fill out the form as well! And if you are someone looking around for match experience narratives, well, here’s hoping you like what you read! I shall transcribe the narrative in the first-person so as to retain the flavour of the interview without compromising the identity as my friend preferred to stay anonymous.

Hello! I have matched into a good mid-tier Internal Medicine program in Houston. During the residency we rotate through multiple great hospitals, which adds to the diversity of clinical encounters; although the workload can be a killer, yet, one gains vast clinical experience. And isn’t that exactly what we are looking for during a Residency training?

internal medicine

Types of Doctors: Michelle Au

There were several contributing elements in my successfully matching into what is generally considered a highly ranked place. I had good letters of recommendation from the professors at the same University to go with what I think is a good overall profile and scores. I also had a bit of US Clinical Experience under my belt. The fact that the interview day went off quite well was an added advantage. I sent personalised “thank you” emails to the faculty/interviewers after the interview was done and I believe that was an added factor. I also made sure that I let them know that I planned to rank them high on my rank order list. I emphasised on this during the interview as well as in the thank you emails I sent later on. However, this is a tricky bit of strategy as the interviewer might misconstrue the intention behind the statements and one might end up alienating them. I believe that it worked for me, may not be the same for you!

But one of the most important things that bolstered my application were my scores. I had scores well in excess of 260 on both the steps, and a comfortable pass in the step 2 CS exam. I haven’t taken the Step 3 yet. Considering how competitive the whole USMLE has become right now, I think it is imperative to have good scores in order to make the cut. There is no way one should compromise on the scores.

The interview experience is of course a vital component of the match process. I was a little stressed out at the beginning of the first interview but then, things went on smoothly from there. Some vital tips for the USMLE Interview, which I can distil from my experience would be:
  • Prepare thoroughly so as to appear spontaneous during the interview. Answers to some standard questions, like, “So, why do you want to come here?” and “Why should we take you?” should be well rehearsed. Although it is probably true that these sort of questions are mostly asked by old school interviewers, you never know who will sit on your interview day. Also, these questions cover several domains, so it might be helpful to sort out other similar questions.
  • Know your CV inside out. This is point of conversation, sometimes a conversation starter if the interviewers like a particular aspect of your CV. Have a good recollection of what you wrote, especially regarding your achievements, as they will be the key pointers to prove your worth to the interviewers.
  • Appear confident, but not cocky. You do not want to throw off the interviewers by being too arrogant and too self-assured (if one can be that during a life-altering event like the USMLE interview!).
  • Look interested and invested during the questioning. Body language is critical and it is vital that you do not make the interviewers feel that you are too bored with the process!
  • Dress well, be personable. Appear professional and behave in a manner that is befitting the situation. If the interviewers ask you whether you have any questions for them, try to ask thoughtful questions.
  • If you can make the interviewer laugh, you are golden. But if you cannot, do not try to force jokes. If it happens naturally, that is the best thing. Humor can never be forced.
  • Go through the SDN thread on “How to blow your shot at a residency.” It is difficult to list out all the do-don’t points but this discussion is an enjoyable read through anyways.
  • For your top programs, fly into the city one day in advance. You don’t want to miss out on the interview at your top choice because of flight cancellations.
The Oatmeal Guide to Interviewing

The Oatmeal Guide to Interviewing

Another point that I believe went for me was my extensive United States clinical experience. I had about six months of experience behind me; two as clerkship, three as externships and an observership for a month. I has some clinical research and several publications and research presentations in conferences at my home country. Some programs did not seem to care for it because it was not US-based research while others seemed very impressed by it and asked me a lot of questions about it. Seems like having non-US research experience is a bit of a hit and miss affair. I had a wide variety of publications, including multiple first author original articles, several case reports, clinical images and letters to the editor. I did not have too many extra-curricular activities on my CV; it did not seem to weigh me down though some people are of the opinion that it helps to have some as it shows a well-rounded personality. I did not feel that it weighed me down.
Publish or ...

Publish or …

Relative importance of some aspects of the match according to me:
Step 1 Score: 10/10
Step 2 score  10/10
Personal statement  10/10 Try to throw in some humor, but be careful.
Clinical experience  15/10
Research experience  20/10 If you can get it from a good university in the US.
Publications  5/10, unless these are in reputed journals, then 10/10. But I think most university programs would appreciate it if you demonstrate scholarly activity.
Interview  10/10.  Year of graduation is also very important.
At the end of the day, different programs use different ways to rank candidates. As an IMG needing a Visa and working from my home country, it has been a challenging experience from me, but then again, anything worth obtaining is worth fighting for. Sometimes it may seem that the gradient is tough and the time line is too complex, but in order to be able to achieve your dreams, one has to make a lot of sacrifices and adjustments. This exam is not just a scholastic journey, but also one where you grow from strength to strength!
All the best!
Wish you a minion successes!

Wish you a minion successes!

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Rural Posting Post-MBBS: Part 1 – Why it is a bad idea

These past couple of days, the medical student community of Delhi (and by extension, India) has been seething with discontent over a piece of legislation that has been reverted after intense pressure from junior doctors at all levels. I have been very vocal on twitter and social media about the unfairness of this sudden imposition of a policy, to the level that I managed to alienate a dear friend who differed with me on this issue. So, I resolved I would write a couple of posts trying to highlight the pros and cons of this decision. In this post I shall present the popular view: that the imposition of the rural posting was an unethical one and needed to be reverted.

One has to face so many troughs and peaks in the roller coaster of a ride of a career in medicine, that sometimes, weariness creeps in; and sometimes, when that happens to me, Sir William Osler comes to my rescue. So, I would like to begin this post that stinks of weariness (and some shall label it saturated with selfishness as well) with these words that have sustained me through times lean and mean in a short career which has seen dizzying highs and depressing lows:

Oslerphilia Unplugged...

Oslerphilia Unplugged…

Before I begin to dissect the issue, a little background about how the Indian medical education system works for my non-Indian readers who may not be acquainted with the uniquely weird system that we are accustomed to.

India has a two-level medical education system. The first level commences right after high school after one qualifies a gruelling entrance examination. This consists of 4.5 years of didactic training in four different slots, teaching 14 major subjects. This is followed by 1 year of hands on “internship” where one is supposed to learn the ins and outs of the business of being a doctor. Following this 5.5 year ride, one gets the degree of MBBS, which is the primary medical degree in India. An MBBS doctor is the primary care giver in India, but owing primarily to the better employment opportunity afforded by specialisation, through obtaining of an MD/MS degree, the MBBS degree has slowly lost its sheen. It used to be a matter of great pride to be an MBBS doctor even till our parents’ generation; and within ONE generation, it has become redundant. In fact, it has been quite a while since I wrote about my views on the MBBS being a vestigial degree (and received a lot of mixed reactions for it!). The truth remains that this MD/MS degree, which is a 3-year course and can be done after one clears another entrance exam (the eligibility for which is the MBBS degree), has changed the landscape of medical education. Without going into the specifics, let me just say that one’s medical career is considered worthless if one does not obtain an MD/MS specialisation. Truth be told, the better employment opportunities, combined with the fact that Indian society is still a hubris-fuelled, intellectual feudal system, has elevated the status of MD/MS to an astronomical level. Students nowadays commit suicide if they do not get into a “good field” at the MD level. I know people who are worried about getting married because they think that their lack of an MD degree renders them poor “marriage material”. However, one fact that makes it even worse is that the whole postgraudation system is super-skewed. For about 45,000 MBBS graduates every year, there are 7,000 MD/MD/Diploma seats (give or take some) every year. Given the large “waiting list”, the ratio of applicants per seat sometimes exceeds 12-13. With such infinitesimal chances, and such a huge premium placed on the value of an MD degree, I guess you can imagine what must be going through the minds of a medical graduate who is fighting for an MD seat…

The point in making this long-winding introduction was to state the gargantuan importance of the post graduation degree in our lives.

In this scenario, the health ministry comes up, quite unilaterally, with the demand that the 5.5 year MBBS course be extended by a year, by adding one more year to the internship (making it a 2-year internship) and then add another optional year of rural service in order to make the MBBS graduate eligible for taking MD-entrance examinations. Here is a screenshot of the notice that makes these propositions:

Notice for 7.5 year MBBS course in India

Look at Point No.2

Understandably, the medic students and interns, who were facing the butt of these new regulations were infuriated. Many viewed these unilaterally taken decisions to be driven not by altruism and a good will to develop the healthcare system, but as a populist agenda, with an eye on the vote-bank politics. The fact that the legislation was put into effect with the myopic, one-shot solution of sending doctors, without having anything to say about infrastructure development, provision of drugs, para-medical and nursing staff, did not help either. Also, given the disequilibrium in the number of PG seats when compared to MBBS seats, it would mean that a greater fraction of the graduates would be doing this rural posting without eventually getting to do an MD/MS. This sounds like an unfair deal to me, especially since the understanding was, when these students joined the MBBS course, that it would be a 5.5 year ordeal.

On a personal level, I find it morally repugnant that the MBBS student is being arm-wrenched and coerced to go to a rural posting with the gun of being ineligible for PG being held to their heads. The truth is that given an option most MBBS graduates would rather stay in the cities, and turn their back on the rural side. One may argue that it is a major reason why, despite increasing the MBBS seats, there remains (and shall also remain in the future), a dearth of physicians in the rural India.

However, sending a fresh pass-out to fend for himself or herself in the trenches of rural medicine seems a little cruel and misdirected. It seems, in the garb of providing healthcare, a veiled assertion that the rural Indian deserves this. The very logic that “this is better than no care” also stinks of populist agenda. So, we get to keep the MDs and specialists in the cities and send in the rookie, newly drafted physicians to the rural hinterlands to find their way via trial and error; without oversight, without supervision and without the infrastructure to deal with the issues being handed to them. While one may argue that there is no point sending a radiologist or plastic surgeon to the rural primary healthcare centre where there no facilities to utilise their skills, the question is, why not? While one may not expect an MRI or CT scanner, a USG or an X-Ray machine should be present to aid diagnostics. Otherwise the over reliance on quacks, private practitioners and abuse of the referral system within the traditional chain of primary>secondary>tertiary care system will continue unabated. This is where the demand for infrastructure development comes in. Each PHC, ideally, should serve the basic needs of the patient. When I was an intern, not too long ago, I was left aghast to see cases of malaria, diarrhoea and typhoid, to name a few, (which are all very common diseases in rural India), being referred through the entire primary>secondary>tertiary care framework. Eventually, a simple case of dehydration caused by diarrhoea would end in disaster because by the time the patient was brought in to the tertiary care centre, he was in shock, his kidneys had shut down and things were spiralling down faster than one could manage.

Sending an inexperience, unsupervised MBBS graduate to an ill-equipped rural PHC might look great on paper, but in reality, will solve nothing, as practically they shall be recruiting one pair of extra hands to send patients up the referral chain.

At the same time, I find myself disgusted to say that post-internship MBBS students are really poorly equipped to deal with patients on their own. I find students who have not undertaken normal vaginal deliveries or repaired episiotomies in their entire internship tenures. While some contend a two-year internship would be a good way to improve the lacking skills, I seriously doubt it. If one year in this particular system has not helped them to develop the skills, where is the logic in saying that double the time shall? One good way to ensure that their skills, theoretically and practically, could be tested was the common exit test (which came with its own retinue of issues). However, that seems like a distant nightmare now, and the medical education system, by taking these poorly designed, tentative steps is pushing development backwards instead of taking it forwards. Now all change in policy will be viewed with suspicion and anger.

So, MBBS graduates are too selfish to attend to the rural Indian? I am sure if given a proper set-up to work with, and properly incentivised, a large fragment would still go for this rural stint. One way I see this can work, at multiple levels, is if one is sent off for a year of rural posting immediately after qualifying for MD. In that case, another major issue, that of accommodating 45,000-50,000 (and growing) MBBS students into a fixed number of jobs (with a good pay as well) could be dealt with. These doctors, who have just crossed the threshold of the MD-entrance examination are still MBBS and are not yet specialists, so one cannot argue that their skills shall be wasted in a bare bones PHC. While there is some merit to the argument that the MD course is meant for specialisation and not for working as general practitioners, this could be taken as an eligibility criterion to sit for the MD exams. This could be somewhat like the thesis or dissertation that one has to submit in order to obtain eligibility for sitting the MD final examination. Indeed many students undertake an MD course with the view of becoming a clinician and not a researcher; so if they can be “forced” to do a thesis, why not “force” them to do a year in a rural PHC?

These rural PHCs could be tied in with a mother tertiary care centre. This would ensure that there is  a better communication between the members of the referral chain and would actually bring more teeth to the curriculum of Community Medicine and Public Health that caters to this particular branch of healthcare management. Another irksome problem could be solved by enacting that one cannot quit the course during the rural stint year: that of PG seat wastage. These days, a growing trend is to take up one subject in MD/MS, work and study for a year, get a better rank in the entrance exam next year, quit and take up something else. If the rural stint was associated with the eligibility to write the MD final exam and one was not allowed to quit during this year, it would mean that quitters would have to do two years in rural service instead of one. This would dissuade casual candidates from taking up and blocking or wasting seats.

Of course, there is no saying that the skills of these MD first year students will be any better than post-internship students; probably they shall not be any better, but at least they shall not be coerced into going as the MBBS students are being now. And for those who do not end up doing an MD/MS specialisation, which is a significantly large number, one year would not be wasted in the wilderness doing rural service. They could explore alternate routes to further their careers.

Some have also claimed a different solution. A significant number of students come from rural backgrounds. Like the US Military (or even the Indian AFMC grads) scholarships, could we incentivise their training in exchange for ensuring that they serve a certain period following graduation in a rural setup? Could we, maybe, reverse the trend of caste-based reservations, for reservations based on economic considerations and then use this corpus to build up a force of empowered, dedicated rural physicians who shall be working in a system that they have grown up in (rather than sending in city slicks who shall need time to acclimatise)? I know this is too radical to happen in the next two decades, and given the proclivity of Indian politics to entertain populist vote bank agenda (and the strong caste-based system entrenched in the system), in forever, but this would solve several problems in one fell stroke.

I know that the issue of being a doctor and protesting against a rural stint seems antithetical. It is almost as if I am betraying the Hippocrates’ oath, but the truth could not be further from it. If the ministry enacts a law asking MD students to do a year of rural service, I would be the first one to sign up. And I think so would most others. because despite what society thinks of doctors in general, we still have those dreams in our eyes where we are making a contribution to the segment of society that needs us the most. In exchange, all we ask, is that we are given the infrastructure and the system for us to execute our skill set and some safety, and incentives. Is that too unreasonable a demand? I believe not.

It is not an ideal solution: there is a real problem; people are dying for the lack of a trained, credible care giver. And standing at the juncture of such a problem it seems trivial to cavil over one year this way or that. But then again, one cannot also take the matter of the lives and careers of thousands of the best minds for granted. This is a catch-22 situation and any policymaker would hate to take a call either ways. There is no right decision. There is only derision and criticism. There is choosing between disenfranchising the poor further (or providing them with band-aid healthcare) and pushing the best minds of a generation away from the system, by encouraging brain drain with a policy that is viewed a punitive (or populist). One can only wait and see how things work out over time; whether a graded, incentivised rural posting system can be brought in; or whether a blanket system is enforced, coercing students to go to “serve” against their will, dispensing a service they are ill-equipped to provide.

I began the post with a quote from Osler. I would like to end with another quote. This one from one of Osler’s disciples and one of his best known followers (though not a direct student). This reflects our belief in the nobility of the profession, reflects our passion, pride and joy in being doctors, our destiny as physicians… and this reiterates that we are not petty, feudal, feuding clans clashing for personal aggrandisements but we still have an iota of passion to serve left in us. It is a reminder for each one of us, to lift our noses from our sweat-stained books, and for a moment, remember how romantic it is to be a doctor…

A Physician's Destiny...

A Physician’s Destiny…

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USMLE Match 2013: Part 1: Positions per Applicant – Revealing the IMG Story

This post has been long due, and I have been rather flattered that I received several “requests” for this post as a follow up to my previous ones; you can find the previous (recent) posts related to USMLE:

US Budget FY 2014: Did the US Govt Make USMLE Tougher for IMGs?

USMLE 2013 and IMGs: All That Glitters is NOT Gold

The USA Dream for IMGs: Coming to an end? Analysing the 2012 Match

The problem is, it takes quite a lot of time to go through the 116 page results document, in addition to the additional documents that the NRMP comes out with. Then there is the time to read and extract the bits I want to write about. And then finally sit down and write it out. It all means a significant time investment, which I have not been able to make of late. So, I finally decided that it was high time I got these posts out (since interview season is almost done, it is indeed too late for this post already), but I thought it would be better to send them out in parts as it would give me a better chance of writing them out. Once again, these analyses and interpretations are very personal and you should not judge the exam or make any career decisions based on these. I would exhort you to exert yourself and chase down your dreams and not let anyone’s blogging bog you down! Read on then…

This is a long post; if you do not have the time or the patience to go through this, I encourage you to scroll down to the last paragraph for the TL;DR version.

One of the most important metrics that goes into identifying how good a chance one has in any competitive exam is the metric of positions available per applicant. This has consistently been reported since the system came into being in the annual NRMP match report and has become a focus of attention for me. The importance of positions per applicant is in the fact that with each year more and more people compete for the USMLE and it is rapidly becoming a difficult nut to crack. We take comfort in the fact that each year more and more seats are added to the matrix and tell ourselves that it affords us slightly more breathing space, but the story doesn’t end there.

The real metric here at play is the positions available per active applicant. Now let us take a look at the numbers.

This year, a record number of applicants put their names in the hat. 40,355! This is an increment of almost 2,000 students as compared to last year. Out of these, there were 34,355 active applicants. An active applicant is anyone who has submitted a rank list. A lot of candidates withdraw from the match process, and they do not get counted in the final tally. The active application number went up by 3,000 as compared to last year. Here is the overall break-up of the numbers of applicants over the last 5 years:

Overall numbers of active applicants in the USMLE

Overall numbers of active applicants in the USMLE

There was a slight reduction in the number of US active applicants last year, following which there has been a major bump in 2013, which has led to a record number of US grads applying in 2013. However this is set to get worse in 2015 as a spate of new AMGs will flood the systems as they come out of the newly established schools and set foot into the entry portals of residency. How the numbers change then would be an interesting study.

Active US Senior Applicants in the USMLE

Active US Senior Applicants in the USMLE

The number of US citizen and non-US citizen (or, as we call them, the true IMG) international medical graduates who applied for the USMLE this year also saw a record bump in numbers (I get this feeling we are going to use this sentence over and over again in the days to come!):

Active US and non-US Citizen IMG Applicants in USMLE

Active US and non-US Citizen IMG Applicants in USMLE

With this backdrop in mind, we need to understand the implications of the calculations that follow. First up, if they seem extremely rosy as compared to last year, beware that this might be because of the “all-in or all-out” system that has been put up in place from the 2013 match onwards. There has been some discussions as to what that might mean in the long run, some of which I had summarised in a previous post here: USMLE 2013 and IMGs: All That Glitters is NOT Gold.

Before we move on to the finer numbers, let us take a look at the way the Positions Per Applicant (let me shorten it as PPA as I shall be using it abundantly in this post) has changed over time:

Positions/Applicant over time (AMGs red; IMGs dark blue)

Positions/Applicant over time

The edits I added in red indicate the values for the US graduates and the ones in what I believe is a dark blue is for the IMGs. In the 2013 match although there were a record number of unmatched US grads, it was also by far the best year for US grads to match in based purely on the metric of PPA. The assumption is that AMGs would have applied uniformly to all the specialties, but that is not the case. The NRMP has come out with detailed match statistics on a specialty basis this year, which I intend to pick up in a later post; it is most likely that the higher unmatched numbers are due to the fact that more AMGs tried to match into the more competitive specialties with lower match rates in general. This has led to a large number of unmatched candidates despite having a very favourable PPA overall. I shall dwell on this aspect in a later post.

Anyways, coming back to the PPA analysis, one thing that has stood out is that the NRMP has declared only the overall and US IMG PPAs. They have left the numbers for IMGs out. Although the data needed to calculate that has always been around, I do not think anyone really had the time to bother about it. The overall and US trends have usually been a good indicator of the stats. However, since more than half of the active applicants are US grads, it is most likely that the overall PPA would be pulled up by their numbers. Here again, we are working on the assumption that given a chance an AMG will match into a position when compared to an IMG (which should be how it is, considering that it is the American system after all and it would be unfair to disenfranchise the AMGs of what is rightfully theirs). Anyways, so I decided to calculate the figures for the IMGs in order to unearth what the prospects actually looked like for the IMGs.

Now the thing is IMGs can be of two types, the ever-growing numbers of US citizen IMGs and the non-US citizen IMGs. The impression was that the former are slightly better off and that has been reflected in their marginally higher match rates as well; but given the diverse backgrounds of the whole brand of “IMGs”, it is a difficult (and possibly biased) endeavour to classify them all under one statistical umbrella; but there is no way out and hence this generalisation will have to be accepted for all its flaws.

The overall PPA has stayed fixed at 0.77 for the past three years, which as 0.75 (the lowest ever) the two years preceding that. The fact that despite the addition of almost 3000 extra positions this year thanks to expansion of programs, and more so due to the all in principle, this should have seen a sharp spike. The fact that it did not points to the issue that the competition is growing more intense each year. Let us see how the IMGs have fared overall, in comparison to the US grads and overall picture. For the analyses from here onwards, I shall majorly restrict myself to the past 5 years as that is the time frame with the complete data set in the report:

PPA of US Seniors, All participants and IMGs combined

PPA of US Seniors, All participants and IMGs combined

ppa_usa is the PPA for the AMGs, ppa_overall is the PPA for all active applicants and ppa_img is the PPA for the IMGs combined.

So we see that the PPA has risen sharply both for the IMGs and the AMGs but have not been changing overall. The only way I can account for the discrepancy is that there has been a concomitant increase in the osteopathic and other candidates (US Seniors, Canadian, fifth pathway), which has accounted for the stagnation of the PPA despite a fresh influx of positions that has bumped the numbers for both IMGs and AMGs.

In order to arrive at the PPA for IMGs, I assumed that all AMGs, Osteopathic students, 5th Pathway applicants, US Seniors and Canadian students would match ahead of the IMGs. While this is definitely not a reflection of reality where a lot of IMGs give the AMGs a run for their money, I believe while assessing our possible futures, it is better to play safe with pessimistic numbers.  So, I deducted all the seats consumed by the matched groups to come up with the IMG PPA metric.

Further, in order to understand whether US IMGs fared better than non-US IMGs, I further split up the data for the IMGs, working on the principle that US citizen IMGs would match ahead of the others. So, comparing these two groups, we see:



ppa_usimg is the PPA for US Citizen IMGs and ppa_net_img is the PPA for non-US Citizen IMGs.

As the numbers for the true IMGs (please do not take it the wrong way) emerge, we see the wide gulf that separates the IMGs from the other groups. The smaller number of US Citizen IMGs is probably responsible for the rather high PPAs. Notably, though US IMGs have a slightly better match rate (in the 50% zone) than the IMGs overall (around the 40-42% zone), the numbers are starting to look up. Though I assumed that the US IMGs would match ahead of the non-US IMGs, and the data does show a slight trend to that effect, for all practical purposes, in terms of raw numbers, the difference is hardly worth noticing. Here is a table that depicts the match rates over time:

Match Rates of Different Classes of Applicants Over Time

Match Rates of Different Classes of Applicants Over Time

So, to come to the TL;DR version of the whole ramble:

  • with the all-in system, numbers all across the board took a big jump as more seats opened up for the applicants
  • AMGs continued to enjoy a good match rate despite the initial fears caused by the widespread reporting of about 1,100 unmatched AMGs, the highest till date
  • AMGs had the highest ever PPA (positions per applicant), 1.51
  • the US citizen IMGs had a slight improvement in PPA, going from 1.40 to 1.42
  • the non-US citizen IMGs also enjoyed the benefits of the all-in system as their PPA jumped from 0.37 (on which it had been stuck for 3 consecutive years) to 0.39. This is still a rather sorry figure
  • despite these subgroups enjoying a higher PPA, the overall PPA stayed stuck at 0.77 for the third consecutive year, which is a slight improvement over the worst-ever figure of 0.75 in the two preceding years. This stagnation can be accounted for by the increase in the numbers of US previous graduates and specially osteopathic students.
  • a record number of students of all types applied for the match this year; and this is set to get only bigger next year. There was a significant increase in the active applicants across board (except for fifth pathway applicants who comprise a very small and rapidly vanishing segment)

With these numbers in mind, I would like to think that this year might be a better match year than before. In fact, considering the amount of seats (1000+) that went into SOAP in 2013 and anecdotal evidence of how people did not want to go with pre-match programs, more programs will decide to go all-in. Applicants are anyways wary of programs that are taking students all-out through the pre-match because of concerns about quality of training and other stuff, and keeping that in mind, more programs are likely to go all in this time. That would mean the highest ever available positions, and the best possible metric for PPA (even with the ever expanding numbers of applicants).

So, if you are a USMLE aspirant and can make it to the end of the road by September, I say go for it, put your name in the hat, statistics might just get you a program!

XKCD: For me it is the USMLE!

XKCD: For me it is the USMLE!

More analyses of the 2013 match stats in an upcoming post!


The Death of a Disease: India Eradicates Polio

Today (13th January, 2014) is a landmark day in the history of public health in India. It is exactly three years since the last Polio case was detected in India. Ruksha Shah, from the Subharara village in the Panchla block of District Howrah, West Bengal was the last recorded case of Polio in India. India has traditionally been a difficult country to eradicate polio from. There has been a steady trickle of cases despite massive efforts to control the disease and there have been pockets that have been difficult to reach, both due to geographic and cultural reasons. However, all of these are now slowly being pushed into the background as India is awakening to a new era: of official polio eradication status.


Image Courtesy: GAVI

It is indeed a wonderful achievement simply because of the enormity and the logistic immensity of the issue. Imagine reaching every nook and cranny of a billion-strong nation, a cultural cornucopia, a polyglot of languages, a social-cultural-economic potpourri with one single message: two drops of life (the oral polio vaccine, of which two drops are given, was popularised with this catchphrase in India: do boond zindagi ki) and armed with a small vial of vaccine. Imagine meeting resistance from cultural pockets that believed that the vaccine was actually a vile ploy to cause sterility and control population; then trying to convince an entire community that it was not the purpose for the vaccine. Imagine the man-hours and the money that needed to be pumped in to ensure that the target groups were vaccinated, then a door-to-door round up was done to ensure nobody was missed; followed by an external monitoring system for quality assurance! And all of this concerted effort in order to bring down a disease that had almost been uprooted, but obstinately refused to be eradicated completely.

One must remember that this national-level concept of eradication, however, is slightly naive. Yes, it does bear testimony to India’s commitment to eradicating the disease, yet, the very concept of disease eradication at a national level remains pretty much redundant in today’s global village. A small example of the fact:

Image from: GPEI: http://polioeradication.org

Image from: GPEI: http://polioeradication.org

Globally, in 2013, it has been the non-endemic countries that have contributed more to the load of polio cases. That is, countries that had eradicated the disease (like India), were the ones which got re-infected with the stubborn virus. Importation of cases is a major problem that has been the bane of the eradication efforts. The three countries that still remain endemic for Polio, Pakistan, Afghanistan and Nigeria, have scaled up the efforts to reach eradication status, but that seems to be a distant dream. Especially true for ares in which there is political unrest and organised terrorism, for these countries, and many others in which polio is an emerging threat, the virus is but a mere part in the whole game. Social, political, economic and cultural determinants have become equally, if not more, important factors in the bid to eradicate polio.

A classic example of Polio becoming a biosocial phenomenon with aetiologies grounded in more than just biomedical issues is the case of the Syrian Arab Republic. The site of an ongoing political unrest, with the resultant breakdown of social and other security systems, this nation experienced an importation outbreak resulting in 17 cases in October 2013. What has to be noted is that Syria had not reported a single case of polio since 1999 and a decade and half long success crumbled in the face of a mere few months of instability. This does not bode well for any nation, globally speaking, as long as there is transmission of the virus and reporting of cases from the endemic nations.

Being a subclinical infection that can be carried around without any obvious symptomatic appearance, polio has managed to spread on a global level from a few foci. And though we have many reasons to laud the efforts in India, we still have to keep up our guard. The threat of importation is real, with the complex geopolitical issues at play. And the need to maintain a high level of herd immunity to ward off imported virus is self-evident. Also important is the need to have in place a strategy that phases out the live, attenuated oral vaccine and instead shift to the killed, injectable one. This is an important shift because this will have to use more trained personnel as an injection is a procedure with higher complication risks than just delivering drops orally.

There is no room for slackening. The fear is that, with the news and celebration of the eradication coming through, there will be some sort of a release phenomenon and some complacence will set in. There is, however, no room for slowing down. The momentum needs to be maintained and, if anything, an increased alertness should be instituted to keep up the morale of the workers who might want to slow down. It might be easy for the community to regress into a state of denial about vaccination and lose the ground gained in the past few years.

It has been a long time coming, and rarely does one have to wait for success to be served cold. However, the three years is up and India and her public health professionals are awakening again, it is the moment of our tryst with destiny. It is our unique opportunity to create a watershed line and mark the rise of a healthier nation.


Showing Polio the Finger: A Lesson in Public Health

As students of Public Health, we, in India, are witnessing history in the making. It is not often that one gets to see, and be a part of a revolution that is the eradication of a disease. I know that global polio eradication is still under threat because of multiple issues. And with countries in which eradication had been achieved falling prey to re-emergence of the virus, the question looms large whether we shall be able to achieve global eradication in time (or ever at all!). However, India is merely weeks away from reaching the third consecutive year without registering a single polio case and is well on its way to become one of the countries with eradication status. One prime driver for this sustained success has been the massive vaccination campaign that has targeted the disease in a way one has never seen before.

As part of the push for universal vaccination, monitoring of supplementary immunization activities is a critical event. We were posted as External Monitors working with the NPSP in order to monitor and report back on the efficiency of the booth-based, as well as house-to-house vaccination against polio. I was posted way back in February and ever since I have wanted to write about this experience of mine. The only thing holding me back, aside from my laziness, was the fact that I wanted to hear my colleagues’ experience of working in this posting.

During the monitoring, we were sent to vulnerable areas to assess vaccine coverage. I shall not go into the boring methodological details of how we were supposed to cover every area and sample kids in clusters in order to assess vaccination status. I shall try to distill in this narrative my experiences of working in the “trenches of Public Health”.

Although New Delhi has, officially, like less than 5% of rural areas, as a result of the rapid urbanization and growth of the city, it has seen development of urban slums and resettlement colonies and clusters of mobile populations who are at high risk for poor vaccine coverage as well as act as mobile disease vectors.

I was posted to one of the best areas in terms of vaccine coverage. All through the week, I had to wend my way through alley ways with clustered tenements. Sometimes, they were claustrophobic in their arrangement, and the population pressure was clearly visible there.

SONY DSCSome of the houses, which were usually only single storeyed, had a rigged together “upper floor” built on, and the only way one could access the family living upstairs was using a ladder that laid angled against the wall. There were other entrances, but sometimes, to access those stairwells, I would have togo through as many as four different families’ living quarters. It was an extremely uncomfortable notion for my city sensibilities, where we mark our territories with almost feline ferocity. Here I saw children from one family freely mingling with those of the next, families sharing space (or the lack thereof) with a sense of community that we, in our cubby-holed, pigeon-cooped flattened out lives would consider to be nightmarish. I am sure this extreme proximity also prompts friction that can add to the ardors of life, but there must be a feeling of community fraternity to balance the scales as well.

SONY DSCOne thing that struck me was the efficiency of the ASHA and Anganwadi Workers in one particularly densely populated slum. The ASHA worker, one Ms. Shabana, was particularly impressive in her knowledge of the terrain of the slum and the residents thereof. If an External Monitor unearths unvaccinated cases, it comes down really heavily on these workers, since they are the interface between the system and the people, hence, sometimes, they tend to hurry the Monitor along as they traverse through areas they know are liable to carry missed children. This group of workers, on the contrary, would urge me to choose any house to go into, and even predict the names and numbers of children living in each of the blocks.

One could well argue the case that this group of workers were very close to the ideal model social health workers, who brought health and awareness to the homes and hearth of people.

During the course of my monitoring visits, I made it a point to talk to the locals, the mothers, the grandmothers, the mothers-in-law, and understand their perceptions of the disease and the process of vaccination. In this particular constituency, I was surprised with the high awareness levels, high routine immunization coverage and high socio-cultural acceptability of the concept of vaccination amongst the least educated groups. This was an eye opener that pointed out how effective a motivated social health worker might be in instituting change at the level that matters the most: the women of the household.

SONY DSCIt was, therefore, a matter of great joy, when a whole group of children swarmed their “didi”s (elder sister) and gleefully held up their little fingers (that is the finger that is marked with indelible ink when a child has been given the oral polio vaccine) to show off their vaccinated status; and I got one of the most enjoyable, precious moments in my short life in the field of public health ad disease prevention.

Some other areas were, however, less impressive. One area was, in particular, very drastic. I detected a number of unvaccinated children in this area. It was basically a construction site, which spanned over a kilometer in length and width. There were scattered families of construction workers living in the half-built houses, behind plastic sheets, or in dark, dingy and damp underground basements which afforded protection from the merciless Delhi afternoon sun.

SONY DSCThis was in the aftermath of the infamous Delhi rape case and because of the shifty nature of the area, the vaccinators, who were mostly women, were very wary of walking into the area or into the basements to seek out renegade children. Given the fact that these families were mostly nomadic construction workers who traveled in bands of 3-4 families (originating mainly from Uttar Pradesh and Bihar; and eastern fringes of West Bengal, as well as Bangladesh), there was an inherent mistrust as well. This led to the obvious result that the vaccine coverage was atrocious.

SONY DSCThis experience further reinforced my belief that health is not attainable merely within the framework of investment in the halthcare system. We need a wide view, encompassing social, cultural and economic growth and inclusion, without which all efforts at attaining public health nirvana is like trying to stop a leaking dam with band aid. Organized terrorism or even local disturbances are an emerging socio-political threat to public health systems and we need to evolve with the changing nature of the threats we face if we are to continue on the train of disease elimination.

SONY DSCOne particularly humbling experience was what led me to my second biggest catch of unvaccinated children. There was a huge mound of refuse and stinky garbage lying in between two building blocks. The stench was so repulsive and the leaching fluid around the mound of refuse so nauseating, that it was inconceivable for anyone to venture in that direction. I was on the verge of turning back on the abhorrent effluvium when I noticed a few children playing and running past the mound, even looking at which brought tears to my eyes.

And then I saw three children run off behind the noisome dunes of refuse. For a moment, I considered giving up the chase and dithered. There wasn’t much of another way into the block, unless I considered going the whole length around a block of barricaded and scaffolded buildings. But that would definitely take too long and there was scant opportunity that I would be able to get to the children in time to get a look at their left hand little fingers for the tell tale mark. So, after a moment’s hesitation, I took off after the children, running through the squishy gunk, my boots sinking into the soft, quick sand like ground underfoot, as I tried to switch off my mind from the revolting wave of odor that hit my senses. In a moment, I had gone across the huge pile of refuse and was standing in a clearing, dotted with children playing and running around. I sensed the vaccinator team warily making their way across the swamp of bubbling, rotting refuse that I had navigated, like the children, with scant consideration of what I was stepping on.

SONY DSCAs expected, it turned out that several children living in the huts there were unvaccinated and with good reason too. It would be unreasonable to expect the poorly paid, almost-voluntary activists to take so much pains to find children living in such difficult to access areas.

Another thing that caught my attention was how the existing routine immunization and ICDS/Anganwadi system infrastructure was being utilized to implement oral polio vaccination. The commitment of the teams all across the boards was laudable. Indeed, without such highly committed people, toiling for little money, and even lesser appreciation, the whole program would have fallen flat on its face. The warmth with which the teams received me was also humbling. I found these under-appreciated people, who work far from the highlights of acclaim and fame to be much more committed to the cause of eradicating polio than many of their much vaunted, celebrated bosses. In fact, even the areas in which I uncovered unvaccinated children and recommended repeat immunization activities, the teams were not just apologetic for missing out, but resolved to change the picture over the next times. Although I would not go back to those areas again, I am confident that the steely resolve I saw in the eyes of some of the center coordinators where I had recommended repeat activities would bear fruits in the times to come.

SONY DSCWe still have some distance to go before we are certified polio-free, but I guess we are one helluva lucky generation of public health people. We are witnessing the eradication of a disease so early on in our careers, that we might become one of the few clutches of people to have seen multiple diseases being wiped out from the face of the earth.

However, at this juncture, I would be failing this post if I did not mention one rather discouraging aspect of the whole business that struck me: the tendency of the general public to be relaxed and casual about the business of vaccination. Most of the children who had been vaccinated were given the oral polio vaccine during the house-to-house trips by the vaccinator teams. Fewer and fewer people seemed to be motivated enough to go to the booths that are set up on “Polio Sundays” in order to get their kids the vaccine. Their argument was the workers come over anyways, so why bother finding time from an already packed “family day” to go get their children vaccines? I consider this a disconcerting trend because the house-to-house visits are not, primarily, for vaccinating children. They are a safety net to catch children who may have slipped through the system and stayed unvaccinated. However, with more and more parents assuming the rather passive role where they now demand as a right that the vaccinators come and provide vaccination at their homes, this might not be a good trend. In fact, if this mentality was to spread into the matter of other vaccinations, it could be a major disaster for the routine immunisation activities. In our centers we are often non-plussed to find parents who bring in children late for vaccination, sometimes by months, simply because they were too passive or too casual about it.

This trend apart, the system that has been worked up to kill polio is fantastic on so many levels. In his book “Better”, Atul Gawande talks about his brush with the massive polio vaccination work that is going on in India. He talks about the mop up activity following the detection of an index case of polio in Karnataka. We have been fortunate enough to not have a brush with a case of polio in almost three years now, but the scale on which the polio eradication and surveillance program is running has left me dumbfounded. It is one thing to read about it in the drab and dreary textbooks, and an entirely different experience to see it in action, on the ground, in the real world, in real time.

Gone are the days of wards filled with patients on negative pressure respirators that helped the polio afflicted people tide over the acute phase of respiratory muscle weakness. Now the polio afflicted can be counted on your finger tips (well, not anymore this year, thanks to the explosive outbreak in the Horn of Africa). The disease that once made us gasp for breath is now gasping its final breaths.

Put out the light, and then put out the light.
If I quench thee, thou flaming minister,
I can again thy former light restore
Should I repent me. But once put out thy light,
Thou cunning’st pattern of excelling nature,
I know not where is that Promethean heat
That can thy light relume. When I have plucked thy rose
I cannot give it vital growth again,
It must needs wither.
- Othello, Act 5, Scene 2
William Shakespeare

Polio patients on rion lungs

Polio patients on rion lungs


The Family Physician: A Dying Romantic Idea

I have been known to lament the loss of the prestige of the basic medical degree (MBBS) in India. While you may or may not agree with it, the truth remains that nobody who is doing (or has recently done) an MBBS course wants to stay out at that level. Everyone wants to go and be a specialist or super-specialist. In the melee of confusion arising therefrom, we are slowly pushing the generalist, family physician to an early extinction.

Even William Osler, the Father of Modern Clinical Medicine, was enamored by the concept of the omnipresent (and often omniscient) general practitioner. Osler once said:

“It cannot be too often or too forcibly brought home to us that the hope of the profession is with the men who do its daily work in general practice.”

That is the reason, why, every time I come across a feel good story about a family physician working out from the rural hinterlands, helping people without regard for money or fame, I feel a small twinge at the depths of my heart. I am sure we all do feel that pull some time or the other. However, society and economics have warped us into calculative beings that always try to balance both sides of the ledger and then leave a lot on the savings column. There is no denying that life is like that and turning away from it is being in denial, but, sometimes, I wonder if it would do the skewed, curative-obsessed, over-medicalized culture today some good to have them re-oriented to the primary care model.

That is part of the reason why I read the news article about Dr. Russell Dohner from Rushville, Illinois with considerable interest. The other bit that really drew me to the piece was the fee he charged from his patients: 5$!

This is a bit of an old article from Yahoo! News, and I am linking to it so that you can check out the whole story for yourself, and without having me to spew the same stuff over again.

dr russell dohner

Image Credits: Associated Press/Jeff Roberson (from Yahoo! article)

I understand that having an alternate, steady income, (he admits that his livelihood is maintained by the money the farm brings in) and not embracing the expensive modern gadgetry (computers, fax, EMRs) has kept his practice alive. He also does not take any medical insurance and often waives the fees for patients when they are in a spot of bother. He is, in every manner, the quintessential country family doctor, who, the article reckons, has delivered the whole town. I also recognize the fact that his advanced age (he was 87 years old at the time of the publication of the Yahoo! article) would be a deterrent for practice in most institutions. Asking anyone to even emulate his actions would be an act of insanity in an age where medical care is rapidly becoming the most expensive commodity up for grabs.

However, these issues aside, he has chosen to forego the fees that his seven-decade spanning experience deserves. He charges a nominal fragment of what he could have easily asked for. The farm-is-there logic is strong, but it also shows that he did not run after the lucre. Despite everything, it even softens the cynic’s heart.

However, when you are 28 years old, sometimes with a family to take care of, and with an inhuman load of $300,000 or more in student debts on your shoulder, the last thing that you want to do is to repair to rural Illinois and serve as a Family Physician looking at patients for a farthing (and sometimes, not even that!). Dr. Dohner, I am afraid, may be the last one of a dying breed. With his demise, the chapter on the altruistic, ever-on-call-at-hand, ready to help Family Physician may go out of vogue. Now your FP may be a person in a conglomerated private practice who works on the same principle that any corporate body functions with – making profits. And you cannot blame him for that!

We may not have fields or farms to fiscally support our eccentric medical desires; we may not have our medical educations sponsored by the government, and hence, being debt-free, turn our lives in for society; we may have the very-understandable foibles of wanting to live a good life; but I am also very sure, there is that one neglected corner in our hearts that we are in denial about, where we want to be the Dr, Dohner, for whom people from four or five counties can vouch for.

Not unlike this old country doctor, who caught the poet’s fancy with his frugal life and limited desires:

Old Doc Brown

He was just an old country doctor
In a little Kentucky town
Fame and fortune had passed him by
But we never saw him frown

As day by day in his kindly way
He served us one and all
Many a patient forgot to pay
Altho’ Doc’s fees were small;

But Old Doc Brown didn’t seem to mind
He didn’t even send out bills
His only ambition was to find
Sure cures for aches and ills

Why nearly half the folks in my home town
Yes, I’m one of them too
Were ushered in by Old Doc Brown
When we made our first debut;

Tho’ he needed his dimes and there were times
That he’d receive a fee
He’d pass it on to some poor soul
That needed it worse than he

But when the depression hit our town
And drained each meager purse
The scanty income of Old Doc Brown
Just went from bad to worse;

He had to sell all of his furniture
Why, he couldn’t even pay his office rent
So to a dusty room over a livery stable
Doc Brown and his satchel went

On the hitching post at the curb below
To advertise his wares
He nailed a little sign that read
‘Doc Brown has moved upstairs’;

There he kept on helpin’ folks get well
And his heart was just pure gold
But anyone with eyes could see
That Doc was gettin’ old

And then one day he didn’t even answer
When they knocked upon his door
Old Doc Brown was a-lyin’ down
But his soul – was no more;

They found him there in an old black suit
And on his face was a smile of content
But all the money they could find on him
Was a quarter and a copper cent

So they opened up his ledger
And what they saw gave their hearts a pull
Beside each debtor’s name
Old Doc had writ these words, ‘Paid in full’;

It looked like the potter’s field for Doc
That caused us some alarm
Til someone ‘membered the family graveyard
Out on the Simmons farm

Old doc had brought six of their children
And Simmons was a grateful cuss
He said “Doc’s been like one of the family
So, you can let him sleep with us;”

Old Doc should have had a funeral
Fine enough for a king
It’s a ghastly joke that our town was broke
And no one could give a thing

‘Cept Jones, the undertaker
He did mighty well
Donatin’ an old iron casket
That he’d never been able to sell;

And the funeral procession, it wasn’t much
For grace and pomp and style
But those wagonloads of mourners
They stretched out for more than a mile

And we breathed a prayer as we layed him there
To rest beneath the sod
This man who’d earned the right
To be on speaking terms with God;

His grave was covered with flowers
But not from the floral shops
Just roses and things from folks’ garden
And one or two dandelion tops

For the depression had hit our little town hard
And each man carried a load
So some just picked the wildflowers
As they passed along the road;

We wanted to give him a monument
Kinda figured we owed him one
‘Cause he’d made our town a better place
For all the good he’d done

But monuments cost money
So, we did the best we could
And on his grave we gently placed
A monument – of wood;

We pulled up that old hitchin’ post
Where Doc had nailed his sign
And we painted it white and to all of us
It certainly did look fine

Now the rains and snow has washed away
Our white trimmings of paint
And there ain’t nothin’ left but Doc’s own sign
And that is gettin’ faint;

Still, when southern breezes and flickering stars
Carress our sleeping town
And the pale moon shines through Kentucky pines
On the grave of Old Doc Brown

You can still see that old hitchin’ post
As if an answer to our prayers
Mutely telling the whole wide world
‘Doc Brown has moved upstairs’.

Regular program of bitter, cynical writings shall commence soon. Don’t lose hope, ye ones of little faith.


USMLE 2013 and IMGs: All That Glitters is NOT Gold

I have pretty much been declared the official (Indian) USMLE rumor-monger by one of the most famous USMLE coaching institutes that held introductory classes to tell the masses what USMLE was all about. Thank you sir, you made my day.


Now, again, another disclaimer. The last time I wrote about the USMLE match (this one: The USA Dream for IMGs: Coming to an end? Analyzing the 2012 Match) I received a lot of hate mail and comments telling me, pretty much, to buzz off. Hence this time, before launching into my tirade, I shall dwell on this paragraph a while longer. I am NOT trying to dissuade anyone. I am NOT spreading rumors. I am simply trying to analyze the numbers being given out by the authorities in charge of the system and trying to interpret them within the limits of my intellectual and academic abilities. I may well be wrong, so please do not take my word to be sacred, and end up bashing me or praising me. I am just following the logical train of thought that I can construct. Where it leads me to is not in my control. Also, whatever I am writing is MY understanding of a very complicated system. And it maybe entirely WRONG. If it is, let me know, I shall make the required edits.

Ok. So then, down to the brass tacks.

The NRMP has not yet come up with the detailed analysis and numbers yet – another couple of months for that – but they have released an advanced report and press releases that have quite a lot about the IMGs, which specifically is my area of interest. You can read the whole thing over at the ECFMG Reporter.

Before I start with the number crunching, let me first make sure you all have heard of this new thing this year, called the “all-in system”. Till the last year’s match, programs were not compelled to fill all their seats through the Match. Now before you start shoving knives into my throat let me explain. This meant that the programs could fill in seats through systems beyond the match. Pre-match offers, for example. This year, to ensure that there was a more level playing field and more or less uniform judgment of all applicants, the NRMP declared that programs had to go all-in or all-out. That means, they had to declare that they were going to fill ALL their slots either through the Match or through other non-match routes. No more walking the dual path. And although it is not yet clear how many programs chose to be all-out (hopefully, the NRMP will come out with that data when the publish the detailed numbers for this year’s match), it is only reasonable to assume that most programs would have opted to go for filling residency slots through the match. So, do not let the higher numbers fool you into believing that the future is rosy. In fact, the ECFMG Reporter reports:

This policy is a factor in the higher numbers, compared to last year, of both positions offered through the 2013 Match (up 2,358 or 9.8%) and the number of IMGs participating in the 2013 Match (up 1,549 or 13.9%). It also, presumably, reduced the number of positions available outside of the 2013 Match.

Now, what that means is that there were more seats to deal with in the Match this time around than any of the previous years. So, whenever you see a spike in this year’s numbers, keep in mind that they might have been because of this newly placed policy rather than because of an increase in scope. I am not denying there is an increase in scope. There possibly is. But until and unless the end-of-the-year data for 2012 match is released, we cannot say that for sure. For the purposes of this post, I shall stick to the numbers from 2011 match for data whenever the ones from 2012 are not available or are incomplete.




Total Residency Slots available 26,392 24,034 +2,358
IMGs Participating 12,683 11,107 +1,576
IMGs Matched
Non-US IMG Applicants 7,568 6,835 +733
Non-US IMGs Matched 3,601
US IMG Applicants 5,095 4,281 814
US IMGs Matched 2,706

These numbers are all very rosy, until you take a look at the situation that eventually transpires when the non-match candidates are chucked into the equation. For this purpose, we shall cast a glance on the 2011 numbers, In the 2011 match:

Positions filled by IMGS through Match = 4,626

Total IMGs entering PGY-1 for the year 2011-12= 6,754

Thus IMGs entering by non-Match routes= 2,128

So, in 2011, almost a third (31.5%) of the positions filled by IMGs were filled through non-Match routes.

Though I do not have the US/Non-US break up for this number, yet, this seems like a pretty serious bit of statistics to me. And, if you notice, the eventual number of IMGs matching into the system in 2011-12 was much more than those that matched in the match in 2012-13 and even the all-in system of 2013-14, So if you are an IMG who managed to snag a position this year, well, that’s a pretty darn good job. Give yourself a pat on the back.

Mean times, if you, fellow student, are traveling the arduous journey along the path of USMLE, well, if you want to attain nirvana, hurry up. Otherwise, the journey may end in a cul-de-sac!

Yes, the numbers this year may still be a bit higher than what has been reported, but since not many programs would have opted to go all-out, it is unlikely that the bump would be significantly large.

So, in conclusion,the following stand out:

1. There has been a large spike in the proportion of non-US IMGs matching into PGY1 positions this year, but how much of it is attributable to the all-in system needs to be factored in before jumping with joy.

2. The rate at which the IMGs are applying is fast outstripping the rate at which the positions are increasing. Even with the all-in system in place, the growth difference this year was about 4%, which is a pretty steep climb.

3. Another metric that is of utmost importance is the positions/applicant ratio. This metric was 0.77 overall last year and 0.91 for US Seniors. In comparison, this year, the positions/IMG applicant is 2 and for non-US IMGs, it is 2.1. Although this is much better than any odds you may face in India, this is not very hot as compared to the other years in the USMLE history!

4. The rates of US-IMGs matching into PGY1 positions is also increasing, as expected. And this year, there was a major spike in the number of US-IMGs applying for Residency. As US medical education remains unacceptably, and often, unaffordably expensive, more and more US students will see it fit to gather their undergraduate degree from one of the developing world countries, where they can get by wit a fraction of the 300,000$ they would otherwise may have been burdened with. As this trend continues, it shall spell more pain for the IMGs. The way I see it, and I may be wrong, is that, any program will be happy to accept an American applicant over an International Grad who may have slightly superior credentials than his US colleague. The fact that they would not present a diplomatic difficulty, what with Visa and other laws changing every year in different countries, is indeed a tempting proposition.

Bottomline, USMLE still seems like a better bet, at least numerically speaking than the Indian PG exams. However, you need to factor in the costs, the time and the rapidly shrinking opportunities (as compared to the previous years) before you make this apples-oranges comparison.

And if you are a USMLE aspirant, I wish you all the best, and hope you shall not be dissuaded by this post simply because the numbers-gradient is fast becoming steeper.



Several friends of mine have matched into the PGY1 positions this year. And none of them will say that the process was without pain or heartache or headache. It just comes with the terrain. My intentions in writing these USMLE series of posts is NOT to discourage people, but to make them understand the risks, as I understand them, before they take this very expensive, very time-consuming leap. This also feeds my interest in Medical Education, because this is an extraordinarily transparent and open system which lends itself to analysis (and criticism), as far as the outcomes are concerned. We all know the great mystery of the USMLE scores and interviews process, so no comments on that!!!

I only wish that the Indian PG entrance system gets streamlined lends itself to a similar vein of accountability, and I believe that instituting the NEET-PG, a unified entrance exam for Post-Graduate Medical Education in India is the right formula to that end.

So, friends, whether or not you are a doctor/medical student/PG aspirant/USMLEan, follow nd support the #saveNEETPG movement on your social circles. Thanks.

Now you may post your blasting of my thoughts again. Or if you want to stay anonymous, use the contact form on my contact page.

Image Credits: First one, FizzzySecond one: Random Facebook share.


The USA Dream for IMGs: Coming to an end? Analysing the 2012 Match

My attention was drawn to an article in the JAMA today (1) by one of my friends who is actively pursuing the USMLE route. And after reading this, I guess I have to admit that one now has to make haste in order to prevent waste. Now I have long been wanting to write about this but somehow never came around to do it. Finally, having read this article today, I decided to give it a go. Now this is entirely my perspective on last year’s match and it may be entirely off-base. So do not put too much of thought into this. This year several of my friends are appearing for the match and I wish them the very best of luck. Also, this post is intended to be a wake up call for those who have been sitting on their dates, trying to do that extra bit to eke out an exceptional score. it is time to take the plunge!

ResearchBlogging.orgLet us start with some number crunching first – get the boring stuff out of the way before the real horror movie starts. No, just kidding… The number of students applying for residency in the US programs has increased in leaps and bounds, as the NRMP report shows in this trend-chart dating back to 1952 (2):


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William Gosset: A True Student

Today I attended a Basic Epidemiology class meant for the undergraduate students as I thought it would be good to brush up on my basic knowledge. The topics for the day were Hypothesis Testing and An Introduction to Randomized Controlled Trials, both pretty important ones, no matter which level you are studying at. What struck me was the amount of details the students were taught. To be entirely honest, in my undergrad days we did not get such detailed statistical teaching, and I was borderline jealous of the lucky 7th semester students. However, this post is not about the class or its importance (or the lack thereof), but what stood out for me – a moment from the history of medicine. This post is a result of some online meandering following up on that momentary whim.

ResearchBlogging.orgWe have all used the Student’s t-test at one point of time or another during our lives but I wonder how many of us ever wondered who this “Student” fellow was. Well, to be entirely honest, till today, I had dismissed him as a brooding Statistician with a long white beard, heavy monocles and an intent look… you know, the ones you find on Wikipedia. While I was quite correct in stereotyping the look, digging beneath the surface revealed a much fancier and colorful story behind the apparently benign (and somewhat boring)name of Student.


Born to Agnes Sealy Vidal and Col. Frederic Gosset (June 13. 1876) at Oxfordshire, he went to New College, Oxford, where he studied Chemistry and Mathematics. He was awarded First Class degrees in both subjects, obtaining his Mathematics degree in 1897 and his Chemistry degree in 1899. The same year, he went to work with Arthur Guinness and Son as a Chemist. Yeah, you read it right, He went to work for THE Guinness company and was posted at Dublin.

Digressing for a while here, I must say that the history of the Guinness company is in itself an interesting study, especially since in its long 253 year history, it has withstood the ravages of two world wars and three major economic meltdowns – no mean feat that – but what probably makes the brand instantly recognizable for the aficionado of historical trivia is its association with the Battle of Waterloo. Apparently it was so famous in 1815 that the wounded soldiers at Waterloo were asking for Guinness by name, and were getting magically revived by partaking of the wonder-drink. The company cashed in on the legends by publishing a series of advertisements on this theme in the 1930s and 1940s when the print media was just taking off. They say it went viral…

1941 guinness ad

Anyways, coming back to the story of Student. Guinness had a policy of employing the brightest minds coming out of Cambridge and Oxford in order to bolster the statistical and biochemical working of the company.(3) Being a brilliant student, Gosset naturally was picked up by the company. It was thus a stroke of great luck for future statisticians and researchers that he did not go on to become an Engineer like his father owing to his poor eyesight.(4) Now for those who are wondering why I am obsessing over the Guinness company (beside the obvious reason), well, just hold on to your hats, let me just say that this company also had a major role to play in Gossett getting his moniker of Student. While this is pure speculation, I must say if Gossett were alive today, and had seen the popularity that his discovery had found, he would rather had it called Gosset’s t-test than Student’s t-test! But then again, he was a very unassuming and humble person, so…

When Gosset joined Guinness, Dublin, his task was to perfect the process of brewing beer.(5) The principle was that one had to add an exact amount of yeast colonies to a certain amount of fermenting barley to turn it into beer. Too few colonies and the brew would be incompletely fermented and too much, it would become bitter. So the challenge was to count the colonies and add just the right number of them. Gosset innovated around this problem by using the newly developed Hemocytometer to count the yeast colonies. However, the challenge was to extrapolate the findings from a small sample of the yeast extract to entire jars of the sludge! This is akin to the problem medical or social scientists face when they draw a small sample from the huge universe to study some factors! It was in this setting that the mathematical and statistical training Gosset had acquired, came into the picture.

It was the use of the hemocytometer that resulted in Gosset’s first publication and the assumption of his pseudonym, Student. A researcher at Guinness had previously published his work, leading to loss of trade secrets of the Guinness brewery and hence the company had put a blanket ban on all publication efforts by their employees. While in today’s “publish or perish” world this would seem like a counterproductive policy that would drive away the best brains from the company, those were rosier and better times, where the weight of one’s achievements was not measured by the length of their publishography.

Gosset had to plead with the brewery that the paper which he proposed to publish was an absolutely philosophical and mathematical assertion and would have no dealings with the secret workings of the Guinness factories and hence, would be of no practical importance to the competition. The authorities gave in, but added the rather practical rider that he was better off publishing them under a pseudonym (he chose “Student”) in order to avoid conflicts with other staff member with publication ambitions.(6) At this juncture, Gosset’s friendship with Karl Pearson came in handy. Pearson agreed to hide Gosset’s personal information and allowed him to publish under a pseudonym in Biometrika, the statistics journal he had founded in October 1901. In this article (7) Gosset discussed “how the scatters of the yeast colony counts using the hemocytometer was similar to the exponential limits of the binomial distribution”.(5) Thus, with this publication, the transformation of Gosset into Student began!

Pearson was a giant in his field and he first met Gosset in 1905. He was one of the people who built up the fundamentals of modern statistics. Gosset worked under him for two terms in 1906-1907 and worked on Poisson’s distributions and helped Pearson with the statistical work for his papers. In 1908, when Gosset was working on the theory for the t-test, Pearson helped him, but apparently did not recognize the importance of his work.

Pearson also believed that the only method to assess population parameters was by using large samples. Gosset set about to try and formulate a formal method in which he could try using small samples in order to generate representative statistics. He conducted some empirical experiments, like the following:(5)

In 1 experiment, Gosset prepared 3000 pieces of cardboard, on each of which he wrote 2 sets of data on 3000 “criminals.” One set of values were heights, and the other values were the lengths of the left middle fingers. Gosset shuffled the cards, drew at random 750 samples of 4 cards each, and computed means and standard deviations of each. Then he obtained the difference between each sample mean and the population mean (n=3000) and divided the difference by the sample standard deviation to obtain 750 z scores. He plotted the scores as probability functions and discovered that even without any of 4 parameters of Pearson, one could estimate the population mean and the associated error with a degree of certainty.

The four parameters Pearson had suggested were:

1. Mean

2. Standard Deviation

3. Symmetry

4. Kurtosis

Pearson contended that if one knew the four parameters for a set of variables then once could locate the position of one observation in the entire spectrum of observations. In order to describe the scatter of the observations, he introduced a set of skewed curves as well.(5)

These empirical experiments led to the publication of the second paper.(8) This was a long algebraic discourse but later readers have described it to be surprisingly lucid and jargon-free.(5)


Image is from the authors of (5). If you are so inclined, you can check out the cleaned out version of the real paper as a PDF on the University of York, Department of Mathematics page here. If you can cross the paywall, then take a look at the real deal on the Biometrika page here. Although this is a debate for another time, but I find it very irksome to see that an article published over a century ago is still under copyright wraps. This just points to one of the so many things that ail the scientific publication world. I’ll save the rant about open access and copyrights for another day…

As is often the thing with concepts that are ahead of their time, Gosset’s (who was now known as Student to the publishing intelligentsia) work did not find much appreciation from the statistical world. It was not until Ronald Fisher had found a formal proof and enlisted practical applications of the t-test that people started to sit up and take notice. Apparently Gosset had written to Fisher informing him about his paper, saying that: “I am sending you a copy of Student’s Tables as you are the only man that’s ever likely to use them!”(9) Fisher modified the t-tests (don’t ask me how or why, I am statistically too impaired to go into the workings of that answer) to suit his theory of the degrees of freedom. Fisher was also responsible for the introduction of Gosset’s t-distribution in regression.

Gosset worked with a lot of the major statisticians of the day. Besides maintaining an active friendship with both Pearson and Fisher, two of the leading lights in the world of statistics at that time, he also maintained fruitful liaisons with others like Neymar. Karl Pearson’s son, Egon, himself a master number-wizard, pieced together a lot of information about the life and work of Gosset from the vast epistolary evidence he left behind, being the over-zealous letter writer that he was. Wikipedia claims that maintaining friendships with both Pearson and Fisher simultaneously was no mean feat because both had huge egos and a massive loathing for each other. It would take a man with a special amount of resilience and equanimity to be friends with both the vitriolic rivals. And Gosset was just that kind of a person. McMullen, a personal friend of Gosset’s, wrote: (10)

… he was very kindly and tolerant and absolutely devoid of malice. He rarely spoke about personal matters but when he did his opinion was well worth listening to and not in the least superficial.

A humble man despite the heights of his achievements, what struck me was the way he would interject his admirers. He would cut them short saying: “Fisher would have discovered it all anyway.”(9)

In 1934 he met with an accident and was confined to a sedentary life for a while. This time saw an explosion in the production of the statistical work by Gosset. He was bed-ridden for three months and took almost a year to recover. However, the accident left him with a limp that he carried for the rest of his life. Although he was transferred to London in 1835 to take charge of the new Guinness brewery opening there, it did not hamper his statistical work and he kept producing papers under his assumed identity of Student. He also branched out into working on theories of resistant strains of barley that would grow in adverse situations. Thus, his contributions cut across borders of different disciplines – statistics, botany, business – he was truly a man of multiple interests.

He succumbed to a heart attack in 1937 at the age of 61 years. There were multiple obituaries in Biometrika, which had been the major publisher of his life’s works. Even the usually secretive Guinness company relented and allowed his friends to posthumously publish a selection of his works in 1942.(11)

The appearance of articles written by Student was surrounded by an aura of mystery and romanticism as very few people outside of the closely knit statistical group knew the actual identity of Student. And although the obituary in Times finally removed the shroud on the question of who Student really was, it was still quite some time before he was accredited directly for his work:

Gosset_obituary_the times

All but one of Gosset’s papers were published under his assumed pseudonym. The t-test has now become a routine tool in the repertoire of pretty much anyone who has dabbled with research, irrespective of the field of research. I think there could have been but fewer apt eulogies for a person of such caliber than the one that was proposed by Ronald Fisher: Gosset was the “Faraday of statistics”.(12)


1. Image of William Sealy Gosset from Wikipedia: Now in public domain in the EU and Australia and some other countries 70 years after the death of the individual.

2. 1941 Guinness Ad image from this link associated with the EBay UK listing here. It seems that the advert is no longer available for sale.

3. O’Connor, John J.; Robertson, Edmund F., “Student’s t-test”, MacTutor History of Mathematics archive, University of St Andrews.

4. Plackett RL. Student’: A Statistical Biography of William Sealy Gosset. Oxford, United Kingdom: Vlarendon Press; 1990

ResearchBlogging.org5. Raju TN (2005). William Sealy Gosset and William A. Silverman: two “students” of science Paediatrics, 116 (3), 732-735 DOI: 10.1542/peds.2005-1134

6. ^ Hotelling, H.. British Statistics and Statisticians Today. Journal of the American Statistical Association. 1930;25:186–190.

7. “On the error of counting with hæmacytometer”. Biometrika 5 (3): 351–360. February 1907.

8. Student. The probable error of a mean. Biometrika. 1908;6:1–25

9. Wikipedia: William Sealy Gossett Accessed on 22nd September, 2012

10. William Sealy Gosset, 1876-1937, in E S Pearson and M G Kendall, Studies in the History of Statistics and Probability(London, 1970), 355-404.

11. Gosset WS. “Student”’s Collected Papers. Pearson ES, Wishart J, eds. Cambridge, United Kingdom: Cambridge University Press; 1942

12. H. Kohler: Life of Gosset


Remembering Tinsley Harrison, the Oslerphile Physician

ResearchBlogging.orgThe past few weeks have been very demanding on me and I have not had the best of times, either on the personal or on the professional front. So, today, I took a break from the usual drudgery of life and decided to take a step back and remind myself of the bigger picture of things. While reading through Osler’s Aequanimitas (check it out here) I was reminded of how Osler had been a guiding spirit in the life of another great medical hero that we have idolized over the years: Tinsler Randolph Harrison.

aequanimitas - the book

Tinsley Harrison (TH) was the son of a sixth generation physician, William Groce Harrison, who worked in close proximity with Osler for a short period and was the conduit through which the Oslerian wisdom flowed down into TH. If I have my dates correct, the lives of TH and Sir William Osler did not overlap too much because Osler passed away when TH entered Johns Hopkins in 1919.

TH was a bit of a prodigy and was done with high school at the age of 15 years and entered the sophomore class of 1916 at the University of Michigan. He excelled there and was permitted to pursue graduate school while in the fourth year of college. TH was intensely interested in studying Law and probably would have done that has his father not intervened. Osler had advised Groce Harrison to make his son a “teacher of medicine” when TH was barely three years old. At this juncture it is worthwhile to mention that Groce Harrison virtually worshipped Osler. In fact, anecdotes go that young Tinsley could distinguish between God, Jesus Christ and Sir William Osler by the time he was four years old! So, at the behest of his father, Tinsley decided to take up Medicine. So, his final year at Michigan in college was also his first year in medical school. It was 1918 and he had started medical school at the unusually precocious age of 18 years only!

Now Groce Harrison, being the protégé of Osler that he was, insisted that Tinsley complete the rest of his medical training at Johns Hopkins, which was virtually synonymous with the work of Osler. As I said before, unfortunately, Osler passed away the same year as TH went to Johns, but that did not stop him from building Osler up as the model of the perfect physician. Osler was not just an inspiration for TH during his medical school, but throughout his career and life. Osler and his musings were a part of the very fabric of life and philosophy that TH believed in. In fact, it is famously said by his students that TH would ask all his students to keep a copy of Osler’s Aequanimitas by their bedside and read it as often as possible!


Image Credits: Wikimedia

It must be mentioned that TH was in great company while he was in medical school itself. His room mate and tennis partner at Johns was none other than Alfred Blalock, pioneer surgeon, who developed a greater understanding of the pathophysiology of hemorrhagic shock, the Blalock-Taussing Shunt and surgical treatment of Tetralogy of Fallot, the so-called series of Blue Baby surgeries (on account of the fact that the babies became blue during cyanotic spells). Blalock himself was no mean a mind and though he was dogged with ill health, suffering several bouts of tuberculosis that impeded his work to a large degree in the early years, he left an indelible mark in the world of Surgery. He shared a lifelong friendship with his med school friend Harrison and their careers would cross paths several times in the years to come. Interestingly, one should note that like TH, Blalock was also an early prodigy and entered med school at the unusual age of 19 years! It is said that the first paper that he published in 1927 regarding the pathophysiology of surgical shock was originally written by none other than TH himself, based on the data collected by Blalock because he was down with a severe bout of tuberculosis at that point of time.

karsh2_blalock and the 1000th blue baby

Image Credits: Medical Archives of the Johns Hopkins Medical Institutions

Harrison’s protégés remember him as a fantastic teacher, a passionate clinician and in the true Oslerian philosophy, a believer in the ways of the clinical diagnoses rather than an over-reliance on instruments/investigations. It is said that he possessed a disdain for gadgetry and over reliance on testing in order to reach a diagnosis and believed in a thorough history taking and clinical examinations. One of the most famous stories about TH is about the time when he was the Distinguished Professor of Medicine of the Veterans’ Administration. There was a case at one of the VA hospitals that had left the Housestaff stumped for a diagnosis despite multiple tests. TH started on the patient with the history and followed it up with a three minute long palpation of the precordium which led him to a diagnosis of ventricular aneurysm. So remarkable was his method that it is said that the audience gave him a standing ovation for this. Of course, later cardiac catheterization was done and the diagnosis was confirmed. More recent studies have concluded that the precordial palpation has special importance in the diagnosis of cardiac diseases (1);

An apical impulse lateral to the mid-clavicular line or greater than 10 cm from the mid-sternal line was sensitive but not specific as an indicator of left ventricular enlargement. In patients without left ventricular hypertrophy, an apical diameter greater than 3 cm in the left lateral decubitus was sensitive (92%) and specific (91%) for an enlarged left ventricle. The positive and negative predictive values were 86% and 95% respectively.

That TH was a prodigy is also stated by some of his peers who talk about how an IQ test was administered to him when he was once hospitalized during the later years of his life. It is said that he came out with a score of 185! (2)

Harrison embodied the concept of the researching physician. His prolific clinical skills are legendary but his foray into the world of medical research, the numerous breakthroughs in the disciplines of cardiology and shock are somewhat dwarfed by the image of Harrison the clinician and Harrison the educator. He joined the newly reopened vanderbilt University school of medicine at Nashville as the Chief Resident in 1925 (incidentally, Blalock joined as the Chief Resident in Surgery at the same time). He stayed on the staff of Vanderbilt for 16 years, during which he published a mind boggling 107 original papers! He also brought out the first two editions of the authoritative tome, The Failure of Circulation while he was there in 1935 and 1938. There is an interesting tale about the 3rd edition of the book, which, incidentally never got published. In 1944, the Harrison family was moving from North Carolina to Texas in two vans when one of them caught fire. The fire was so devastating that nothing could be salvaged, including the completed manuscript of the 3rd edition of The Failure of Circulation, which, ultimately, never came out.

After a brief stint at Dallas, where he served as the Dean for a short period of time, he went back to his roots at Birmingham to Chair the Department of Medicine at the University of Alabama School of Medicine. He initiated here, like he did previously at Vanderbilt, a unique system of coordination between the different clinical and pre-clinical/diagnostic departments of both the medical and surgical specialties. He would use his personality and his stature to recruit physicians of national prominence from Harvard and Mayo. Under his leadership, the University of Alabama School of Medicine rose to be one of the most respected institutes nationally.

It was in 1950 itself, when he was moving back to Birmingham, that the thought of editing the first edition of what is today THE textbook for all medicine aspirants was conceived. (3) He led a team of the best professors – Adams, Beeson, Resnick, Thorn and Wintrobe – to bring out 5 editions of the tome in his lifetime. Now in its 18th edition, this book represents a unique movement in the world of medical texts seeing as how it is closest to being one of the most complete texts possible. Now while that makes the size of this book a little intimidating, yet, it remains a joy to read. I searched extensively online to see if I could dredge out an image of the very first edition, but it was in vain, so here, let me show off mine!


Tinsley Harrison was not just a clinician. He was a remarkably well rounded personality. Aside from his academic life, he is said to be the prototype of the forgetful professor that one would guess he was. His peers say that it was a largely his wife’s credit to have kept the absent minded professor free from dealing with the drudgeries of daily living by making his life as organized as possible. Following the completion of his medical school at Johns Hopkins, Harrison moved to Peter Bent Brigham hospital where he worked for two years. It was during his sojourn at the Brigham, that he married Betty Woodward, who remained a strong and calming influence in his life. Notably, while he was working at the Brigham, he was associated with the likes of Samuel Levine, William Dock, Chester Keefer and henry Christian. His lifelong love for the circulation system was also implanted during this phase when Samuel Grant introduced him to the clinical investigations of the cardiovascular system using the Fick principle.

fick principle

CO = Cardiac Output, Ca = Oxygen concentration of arterial blood and Cv = Oxygen concentration of mixed venous blood. Image Credits: Wikipedia

Harrison was also a bit of a sportsman. He was the Southern Doubled Tennis Champion (his partner was none other than Blalock!), an avid golfer and even at the age of 70, he was adept at water skiing!

I have left one of the most interesting aspects of Harrison’s bedside teaching for the last because this is something I really enjoyed learning about. His bedside teaching skills are legendary but he would organize the bedside teaching in a unique way which would cater to all the echelons of medical professionals that flocked to his lectures. In every bedside excursion, he would take the history only and make his diagnosis or set of differentials based on the findings that he would elicit in the history. He would then ask the resident to do the physical examination in addition to the history of the case and based on those findings, the resident had to reach a set of differentials, if not a final diagnosis. The intern was allowed a little more leeway in that he would have access to the routine laboratory findings in addition to the history and physical examination in order to aid his diagnosis. And finally, the “lowly” medical student would be allowed to ask for additional investigations, imaging, etc. in order to get to the diagnosis. This is a unique format that would provide an intellectual stimulus to all the people present there and not just let the residents run away with the game. As an avid mediquizzer myself, I can only imagine the kind of excitement that this format of bedside teaching would generate!

Tinsley Randolph Harrison and Sir William Osler have been two of the biggest names in Medicine in the past century. They are legends in their own rights, but somehow, the more I read about Tinsley Harrison, the more I seem to think that he was somehow the carrier of the baton that Sir Osler left behind. It feels wonderful to be part of a profession that boasts of intellectual giants as these. It reminds me that I am part of a much larger game, extending much further beyond the limits of a few examinations and a few disappointments. I am part of a culture of medicine that has triumphed over mechanization of thoughts, actions and execution.

From time to time a personality scintillates across the medical firmament, who dazzles all beholders. Tinsley Harrison was such a person, a delightful, passionate, vivacious physician. He stimulated everyone with whom he came in contact and he placed an indelible stamp on the medical events of his day. (4)

Dedication page of the 9th edition of Harrison’s Internal Medicine which was published after the death of Tinsley R. Harrison in 1978.

The dedication above was wrong. Tinsley Harrison continues to stimulate and inspire people. People like me, who sometime lose sight of the real reasons they fell in love with Medicine in the first place while navigating through the bumpy terrain of life. People whose closest association with him is through a book… Thank you for reminding me of the real reason that inspired the passion in me to do medicine. Thank you for making me fee rejuvenated once again so that I can take the bull by the horns and live to fight another day. And above all, thank you, for reminding me of the “master word” that your idol asked us students of medicine to engrave in the tablets of our hearts:

“Though a little one, the master-word looms large in meaning. It is the ‘Open Sesame’ to every portal, the great equalizer in the world, the true philosopher’s stone which transmutes all the base metals of humanity into gold. The stupid man among you it will make bright, the bright man brilliant, and the brilliant student steady. With the magic word in your heart, all things are possible, and without it all study is vanity and vexation. The miracles of life are with it; the blind see by touch, the deaf hear with eyes, the dumb speak with fingers. To the youth it brings hope, to the middle-aged confidence, to the aged repose. True balm of hurt minds, in its presence the heart of the sorrowful is lightened and consoled. It is directly responsible for all advances in medicine during the past twenty-five centuries.And the master-word is Work, a little one, as I have said, but fraught with momentous sequences if you can but write it on the tablets of your hearts, and bind it upon your foreheads.” (5)


1. Eilen SD, Crawford MH, O’Rourke RA. Accuracy of precordial palpation for detecting increased left ventricular volume. Ann Intern Med. 1983 Nov;99(5):628-30. PubMed PMID: 6227265.

2. Merrill AJ. Memorial. Tinsley Randolph Harrison. Trans Am Clin Climatol Assoc. 1979;90:xxxviii-xi. PubMed PMID: 390820; PubMed Central PMCID: PMC2279388.

ResearchBlogging.org3. Dalton ML (2001). William Osler’s influence on the career of Tinsley Randolph Harrison. Southern medical journal, 94 (7), 724-7 PMID: 11531181

4. Isselbacher KJ, Adams RD, Braunwald E, et al. Harrison’s Principles of Internal Medicine. New York. McGraw Hill Inc. 9th Ed. 1980, Dedication page.

5. Osler W. An Address ON THE MASTER-WORD IN MEDICINE: Delivered to Medical Students on the Occasion of the Opening of the New Laboratories of the Medical Faculty of the University of Toronto, October 1st, 1903. Br Med J. 1903 Nov 7;2(2236):1196-200. PubMed PMID: 20761153; PubMed Central PMCID: PMC2514735.


The Map of the Cat Conundrum: Richard Feynman and AIIMS November 2011

Well, that sounds like an odd assortment of topics to group under the same heading, does it not? Well, today I had the misfortune of experiencing first hand what Feynman had described ages ago in Surely You’re Joking, Mr. Feynman?

As my blog readers might know, I had an examination today, and before you ask me, I will submit that it did not go all too well. In this post I would like to discuss an aspect of the question paper that I found particularly irksome. Now I am not, for one moment, saying that these particular problems caused me to take a really bad test, but what I am saying is that questions like these make studying for an exam a pain in the neck. I know I was not too well prepped for the exam as it was, and expecting a miracle would not be scientifically sound judgment, but anyways, my point is, an exam should be geared towards a constructive assessment of a student and NOT a “destructive” one.

Anyways. As any Feynman fan will remember, he decided to drop out of Physics for a while and check out Biology while he was in Princeton to just get a feel for what was going on in the world of science around him. Trust a scientific genius like him to do something weird like this. Anyways, so when he was doing Biology, he had a rather fun run in with a librarian when he demanded a “map of a cat” to study its anatomy.

map of the cat

Now, in order to preserve the joy of the original reading, let me quote to you:

The next paper selected for me was by Adrian and Bronk. They demonstrated that nerve impulses were sharp, single-pulse phenomena. They had done experiments with cats in which they had measured voltages on nerves.I began to read the paper. It kept talking about extensors and flexors, the gastrocnemius muscle, and so on. This and that muscle were named, but I hadn’t the foggiest idea of where they were located in relation to the nerves or to the cat. So I went to the librarian in the biology section and asked her if she could find me a map of the cat.

“A map of the cat, sir?” she asked, horrified. “You mean a zoological chart!” From then on there were rumors about some dumb biology graduate student who was looking for a “map of the cat.”

When it came time for me to give my talk on the subject, I started off by drawing an outline of the cat and began to name the various muscles.

The other students in the class interrupt me: “We know all that!”

[Now THIS is my favorite part!]

“Oh,” I say, “you do? Then no wonder I can catch up with you so fast after you’ve had four years of biology.” They had wasted all their time memorizing stuff like that, when it could be looked up in fifteen minutes.

So, it goes without saying, something similar happened in today’s exam. We had a series of questions on Indian Penal Code [I remember the questions all to well, and plan to recall them in a later post, like I had done before – major crowd pullers, these; sorry to game the Goog dear reader, but I love getting me some hits!].

Now I find questions that ask us for information about the principles of the law or for that matter, punishments and other stipulations a meaningful enquiry, but what I absolutely do not get is why they would ask us questions like:

A doctor can be punished for issuing a false certificate under which of the following section of the Indian Penal Code:
a. 197
b. 147
c. 157
d. 167

I understand, we need to know that there is a legal framework against issuing of a false medical document, and we are held primarily responsible for it. But how does it do me, a doctor, any good to know WHICH section I shall be tried under for this? My mother is a lawyer and even she has no idea what the answer should be. [But I do, and I think that is pathetic!]

ohcmI have seen the Indian Penal Code, and it is a book hardly any bigger than the OHCM. And the Penal Codes are VERY well arranged. it would hardly take anybody who knows how to read, not more than 5 minutes to locate the answer to this particular question. There were 3 other questions like this, specifically asking for the particular Penal Code section involved.

Another reason I find this line of questions very illogical and impractical is the fact that Indian legal system is a veritable mine of legal documents. One of the oft quoted legal booklets is the Criminal Procedure Code and we are routinely drilled on the contents of the same. So, how many of these legal books should I read? As a doctor, I can justify any number of crimes I could commit in course of my professional life [if I was a betting man, and I am not, my money would be on the fact that some of our professional brethren may already have done that sort of thing!] that could be covered by the obscurest of Indian legal paraphernalia. Does that mean I have to learn the specific portions? Heck, since when did we stop making the lawyers?

This time around there was a question which asked us what the maximum sentence for breaking the Organ Transplantation Act of 1994 was. It is still a more reasonable question, since knowing that I can be docked for more than 5 years might keep me from stealing a kidney or something [no, really, I mean it], but in the previous years, they have asked WHICH YEAR the law was implemented. Once again, what good does it do if I know that the law was implemented in 1994? Does it have any bearing on my clinical abilities or my medical acumen or whatever?

Another question which has an interesting bent ONLY if you are in jurisprudence or whatever was:

A chronic alcoholic, who was brought in for medical examination following a violent assault on his neighbor had not consumed alcohol in the past  four days and was found to be suffering from delirium tremens. In this case, according to the Indian Penal Code:a. He has no criminal responsibilities for his actions
b. He has criminal responsibilities for his actions
c. He has partial responsibilities for his actions
d. He has diminished responsibilities for his actions

Now I bet if you asked a lawyer this question, he would ask you back: “What do you want it to be?” but the truth remains that the final decision on his criminal responsibility does not really lie with the doctor. It is good enough that he can diagnose the person to be suffering from delirium tremens, and the rest of the work should be done by the legal eagles.

Just in case you are wondering what this answer might be, I will invite you to read this excellent paper on: Intoxication as a defense in criminal law.

Now you know what a deviously complicated question that was! What good does it do to a doctor to know about this issue?

These questions are basically just sieves put in place to separate the “grain” from the “chaff”. They encourage rote based learning, something that is at the bottom of the problems plaguing the whole Indian educational system, not just the medical front. If we are to be tested as proper medics, do us the honor of asking us proper questions. I am not saying that these questions altered the outcome of the exam for me. My preparations, if not adequate, will not take me across any kind of an examination. But I would surely like to take an exam where I am not left looking at the paper and wondering why I had not spent more time mugging up “the map of the cat”.


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The Parable of the Farmers Plagued by Rats: AKA Publications in Advancing Medical Careers

There was a small island kingdom, inhabited by a peaceful race of people who prospered through the advances they had made in agriculture. One day, they were visited by a shipful of traders from a faraway and exotic country. However, unknown to them, stowed away in the holds of the ship, came a few rats. Now these rats had a free run in the island and started to multiply rapidly. Soon, they started to devour the crops no sooner had they started to flourish. The farmers started to get worried by this and when this reached a crisis situation, they demanded to meet with the king.


Now the king was a kind old man and he and his court of ministers heard the plight of the farmers. He was very disturbed to learn that his beloved farmlands were being ravaged by the foreign vermin. He asked his advisory council to convene in order to deliberate on the issues at hand. The council came up with a novel idea: the best way to get rid of the rats was to outsource the process of the killing of rats to the farmers themselves. Since it was a matter close to their heart, they would be vigilant in getting rid of the rodents with utmost vigilance. So, the kind old King announced that whoever brings to the council a fully grown dead rat would receive one gold coin. At this, the farmers heaved a sigh of relief and started about their life.

A special committee was formed to accept and dispose the dead rats while handing over the reward coin to the farmers on the spot. The program was a massive success and everyone enthusiastically came to arms; it was a matter of survival, after all. In a couple of weeks, the Royal Granarian reported that there was an uptick in the national grain production for the first time in weeks. It seemed that the King and the Council had prevailed, as the problem of the rat infestation seemed to have been beaten back.

However, this positive flicker was not to last too long. A few weeks later, the Royal Granarian sought audience with the King. He reported that the initial uptick was not long lasting and since then, the grain production has been going down exponentially, and there were almost no production at the moment. This shocked the King, who summoned his committee of rat disposal. Disheveled, tired and slightly panicky, the committee members arrived before the King and reported that more and more people were coming with dead rats. There seemed to be no end to people turning up with dead rats and demanding their reward. They reckoned at this rate, the kingdom would go bankrupt within a week or two.

The King was shocked on hearing the two sides of the story, and he immediately convened a meeting of the Council members and advisors. Nobody could gauge why the grain production was still suffering despite such massive rodent mortality; finally it was decided that they would launch an investigation to assess the situation.

The king decided to send a covert observer to the villages. The observer toured through the villages across the small island nation and returned to report to the king after a few weeks.

He seemed quite scared and panicked when he told the King about what he had seen. He had seen that the farmers had stopped agriculture entirely and at the present moment, all they were doing, was breeding rats in huge containment areas constructed across their lands. The entire population was breeding rats in order to kill them when they had grown up and bring them to the committee to claim their reward of one gold coin.

Credits: PhDComics

Credits: PhDComics

New Delhi, the 3rd November, 2010

(iv). In the “Minimum Qualification for Teachers in Medical Institutions Regulations, 1998”, in ‘TABLE-1’ under the heading “REQUIREMENTS OF ACADEMIC QUALIFICATIONS, TEACHING AND RESEARCH EXPERIENCE”, as amended vide notifications dated 21/07/2009, 28/10/2009 and 15/12/2009, the ‘Research Experience’ against the post of ‘Professor’, for all the specialities, shall be substituted as under: -

“Four Research papers accepted/published in index /national journal as first/second author on cumulative basis.  Out of these four research publications minimum two research publication must be published during the tenure of the Associate Professor.”

(v). In the “Minimum Qualification for Teachers in Medical Institutions Regulations, 1998”, in ‘TABLE-1’ under the heading “REQUIREMENTS OF ACADEMIC QUALIFICATIONS, TEACHING AND RESEARCH EXPERIENCE”, as amended vide notifications dated 21/07/2009, 28/10/2009 and 15/12/2009, the ‘Research Experience’ against the post of ‘Associate Professor/Reader’, for all the specialities, shall be substituted as under: -

“Two Research papers accepted/published in index /national journal as first/second author during the tenure of Assistant Professor.”

(vi). In the “Minimum Qualification for Teachers in Medical Institutions Regulations, 1998”, in ‘TABLE-1’ under the heading “REQUIREMENTS OF ACADEMIC QUALIFICATIONS, TEACHING AND RESEARCH EXPERIENCE”, as amended vide notifications dated 21/07/2009, 28/10/2009 and 15/12/2009, the ‘Research Experience’ against the post of ‘Assistant Professor/Lecturer’, for all the specialities, the following shall be inserted: -

“For the candidates obtaining DNB qualification from centers other than MCI recognized medical colleges/central institutes, the concerned candidate should have minimum two publications (accepted/published) in the index journal(national/international as first/second author).  In case, the concerned candidate does not have the required publication, he/she must have a total of three years teaching experience in a recongised medical college/central institute after possessing DNB qualification.”


Credits: Saturday Morning Breakfast Cereal

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DNA Digest’s Twitter Competition for Data Sharing in Genetics

As any reader of Ben Goldacre’s blog and books will know, open data is the big debate. And the bigger the diagnostic or therapeutic implications of the data concerned, the bigger need to keep it open (or closed, depending on your proclivities). Genes and genetic studies have long been touted as the final frontier for diagnostics, and as such, a field in dire need of open data. The DNA Digest has initiated an interesting competition (named, quite boringly, I must say, as “twitter competition”: they really do not want any ambiguity here!) to promote the use of tools and mechanisms that promote open data.

The competition is basically “tweet for data sharing”. The team will pick the best tweeter and contact them directly to award them a 50$ voucher. This not only promotes open data, tools that encourage open data efforts, but also gets DNA Digest a bunch of targeted followers. It is win-win all around.

So if you are interested in genetics, in open data, in twitter, or a 50$ voucher, check this out:

Tweet for data sharing! Open for entries from the 10th to the 23rd of February 2014.

Tweet for data sharing! Open for entries from the 10th to the 23rd of February 2014.


Hacking of the National Institute of Epidemiology and Musings on Hacktivism

Yesterday, my friend and medical blogging maestro, SoumyadeepB brought this to my notice:

NIE Hacked!

NIE Hacked!

So, apparently, the National Institute of Epidemiology got hacked by a member identified as what I think reads as Haxorioux Mind who apparently belongs to a high-profile group of hackers called Team Madleets. They identify themselves as white hat hackers. White hat hackers are computer security experts who believe in making website owners aware of the weaknesses in their site security and are not fuelled by malicious intent.

This group has also hacked high profile sites, according to their Facebook page, which claims responsibility for the following:

Our* biggest hacks so far:
✔ nic.me
✔ nic.tc
✔ nic.vg
✔ nic.lc
✔ nic.ag
✔ nic.sb
✔ nic.cx
✔ nic.nf
✔ nic.gs
✔ nic.tl
✔ nic.ki
✔ nic.tg
✔ nic.bt
✔ dns.cv
✔ nic.net.nf
✔ cocca.cx
✔ cocca.org.nz
✔ coccaregistry.com
✔ coccaregistry.net
✔ coccaregistry.org
✔ domain.me
✔ domen.me
✔ google.com.my
✔ google.my
✔ google.bi
✔ google.co.bi
✔ google.com.bi
✔ google.rs
✔ google.co.ke
✔ msn.co.il
✔ skype.co.il
✔ bing.co.il
✔ forum.whmcs.com
✔ forum.directadmin.com
✔ press.t-mobile.com
✔ boards.dailymail.co.uk
✔ forums.suse.com

So, they have a rather funny meme-toon about their repeated encounters with Google:


This is the first time, to my knowledge, that a .gov.in site has been hacked. Indian National Informatics Center sites have been hacked multiple times before, most famously, by the online Hacktivism group called Anonymous, who took down the e-governance site as a token of protest against rampant corruption in all walks of life in the nation, and replaced it with a page showing this:

Anonymous Hacked NIC

Anonymous Hacked NIC

There are many sides to this debate and though my rebel spirit supports the spirit of white hat hackers (or simply hackers as some prefer to call the black hat hackers or illegal or criminal hackers as crackers and those on this side of the legal divide as hackers) and hacktivists, sometimes, I hear this lurking voice at the back of my brain, that reminds me of Neitzsche’s famous words:

Aphorisms of Neitzsche

Aphorisms of Neitzsche

So, on some days, I feel very pro-hacktivism when, as a common man, with the illusion of empowerment, but no real empowerment as such, I feel frustrated with a machinery that rolls on along at its own pace, without thought or consideration of what the man on the street needs or wants. It is no secret that I was a big supporter of Aaron Swartz and the work he was doing to conduct a “civil disobedience” in academic publication; and I felt  a personal sense of loss and devastation when, embroiled in legal tangles, he ended his life abruptly. I have been a strong supporter of “guerrilla open access” groups that work behind the scenes to help connect academics and scholars across nations and help them out with full versions of paywalled academic articles. I also lauded Anonymous when they hacked the MIT sites as a tribute to the recently deceased Swartz. But, sometimes, it feels scary to have someone wield so much power; and the Machiavellian ploy keeps circling in one’s mind: power corrupts and absolute power corrupts absolutely. Hactivists wield absolute power in this age of digital information. And how they use that power is key in deciding whether or not it a force of evil or force of good.

So, what is your take on this? Do you think hacktivism is a good power or is it an element of anarchy just waiting to unleash chaos in our well-structured, albeit poorly-run, lives?

For me, despite these momentary vacillations between the two extreme poles, I think the perfect balance is struck by none other than Richard Feynman, one person I hold in high esteem:

Screen Shot 2014-01-29 at 5.12.47 am

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