Internist

In past years, I believe the approximate figure was around one to four (1:4). That is, we interviewed around 180 and were able to accept about 45 of them. I may be off somewhat with these figures, but I'm sure they're sufficiently accurate to give a fair sense of things.

It's almost moot nowadays, since so few schools use anything other than a P/F system. Where grades are available, they are pretty much weighted the same regardless of year. So, someone with lots of 'honours' grades in yrs I and III but no so many in yr II is looked at much the same as someone with lots of honours grades in yrs II and III, but not I. Now, if by "preclinical" you mean pre-medical grades, those are not really weighted at all. At best, if someone has an absolutely outstanding set of grades during their BSc studies, it may nudge them a bit higher in the ranking, and then only if the people who reviewed his/her file noticed it and were impressed by it. Some file reviewers don't even look at the pre-medical school grades as far as I can tell. Me? Oh, yeah. I look. And if I see three or four years of A+ grades (especially if the class average is given and is much lower), I tend to advocate more for that candidate. Others would disagree and ask instead how the candidate has done since entering med school. Have the A+ grades morphed into "honours" in med school, or was there no apparent effect on his/her med school performance by having such outstanding grades in the undergrad BSc years? Some of these can definitely play a (positive) role. As I said in this thread last February, "Extracurricular interests, well-roundedness helps, especially in the gestalt. Personally, I bump up people who are accomplished (not in research, but in real life stuff) or who have unique talents/skills they'll bring to us (e.g. music, language, unique academic or social background, etc.). Again, speaking personally, I am not impressed by being active in student politics, e.g. various faculty committees." Later on I said, and still feel that,"unique and impressive life accomplishments (should and will usually help the candidate in his/her ranking). This is, of course, quite vague but, as mentioned somewhere else in this thread, I'm talking about stuff like excelling (not just participating) in a sport or a hobby such as music. I'm also referring to things like overcoming adversity at some point in their life, or doing something 'special' while in Med school (e.g. started organization to bring health care to impoverished or disenfranchised group)." Finally, I said earlier, "my sense is that most people on the U of T committee share my sentiment that real life accomplishments are worth something. How much that something is worth, is going to vary among members. Now, as to what constitutes a meritorious accomplishment, that's also going to vary. I think it's safe to say that most of us would say research achievements if accompanied by outstanding clinical characteristics, are certainly going to help. Likewise, and judging from the comments made by other committee members, most of us believe that if someone has persevered through and overcome some life challenge, or somehow found the time and energy to achieve 'something special' (especially if contemporaneous with med school), then that person is going to overcome the challenges of an Int Med residency. One specific case of non-medical accomplishment deserves special mention. To wit, if someone has a unique way of looking at things, and has demonstrated that their way is a productive and/or innovative one, that can make a big (positive) difference for them. As an example, if an applicant was responsible for a quality control initiative in industry (perhaps as a coop student or even in a real job before med school) and says he/she has been observing the way patients are triaged in the E.R. and now has some (practical) ideas how to improve the quality and safety of that process, that would be a plus in many committee members' eyes."

The vast majority of interviews, essentially all, are conducted by members of the Selection Committee. Very, very rarely, say because of last minute scheduling problems (such as illness) or an unrecognized conflict of interest, someone from outside the Committee may have to be brought in to do one or two interviews. Frankly, I can't even remember the last time that's happened. As I said, it's very unusual for an applicant to be interviewed by someone who's not on the Committee.

Historically, the interview lasts about 20 to 25 minutes. Still, since there will be a resident available to chat while you're waiting for and when you're finished your interview, many people wind up staying for an hour or two (talking with said resident). The questions will range from the obvious ('Why Internal Medicine'), to the less so. Be prepared to give your opinion on "ethics" type questions but don't worry at all about being asked the differential diagnosis for monocytosis! In other words, clinical questions are "never" asked. That being said, you may be asked to 'present' a case you had (just the major points of course). I better not say any more . . . Absolutely, go for it. Ask them to reconsider; perhaps an error was made in reviewing your file. Or, suggest to them that you are certain that if only you could meet them in person, they'd see why you are right for them, etc. IOW, ask them for an interview even if you're initially rejected for one. Often, they will relent. Even if they don't, what's it cost you. Do it! As I said to your colleague (and I know you couldn't have seen that given that I replied only seconds ago), I'm sorry but I really don't know how the IMG process works.

Sorry, that's not something I'm involved with. I'd just be guessing, and you don't want that. I'm not sure I understand. For Internal Medicine, everyone already will have exposure to the area through their own CTUs. If you are wondering whether it pays to demonstrate your interest in Internal by taking electives in it (or a specialty) in addition to your core rotation, yes, I think that helps. If nothing else it confirms you are committed. Further, as I think you are implying, it's a chance to get known by at a different university (or even by different people at the same one - this is important insofar as the more, and the more diverse, support you have at your own centre, the better off you'll be). It's also good to take electives to simply improve. That can be a very wise thing if you can arrange the elective before your core CTU rotation. Doing so will cause you to arrive at the CTU with advanced skills and knowledge compared to your peers. Yes, I know that sounds a bit venal, but it IS after all your career on the line. Electives in a medical subspecialty (e.g. rheum, cardio, or endo) are, of course, worthwhile in and of themselves. Still, from the CaRMS perspective, they're even better if you take such an elective with someone who is respected by the PGY1 selection committee(s) of where you want to go.

In my opinion (and I doubt there would be a general consensus by my colleagues on the Committee), at least two weeks are needed to show your skills and abilities to the point of providing a good basis for a reference letter. I, personally, don't give a lot of credence to letters written by someone who knows the student for just one week. The exception to this might be where the letter writer was one of several supervisors each in charge for, say, a week and where it's stated explicitly that the input of the other preceptors has been sought and incorporated into the letter. I really don't know how this works. In fact, it's not even clear to me how this works in my own division, let alone elsewhere in the province (or country). I agree, however, that it can be very difficult to get an elective arranged for a specific time and duration, and almost impossible to insure you get a specific preceptor. This is one reason why taking an elective with the "right" type of subspecialist may be preferable to the usual CTU elective, i.e. subspecialists can usually commit to specific dates and, critically, do not assign you to a colleague (or what's worse, a senior resident) if they can't do it themselves. If nothing else, it's far easier to get a straight answer from a subspecialist. What is the "right" type of subspecialist for a reference letter? I'd say, and this is all just my opinion, that you're looking for as many as possible of the following: 1. he/she should be known and respected by the members of your centre's PGY1 selection committee (often this simply translates into it being someone senior and/or someone who was/is a Royal College examiner in Internal Medicine (not his/her subspeciality)) 2. ideally he/she should attend on the CTUs (at least occasionally) and not just on his/her subspeciality 3. he/she should have some experience in writing these types of letters. Frankly, you don't want someone who's prone to understatement. Further, he/she should have some sense for what the Committee is looking for. Again, this may simply be another way of saying that you want someone senior, or more to the point, someone who's had LOTS of students over the years. By now, such a person will often seem to know intuitively the type of things to note in the letter (e.g. comparative assessments with other students he/she has had). What is not emphasized enough in choosing references is (and as always this is just my opinion and experience) that many subspecialist letter writers feel compelled to address each and every point on the list of instructions provided by CaRMS. That almost always has the effect of diluting down the letter (since, for example, there are going to be some areas where the referee won't have much to say and then winds up sounding blase or unenthusiastic, at least with respect to those areas). The bottom line is that such letters will usually contain sections that sound very average. What you want is a letter that from beginning to end, and everywhere in between, is unequivocally positive, and in the strongest possible terms. The reader should have no doubt that you're excellent and it shouldn't matter where his/her eyes fall if they just skim the letter - they should "always" land on words of high praise (and not on, for example, some feeble attempt to describe your research abilities or ability to do procedures simply because the CaRMS instructions said that those areas should be addressed.) An experienced, and confident, referee, doesn't feel he/she must address every last area, eg. procedures. In fact, an experienced, confident letter writer often seems to pay no heed to the CaRMS instructions! But that can be a very good thing since it allows the writer to speak in free text about you, rather than in the stilted manner which usually results from addressing all the items in a list. It also allows much more readily for statements of praise to be included - again, it's not always easy to do so in a letter based on a formal list of areas to appraise and on which to report. Don't quote me, but you may want to tell your referees that they can safely ignore the specifics of the CaRMS instructions. What matters is that they say who they are (rank, position, etc), how they know you and for how long (and, recall, only letters from people you've worked with clinically count for much), and speak to your knowledge and skills, intellectual ability, judgment, work ethic, reliability, enthusiasm, collegiality and team relationships, patient family interactions, and did I mention knowledge and work ethic? And how about knowledge and work ethic? And reliability? . . .

No, at least not directly. However, by not having any electives with us specifically, there is no way, of course, that we can ever see first hand how excellent they are. So, even though they won't be penalized, they will, in fact, still tend to slip down the list a bit by virtue of the fact that others (who did do an elective with us, and did an outstanding job) will have been moved up. Yes, if they are from a CTU rotation. Likewise, a specialist who knows the candidate by virtue of supervising him/her on a CTU (when they, the staff, were functioning as de facto general internists) makes an excellent choice for a reference In my opinion, neither here nor there (pardon the pun). What counts is the reputation of the supervisor (or, what is much more often the case, our total lack of any knowledge about the elective supervisor/preceptor). So, for example, a reference arising from an elective taken in Asia or Africa with someone we've never heard of, and have no sense of, must be interpreted with great caution. By definition, such a reference won't be weighted heavily by us. Hence, it isn't usually a great choice. That being said, the very fact that a candidate wanted to go to, say, Africa, and put it together, speaks volume about his/her character and initiative and can be, therefore, a real plus. (How's that for equivocating?)

. . . pretty much anything you want. But, obviously, confidential stuff will have to be kept that way. BTW, as my username probably suggests, I am on an Internal Medicine CaRMS selection committee so doubt I have anything of interest to say for people not applying to Internal (and, anything I *did* say about non-Internal Medicine programs would have to be taken with a *huge* grain of salt). A suggestion, please - take a peek at this thread so far wherein many of your question and concerns are addressed if not answered. I'm going to apologize in advance for any tardiness in responding. This is a pretty busy time for me and I doubt I'll be able to participate here more than a couple of times a week. I'm all ears . . .

Sorry for my tardiness. It's been wild at my end lately. You know, and it pains me to say this, I don't think many, if any, people on the Committee appreciate this. At least, I can't recall EVER hearing even one allusion to it during our discussions. And, frankly, I was not really aware of it, though I did suspect it given the nature of some people's reference choices (honestly). Specifically, there are always letters from, say, a nephrologist or a community-based internist which, in their very first lines state that so and so did part of their "assigned" medicine rotations with them. The key word is 'assigned' which I took to be saying that they had no CTU rotation but this assigned rotation was in lieu of that. So, although I didn't know the specifics of the "intergrated" clerkship, I assumed that at least some people were not getting classical CTU rotations but, instead, had been shipped out to various sites for an alternative medicine clerkship experience. IIRC, this phenomenon seemed to be more the case out east, at either Dal or Memorial (I can't recall which, or whether it might have even been both). Suggestion: Just to ensure that all the 'right' people DO understand the nature of the integrated clerkship' (and especially its effect on reference letters), and even though it won't help the current CaRMS cohort, it would be worth having the Assoc Dean Undergrad Educ from the relevant school(s) write the chairs of the various selection committees (that would be Heather MacDonald-Blumer at Toronto) and tell them explicitly a) that their school doesn't offer a CTU rotation (or maybe, at least, not to all their students) and ask them to please make sure the committee members at their school have been clearly apprised of that. Such a notification would have the most impact if it was devoted exclusively to those points and didn't dilute out the key message by talking about other stuff too. One last point, basically restating something from earlier, is that even though I have emphasized that not having a letter from your CTU rotation is often a 'red flag', I wouldn't worry if that applies to you, i.e. most, maybe all, letter writers for people in such situations say that so and so was 'assigned' to them for (at least part of) their medicine clerkship. By doing so, it becomes fairly clear to the reader that there was no CTU rotation offered for that student, and that said assignment was as close as it comes for them to have a CTU rotation. Hope that makes sense. Bottom line is that applicants from places with integrated clerkships have probably not been hurt although I can't swear it's never happened.

I would definitely recommend going away for at least some of your electives. Programs tend to rank people they know higher than people who are just a name to them. And, given that not everyone is going to get into U of T Int Med, it's very wise to have a back-up plan. Further, you will still have your core Int Med rotation at Toronto, so you should be able to get at least one reference from U of T anyway. Conversely, your only way of getting a letter from somewhere else is to go there (in most cases). Beyond the pursuit of reference letters, I think there's another important reason to spend at least some of your elective time elsewhere - you may find that you actually really like what you see, and wind up choosing to go there for your core years (and beyond). And, even if not, the experience and insights you get during your stay there can be very valuable (with respect both to Int Med training specifically, and "life" in general). Finally, a letter secured as a result of an elective taken out-of-town, so long as it's from someone "known and respected" by the selection committee (and most letters from academic internists will fit that description), is still very helpful at U of T.

Implicit in your question is an absolutely critical point: A 'P' on your core Internal Medicine rotation is NOT the kiss of death. Many people get accepted into our program who got a 'pass', and not 'honours', on the penultimate year Internal Medicine rotation. How, why? They had reference letters that made it clear they were excellent, their 'P' grade in Int Med was one of only a few 'P's overall on their transcript, someone on the committee worked with them and could attest to their outstanding ability (and speculate that they must have had a bad day on the written exam and that was what brought their mark down into the 'P' range), or, importantly, it became apparent from reading their personal letter, or from their interview, that while they were doing their Int Med rotation, something 'stressful' was going on in their lives. Sorry, I honestly don't know the answer to either of those questions

For Int Med (again, I speak for U of T only), that would be a fine set of experiences. One reason that, frankly, seems to be forgotten by referees, is that the more rotations you do on CTUs, the better you're going to perform on the later (CTU) rotations. I've seen this phenomenon many, many times, e.g. someone does an elective on a CTU, say, at St. Mikes. They then do another CTU elective at the TGH. Would you be surprised to learn that they were considered "outstanding" by the TGH CTU preceptor? Obviously not - they have had (at least) twice the CTU experience as their peers on the TGH rotation (usually). I know this makes us sound parochial, but we do not put much value on either electives taken outside of Int Med or referee letters from outside of Int Med. In other words, taking only Int Med electives is a very good plan for an aspiring U of T Int Med applicant. The converse, of course, is not such a good idea. This is a tough question without an unequivocal answer. And, really, it goes to the heart of the notion that the selection process is inherently flawed, or at least non-standardized. That being said, my sense is that most people on the U of T committee share my sentiment that real life accomplishments are worth something. How much that something is worth, is going to vary among members. Now, as to what constitutes a meritorious accomplishment, that's also going to vary. I think it's safe to say that most of us would say research achievements if accompanied by outstanding clinical characteristics, are certainly going to help. Likewise, and judging from the comments made by other committee members, most of us believe that if someone has persevered through and overcome some life challenge, or somehow found the time and energy to achieve 'something special' (especially if contemporaneous with med school), then that person is going to overcome the challenges of an Int Med residency. One specific case of non-medical accomplishment deserves special mention. To wit, if someone has a unique way of looking at things, and has demonstrated that their way is a productive and/or innovative one, that can make a big (positive) difference for them. As an example, if an applicant was responsible for a quality control initiative in industry (perhaps as a coop student or even in a real job before med school) and says he/she has been observing the way patients are triaged in the E.R. and now has some (practical) ideas how to improve the quality and safety of that process, that would be a plus in many committee members' eyes (how's that for a run on sentence?). But, back to your question, I really don't have a clear, uniformly agreed upon, answer.

As you may have seen, I was up early today and I'm getting punchy. Besides, my husband is frowning (he thinks I spend too much time on the computer). So, to lostintime in particular, and quoting 'Ahnold', let me say: I'll be back!

Like me, but younger. At the risk of sounding evasive, there really isn't one prototype. That being said, year after year, the people who get ranked most favourably tend to have the following in their package: 1. strong letters of reference from people that the Selection Committee respect (and believe). Further, the letters are consistent in their high praise. When I say "strong letters", I mean ones where words like outstanding are used (as opposed to 'very good') and where there is often a literal bottom line with sentiments to the effect of, "John is simply one of the very best. I've supervised trainees for over ten years and have no hesitation in stating that he is one of the most outstanding students I've ever encountered". That being said, not everyone can get letters like that. Don't worry though, even "lesser" praise is fine. Many "ideal" candidates are described as functioning at the level of a PGY 1 (or sometimes PGY2's!) even if there is no explicit comparison to their peers (e.g. "top 10 percent") or bottom line statement as described. I've mentioned earlier, or at least implied, that in addition to strong letters, "ideal" candidates have references from people we expect (and usually know) to be good judges of what we're looking for (i.e. academic internists who have considerable experience with students and aren't blown away by the only one they've worked with in the last two years). 2. outstanding academic achievement in Med School. By this, I'm getting at 'honours' (where possible), awards and scholarships for academic excellence, and unusually strong praise in verbatim text comments on their clerkship rotation evaluations (they are often summarized, or listed outright on those letters) 3. unique and impressive life accomplishments. This is, of course, quite vague but, as mentioned somewhere else in this thread, I'm talking about stuff like excelling (not just participating) in a sport or a hobby such as music. I'm also referring to things like overcoming adversity at some point in their life, or doing something 'special' while in Med school (e.g. started organization to bring health care to impoverished or disenfranchised group). 4. In my opinion (i.e. I am not speaking for others with respect to this point), an "ideal" candidate has worked with someone locally and was "clearly" superb. Obviously, this is most applicable to people from outside U of T. And, what does "superb" mean? Excellent knowledge, enthusiasm, reliable, clearly enjoys what she's doing, loved by patients, great team player, good sense of humour. I'm sure none of this surprises any of you. Evasiveness, skirting questions, over confident, zero knowledge of our program, failing to leave sufficient cash in the envelope, are all things that won't help a candidate. But it's awful hard to "blow" the interview, these things notwithstanding. Frankly, I'm not sure. To a large extent, given the "busyness" factor for all of us, it may largely be a matter of who's available that day. I could, but then I'd have to shoot you. It is my pleasure. You are most welcome.

InternalMed06: Time for me to actually do some work. I will answer you later (hopefully in about 5 or 6 hours).