Thomas Jefferson University Hospital

First Impressions: I got a voicemail from the program coordinator one week ago saying that they had an opening in their interview schedule and asked if I'd be able to make it. I originally said no because I was on call that day, but after thinking about it I called them back and said I'd find a way to be there. Fortunately since my interview was in Philly and would end at 1 pm, the chiefs gave me permission to miss half a day of MICU and then return to complete my call. I hadn't heard too much about Jeff except that its fellows worked very hard and that the program liked to takes its own residents into their fellowship.
Interview Day: I thought seeing snow in Stony Brook in late March was unusual, but as I walked to my interview there were big fat snowflakes falling from the sky. There were only 3 applicants at the interview (one of whom I'd met at Montefiore), and the program coordinator was quick to tell us about the program and, more importantly, how we were graded on our interviews. We got a copy of the "grade sheet" every interviewer gets; basically, the ideal applicant would have board scores in the top 10%, have rec letters from prominent leaders in heme/onc, excellent personal statement, strong interest in research and academics, etc. If I had to grade myself, I'd rank smack-dab in the middle, and wondered how they even selected me for an interview in the first place. I think the only thing I had going for me was my personal statement. There were four interviews total. The first was with a hematologist who was infamous for cutting interviews short if he didn't find you worth his time. Fortunately we were able to talk for the full 20 min, though I could tell he was very hard to please. The second interview was with the program director, who was a HUH grad and commented that HUH grads usually do well in the heme/onc program at Jeff. The other two interviews passed by in a blur. Afterwards we had a tour of the hospital (which was well lit and nice) and infusion centers, then had lunch while a fellow spoke with us. We were done by 1:15 pm and I was able to get back to work before 2 pm. The resident who covered my morning shift said it was the easiest call ever for him.
Overall Impression: Pros: Diverse pathology, 5 fellows a year. Located in Philly, associated with Kimmel Cancer Center. Very strong in hematology.
Cons: Weaker in solid tumors, emphasis on research, likes to take their own residents, no free parking in Center City (which my own program offers)

Stony Brook University

First Impressions: I met a guy from Stony Brook at my RWJMS interview and had asked him back then what the program was like. He said there was more emphasis on clinical practice, less on research, but that it was a great program. I drove to Stony Brook the night before my interview accompanied by a classmate's fiancee, who was a PGY2 at Stony Brook and needed a ride back home. She was able to tell me where to go since my GPS was not working, and let me tell you, the night sight of NYC from the Verrazano Bridge was amazing.

Interview Day: It was snowing/raining as I drove to Stony Brook University Cancer Center, which seemed a bit bizarre for March. Incidentally I ran into the guy from RWJMS outside the entrance, and he said, "Welcome to Stony Brook." There were 5 of us total interviewing that day; two of which were from Stony Brook. The other two applicants I'd met at the Drexel interview just last week; both of them had interviewed at Jefferson (my next interview) just two days. We had a brief overview of the program from the PD before one of the fellows took us on a tour of the hospital. The hospital consisted of two round towers connected by a walkway; all the floors had a circular pattern. I immediately made note of the Starbucks on the ground floor ;) There was also a VA located about 30 min away where fellows do their continuity clinic (and have plenty of autonomy while doing so), but we didn't go there.

We had two interviews each today, and I think I got extremely lucky with my interviewers. The first was a breast cancer specialist not too far out of fellowship, so he was extremely easy to talk to. We chatted about breast cancer, non-fiction books dealing with medicine (i.e. the infamous House of God), medical TV shows, and more. My next interview was with an attending from the VA who also happened to be Taiwanese, so we talked briefly about places in Taiwan worth visiting. He made it clear that he wanted to know who I was as a person, not about how much reseach I've done (thank goodness), and asked questions about my life and my family. He took lots of notes about me, and when I told him why I wanted to specialize in heme onc (my mother was a breast cancer survivor), he looked impressed and said he would like to see me here next year. O.O That is the most positive feedback I have ever received at any interview.

Overall Impression:
Pros: Good balance in both heme and onc, diverse pathology throughout Long Island, 3 fellows a year. Autonomy in decision making and patient care at the VA. Emphasis on clinical training. Friendly fellows and attendings. Located 1 hr away from NYC and JFK International Airport. Long Island known to have famous beaches and diverse outdoor life.
Cons: Stony Brook seems a bit isolated, surrounded by small suburbs. Still, there are Starbucks, Barnes and Noble, and even a Cheesecake Factory nearby, so it can't be too bad.

Trying to Die

In residency I've been a relatively white cloud, and so far my MICU calls have never been overwhelmingly busy. That's not to say, however, that the patients on my census are well. My GI bleed from two calls ago was still on 4 pressors and officially in multi-organ failure, so finally his family withdrew care and allowed him to pass on. I was sad about that; this man came into the ED one week ago for a lower GI bleed which was fixed, but for some unknown reason he went into vasodilatory shock afterwards. He himself had given consent to be intubated after he coughed up bright red blood, believing that after the EGD he'd be extubated. Sadly he didn't make it.

Last night I was able to sleep for about 45 minutes before midnight before my fellow called and said there was a multi-drug overdose in the ED. The patient was a young man close to my age who attempted suicide by swallowing TCAs, an entire bottle of aspirin, and some Tylenol. When I got downstairs, he was undergoing gastric lavage and the ER was trying to get ahold of nephrology for immediate dialysis. The reason being was that despite taking tons of TCAs (which would make him dry), he was diaphoretic, indicating aspirin toxicity. His initial labs, however, showed normal levels of the drug and no signs of lactic acidosis, and the nephrology fellow argued that based on the current labs she had no reason to emergently dialyze this patient. Both the ER attending and toxicologist insisted that this was a life threatening overdose and that the patient would die without HD. This was the first time I ever perceived relations between the emergency department and medicine department to be hostile (though the attending was more welcoming toward me and my fellow, since we'd be taking the patient to the ICU), but I could see where the ED people were coming from.

Just a few months ago, a patient died from a metformin overdose because his labs on admission were "normal" and he was sent to a step-down unit instead of the ICU. By the time he made it to the ICU until his pH was already 7.1 and his bicarb was in the single digits. Almost every department in the hospital attended the M&M that followed his death, and the conclusions we came to was that presenting labs can be deceiving, and that we need to anticipate the progression of the toxicity of any drug overdose. If "Metformin Man" had received bicarb and emergent dialysis on admission, he probably would have lived. And now looking at this TCA/ASA overdose, I couldn't help but remember what had happened to the Metformin Man, and I hoped that we would be able to save this patient.

Fortunately repeat labs showed that the aspirin level had tripled, providing the nephrology fellow with a reason to start HD. HD was started 3 hrs after admission, and he was put on IV Mucomyst and a bicarb drip. I got my first truly successful A-line in him. By mid morning his drug levels were trending down and his labs remained stable, so I'm hoping he does all right. What saddened us was the reason behind his drug overdose: he didn't match for residency last week =/

Drexel University College of Medicine/Hahnemann University Hospital

First Impressions: Ahh...good old HUH. A common question I've gotten on the interview trail is why I came all the way to Philly to do my residency instead of staying in TX. I'd had my best interview here, and the camaraderie among the residents and faculty really appealed to me, so I ranked the program high on my list. I have no regrets about my decision to go out of state for residency, as I've made many friends here and have grown to love living on the East Coast.

Knowing from day 1 that I wanted to apply to heme-onc, I immediately went about making myself known. I did inpatient heme-onc floors at both HUH and the "Bing," selected heme-onc electives, and started doing a secondary clinic this year at the outpatient heme-onc office. All the attendings knew me and, for the most part, knew my work ethic and personality. I was told that HUH likes to takes its own applicants for heme-onc, and hopefully that's still the case.

Interview Day: All interviews are held on a Saturday, which was good and bad (good being that I didn't have to take a day off from work to interview, bad in that you don't see as much on the weekends). There were about 12 of us, and of those 12 only I was from HUH. That was a mistake on the program's part; usually they interview all HUH applicants early in the season but somehow my file got overlooked and they had to squeeze me in at a later date. The program director gave a very straightforward powerpoint presentation describing the fellowship in detail, and then three attendings took turns interviewing us. They saved me for last since they knew me already, but in the meantime two fellows came to chat with us about the program. One of the fellows I knew well, since I was helping him on a Phase II project earlier in the year, and the other was surprised to see me since he didn't know I was applying heme-onc. My interviews were extremely laid back; the first one was with an attending I knew well and we talked about patients I was currently seeing in the ICU. She also asked me what games I had on my iPhone, so I gave a brief demonstration of how to play "Angry Birds." It was fun at the time, but after I left her office I thought, "What just happened?" Not your everyday interview. They told me I didn't have to meet with the program director b/c he wrote my rec letter, but I sat down with him anyway for about 10 minutes to update him on what has been happening with me.

This program has a university name but runs more like a community program. There are no specialists in any particular organ system; all the attendings here are "general oncologists" who see all types of malignancies. The clinics, also, are combined so there is no "breast clinic" or "lung clinic;" you see all types on any given day.

Overall Impression:
Pros: Good balance in both heme and onc, diverse pathology, 3 fellows a year. Having been here for the past 20 months, I am very familiar with the archaic computer system and how the inpatient, outpatient, and consult services work. Philly is a pretty good place to live (2 hrs from NY, 2.5 hrs from DC), most rotations done at HUH except electives at other hospitals. Good relationship with the attendings, very hopeful that I'll be ranked high.
Cons: No subspecialists within hematology/oncology; this program tends to produce general oncologists going into private practice.

Futile

I am currently doing my ICU month, which I have been dreading for ages. To put it bluntly, I do not like critical care. I have never been good at thinking on my feet and dealing with stress. The ICU attendings, thank goodness, are all good people who aim to teach and not criticize. Even when I forgot to lavage a guy bleeding from his rectum (it turned out he had bleeding duodenal ulcers as well), the attending just said that I didn't work up the patient well enough. No blame, no yelling. I still felt awful afterwards and blamed myself for not being thorough (even though my fellow residents thought I was making too much out of it), but it felt better knowing that despite my poor intensive care skills, I still had the support of my friends and attendings.

Currently there are about 24 patients in the ICU, and 4 of my 5 patients were complete trainwrecks. First is the GI bleeder mentioned above; he was scoped from both ends with no evidence of bleeding (just a few superficial orders), and then he had another giant maroon BM and needed another emergent endoscopy that revealed vessels in 2 ulcers that were clipped. Hopefully that'll be the end of that. Another is a man with ESLD, partial SBO, and the worst respiratory drive I've ever seen. Sometimes he became hypoxic, othertimes he was tachypneic in the 30s, and we couldn't change the vent fast enough to keep up with him. His ABGs were slightly on the acidotic side but uncorrectable with vent settings; getting good ABGs on him was a nightmare. Another ESRD guy practically looks like a skeleton and has self-extubated himself twice since I've been on this service (each time needing to reintubated again), and his wife won't make him DNR despite his poor prognosis.

Then there's my lone female patient, a woman in her 50s who presented with a 6-month history of intractable cough and ended up requiring intubation (and later trach) due to hypoxia. She had multiple lung nodules on CT and a pleural fluid biopsy revealed lung adenocarcinoma. There was a time where she was completely obtunded and people feared she'd never wake up. She started stirring when I started the service, and now she's wide awake. Despite our best efforts, however, we have never been able to wean her off the vent. She has continued to have coughing fits while trached, and this comes out in loud gasping cries that can be heard throughout the center part of the ICU. Sometimes she's able to speak through the vent and say, "Help me." We can all hear her, and it's absolutely heartbreaking. It seems that if she can speak, she should be able to make it off the vent, but she gets so agitated all the time that she becomes tachypneic and weaning becomes impossible. I don't know how to help her. She's allergic to codeine and can't take Tessalon through her Dobbhoff, and the Robitussen isn't touching her gag reflex at all. I know that it's impossible to cure everyone in the ICU, but I feel like we're prolonging her suffering.

Sometimes I wonder how people can go into pulm/crit without being completely drained. I've been on service for 9 days straight (black weekend), and I'm already tired and frustrated that I can't help my patients get better. Sad thing is, with the exception of my GI bleeder, the other three are going to be with me until they either die or go to hospice. There is no getting better. And that's the worst part of this job.

RWJMS - Cancer Institute of New Jersey

First Impressions: I could have easily driven to New Brunswick (about 90 min from Philly) the morning of my interview, but since I was post-call the day before I just decided to spend the night in New Brunswick. Home to Rutgers University (the equivalent of UT in TX), New Brunswick is essentially a college town, and the hospital sits right on the edge of the Rutgers campus. They had a few places that sold boba tea on campus so I got one after dinner. It was all right; better than Philly's boba tea, at any rate.
Interview Day: There were six applicants today, one of which was from Univ of Rochester where one of my best friends is doing her residency (small world). The program directors gave us a good overview of what the program has to offer (a lot), and then the six of us took turns interviewing with four faculty members. I think because we were a small group, we found it easy to chat between interviews, and we also shared our experiences interviewing at other hospitals. Two of the applicants just had their Montefiore interviews yesterday, and it was interesting to note that their interview day there was just as awkward and poorly planned as mine was. We each interviewed with two hematologists and two oncologists; I think I got along great with the oncologists, but the hematologists were a bit harder to connect with because I've had almost no heme experience in residency (the attendings at HUH are primarily solid tumor oncologists)

This program is a good one in that it's balanced in both heme and onc training, and it's affiliated with the Cancer Institute of New Jersey, one of only 40 NCI comprehensive canter centers in the nation. That means excellent resources for research and training. The program also has programs in Phase I trials, stem cell transplants, and even special centers for hemophiliacs and thromboses (which I'd never heard of until today), which I all found interesting. We had 1-2 fellows come to speak with us during lunch, one of whom used to be a chief resident at RWJMS so she knew all the ins and outs of the program. One thing she emphasized was the close relationship between faculty members and fellows; the fellows never have to worry about getting yelled at when they have to call an attending at 4 a.m. to go over a patient.

Overall Impression:
Pros: Good balance in both heme and onc, association with CINJ means lots of diverse pathology, specialists within each department (breast, lung, colorectal, heme, etc) for focused treatment and care, cancer center on site, plenty of research opportunities in either clinical or laboratory settings. 4 fellows a year. 90 minutes from Philly, 45 minutes to NY. Most rotations done on site except for clinic on Jersey Shore one month a year. Will rank high for sure
Cons: None that I can think of at the moment.

Albert Einstein-Montefiore Medical Center

First Impressions: The name "Montefiore," aka "Monte," is a good one on the East Coast, as it has strong residency and fellowship programs well known for preparing its graduates for anything (my ICU attending used to be at Monte and he's one of the smartest people I've ever met). One of the PGY3's in my program matched here and will start in July, and I looked forward to seeing what kind of program this was.

Since I had taken a day off after getting stranded in Charlotte overnight (see previous post), I was able to leave Philly at 1 pm. (after taking a 3 hr nap) and arrive in the Bronx by 3:30 pm. The Days Inn I stayed at was a 1/2 mile walk to the subway, which I took to the NYU area for my usually trip to get Pinkberry frozen yogurt. Walking back to the hotel at night, however, was a pretty terrifying experience; the Bronx is not exactly the safest part of NY. My biggest gripe with my hotel room was that it smelled faintly of urine. Ugh.
Pre-Interview dinner: None. I had dinner at Saint Alps, a Hong-Kong/Taiwanese cafe that serves delicious boba tea (which I can't get in Philly)
Interview Day: The drive to Montefiore Medical Center was, fortunately, not a bad one. My first impression of the hospital was that it was old, even more decrepit than JPS (which looked great by comparison). There were about 11 of us at the interview, and each of us would interview with both program directors. So the entire morning consisted of the two interviews, or else waiting for the interviews. Very poorly organized. There were 1-2 fellows who came to speak to us but that was it. We were not a talkative bunch, either; most of our downtime was spent on our smartphones checking email or sending texts. I did learn that I got another interview during this time (at my home institution), so thank goodness I got my iPhone. My interviews were not the greatest; one PD asked me about research I did in 2003, and the other asked how I'd work up a patient for leukocytosis. Not the best time to ask considering my computer was in the shop (got a Trojan) and I hadn't had time to review my application.

After a brief tour of the hospital (gloomy), we had to take a shuttle to the research campus of Albert Einstein Medical Center for lunch and a brief talk about the research opportunities here. We couldn't all fit in the shuttle so some had to take the taxi. We didn't eat until 1:30 pm, and then we went to a lecture about some of the projects that were being done here. Even THAT was cut short because we then had to take a shuttle back to Montefiore. And by the time I got to the parking garage, some idiot had parallel parked his car behind mine. Thank goodness someone was there to move the car, but I saw that there were other cars parked similarly within the garage b/c there were no more spots yet. Talk about inconsiderate! (then again, this is New York). Bronx traffic was horrible too; I was glad when I crossed the bridge into New Jersey.
Overall Impression:
Pros: Very strong program in both academics and research. Well balanced in hematology and oncology. Lots of diverse pathology, specialists within each department (breast, lung, colorectal, heme, etc) for focused treatment and care, plenty of research opportunities in either clinical or laboratory settings. 8 fellows a year, subsidized fellow housing, reasonable parking prices (for those who keep their car, which I would like to do), a 20 min train ride to Manhattan.
Cons: Way too much emphasis on research, fellows rotate through 3 different hospitals, unable to gauge whether fellows are truly happy to be there. Bronx isn't the safest place to live; not completely sold on living in NY, as cost of living is ridiculously high. Program did a poor job of selling the program.

University of Florida @ Gainesville

First Impressions: I got my first invite from this program in early January, and there are lots of good things to be said about UF. Shands, its teaching hospital, is ranked 29th in the nation in cancer care, and they have a brand new cancer center that just opened in 2009. It's also somewhat associated with Moffitt Cancer Center, one of the top cancer centers in the nation located in Tampa.

Gainesville has a tiny airport with only 3-4 gates (impossible to get lost); I had to catch a connecting flight in Charlotte to get there. I rented a car for the interview, and as I drove through Gainesville, it was hard to complain about the 70 degree weather and palm trees lining the streets. The hospital was located right beside the undergraduate campus of UF; truly a college town.
Pre-Interview dinner: I met the 2 program directors (who are both very young; if I hadn't seen the PD's face on the website I would have mistaken him for a fellow, and some of the applicants did think he was a fellow) and other applicants at the hospital before we carpooled to an Asian fusion restaurant called Liquid Ginger (or "Liquid G" as one of my interviewers would refer to it). There was a lot of good food on the menu, everything from steak to pad thai. I didn't want to cost the PD too much money, however, and so avoided the ribeye and got a shrimp and scallop dish that was really good. I met another applicant from UTHSC who knew a few people I'd known from undergrad; small world. Dessert was red bean ice cream. It was a nice relaxed dinner, and I didn't feel quite so nervous about the upcoming interview.
Interview Day:
The PDs welcomed us to the program and gave a very informative powerpoint presentation about what UF had to offer. My first interview was at the VA across the street with a head-and-neck specialist who was interested in hearing about a project I was doing on head-and-neck cancer. It was slightly embarrassing when I didn't know what the side effects of cetuximab were (despite it being used in the project), but he didn't make me feel like an idiot. After that we toured the new Cancer Center and the VA, also checking out "Fellow Land" (where the fellows have cubicles and computers). Lunch was with the fellows, and then we walked almost across campus to the outpatient clinics. There was a LOT of walking to be done on this day, and I wasn't wearing the most comfortable shoes either. I ended up going across the street to the VA three times (twice for interviews), and in the afternoon it was hot and humid outside. My second interview went very well, I thought; the attending was interested in topics such as breast cancer, patient-doctor relations, and palliative care, all of which I could talk about for a LONG time. If anything can get me into this program, it was this interview.

I wish I could say that after that interview I was able to fly safely back to Philly, but things didn't happen that way. My flight from Gainesville to Charlotte was delayed 1.5 hrs because of a storm in the Carolinas and Georgia, and even then we flew for 2 hours instead of 1 b/c the pilot made a wide detour to Alabama to avoid the storm. By the time we landed in Charlotte, my flight to Philly had already departed (missed it by less than 30 minutes). Needless to say there were tons of people stranded at the airport because of missed connection flights. I went to the Special Service line and was able to get a seat on the 6:30 a.m. flight back to Philly the following day, but then I hit another problem: lodging. Just about every hotel in the vicinity was completely booked due to people missing their flights, except for a Westin with rooms starting at $319. Since it was midnight anyway, I decided to suck it up and try to get some rest in the airport. In a way I felt like I was on call minus the beeping pager. All I'd had for dinner was Cheerios at Gainesville and all the restaurants were closed; fortunately a Starbucks stayed open just for us and I got a smoothie and muffin to sustain me until morning. With the help of my travel pillow, backpack (for back support) and fleece-lined ski jacket, I managed to get somewhat comfortable in a chair and slept on and off until 4:45 a.m. I boarded the plane at 6 a.m. and was back in Philly by 8 a.m, after which I slept 3 hrs before driving to New York for my next interview.
Overall Impression:
Pros: Really liked this program. Lots of diverse pathology, specialists within each department (breast, lung, colorectal, heme, etc) for focused treatment and care, new cancer center, plenty of research opportunities in either clinical or laboratory settings. 5 fellows a year, PDs friendly and approachable, personalized training with different tracks (i.e. more research electives for those interested in academia, more clinical electives for those interested in clinical practice), strong in both solid tumors and hematology, affordable living in Gainesville, guaranteed good boba drinks in Gainesville (found a Lollicup cafe not far from the hospital). Florida. Sunshine.
Cons: Gainesville is not easily accessible by plane; most major airlines fly to nearby cities Orlando and Jacksonville and people drive to Gainesville from there. Chances of getting in are very slim given UF's history for taking their own residents into their fellowships; both PDs did medical school, residency, and fellowship at UF, and the same could be said for some of their fellows. All that aside I definitely plan to rank this program high.