#AAMC13 #BeyondFlexner: Tweeting Back to the Future

5 11 2013

I am just returning from AAMC 13 in Philadelphia, which happens to be the site of the very first AAMC conference in 1876.  Perhaps it is this historic backdrop which made it more poignant when AAMC President and CEO Dr. Darrell Kirch charged the audience to rise to the occasion during our most challenging time, or our healthcare system’s “moment of truth.”  Between sessions on how academic health centers needed to evolve to survive healthcare reform and how medical students need to avoid the “jaws of death” from the Match, there was certainly much to fear and much to learn. In spite of this, there are always moments where it was undeniable that the future was bright.  But, the most interesting moments at this meeting where when it felt like we were going back to the future.

One of those moments was sitting in on the CLER (Clinical Learning Environment Review), or the new ACGME institutional site visit process which is not meant to be scary, but helpful!  As a non-punitive visit, its meant to catalyze the necessary changes needed to help improve the learning climate in teaching hospitals. This session was particularly salient for me as I transitioned from being an Associate Program Director into role of Director for GME Clinical Learning Environment Innovation about a month ago.  At one point, Dr. Kevin Weiss described the CLER site visitors observing a handoff- and in that one moment, they saw the resident bashing the ER, failure of supervision, the medical students left out, and an opportunity to report a near miss that was ignored.  Even though CLER is new, he made it sound like the site visitors were going back in time and nothing had changed.  Have we not made a dent in any of these areas?  I guess it’s probably safest to pretend like its 2003 and we need a lot more training in quality, safety, handoffs, supervision, fatigue, and everyone’s favorite…professionalism.

After being the only tweeter at times in the Group of Resident Affairs sessions, I ventured into the tweeting epicenter of the meeting at the digital literacy session.  There, I not only learned about a very cool digital literacy toolkit for educators, but also got to connect with some awesome social media mavens who use technology to advance medical education. While I have access to these technophiles through Twitter (you know who you are), it was NOT the same as talking about the future of social media and medical education face-to-face.  Call me old-fashioned, but connecting with this group over a meal was just what this doctor ordered.  My only wish is that we had more time together…

Lastly, we went back to the future in our session showcasing the winners of the Teaching Value and Choosing Wisely Competition at both the AAMC and ABIM Foundation meeting last week.   One of the recurring themes that keeps emerging in these sessions, in addition to a recent #meded tweet chat, is that the death of clinical skills (history taking and physical exam) promotes overuse and reliance on tests in teaching hospitals.  Could it be that by reinvigorating these bedrock clinical skills and bringing back the “master clinician”, we could liberate our patients from unnecessary and wasteful tests?  I certainly hope so…and it can’t hurt to be a better doctor.  Moreover, one of the most powerful tools that was mentioned was the time-honored case report!  In fact, case reports have been resurrected to highlight avoidable care in a new JAMA Internal Medicine series called “Teachable Moments.”

And lastly, in the spirit of going back to the bedside, our MERITS (medical education fellowship team) submitted a video entry to the Beyond Flexner competition on what medical education would be like in 2033.  While the impressive winners are showcased here,  our nostalgic entry was aptly titled Back to the Future and Back to the Bedside, and envisioned a future where all students, regardless of their year, are doing what they came to medical school to do, see patients.

–Vineet Arora MD





Vampires and Urban Legends: Teaching Residents about Healthcare Costs

24 05 2011

This past weekend, I gave a talk at the Committee of Interns and Residents, the largest housestaff union in the United States.  The most inspiring moment of the meeting that I witnessed were the 2 standing ovations earned by Dr. Koffler for advocating for residents to get paid in 1936 (her first paycheck was 15 dollars a month!).   How could I follow that…especially with a talk on how to train cost-conscious physicians?   Those who know my work well may even wonder how I got invited to talk about this.  Well, earlier this December, I wrote on the blog about my holiday wish list for medical education and #2 was a curriculum on cost conscious practice for medical trainees.   In addition to lack of a formal curriculum, there were several other barriers on teaching residents how to practice cost-conscious medicine that I discussed.

  • Faculty are not trained.  The largest barrier of course is that faculty don’t know how to do this.  A study in Journal of Hospital Medicine showed that faculty physicians could not identify what things cost.
  • No one knows what the cost of anything is.  Because each hospital negotiates its own prices with suppliers, it is very difficult for residents to know how much things cost.  In trying to find out how much your hospital charges for various tests, you may end up on a wild goose chase until you find the helpful person who may or may not even be in your state!
  • Bad systems promote costly workarounds.  Most of the time, residents are too concerned that they won’t be able to get a test or worse, it will delay a patient’s discharge.  The system is set up to order the test even if the attending thinks about it.  Some of our own data shows that interns learn during internship to misrepresent tests as urgent to get the job done.
  • Rumors and hospital legends spread quickly.  The highly connected residency program can actually spread rumors about how much things cost or give rise to urban legends when patients actually pay and don’t pay.
  • Underordering, not overordering, is penalized.  Due to the highly litiginous environment, most attendings encourage residents to err on the side of getting a test since the biggest fear we all have is of missing the ‘can’t miss’ diagnosis.  More reasons doctors over-order tests here.

So what can we do to teach residents about cost-conscious practice?  Well here are just a few of the things we can do..

  • Empower residents to find out how much their hospital charges for things.  As I said at the conference, we may need to start a support group for those that start down this daunting path – but it is the first step to understanding how to control costs.  Starting with senior leadership could be helpful – after all, how many C-suite leaders would not want to find out how to teach residents to control their costs? There is also a related movement to improve price transparency for patients.
  • Show residents how much they spend.  At least in the case of daily phlebotomy, a recent study dubbed “Surgical Vampires” (due to the daily blood draws ordered by the surgical interns) highlighted that letting residents know how much things cost actually reduced the cost of lab ordering per patient and resulted in 50,000 dollars saved over 11 weeks!  Studies with electronic health records at the point of care show even greater results!
  • Use unbiased resources that promote better cost-effective decisions.  Specialty societies like the American College of Physicians and the American College of Radiology are now starting to create guidelines that encourage cost-effective practice through more judicious use of imaging or other therapeutic modalities.   The popular 4 dollar list for medications is another example.
  • Incorporate discussions of costs into routine educational conferences.  At Harvard, one chief resident started a Hospital Bill Morning Report for the residents to review what a patient bill is like.  In our medical student lectures on radiology, the costs of the tests are also now discussed.
  • Educate patients that less is sometimes more.  Letting patients know about the risks of overordering tests- specifically workups of incidentalomas and pseudodisease may be helpful in explaining your new approach to cost-conscious medicine.   The pushback from patients may be the fear of rationing,  which is of course irrational since it already occurs.  A helpful summary for patients on high value cost conscious medicine appeared in Annals of Internal Medicine.
As with all things, there is the potential for unintended consequences in teaching cost-conscious medicine.  The most egregious of which would be to hide behind the veil of practicing cost-conscious medicine in order to shirk work and avoid getting an indicated test when needed.   This is especially important to watch out for as burnout sets in late in the academic year.  So, as we resist our inner vampire urge to order blood tests and uncover hospital urban legends and myths about healthcare costs, its equally important not to morph into the haphazard and dangerous cost-cutting monsters that we all fear most.
–Vineet Arora, MD




Healthcare Horrors: Needles, Medical Studentitis & Other Medical Phobias

3 11 2010

Every Halloween, I take note of some of the most infamous Doctor costumes, ranging from the mad scientist who created Frankenstein to Dr. Jekyll and Mr. Hyde.  Even if you don’t dress up as a doctor, there’s enough medical paraphernalia that contributes to costumes including all that medical gauze for the perfect mummy costume, the skeleton head for your porch, or the fake blood for the perfect vampire or zombie.  This does beg the question, what is it about doctors and healthcare that is scary?  As it turns out, fear of doctors and healthcare is very common.  Here is a short rundown of the more common healthcare-associated phobias.

  • Iatrophobia is a fear of doctors.  Interestingly, these phobias are actually types of social phobias in which the afflicted is afraid of interacting with the doctor, discussing their personal illness, or being examined.  Some suggest that ‘white coat syndrome’ or higher blood pressure in the doctor’s office is part of this syndrome.  
  • Dentophobia is the fear of dental care or dental procedures.  Unlike iatrophobia, this is quite common and some sources cite estimates as high as 75% of Americans suffer from some form of ‘dental fear’. Some suggest this is actually a variant of post-traumatic stress disorder due to the pain associated with a prior dental procedure.  Not surprisingly, the dentist’s professional demeanor is also important.  Anyone scared of Willy Wonka’s dentist dad in Tim Burton’s Charlie and the Chocolate factory?
  • Nosocomephobia is fear of going to the hospital, which is either related to fear of death or could also be related to fear of contracting illness or disease (germophobia initially described in JAMA in 1910) and may be a variation on obsessive-compulsive disorder. Of course, it is important to distinguish this pathological fear from normal concern since hospitals are reservoirs for germs and disease and hospital associated infections are on the rise
  • Pharmacophobia is the fear of taking medicine, which is often related to fear of rare side effects due to a medication.  This can sometimes manifest itself as medication ‘noncompliance’, which doctors often assume patients are intentionally not following directions.  It is also often associated with prior adverse drug events.  Perhaps the best known pharmacophobia is currently manifest as the fear of vaccines in which it is not the fear of the needle (see below) but the fear the risks of vaccination like autism or that the flu shot causes the flu.
  • Needle phobia is a very common phobia.  Some estimates say at least 10% of Americans are trypanophobic, and are likely to faint during a needle stick.  This may even be an underestimate since those with needle phobia are not likely to seek medical care.  This is a very serious phobia since needle phobia is characterized by very low blood pressure and shock when presented with needles, and there have been reports of patient deaths.  Unfortunately, people with needle phobia often avoid recommended vaccinations and blood tests, placing them at higher risk of illness.
  • Nosophobia is the fear of contracting disease.  Perhaps the most classic example of this occurs in medical students (typically in their second year) who believe they or others around them are suffering from the symptoms of the diseases they study.  Medicalstudentitis was reported as early as 1964, and it is still alive and well.  One study estimated 80% of students suffered from this and a Facebook support group even claims 1000 members.  Nosophobia can also manifest itself in patients who spend a lot of time online searching for causes of their symptoms.  Cyberchondria is a type of nosophobia the unfounded concern that common symptoms are harbingers of serious disease due to online searching.

While these phobias may sound harmless, exaggerated or silly, it is actually important to identify people with these phobias and help them seek professional treatment early.  Patients with healthcare phobias are likely to avoid seeking care for actual symptoms which places them at higher risk of morbidity and mortality.  Now, that’s a scary thought!

–Vineet Arora, MD





Reviving Case Reports: Chasing Zebras or Solving Mysteries?

31 08 2010

I am teaching a new course this week entitled “Turning your Clinical Cases into Scholarly Work.”  I hope to draw on my own experiences through the years mentoring students and residents in writing up several clinical cases, but also in making diagnoses.  In preparing for this course, I have also learned quite a bit about the controversy surrounding case reports and the challenges that they face in today’s healthcare system. 

Unfortunately, case reports have fallen out of vogue.  Many journals no longer accept case reports or they have relegated them to the 2nd class ‘online’ only publication since they are often not highly cited and lead to a lower journal impact factor.  Critics of case reports actually say they overemphasize the unusual at the expense of the ordinary and are not evidence-based.  Furthermore, in today’s era of cost consciousness medicine, chasing ‘zebras’ or unique diagnosis is often frowned upon due to the potential for inappropriate or overuse of tests, with the possible unintended consequences of working up incidentilomas

Despite these concerns, case reports have had a major impact on the discovery of new diseases, mechanisms of disease and even drug therapies.  The first cases of AIDS were reported as case reports.  Side effects of drugs are often discovered through case reports and can lead to changes clinical practice (MRI contrast and nephrogenic systemic fibrosis) to prevent harm.  Cases reporting potentially desired side effects can also prompt accidental discovery of new drugs that can change quality of life for many people, as is the case with Viagra

So, how can we promote the art of case reports without creating zebra chasers who drive up healthcare costs?  Well, the key may lie in Sherlock Holmes.  Medicine is often compared to detective work and it is well known that Sherlock Holmes used the power of observation to make informed deduction.  While Holmes was a fictional character, the invention of Sir Arthur Conan Doyle (a doctor turned writer), he was modeled after Dr. Joseph Bell, Doyle’s former physician-mentor.  To get his trainees interested in observation, Dr. Bell used the power of observation to deduce mundane things like occupation and recent activity in passersby.  In essence, the clues to making the diagnosis lie in careful understanding of the patient’s story and observation of the physical cues.    

Unfortunately, the powers of observation are declining these days due to the ease of ordering CT scans without thinking about a patient.  Fear of malpractice also drives the use of diagnostic testing over trusting one’s self.  To make matters worse, diagnostic tests are financially rewarded, while thinking about the right test to order to make the diagnosis is not.  If the art of diagnosis were more handsomely rewarded, more hospitals would actually have a “Department of Diagnostic Medicine” led by their own version of Dr. House (who is based on Holmes incidentally …and Chasing Zebras was considered as a title of the show).  As stated by Rapezzi and colleagues…

Current trend towards mass use of sophisticated diagnostic tools in routine practice—accompanied by a blind faith in technology and predefined diagnostic algorithms—is threatening to kill off the science and art of clinical reasoning. Besides burning a lot of public and private money to make diagnostic work rather superficial, doctors also risk losing the intellectual pleasure that comes from careful diagnostic reasoning.

So, in considering how to revive case reports and the art of diagnosis, its worth revisiting lessons dating back to the old adages that been used to teach generations of doctors before the proliferation of imaging.  While each of these rules has its faults, they represent a return to thinking about the diagnosis.   If only it was only as simple as, “It’s elementary, my dear Watson”…   

Occam’s Razor – “entities must not be multiplied beyond necessity” refers to the thought there is usually one unifying diagnosis.  The term razor is used to highlight shaving away unnecessary assumptions to get to simplest explanation. 

Hickam’s dictum – “Patients can have as many diseases as they well please” The counterfactual to Occam’s razor is credited to John Hickam, MD who highlights that it is statistically more likely for a patient to have several common diseases explaining a constellation of symptoms rather than a rare zebra.  The best example of this is Saint’s triad which consists of gallstones, hiatal hernia, and diverticulosis which don’t have anything to do with each other other than they are often common in patients.

Pasteur’s dictum  – ‘chance favors only the prepared mind’  This refers to the fact that to make the ‘leap’ of discovery, one must have the knowledge & skills to be able to make the connection.  In other words, you cannot find an interesting case if you are not reading and know what to look for.

Sutton’s law- First, consider the obvious.  In other words, conduct the test which will confirm (or rule out) the most likely diagnosis.  This phrase is named for bank robber Willie Sutton, who when asked why he robbed banks supposedly answered “because that’s where the money is.”





Professionalism is a dirty word… and why are medicine docs called fleas?

7 06 2010

At the recent AAMC meeting on how to integrate quality into teaching hospitals, the question that kept popping up from speaker after speaker was how to address the fact that doctors in teaching hospitals don’t get along.  Unfortunately, all the specialty bashing that takes place prevents the adoption of a team based culture necessary to advance quality and safety.  As one speaker highlighted, how can we really start to address this topic when specialty services are busy blocking the consult or disparaging the internal medicine doctor by calling them a ‘flea.’  I hadn’t heard the term ‘flea’ in a while but many onlookers were nodding in agreement, possibly thinking about the last time they heard someone disparaging the ER for an incomplete workup or a specialist blocking the consult as ‘inappropriate.’  The discussion about quality and safety morphed into every medical educator’s favorite topic, ‘professionalism.’ 

Ironically, while medical educators love discussing professionalism, this word has become despised by medical students.  It has been the subject of the last 2 years of senior class shows at Pritzker.  Why?  Because in response to numerous calls by the AAMC and other groups including the public, Pritzker, like many other schools, have launched a professionalism initiative designed to promote professionalism.  As you can guess, any efforts to ‘teach professionalism’ to students seem preachy and insincere.  So, what’s a medical educator to do?  After years of contemplating this problem with colleagues and experts, we concluded that we first need to identify and reward faculty role models and ensure that our faculty and residents emulate the behaviors that we wish to see in our students.  Apparently, we aren’t alone.  The American Board of Internal Medicine Foundation has awarded 6 grants to variety of organizations to promote professionalism among physicians in practice.  We are fortunate to have received funding through this mechanism to actually address the topic at hand – specialty bashing in teaching hospitals– particularly between hospitalists, primary care physicians, and emergency medicine doctors.  Interestingly, this problem is more prevalent in teaching hospitals.  When our residents rotate at a nearby community hospital, they often comment on how nice the doctors are to each other, even thanking them for consultations!  Of course, unlike the attendings in teaching hospitals on fixed salary, physicians in the community hospital actually make more money for each consultation.  So, aligning financial incentives can actually promote professionalism.

I was at this meeting with one of our 2nd year medical students Marcus Dahlstrom who earned rave reviews for his presentation on student efforts in teaching quality and safety at Pritzker (while I may be biased, you can see his presentation for yourself.)  On the way home, we noted that although professionalism is a dirty word among our students, but that medical educators continue to perseverate on it even at a meeting about quality and safety.  We need a better word and a better way to address these issues.  Because most students are professional, it’s the actions of a few that are remembered by faculty and attributed to all students and their generation. 

On a side note, Marcus also asked me why medicine doctors are called ‘fleas’ since he had not heard that term…yet.   I did not know the answer but here are some potential origins I found – the most useful of sources being StudentDoctor.net

  • Internists can be spotted with a stethoscope around their neck, or a “flea” collar
  • Internists, like fleas, are the last things to leave a dying body
  • They travel in packs on rounds
  • Doctors were very devoted to their plague patients, similar to fleas that were responsible for spreading the deadly disease. 

While I don’t know the exact reason, its interesting that while 3 of the reasons are clearly derogatory, one explanation of ‘fleas’ actually highlights ‘professionalism.’ Ironically, maybe all we have to do to get doctors to stop using this term is to say that it’s part of that dirty p word ‘professionalism.’

–Vineet Arora, MD





Movie Legends & their Medical Problems

22 03 2010

the Mad Hatter of  ‘Alice’, the Vampires and Wolves of Twilight, and the Na’vi of Avatar

After the frenzy of Match Week and in between trying to understand whether health reform would pass this weekend, I went to see the still #1 movie in the land Alice in Wonderland in 3D.  This epic creation by part genius – part disturbed director Tim Burton features the wickedly talented method actor Johnny Depp as the ‘Mad Hatter.’  As I was watching Johnny Depp’s orange hair and freakish eyes, it occurred to me that some of the most popular fiction movies over the last several years have featured some notable legends and their medical problems.  For example, the cult sensation Twilight franchise features Edward and the Cullens (a clan of friendly neighborhood vampires) and introduced us to wolves with the recent release of the New Moon (on DVD this weekend).  Lastly, who could forgot the blue Na’vi people of Avatar earlier this year.  Interestingly, these movies are all in some way linked to very rare medical conditions.   

Mad Hatter-  The Mad Hatter as played by Johnny Depp is clearly disturbed individual but comes to Alice’s rescue.  The Hatter is “mad” due to chronic mercury poisoning.   Hatters used to use mercury, an orange liquid, to make felt for hats.  The liquid was often absorbed through the skin and could result in symptoms of mercury poisoning including confusion and confabulation (Korsakoff’s syndrome also seen with chronic alcohol use).  Other symptoms could include nervousness, irritability, insomnia, tremors, weakness, skin discoloration and eye problems among others.  The most common cause of mercury poisoning today is contaminated fish.  Upon reading about mercury poisoning, it was Depp’s idea to use orange hair for the Mad Hatter.  Burton loved the idea since orange hair is associated with some creepy fixtures of our imagination (who isn’t scared of clowns for example?)  Interestingly, the original Mad Hatter is based on an eccentric furniture dealer and not someone with mercury poisoning.

Vampires  Vampires, like Edward Cullen, are blood thirsty, pale, photophobic, and hate garlic, which are all symptoms associated with porphyria, a group of rare, largely hereditary blood diseases.  Porphyria is a family of disorders of heme (necessary for hemoglobin) synthesis which leads to anemia (low blood count) and leads to pale skin.  In some types of porphyria (cutanea tarda), the nonfunctional heme structures that cannot be made into hemoglobin, if hit by light, result in rashes, leading those individuals to want to avoid sunlight.  The connection between vampires and porphyria went mainstream in 1985 when biochemist David Dolphin explored whether vampires may have suffered from porphyria. Unfortunately, this publicity has resulted in a lot of stigma for porphyria sufferers.  Mary Queen of Scots and King George III are some of the famous sufferers of porphyria (the acute intermittent type). 

Wolf-man or “werewolf” It is true that humans with congenital hypertrichosis lanuginosa look like wolves.  Unlike Jacob, this unfortunate syndrome involves massive amounts of hair on the face and body, resulting in some of the people with this disorder to tour as circus performers.  Interestingly, porphyria, more commonly associated with vampires, can also lead to hypertrichosis, leading some to link the disease to werewolves.  However, another hypothesis is that werewolves and vampires actually suffer from rabies, which can also lead to similar symptoms (including the garlic!).

Na’vi or “blue people”  Although blue skin is considered ‘alien’ in Avatar 3D, there are actually ‘blue people.’  Methemoglobinemia is a blood disorder in which blood cells can’t bind with oxygen which impairs the oxygen supply to parts of the body, resulting in cyanosis (blue skin).   Fortunately, the treatment of methemoglobinemia is actually a blue dye, ‘methylene blue,’ which converts methemoglobin back to to hemoglobin.  There is an acquired form and also a congenital form.  The most famous carriers of this hereditary genetic error are the blue Fugates of Troublesome Creek from Kentucky who dated back to 1800. Their disorder was eventually diagnosed and treated in the 1960’s and the story is incredible.

With these movies, who says learning medicine can’t be fun?

–Vineet Arora

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Making a Match List & Checking it Twice…

14 02 2010

Past, Present, and Future on the Residency Match & Some Last Minute Tips with 48 hours to go
Every 4th year medical student you know is making a list and checking it twice.  This is because rank lists are due to the National Resident Matching Program (NRMP) on Wednesday February 22rd 2012 at 9pm EST.

The history of the Match is actually very interesting.  Historically, physician training in medieval days was arranged when craft guilds matched apprentices with physician masters for their training.  Modern history of the US Match actually describes the situation where hospitals were pressuring students as early as 2nd year to sign up for internship before students knew where else they were competitive for and before hospitals had adequate information about student clinical performance.  In 1952, when the match was first proposed, medical students actually protested the initial algorithm since it penalized students for ranking a hospital who did not want them.  The students proposed the alternate algorithm, the “Boston Pool Modification,” which favored students rank preferences and was ultimately adopted.  Since that time, the growing number of preliminary positions and the need for a couples match has led to redesign of this algorithm, but always preserved favoring the student.

More recently, the Match has persevered in the face of a recent lawsuit that which accused the Match of violating the nation’s antitrust law. The Supreme Court ultimately dismissed the case due to an amendment that was made to antitrust law that exempted the Match.  While the lawsuit painted the NRMP as the evil player, the Court actually concluded that the NRMP and the hospitals’ participation in the Match “are so interdependent that the Court cannot separate them” in the allegations.   One benefit of the match is students are able to make decisions on a standard schedule, without being pressured to commit to a program prematurely.  Both applicants and programs must sign a Match Participation Agreement (MPA), which states that one party cannot solicit a commitment from the other or suggest that ranking is contingent on such a commitment.  Despite this, there is recent concern that these agreements are being violated.

Today, the Match has become even more competitive as the number of US medical graduates has increased with new medical schools and expanded class sizes (a result of the call by the AAMC) while the number of residency slots across the nation remains constant.  Leaders in medical education project that without any increases in residency spots, the number of US medical school graduates will eventually surpass residency spots in 2016.   While calls for increased residency spots continue, for the moment, strategy to optimize successful matching has become increasingly important for US students.  (Update:  2012 is the first year of the “SOAP” or Supplemental Offer and Acceptance Program that will take the place of the prior Scramble.  It is also the first day in recent memory Match Day is on a Friday!)

Here are my top tips for students in the final days of creating their match list:

1. Think twice before leaving off a program that you interviewed at.  Before leaving off a program, consider whether you would rather enter the scramble (aka SOAP) or go to the program.  The length of the rank list is the strongest predictor of matching.  This means you should not “suicide” match – or just list 1 place due to false assumption that you are definitely ‘promised a spot’ there.

2. Consider where you want to live and other non-program factors when constructing your list. When faced with programs that look very similar, think of locations that you would be happy.  Many people settle in the city that they do their residency training in. It may be especially difficult to distinguish between programs the further you go down your list – so definitely consider location at that point.

3. Don’t worry about where the program ranks you.  Remember – the match algorithm works in your favor – so its to your benefit to rank programs in the order you want to go to them and not try to ‘guess’ where they will rank you or reorder your list.

4. Avoid 11th hour changes. These will likely be motivated by faulty reasoning.  Instead, talk over your decisions with your friends and family well before so you can relax

5. Don’t forget to press “certify”! The last thing you want to do is be undone by failure to press this button before February 22nd at 8pm Chicago time.   

 

A video of some of good rank list tips here by Dr. Reddy:

 I should also add that because everyone’s case is different, its important to consult with a faculty member who is knowledgeable about the field and advising you on the process.   Good luck!  I’ll be rooting for you on Match Day.

-Vineet Arora

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