Dear Dr Horton #8: CaRMS Interview Tips

This week’s edition of Dear Dr. Horton” is a general response to the many excellent questions that were submitted in response to the CMAJ call-out for the “Med Life with Dr. Horton” podcast. Find it originally here: https://cmajblogs.com/horton-podcast-carms-interviews/


Dear classes of 2019,

Ah, CaRMS…that beloved hybrid of Survivor and The Bachelor.  You want to be the last one standing, but hopefully that doesn’t mean accepting a proposal that will become your new personal definition of hell.

I’ve coached hundreds of students through the CaRMS process over the years. My approach draws on my experiences as a long-time clinical teacher,CaRMS interviewer, Associate Program Director, Associate Dean, Royal College committee member, Royal College exam coach, and my interest and expertise in communication, cognitive error and mindfulness.  One thing I’ve learned: there are wrong ways to answer questions, but there is no universally right way.

Some interviews start with a variant of that dreaded question, “Tell us about yourself.”  Too frequently, students use that precious first impression to regurgitate dry information that is already included in their CV.  That’s a sure-fire way to get lost in the crowd.

I counsel students to spend time considering how they will structure this question.  It’s always helpful to open with what I think of as an editorial statement.  “I’m so pleased to have the opportunity to be here with you today.  When I reflect on this question, I think there are three things that help give you a window into who I am as a person.  The first thing is X.  The second thing is Y.  The third thing is Z.”

How do you settle on the content of X, Y and Z?  I recommend looking for your three best positive anchors.  Perhaps you are from a small town, in which case X might be your deep sense of community.  Maybe you’re a runner, and Y is that you are a person who has a long game philosophy in life.  Maybe you’re a person who grew up in tough socioeconomic conditions, or you have spent a lot of time in volunteer roles, and Z boils down to your personal commitment to social justice.  

            Why is this approach superior?  Because it frames you in human terms and allows you to cast your personal chronology as a human narrative.  We forget facts, but we remember stories.  Everybody was born somewhere and has degrees, so unless either of those things are unusual achievements or experiences, they don’t need to make it into a 2-3 minute blurb about who you really are.  Also, we all have a U-shaped curve of attention…it will be highest for your interviewers at the beginning and end of your interview.  This is something you can extrapolate from clinical work on cognitive error to your CaRMs interview tour (1).   So don’t let those first precious minutes slip through your fingers.  Prepare for them, again and again.

Another question you can usually anticipate is, “Why do you want to do specialty x?”  It’s amazing how frequently people struggle to come up with a coherent answer to this question.  As a framework, I like to recommend using, “People / place/ thing”.

How does that work?  Let’s say you are applying to ER.  Who are the people in that specialty?  They come from all walks of life, from cradle to grave, and present in moments of vulnerability and need.  What’s the place?  It’s a fast-paced environment that is team-driven, with spaces for everything from trauma to quiet counselling.  What’s the thing?  That’s the actual intellectual content of the specialty….in this case, it’s generalism, or the fact that you need to know everything from how to remove an infected toenail to how to crack open someone’s chest.  Using this approach lets you touch on most of the salient points about a specialty and provides a scaffolding for you to construct a flowing, meaningful answer. 

            It’s common to be asked to talk about someone you admire. I tell people to prepare for this question by using an approach I call “Triple-A”: attitude, actions, and achievements.  Here’s a brief example of an answer to this question that uses an AAA structure:

“Dr. X approaches each day with positivity and enthusiasm; it makes everyone around her feel good.  When you go to clinic with her, she treats everyone with deep respect and compassion; she really knows her patients’ social situations and how they influence their determinants of health.   She is also an accomplished researcher and has published extensively in the field of quality assurance.”

You can extrapolate a bit on each of the triple-A points with more detail, including very brief stories that illustrate each “A”.

Everyone dreads questions about a time they made an error.  I urge you to choose the best example you have, not the safest.  If you use a lame example or something that is actually a humblebrag (ie a time you almost missed a brilliant diagnosis), you’ve blown the opportunity to demonstrate insight.  Using a real error does not make you sound incompetent.  We all make “real” errors and the thing that defines us is what we do with the information we learn from that experience.

For responding to questions about medical error, I advise using what I call a “label and learn” structure.  For more information about labelling, you can read Jerome Groopman’s classic book, “How Doctors Think” (2) or if you are pressed for time, just read Croskerry’s classic article on cognitive error.  Naming the type of error you made demonstrates sophistication and allows for a more elegant discussion of what you learned.  Remember, the whole point of a “medical error” question is to give the committee a sense of your insight. You might start your answer with an editorial statement that goes something like this:

“When I was a resident on the internal medicine service, I had a case that really demonstrated the danger of premature closure (label, then describe event.)  This case taught me the importance of maintaining a broad differential, even when a problem initially seems simplistic.  I learned to ask Croskerry’s classic question that immunize us against cognitive error: ‘What else could this be?’

The “Label and Learn” approach can also apply to questions dealing with interpersonal conflict or team difficulties.  Here, the “label” might be that a colleague felt devalued, or a team wasn’t listening to each other, or that you participated in making false assertions about another physician’s actions without knowing correct facts.  The “learning” could be something along the lines of, “Never assume that what you think you know is true until you have established what is factual”, or, “Letting other people feel heard actually allows me to make my own point more effectively,” etc.  These lessons demonstrate the kind of powerful self-awareness we hope every trainee will cultivate during the course of their medical education.

“Scenario” questions are sometimes dreaded, and they will often fall under the umbrella of professionalism, medical, or interpersonal themes.  To get your bearings and organize your response, I suggest you start with an initial editorial/ diagnostic statement, such as, “This is a scenario that really comes down to two critical themes – patient safety and professionalism.”  This allows you to demonstrate what I frame in exam coaching as “transparency of thinking.”  If the situation is a medical emergency say, “This situation is a medical emergency,” or, “This is a situation where I would need immediate backup because a patient’s welfare is at stake.”   Until you say you know it, I don’t know that you know it.  When you spell it out, you’ve assured me that we’re on the same page.

Here is a final, critical point.  Sometimes in an interview, funny things come out of your mouth.  You say you would handle a situation in a way that is completely discordant with what you would actually do.  You give factually incorrect information.  You said something utterly stupid.  Now it’s out there, and there’s either silence, or the committee has moved on to the next question.  This is your opportunity to do exactly what the medical journals do: issue a retraction.  You say something like,

“I’d just like to go back to something I said a few minutes earlier that in no way reflects my beliefs/ knowledge base/ etc.  I need to clarify that I would NEVER do X.  If I were in that situation, I would do Y.  I apologize, but my nerves hijacked my brain for a minute.”

Have you ruined your interview by doing this?  Not at all.  In fact, you’ve demonstrated a critical quality in a trainee…the ability to correct yourself when you are wrong.

Struggling with confidence and anxiety?  Amy Cuddy’s TED talk on power posturing is beloved by interviewees everywhere (3).  Jane McGonigal writes accessibly about the simple, proven trick of reframing anxiety as excitement (4).  You can hack this by saying quietly to yourself in the moments leading up to your interview, “I’m excited, get excited.”  I personally use both of these strategies before I have to give any kind of talk to a large group and I find them incredibly effective at putting me in a frame of mind to do my best.

Like Survivor, there will be some tough moments around the fire.  Like The Bachelor, there may be a few tears on the ride home.  But for the vast majority of you reading this, everything is going to be alright.  Even if you don’t match in the first round, even though it will be really hard, everything is still going to be alright eventually.  In the end, there may be some thorns along the way, but you will get that rose.

Yours,

Dr. Horton

Sources:

  1. Croskerry, P. The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them. Academic Medicine, 2003. Vol. 78, No. 8.
  2. Groopman, J. How Doctors Think.  Mariner Books, 2008
  3. Cuddy, A. Your Body Language Shapes Who You Are. <https://www.ted.com/talks/amy_cuddy_your_body_language_shapes_who_you_are?language=en>
  4. McGonigal, Jane. SuperBetter: The Power of Living Gamefully. Penguin Books, 2016.

 Dr. Jillian Horton is a general internist in Winnipeg, Manitoba. She was the associate dean of undergraduate student affairs at the University of Manitoba from 2014–2018 and now directs programs in wellness and medical humanities at the Max Rady College of Medicine.

She writes a column for CMAJ Blogs called Dear Dr. Horton: cmajblogs.com/category/dear-dr-horton/

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