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The Prelim Playbook: Tips, Tricks, and Unspoken Rules for Success · Behind The Knife: The Surgery Podcast

• Prelim Podcast #1 === [00:00:00] Welcome back to Behind the Knife. I'm ii a general surgery resident at Duke Hospital and a behind the Knife Fellow. Today we're gonna talk about a unique, grueling, and often misunderstood pathway in surgical training. The preliminary year. Before we start, I want to acknowledge that there are many perspectives we won't cover today and some that we plan to cover in the future. So please let us know any feedback or requests. Also for international medical graduates looking to apply into a residency, I encourage you to listen to our prior podcasts dominate the Match, episode six and seven, where we go through that in detail. Now, back to the discussion for today. The preliminary year is complicated. For some, it's a necessary step on the way to another specialty like interventional radiology or anesthesia. But for others, the non-designated prelims, it's a one year audition with no safety net. It's a year of working the same brutal hours, taking the same calls, and rotating on the same services as categorical residents, [00:01:00] all while simultaneously trying to build a cv, reapply for residency and secure a future position. I talked about the experience of this year with three guests, a program director, and now attending, a former preliminary resident and a current preliminary resident. But , before we go into that, I think it's helpful to briefly talk about how we got here. In the early 20th century, William Hallett established the first formal surgical training program at John Hopkins, heavily inspired by the German system. It was a parametal structure. Machiavellian by design programs would bring in a massive class of interns. But there were only a few spots at the top. Promotion was never guaranteed. There was little to no room for remediation, so you either outworked the surgeon next to you or you were out. This ruthless framework persisted for decades, and it wasn't until 1996 that the residency review committee for surgery finally prohibited PARAMETAL programs. Instead. Programs were only permitted to [00:02:00] offer as many categorical internship positions as they had chief spots to finish, but there was a catch. Surgery programs still need hands to cover the floor and fill vacancies left by attrition or residents stepping away for research and there entered the modern, non-designated preliminary position. Originally, these spots were marketed as a mutually beneficial relationship. Programs got the workforce they desperately needed and unmatched. Applicants got a foot in the door, but as a former prelim, Justine Broker pointed out in her 2023 AWS blog, which I highly recommend reading for current prelims. There is an undeniable power imbalance. Prelims depend on program support to advance. They have to prove themselves daily within a surgical culture, which is no small task. Furthermore, these residents reported lower program satisfaction and felt less collegiality than their categorical peers. Nonetheless, the preliminary system remains a vital entry point. It's a system built [00:03:00] on necessity, steeped in history, and incredibly challenging to navigate. So back to the interviews. We'll start with an interview with Dr. Luis Jackson, an assistant professor of surgery, a colorectal surgeon, and one of the most important educators we have here at Duke. So first, Dr. Jackson, thank you so much for doing this. Do you mind just telling everybody a little bit about how you, , had a prelim position to begin with and what that experience was like? Yes, of course. So, um, I'm from the United Kingdom originally and I trained there for medical school and worked there for about three and a half years, and then decided I wanted to come to the US to train. , And I had no experience, , in the United States. And so when I applied to multiple programs, I think it was over 55 programs, , I did not match in the categorical spot and I ended up scrambling. Do you remember what that felt like? And es especially the scramble and, and [00:04:00] the, you know, the scramble occurs over such a small period of time and I imagine that that's a lot of emotions to manage and a lot of, things to do in a very short window. Yes. So, , I think to honest, not getting the categorical position was not wholly unexpected. , I was. , Pretty far out of medical school, which is generally viewed as a negative. , And I had no observership or US experience and so that wasn't wholly unexpected, but Scramble day was, , still when fax was a really big thing. , And so I had to, I got a second fax machine and then I had all my emails lined up and, , my. Phone ready to do all the international calls. And then the day before I realized the clocks changed a different, , week in America, , than in the uk. And so the actual timing was a whole hour different. Oh, okay. , And I just realized that like the day before scramble day, , but essentially, , how I got my position was the program director at the program I ultimately [00:05:00] matched into, walked into his office and my fax was on the floor in his office. And, . The first call I got was from a program in Texas. They were incredibly kind and we talked for a little bit. , And they basically said, you have a prelim spot here. Just let us know by the end of the day. And, , then I got a second call from the program that I ultimately went to, and, , they offered me a prelims spot. Yeah, I mean, I, I wish we had more time to just talk about that whole story 'cause it sounds, , quite different from what we experience now. Um, uh, I, I, I wanna ask , when you decided to accept the position, , what was going on in your mind before you actually started and what did you do to prepare yourself for success? Now, of course you had a, , some, in some sense an advantage of having already done a surgical, some of a surgical residency in the uk, but I assume that there's still a lot that you did to prepare. Yeah. So, , the first thing was really understanding. So in the uk by that point in time, we were working about 56 hours a week.[00:06:00] And so I was really thinking about work, what it would be like to work an 80 hour work week or more. , And then I needed to find somewhere to live. And I found that on Craigslist and booked my apartment for six months without ever seeing it. , And then I had to figure out how I was gonna get a car and a social security number and, , all of the logistics of how to do that. , And then at that point we didn't have electronic medical records in the uk. , So really thinking about like, how. I was gonna manage all of that. And then I have the worst sense of direction. So being in a new large medical facility, , I'm just used to getting lost for at least the first week. So, , trying to navigate all of those things as well. And did you reach out to anybody before you started or speak to anybody specifically? I did, I had a contact, , who was a faculty surgeon in Wisconsin, , for one of the surgeons I knew in the uk and I talked with him a couple of times on the phone. , And it was [00:07:00] moderately helpful. I mean, he gave me the faculty perspective, but not really the resident perspective. That was just, . When I got here, , just trail by fire, I think. Yeah. And, and I would love to hear about your resident experience because when you started, I imagine, I mean, it's a new system, new way of doing things. At the same time, there was probably a lot of pressure about. What would happen next year. And so can you talk us a little bit about, , , how you navigated, at least the start, what were the biggest challenges and then we can go from there. Yes. So they did a, , intern bootcamp, which was incredibly helpful for things like the EMR, navigating the hospital. And I'd worked for about three and a half years in the uk so I had pretty, , broad general surgery and vascular experience. And the only rotation I didn't wanna start on was ped search, and of course that's the first rotation I had. , And so, , I did a lot of reading. , I relied heavily on my senior resident who, , [00:08:00] was very, . Thoughtful about how he, , taught the juniors and protected them and integrated us into the system. And he'd been a prelim too. So I think that was helpful, , being with him for the first month to really get some mentorship about how to succeed as a prelim and IMG and how to set myself up for the rest of the year. , I will say during that first month. I gave out the home phone number of the chief of pediatric surgery to all the patients to make their follow-up appointments. Oh. And his wife was the sweetest lady and just made the appointments for the children for the first week before he, uh, gave me the correct number and I still managed to stay on for a second year. Oh my God. And so, so it sounds like the mentorship was very helpful. Did you seek out any other formal types of support? . Particularly for your position to try and secure that next year? Yes. I think, um, I had a couple of faculty who were really good [00:09:00] advocates for prelim residents, , that had been prelims themselves. Um, and they gave me very helpful advice. And within that residency program, , they had a lot of prelims. They had at least one prelim a year. , And those residents. Really provided excellent mentorship in how to navigate the year successfully, what the goals were, the timeline of how to get things done, , and provided really excellent support. And how would you advise, let's say, somebody who finds themself in a preliminary position next year that didn't quite expect one. How would you advise 'em to get that same level of mentorship and. Help to navigate their year? Yeah, I think, um, seeking out people who have been prelims and been successful, , is extremely helpful, , to give both perspective and advice. , And it's just, it's helpful to see someone who's done it and succeeded to know that that is possible. , And then. [00:10:00] I think it's, it's so hard because that whole year is essentially an interview. , And so you have to work hard. Do the right thing, be successful, meet the right people, and, , do all of that with good grace and a smile whilst applying for more jobs. And, , having the uncertainty of not knowing if you're going to be successful in even finish surgery, residency. , And also dealing with the. , Feeling of not quite being fully included in everything, , which is, is a matter of perspective 'cause it's not always the case. , But it, you can definitely feel like that as you're going through the year. Yeah. And before we talk about what you've done here at Duke, especially to make that a more comfortable process, just when you were going through, at what times did you feel. That the struggle was the hardest. And what did you do to really, , get yourself [00:11:00] back? I think the biggest parts were, , towards the end of the year, both the first year and the second year. 'cause I was a second year prelim two. Just that uncertainty of not knowing where you're going to be next year, , was the hardest. And going places to interview and coming back to my home program and saying, you know, this place has offered me a job. Are you gonna offer me a job? And trying to navigate all of that from a position of being an intern, you know, you're not in a strong negotiating position. , And then ultimately, the feeling of overwhelming relief when I finally matched into a categorical position. I, I can't imagine having to deal with the politics and everything else and just the stress in addition to being a intern. Now it when, when you advise, , residents here, and for our listeners, you know, you're very involved with the residents here from at all levels, prelims or non prelims. And, , we all very [00:12:00] much appreciate you, , more than you realize. So when you do have somebody come up to you in that position, , what advice do you give them? How do you support them? Yeah, so I think the first thing is having the strongest plan a possible. So, uh. Preparing for each rotation, preparing for each case, preparing for each faculty, , interaction, um, and, , working really hard and relying on the support networks around you, your other residents, your other prelims, , faculty, including myself. Um, to just really do the very best job day to day that you possibly can do, and finding ways to show that you excel, whether that's getting involved in the small research project, even presenting at Eminem, become, become a positive thing in that situation, and just really being prepared for everything. , And then, , putting yourself out there, making those meetings with the program directors, associate program directors, chair of surgery to make sure they know how serious you are [00:13:00] about becoming a surgeon and staying in that program. , The other thing is not being, . Not feeling that you're putting the program out when it's interview time. Your program, especially your program director, fully understands your need to find a job for the year after. And when you're going through that interview cycle as a prelim, it can feel like you're a burden to everybody else and that you're putting people out by taking time away. You are not, and, , you shouldn't feel like that. That is, that is so important for your career and all of the hard work you've put into being an intern at that program, that's, that's their payback for you supporting you through that. Yeah, I agree completely. I think that it is our responsibility. If you take on a prelim resident that you need to support them to not be a prelim resident next year. Yeah. And as I hinted towards having a really strong plan A, it's also really, really important to have a strong plan B so that you have an idea and a thought of what you will do if you don't match and if you're not successful. And I encourage all of our [00:14:00] prelims to, to really think about that in a thoughtful way, , and make sure that they do have a plan B, even if it's uncomfortable to think about it and talk about it. And , how do you navigate scenarios where people had attempted to match into a different subspecialty of surgery and now maybe are seriously considering a general surgery residency? I feel like that is a specific. Cohort of, , residents where it's very challenging to apply reapplying that same fellowship while also trying to think about a future in general surgery. So what advice do you give to those students in particular? Yeah, I think general surgery is a really hard backup option. Yeah. , I don't think it's a great plan B because you have to show commitment and when, , you know, when I'm reading through applications for residency. , That's one of the things I'm really looking for is what are the motivations to go into it and what's their level of commitment. And I think when you are using general surgery as a plan B, I think it's really hard to convey that in an [00:15:00] application. , It's not impossible. We've certainly had people do it here and do it successfully. . But you have to, you also have to make sure from your personal point of view, that it's a good plan B for you. I think if you really want to do orthopedics or plastics or dermatology, , are you truly gonna be happy being a general surgeon? , And so I'm not sure that general surgery is a great plan B in the vast majority of circumstances. Yeah. And I think especially now, things are even more competitive and I imagine that. Nowadays as a program director, it's probably even more, , unappealing to look at a application where you can tell that they're not quite as invested in your specialty. Yeah. The general surgery truly is its own specialty. Yeah. And I think if you come in as an unmatched. Orthopedic resident for general surgery program. I think you've gotta make the decision early on, are you gonna reapply to orthopedics and make that your number one focus? Or are you gonna say, okay, I'm gonna do general surgery and then really spend that year building that [00:16:00] CV and that, , support to write strong letters and , and show that your commitment is fully there one, one way or the other. Yeah. And that comes back to your plan a, plan B type of, you really need to have a strong plan. A Yeah. And it sounds like. Generally, you just can't be your, yeah, your, your plan BI would say in the, in the personal statement and, um, in your reapplication. When you are applying as a prelim to either categorical spots or , to other prelim spots, it's okay to talk about your original plan. It doesn't have to all be completely centered around your time as a prelim. , I see a lot of applications that basically just talk about that prelim year. , But I want to know about all the amazing things that you've done before the prelim year that when you applied that first time round. Don't leave those things out 'cause the. Those are so amazing and lovely to read about. And I, I really wanna get your perspective on navigating a mistake as a preliminary resident. And you kind of hinted on it when you [00:17:00] accidentally gave out that phone number, but, you know, I, I remember my first, the residency very well because, uh, well, you make mistakes and you make a lot of mistakes. Mm-hmm. And, , especially as an intern, I think, I think it's very hard to realize that everyone else has done that as well. And I imagine that as a prelim that feeling is even worse. So. I guess I would love to hear your thoughts on what really is a mistake that you can make as a preliminary resident? What feels like a mistake and isn't a mistake, and how can you really recover? Yeah, I think, , I. I got yelled at a lot as a resident. I think the only time I really got yelled at where I really felt it was when I hadn't called somebody in the middle of the night when I should have, , , I would say just do all the things that you're meant to do and what people are watching and looking for. Is not how many mistakes you make or what mistakes you make, it's how you react to it and respond to it. , As you said, everybody makes mistakes, , and does things that they wish they could change, but what people want to see is that growth [00:18:00] mindset and that when you've made a mistake, once you learn from it and it doesn't happen again. , And there's not a pattern there. , I do think coming in with three years of experience helped. Helped you. Yeah. , It, it certainly makes that clinical side of things a lot easier. But, but like I said, it's not, it's not whether you make mistakes or not all interns make mistakes. It's how you respond to it and grow, grow from them. Yeah. No, thank you. , And if there was one thing you wish you had as advice before you started your year, and if there's just one key thing that you would tell everybody, what would that be? Especially in that time coming up. , Between match and your start date, because I imagine a lot of people listening to this maybe in that position where they're not sure what to do. , Is there anything specific you would advise people to? Yeah, I think if there's any way that you can, , go to the program early and. And spend time there ahead of the start date, , whether that's paid or unpaid, , that time will be well invested so that you hit the ground running from day [00:19:00] one. , And then I think the biggest piece of advice I can give you about getting through that prelim year is try and keep the most positive sunny attitude you can. . I'm not sure whether this is why I got my categorical spot, but the last question I got asked in that interview was, how would your program director describe you? And I said, you know, hardworking and meticulous. And then I finished with the word happy and , I've never seen this anyone's eyebrows shoot off their head, but, , he was like, happy as a prelim resident and I was like, yeah, I love surgery and I love doing this job. And I don't know whether that's what got me the job, but I'm pretty sure it was a large factor in it. Well, thank you Dr. Jackson. That's all my questions, so, and again, thank you so much for taking the time. You are welcome. I'm now joined by Dr. Kevin Shaw, who's a surgical oncologist, , specializing in HPV and Assistant Professor of surgery here at Duke. He's also the general surgery program director. So thank you Dr. Shaw for joining us. [00:20:00] Yeah. Thanks for having me. This is great. I, I think it's very valuable to have your perspective as a program director. And the first question that I have for you is when people are, , applying as medical students or otherwise, and they find out that they didn't match, during that scramble, how do you advise people about choosing between a preliminary position versus maybe taking a year off to do research or taking a different type of route? Yeah, I, I think this is, you know, one of the most difficult, , situations that, you know, medical students or anyone going into, , a residency can find themselves in. Um, you know, the first thing is everyone who's been, through medical school, most of the time they, they've only known success, right? And, , they've achieved, . Things at a really high level, um, you know, at each successive point in their academic career. And so this is probably the first [00:21:00] point where they're, they're met with real, significant professional, , challenges. And so it's very common in the situation for people to just kind of get turned around and unable to figure out what the next step should be. . What you have to do is take a step back and think about why you didn't match. And so, um, you know, there are a few different scenarios that can happen. Sometimes people are applying into a non-general surgery, , position. , And so, you know, they've applied into plastics or ortho or something else and they haven't matched into that specialty. And so they're trying to figure out the, the path forward. , The other scenario is people are trying to get a categorical general surgery position, and, , we're unable to get a categorical position through the match. , I, I think those two situations are a little bit different. , And then there's also the individual factors, right? So, , why you didn't match. [00:22:00] As an individual person. So, , for some people they might have, um, you know. Uh, strong board scores and strong grades, but very limited research. , In that situation. You know, taking a year off and doing research and reapplying, , might be the best strategy for other people. They've got, you know, a whole pile of, , publications, but, , they still didn't match in that case. Doing more research is not the problem. What you have to figure out is where, . , Where the, the weakest point of your application was. Sometimes it's just random. Sometimes there's actually, , something that you can pinpoint. , And so in that situation, doing a prelim year is probably the best bet, , because most of the time if you have, , you know, uh, a strong research background or at least a history of publications, the issue isn't that, the issue is there's some question about your clinical ability or the strategy that you employed in, in applying. , In your experience, who do you think [00:23:00] most commonly finds themself, , to benefit the most from a prelim year? Is it somebody that may be trained overseas, , and has to show a clinical ability in the United States, in the system? , , who is that person that benefits the most? Yeah. You know, probably the, the most common situation is someone who has done their medical education, , outside the us. , And they're trying to get into a, a us, , residency position. , That is probably the most, , you know, that's probably the classic situation, , because. The main concern that people often have when, , trying, you know, thinking about recruiting international medical graduates is what their ability to navigate the US healthcare system is gonna be. And, you know, there's a dual challenge. One is that. When you're an international medical grad, getting clinical experience is really difficult, [00:24:00] right? , Sometimes you're limited to observerships. It's hard to get an actual sub internship. And so that leads to the, the next issue, which is how can you actually prove that you can function well in the US , healthcare system? And so in, in that situation, doing a prelier can really, . , Be something that boosts your application significantly for the next application cycle. , For those that have, , graduated from a US program, , there still is value in doing a prelim year in in many circumstances. , And you, again, you just have to sort of think about what your individual sort, you know, situation is. If your goal is to be a. General surgeon that, you know, um, practices in, , the rural US right? Doing research, , may not be something that you're really interested in and, you know, doing a pre year and working hard and, , , getting another set of [00:25:00] recommendation letters might be, , the thing that helps you secure a position rather than doing research, which is something that you're really not passionate about. , Because when you apply for programs, you're likely not gonna be applying to programs that prioritize research. And so how important that research experience is gonna be, , is really, , I think, , dubious. And as a program director, I'm sure you play a very important role in, especially the prelims that come to Duke. And so when they start their program, what does the conversation look like when you sit down with them and how do you guide them towards a successful year? Yeah, I, I think this is, , a really important question and one that is actually, the answer is a lot simpler than, than people. , Probably make it out to be, , the things that make a good categorical intern are the same things that make a good, , preliminary intern. All the same things that you want any intern [00:26:00] to do. Working hard, being a good part of the team, being prepared, , working efficiently. Those are all the same things that we look for, out of any intern. People approach a preliminary year, they often approach it as like a year long, , audition rotation. And there, there is some value in that, right? You obviously wanna put your best foot forward. You wanna show people what you are capable of. But I, I also think there is a little bit of danger in that because sometimes it takes you a little bit outside of yourself and you're. Constantly trying to prove yourself instead of just doing a good job and showing what you can do through your actual actions. Instead, you're focused more on how can I, demonstrate to somebody that I'm actually doing it. , Having said that, there are important differences that you, you have to, , keep in mind. So, , what we try and do here is. Consciously [00:27:00] give prelims FaceTime with people who might be able to give them letters of recommendation early in the year. , We also, , give them FaceTime with, , try and give them more face time with attendings, , so that people actually know who they are and have a better sense as to, how they're performing in general. No matter if you have FaceTime with an attending or not. The, they're going to hear from the residents about how the interns are doing, right? And so, , even if you don't have a ton of face time with an attending or, with the chair or program director, whoever it may be, , there still are ways in which your performance is gonna be communicated back to them, to sort of inform, . What your level of performance is. So, you know, I, I think people sometimes get carried away trying to prove what they can do. , And the problem is the beginning of intern year overlaps with sub I season, right? And so if you're at a place with a lot of medical students and [00:28:00] sub interns, there's this like tension between the prelims getting FaceTime and the subs getting FaceTime. And so what I would say is, , don't make it a competition and just do your job, , and work hard. And honestly, the, the rest will kind of take care of itself. You have to be strategic obviously, but, , that, that's from a clinical performance standpoint. In terms of preparing your application, there are things that you have to do specifically. If this is your second time around applying for categorical positions, , in another field, you have to try and arrange a, a rotation in that specialty early on in the year so you can get another letter of recommendation. , And, . If you're applying it to general surgery, similarly you want to get rotations where you'll be able to get letters of recommendation. , But you have to start preparing your personal statement, your cv, all those things very well in advance, and then workshop it with. , Either the program director or other faculty [00:29:00] mentors that you have in the department so that you have the most polished application you possibly can. , And then finally being strategic about signals, , and looking for PGY two positions. , that, that's sort of the general approach that I take to, , prelim interns. Yeah, I, I think the audition point was very well. Made because I think one of the hard things for me as a medical student was that feeling of constantly auditioning. And it's definitely, , good to know that you don't really need to do that. You just have to work very hard. , The same as anyone else. And so let's say that somebody really wants to stay at your institution. Is there anything specific that you're looking for in them that maybe can really help somebody stay where they're. Doing that auditioner. That prelier. Yeah. , the first thing that I would say is,, o obviously we've taken, our own prelims as categoricals both as, you know, promoted to PGY two, uh, status and through the match. But, [00:30:00] um. The, the one thing that I would, , advise anyone who's gonna be doing a preliminary year is not to put all your eggs in one basket, meaning you go somewhere to do a prelim year. You shouldn't feel like this is my one and only choice to, , get a categorical position. , I'm, I've seen that, . Happened before where people feel like, , this is the only place that I, I can or will train, and it, it becomes really limiting. You have to take a really broad. , You know, a really broad approach to, , the reapplication process. And truthfully, any categorical position is better than a prelim position. I mean, that, that, I think that's one very important point because I've seen people take prelim positions over categorical positions because it's at a preferred institution. , And that generally is not sound advice because. The number one [00:31:00] goal is to become a surgeon, right? In order to become a surgeon, you have to get a categorical residency position. And once you get that categorical position, you can, you can do what you want after that. , But you gotta take step one first. , If someone wants to stay at the institution where they're at, you know, it's all the same things that I said before. . People are looking for the same things that they would normally look for in a categorical resident, , or a categorical recruit. But the, the main difference is they actually have a record of, , performance when they're looking at a prelim, right? And so in a lot of ways, that's a big advantage that a prelim intern has over, . Over a medical student who's applying for the first time, likely hasn't done a rotation at the institution. Um, and you know, you get a sense from letters of recommendation, but you know, those are not, you know, sort of all encompassing. All encompassing. [00:32:00] Um, so you know. Working hard, doing a good job, and then having, um, if your career goals are aligned with the institution, , and you know, what you wanna do is aligned with what the institution values. That's also an important thing, right. So for us, you know, we're looking for people who are gonna be exceptional technical surgeons, , and great clinical,, surgeons, people who are interested in making impact on the field and, , those that are gonna work well as part of a team. Right? So those, those are like broadly the things that we're looking for. And so just as we would look for that in an MS four, we would look for the same things in a, in a prelim intern, again. There's nothing special you have to do other than work hard, , and, and do a good job. , Trying to, you should indicate interest in staying, but like, trying to sort of convince someone that you should stay there is generally not gonna be effective. , What's gonna be [00:33:00] effective is, showing what your performance is. Thank you, and I would like to ask you briefly about conflict. I think that occasionally, especially in the start of the year, people are still trying to figure out what's going on and conflict arises, whether that's, , between, , residents at the institution and the prelim resident, or. Just conflict within themselves and struggling to perform the way that they would like to perform. , How do you approach those situations and what advice would you give to someone? Because I think if I remember my intern year, well, that first few months, you felt like you were underperforming every single day. So I guess, yeah, I think globally I would just tell people to. Cut themselves a little bit of slack, when you're a day one intern, you've got no clue about what's going on. Like, I still remember like, just looking around like what is happening? Uh, you know, half the things people told me, the abbreviations, I was like, what is this? I, I have no idea. So, you know, everyone is in [00:34:00] that position and, , that's the. Point where the audition mentality can be really damaging, right? Because you feel like every interaction, your future hinges on it, right? It is the same problem that sub eyes often have. They get one question wrong and they think, oh my God, I, I'm, I'm gonna have to like. Do internal medicine now, right? Like you, you just, you got to, you have to take a deep breath and understand that the whole point of residency is you don't know everything. In fact very little. And it takes a long time to acquire that know knowledge. So that's the first thing. Don't beat yourself up about everything that you do wrong because everyone does things wrong. In the beginning, literally every single person you could think about the most famous chair of surgery anywhere. They made a ton of mistakes as an intern, right? So everyone's starting from the same place now. Interpersonal conflict, that's a bigger issue. , And if you're getting into arguments with people all the [00:35:00] time, to me that's, that's not an encouraging sign about your ability to work with others. Even if you are put in this position where. You are right and the other person is wrong. , Or you think you're doing the right thing and , you're trying to advocate for the patient. There's a way to do it that is professional and courteous and, , in the spirit of. , Teamwork and collegiality. And then there's a way to do it that is, , abrasive and, , confrontational. And no matter what the situation, you always have a choice and you can make the choice to be, , professional and calm. It's hard to do sometimes. I mean, I'm, I'm not gonna pretend I'm a saint, right? Like I've, I've lost my cool, , on occasion, but, . You, you always have that choice. And the best thing to do is just take a step back, take a deep breath. , Because if you get in arguments with people, , your chances of one, staying at that [00:36:00] institution go down significantly. And two, the quality of your letters may reflect that. , You had a difficult time getting along with people. I think that's what your question was about. Yeah, exactly. And, , sometimes I feel that other residents can be aggressive or other residents can kind of, , have that mentality of there is a difference and, and how do people best advise it. And I think that your advice of be calm, be collected, and go do it in the most professional way possible is, , important advice. So, yeah, it, it's hard when you feel like you're being scapegoated because interns are the easiest scapegoats. Right? Right. Like, you know, the, the senior resident pins something on you like, ah, this should have been followed up on. , There's not really a situation in which, . You're gonna be able to like argue, argue your way out of that. , The other thing that I would, , advise when people are looking for prelim positions to try and get a feel, and this is very hard thing to do, and oftentimes if [00:37:00] it's during the scramble, it's even harder to do, but get a sense as like what the level of support is, right? , For the prelims. . You may feel like I just gotta get a position. And to some extent there's some truth to that, right? Like you gotta get you, you don't wanna be, , I. Too, , precious about your choices, right? You wanna give yourself an opportunity, then capitalize on that opportunity. But you know, you can get a sense as to whether or not this is gonna be a place that's supportive you of you or not. You can ask about the track record of previous prelim interns, what they went on to do. , You can look at the website even and see , where people came from. , And then, , if you feel like this is a place where they don't really care, , then you may think about whether there are other prelim opportunities, , at another institution. , The other thing is, , know to go back to a previous question about , what if you wanna stay just because. You aren't offered a [00:38:00] position to stay at the institution, doesn't mean that they don't care about you and that they don't want you to succeed. , There are two things. One, there has to be an open spot to give you a spot, right? If there's not an open spot, , unfortunately the reality is they, it's unlikely that a spot can be made. The second thing is, , general surgery is super competitive, right? And even if someone really likes you and thinks that you're doing a great job. You're still competing against. A lot of really phenomenal applicants. , And just because you don't get a spot at the same place where you are doing your prelim year,, doesn't mean that they're not working really hard to get you a spot somewhere else. , And it can feel like a little bit of rejection and, , it, it's hard for it not to feel that way, but. I, I would take a different lens , in, , in the way that , you view that because people generally really want , their prelim interns to succeed and, , places that have a good supportive environment for, , the entire residency don't really [00:39:00] treat the prelim interns to differently than the categorical ones, other than making sure that they're in a position to succeed in the next match cycle. Those are my questions and thank you for taking the time. I really appreciate it. So now I'm joined by a good friend of mine, Rafael Tian Co. Who was a good friend of mine at Tulane University. He went to medical school there and in between, took a two year research fellowship at John Hopkins prior to applying to residency at the time he applied into plastic surgery, ended up soaping into a preliminary position, but is now a general surgery PGY one categorical at Penn State. Rafi. Thanks for joining. Hey, good to see you again. Thanks for having me. Yeah. Do you wanna, do you wanna maybe give a little bit about how you ended up in a preliminary position? What was your pathway to get there and what did it feel like when you found yourself in that scenario? Sure. Yeah, it, it was quite unfortunate, so I [00:40:00] applied, it was the 2024 match. I applied plastic surgery and general surgery. With a research heavy application. , I think what happened was I just came off research and I just wasn't the strongest student and clinical performance was just weighed very heavily in choosing applicants. So that's where I came short. What happened was on March I got the email, I figured I didn't match, met with my advisor and. Fortunately, during the third round of soap accepted a prelim position at LSU I've, I, I am so grateful for that. They literally saved my career. That's pretty much how I ended up there. , I ended up doing well, found new mentors, and fortunately I matched here at Penn State. I'm, I'm really happy things worked out. Yeah, so am I. And thanks for sharing it. I bet it was very difficult. And when you first matched at LSU, you found out, now you're , swapping paths a little bit. This is unexpected. , [00:41:00] You're gonna be taking a preliminary role in general surgery. What immediate actions did you take and did you get any guidance and preparation before you started? Absolutely. So the first thing I did was reach out to my mentors, and actually I cold emailed previous PDs who I interviewed with to see if I can get some feedback. So the, the purpose of that was to determine what my weaknesses are and where I can improve. What did I do well? What did I do poorly? And sometimes these conversations can be difficult. And sometimes you'll figure out, okay, is this somebody who will support me the next time around? Or is this somebody who will just say, , thanks for working with me. , You know, good luck in your next steps. And that's a very important thing to figure out who will be your supporters next year. Because if you don't have somebody who will go up to bat for you , then it'll be , extremely hard for you to match the next year. Next thing I did was, you [00:42:00] know, I had a research project that I was cooking up and during the three months I, you know, was finishing up my fourth year, I just, I just pretty much just knocked it out, just WR wrote it and found a new mentor at LSU because of that. So that's the second thing I did. And pretty much the third and fourth that. Kind of the little things I did afterwards was just redo my personal statement. And, , I did another rotation in general surgery, I believe, and then I started studying for AB site. Yeah, no, , that's, , that's really important and I think something that we hear about a lot is mentorship, and I think that it comes up frequently, but especially in this scenario, it sounds like mentorship really was. , Critical, absolutely crucial. So we have people that listen to this at all stages. , And I guess , it's good to hear just how important it is, especially to, from the attending side, that they [00:43:00] support people like you. Um, so I think that that definitely means a lot. Now, how did you go about finding those mentors at LSU? Yeah, I'm happy to talk about that. So it was a little serendipitous. A lot of my research over in Baltimore was in burn and. Coincidentally, my first rotation at LSU was with the burn department. So they already knew. They're just like, oh, that's guy, that's that guy who was at a BA. And so I think I was able to show off my knowledge, , work hard. There were many nights where I would stay overnight in the burn call room, sleep on the bench, and work patients up and admit I'm in the middle of the night. I was just honestly happy to be there. Made lots of good friends with the nurses, shout out to the New Orleans Burn unit, and that went a long way into getting a good letter from a very well known burn surgeon. And that guy went up to bat for me, especially being another surgical subspecialty that, , you know, is starting to stray away from [00:44:00] general surgery. So without his support, I don't think that. People would've believed me when I said, I really do enjoy general surgery and this is something I want to pursue. . So it was pretty much that having a good relationship with the PD over there because, , he really went up to bat for me and pretty much just having my mentors over at Hopkins to support me as well. And how, how did you go about having a good relationship with the PD and the other mentors? I mean, what advice would you give to somebody who maybe is starting their preliminary or is in the middle of one, or is thinking they might have to take one? What advice would you give to them? Absolutely. I think it should go without being said that you should be the hardest working person there, have a good attitude, et cetera, et cetera. But pretty much it's just, it's just how you present yourself in front of folks. I was honestly just happy to jump back into clinical work. After two years of research, [00:45:00] I might as well call my fourth year of medical school, my third year of research 'cause that's pretty much all I was doing, and I think it went a long way. When you show a good attitude, you might not know everything, you might mess things up, but if you want their good side, they might forgive a couple things and end up being your biggest supporter. As long as you have a good attitude and are willing to learn and just pretty much be a good intern. That's pretty much it. Yeah, I think that's great advice. I think the attitude goes a long way. Nobody expects you to know everything. I think it would be crazy if you did. , But everybody wants someone that they're. , That they're happy to go to work with every day. So that's, that's definitely important. , Now, when you first started, how did you think about your career and your next step? How did you kind of decide whether or not you were gonna. Go again for your subspecialty or go into general surgery or a different [00:46:00] field. And I, I think that that question's important because a lot of people that apply subspecialty find themselves in a prelim position, whether that's surgery or medicine. , And then comes a big question of how do you re redirect yourself in your career if need be? Yeah. So that's, that's a really good question. So I, I always knew that I would be happy being a general surgeon so that is why I felt comfortable going the general surgery route. At the end of the day, I, I'd want to be a board certified general surgeon with additional subspecialty training. So number one, figure out if, if that is your personal goal. Number two, I would try to figure out how bad do you want it, and if there's a path forward, because if you dual apply, it sort of weakens your application. Because it spreads you out too thin. And there are some programs that talk to each other. [00:47:00] And so what I decided is that, look, I'm applying for a second time and the second time I want a categorical position. So that is why I only applied categorical general surgery. And that is how I ended up gaining support from the department. 'cause they knew. I was switching over. . Now, other, other questions for you is when you found yourself now at LSU, did you find that there were differences in how. People treated you based on your role, whether you were a prelim or a categorical, or did you find that your work ethic really negated that distinction? So I think it's program dependent. Where I was at LSU and here at Penn State, I kind of noticed that the prelims and categoricals are treated the same, but it's just you're just on different rotations. That's pretty much it. You might be at different places, but they expect the same things and people are [00:48:00] still willing to teach somebody who's willing to learn. And while you were in that year, you talked about your mentorship, you talked about your work ethic. Do you think there's anything else that you did to really help yourself be successful? And if the answer is no, that's also a great thing. Right? Absolutely. I guess two things that I wish I did more that could have helped me I wish I completed step three. , Some programs , really look at folks who are quote unquote serious about their job and early completion of step three, kind of shows that. The second thing I did, you know, I studied a lot for AB site, but switching over specialties, I pretty much got the average score. And, , I don't think that really did me any favors. And then the third thing I wish I did was, you know, I, I pretty much just hold up and studied all day and worked all day. I wish I, you know, just had, just [00:49:00] went out more socially and got to know my co-residents more. It's kind of scary because this is a one year or two year interview, depending on your, if you're a one or a two, but I just wish I was more open and , just got to know them a little better because at some programs, the residents have a lot of say on who they pick. If you're kind of seen as a wallflower or shy, or if you're seen as overly friendly on the other hand, then they could work against you. Yeah. Very, very tough balance. I think even now everyone has issues with that balance. , Especially when you work so many hours with people. Exactly. Now and then the only thing I'll say is like, you know, research is a plus minus. If you don't have much, maybe it's good to, you know, dip your feet in one project, but then if you have a lot, you should focus on clinical work. Yeah. I I, I feel like, , if you really. Give yourself a good clinical reputation during your pre, that goes miles. I think that really is what people, , would like to see, at least [00:50:00] is my impression. Now, to wrap this up, how do you feel now You're a PGY one categorical spot at Penn State. A fantastic program, and uh, I, you know, I couldn't be happier for you. So how, how does it feel once you're through that process and looking back? I'm pretty freaking happy. I remember texting you like I was, I had like a MetaPort that day and I was like shaking. 'cause I didn't know where I was gonna match. And then I got the email, I'm like, whew. I did it. Yeah. I was thrilled for you. I was so, I was so happy. Yeah. I was, you know, as they say, they had me in the first half, but here we are. I'm, I'm super happy to be here. You know, I'm super thankful for LSU. And, you know, I'm happy to be at my new program. Looking forward to. Looking forward to my time here. That's great. That's great. Well, you know, thank you again for all your time and I appreciate it. Yeah. Good to see you again. So that wraps up this first podcast about the preliminary experience and ways to navigate through the year. [00:51:00] We hope this episode was useful, and for those that made it this far dominate the day I.