By Marcus Toral
Welcome to Vital Sign’s new interview series with residency directors here at the University of Iowa! Homing in on the perfect specialty for you can be difficult, but we’re here to help.
For this series’ premier, I sat down with Internal Medicine Residency director Dr. Manish Suneja. The Internal Medicine Residency at the University of Iowa is a three-year accredited program focused on developing a strong foundation in medicine, while also allowing students to tailor the training to suit their own goals and career aspirations.
Marc: Thanks for sitting down to chat with me! What drew you to Internal Medicine?
Dr. Suneja: I was somebody who actually went to each and every rotation and enjoyed it; I would go to surgery and think, “Oh my god! That’s what I want to do!” Then I’d go to ophthalmology and think, “oh wow, I’ve found it!” By the time I was done with most of my rotations, I wanted to do everything!
When I finally arrived at Internal Medicine, I realized, “well this is one place where I am able to do...pretty much everything.” The possibilities are immense; you can complete a fellowship and specialize and still practice. On top of that, I enjoyed the combination of patient contact, the longitudinal care, and problem solving. The way I envisioned a doctor in my mind before I knew anything about medicine was actually an internist; I don’t think I’m alone there.
Marc: Did you decide to sub-specialize within Internal Medicine?
Dr. Suneja: Yes, I specialized in rheumatology initially, and then I settled on nephrology. There’s about eleven fellowships in internal medicine, so there’s plenty of areas to choose from if you want to specialize.
Marc: Could you tell me how the Internal Medicine program here is unique compared to other programs across the country?
Dr. Suneja: Well, the program here is actually very learner-centered. We’re really focused on getting you to the place you want to be, but in addition, we want all our residents to be well-rounded physicians by the time they leave. So, I see the goal of our residency program as two-sided: One, making sure that we make you a well-rounded physician, and two, we want to make sure that the residents achieve the goals they’ve set for themselves. We work hard to keep these goals aligned.
We also have a very strong emphasis on teaching and make sure our residents are actually practitioners and teachers of medicine. I have a firm belief that in order to learn something, you need to be able to teach something. Because of this we have a focused, longitudinal curriculum. Some of our residents work to get a masters in medical education (MME) after graduation, and I like to think our emphasis on teaching helps ignite this passion.
Marc: Can residents do this masters in medical education in in tandem with their residency?
Dr. Sunjea: Yes! In fact one of our residents just finished up her masters in education just this month.
Marc: What about opportunities for residents who want to do research?
Dr. Suneja: We have a physician-scientist training program here, and we make sure that they have the resources and opportunities they need to become successful physician-scientists. But we take extra care to make sure that they graduate from this program with the same medical skillset that all our residents develop. Providing the opportunity for residents to do research very important to us. I feel that we need physician-scientists and that the best way to ask the right research questions is through good clinical training. So, I think we have a strong research focus and amazing mentors. Our residents have published in Science, JAMA—high impact journals—and our program is proud of that.
Marc: Mentoring and individual education seem to be an emphasis. How does that work?
Dr. Suneja: Well, for research, we have these ‘speed dating’ sessions, every year in the early winter. We call in all of the Internal Medicine divisions—cardiology, gastroenterology, nephrology, etc.— and we ask them to bring mentors who are truly interested in working one-to-one with our residents. Each day we'll book different divisions to come in and present with their mentors, describing their mission and current research projects, and each mentor gives a short blurb on their mentoring style and what they're working on. We let our residents meet with each of the mentors for 5-10 minutes, so they can figure out who they best fit with. This is a fantastic starting point for these mentoring relationships to begin.
Marc: Do all residents here do a research project?
Dr. Suneja: Yes, they do.
Marc: What kind of criteria do you look for in someone applying to this residency program?
Dr. Suneja: Well, we definitely do look at the big picture, rather than one focused area. But—having said that—what's happened over the last three or four years is that for 23 spots I’m getting 3,600 applications. There's no way possible that we can look at each and every application in full. So we do try and look at as may applications as possible using certain criteria like USMLE scores to make the number more manageable. For example, let’s say we only have 23 spots to offer, we may interview maybe 220 people. To get those 220 people, we still look at maybe 700-800 applications in greater detail, of that 3,600.
Marc: Something that we hear as medical students is that if you get a lower Step 1 score than you would have liked, that your Step 2 score can help offset that. How important Step 2 is relative to Step 1? Do you look at both? Is one more important than the other?
Dr. Suneja: My advice is if your USMLE Step 1 is really good, then honestly you don’t need to worry too much about Step 2. But let’s say that your USMLE Step 1 score is 218, 220, or so, and you're looking for a competitive residency in a competitive place, then what I would recommend is that you take Step 2 before applying. If we see that you go from 220 to 250, then frankly I'm going to ignore your earlier score. That improvement between Step 1 and Step 2 is definitely evaluated. But again, if your Step 1 score is high, I don’t want you to worry too much about it because I don't care much what your Step 2 score is.
Now once you make that cut, your step scores become much less important, and we look at many other things: your MSPE, your research, what you’ve done outside of medicine—but the biggest thing I’m looking for is: are you a good fit for my program? I want to do justice to you too; I want to make sure that you will have fun and enjoy being in this program. For some applicants that I feel would be an especially good match for the program, we will occasionally overlook the hard cutoff of scores and give them a holistic review. We really want to know who you are as a person. Are you going to be a good fit based on the culture here?
Marc: What are some student qualities that you feel fit well in your program?
Dr. Suneja: I want to run this program exactly like a community-based program, but still offer you all the advantages and resources of the university. For example, everyone knows each other; the leadership and associate program directors don’t need to look at your badge to figure out who you are. You're not one of maybe 150. You're an individual.
One of the biggest things we look for in applicants: are they going to be a team player? You don’t have to compete against your fellow residents to shine at Iowa. A big part of what we promise with our program is that we will get you where you want to be. It's not necessary to compete with anyone other than yourself.
We put work hard to make sure the learning climate is amazing and not damaged by competition between residents. On the other hand, we’re not okay with our residents just being competent. We really want to push all the residents to be their very best. As a program director, I look for people that don’t think they know everything already; I'm looking for people that genuinely want to learn and have a healthy amount of curiosity. Even while we develop this culture of intense self-development, we try to hold on to that community-based program feel. One of the best things about training here is that people are always willing to help out when needed. Even without me having to ask, 10 people will volunteer.
Marc: What general advice do you have for medical students getting ready to interview?
Dr. Suneja: You really don’t want to lose three years of your life in a place where you feel you don’t belong. So that’s something everyone has to answer for themselves; what do you value in a program? Are you going to be happy here? Go to a place where you feel you fit in, where the residents look genuinely happy. This is key because the residency and program directors will always have a smile on their faces, but residents will have difficulty having a fake smile for more than ten minutes if they’re unhappy. After ten minutes...everything comes out. Beware of places where you have limited contact with the residents themselves! Above all, be honest to yourself. What do you really value? Is this program going to be able to get me that? You need to ask the tough questions. Ask the program director, the faculty, and the residents about the things that are important to you. Don't bother with generic questions.
Another tip is to ask your family and friends who are not in the medical field, “Okay, you know me, what is going to be important for me when I start this new phase of my life?” It’s critical that you find out what motivates you. And of course, I always tell people consider the region where you want to live and then pick schools in that region. And lastly, applicants need to consider their goals. I have nothing against community-based programs—they can be amazing learning experiences—but if you really want to get into a competitive fellowship, a university-based program will give you a better chance of matching into one.
Marc: One last question—for current M3s and M4s who have their hearts set on internal medicine, what advice do you have?
Dr. Suneja: You know, my biggest piece of advice would be don’t over-worry about performing! If you worry too much about this, you will actually perform worse. That's something I tell people when they are coming for interviews—don't pretend to be somebody you're not! Stay true to yourself, and let that shine. The best way to have good grades and have high performance evaluations is to be yourself and have fun during the whole process. If you're not having fun, it's just not worth it. Most faculty don't grade students on what they know; we evaluate students on their curiosity. Do they want to learn? Are they self-directed? Are they excited about being here and seeing patients? This includes both verbal and non-verbal cues. You'd be surprised, but we are very good at picking out who's excited within the first 3 or 4 days.
Internal medicine is one specialty where I can tell you that you’re never going to be able to say you’ve mastered everything. The moment you say that, you’re going to be humbled. I tell people I’m still learning and that I learn something new every day. Because of this, I’m not looking for applicants who feel they’re done after they’ve learned the topics they will be tested on. The biggest disservice we do to medical students is teach that medicine is black and white. Once you start seeing patients, you’ll soon realize there’s a lot of grey and not everything has a clear answer. You need to be comfortable with that uncertainty and still be able to make decisions.
So my advice in one sentence: be yourself, have fun, and be curious.