The Shuffle

Medical school applicants cannot hold more than one acceptance past May 15. Before that magical date, you can sit tight, waffling back and forth, filling out pro/con charts, and otherwise hem-and-ha over which school is right for you. Once accepted applicants are forced to take a stand, the flood-gates open, so to speak, and there is pretty active movement happening on waitlists throughout the country. Schools suddenly find themselves with openings and there is a rapid shuffling to fill them. My husband was hoping that tomorrow might bring an acceptance for me from my state school. Considering that I withdrew my application from them a week ago, it is highly unlikely.

So why did I do it? I'll spill the beans. Out-of-State University of Awesomeness is a Texas school. Have I already sung the praises of Texas medical schools? Let me tell you, they are fantastic! You see, Texas is pretty darn picky with their out-of-staters. State law requires that at least 90% of students are Texas residents. Some admissions offices set that number at 95%. That said, many applicants don't bother to apply to Texas since (1) the chance of getting in is so low and (2) Texas has its own application system for its eight medical schools. [FYI: Baylor is a private school, but it does receive some state funds and shows a preference for Texan applicants. Baylor uses the national AMCAS application.] Though I wasn't a fan of sending transcripts and entering data into an entirely separate and time-consuming database (TMDSAS), I was very pleased with the entire application process. My state school interviews many, many, many more people than they intend to offer positions to. Roughly one-quarter of interviewees are offered admission. Some schools offer admission to about half of their interviewees. Texas schools tend to do a more thorough screening prior to interview. That means that some schools extend acceptances to nearly three-quarters of the applicants that they interview. Got multiple Texas interviews? There is a good chance you'll get in to at least one of them.

Texas does a Match Day for med school that is similar to residency matching. As an out-of-stater, I did not go through the match process, but found it fun to follow on applicant forums. Even without applying early decision, Texas residents (as a whole) were more likely to know where they would end up significantly earlier than the typical med school applicant. Out-of-state applicants are offered admission on a rolling basis. My acceptance came three weeks after interviewing at one school.

But I really haven't gotten to my favorite part. Texas is affordable! The tuition at Texas medical schools is some of the lowest in the nation. My in-state school has a rate of $35,000 per year. Out-of-state tuition at a Texas school is lower than that. Tuition for Texas residents ranges from about $15,000 to $18,000 per year. If you are awarded a competitive scholarship as a non-resident, you may qualify for in-state tuition during your first year. Unlike many states, you can establish residency during your first year and be reclassified. (That is, if you actually meet legal residency requirements.)It's pretty amazing. I am planning on a career in family medicine. The affordable tuition in Texas really makes it possible to pursue that path without feeling over-burdened with debt.

There are other reasons why I am ready to move to Texas. Lots of them. But the freedom of moving into a new career relatively late in life without much debt is one of the greatest feelings imaginable.

Year+ in Review

A med school application cycle is longer than most people realize. Here's what's mine has been like...

January 2012

• Apply to AAMC's fee assistance program to get a discount on the MCAT and AMCAS. (TIP: If you have kids, you must do this or else you are just wasting good money.)
• Write personal statement.

February 2012

• Approach professors about potential letters of recommendation. (TIP: If they don't recognize you, go else where.)
• Revise personal statement.

March 2012

• Sign up for the MCAT (TIP: Do it earlier. I was surprised by how many dates were no longer available)
• Put on five pounds. (Hey, when you are the one studying for the MCAT at 1:00 in the morning, you'll understand.)
• Revise personal statement.

April 2012

• Freak out over MCAT
• Revise personal statement. (No, this isn't hyperbole.)

May 2012

• Take the MCAT (Holy cow! I was not prepared. Revisit my posts from mid-2012.)
• Start AMCAS application.
• Start TMDSAS application.
• Fill out letter of recommendation cover forms and forward to letter writers.
• Pretend that the MCAT couldn't have possibly gone as bad as I thought.
• Revise personal statement.

June 2012

• Get my official score. (Heartbreak and sorrow.)
• Despair for a while.
• Start AACOMAS application.
• Order transcripts (from FIVE schools--can you say "non-traditional"?) to be sent to each application service.
• Sign up for September MCAT (TIP: Only do this once if at all possible.)
• Send reminders to letter writers.
• Revise personal statement.
• Write (and revise, revise, revise) extracurricular activities sections.

July 2012

• Find a letter writer to replace one of my letter writers.
• Send more reminders to professor to submit to the other application service. (TIP: If you get all of your letters sent to Interfolio, you will avoid some of this mess.)
• Find another letter writer to tentatively replace the writer you are now stalking.
• Take four full-length, five-hour practice tests.
• Submit AMCAS.
• Submit TMDSAS.
• Submit AACOMAS.

August 2012

• Study for MCAT
• Get philosophical about where you are in life, what you've accomplished, and how you try to "live in the moment."
• Purchase "I'm a grown-up" suit. (Chocolate brown with turquoise top.)
• Preview secondary application essay prompts.

September 2012

• MCAT redoux.
• Start writing secondary applications.

October 2012

• Continue writing secondary applications.
• Get official MCAT score.
• Cry in relief.
• Get first interview invitation. Then second.
• Get first rejection.
• Get over it.

November 2012

• Buy the "right" purse. (Bright red.)
• Start interviewing.
• Freak out and apply to more schools. (TIP: Apply early so you don't do this! $170 down the drain.)

December 2012

• Keep interviewing.
• Send schools an "update." (TIP: You got to actually have something to update them with such as a new publication or a completed class.)
• Get in.
• Celebrate.
• Cancel interviews at "I'd rather go to accepted school than this one" schools.

January 2013

• Cancel another interview.
• Decline an invitation. (Oh, the table has turned and it feels so good!)
• Fail first biochemistry exam. (TIP: Don't!)

February 2013

• Start telling myself "I didn't want to there anyway" for the schools that have silently wait-listed me.
• Decline yet another invitation to interview.
• Join Facebook Group for Class of 2017 Totally Awesome University of MD Acceptance.
• Try to figure out my ambivalence over my state school (see Valentine).
• File federal tax return so that I can...
• File FAFSA. (Twice! One for me and one for Mini-Me. Looks like she'll get about a $700 Pell Grant.)

Falling in love

Do I fall in love too easily? Today’s visit at Texas College of Osteopathic Medicine felt like love. It felt like they loved me and, frankly, I can reciprocate. The day was sunny and bright and beautiful, and the weather was pretty good, too!

So what’s the love about? TCOM is an innovator. It was one of the first schools to develop a systems-based, integrated curriculum. It has a sim lab that served as the model for Mayo and the anatomy lab was set up by a former surgeon general (C. Everett Koop, I believe—my personal favorite SG.) There are computers at each tank and a mobile camera for all to observe particularly interesting finds on the large-screen monitors throughout the room. Students have 24-hour access to both labs.

 

The classrooms are massive. Not my favorite, but expected for such a large school with 240 students per class. There are screens in the classroom and each student has a personal mike for asking (or answering) questions. The OMM lab has five cameras on the demo table and plenty of monitors throughout.

How do they make the large classes feel not so overwhelming? Students are divided into four “colleges”—think Hogwarts School of Medicine. Each college provides students with a support network for studying and socializing. The students are further divided (not sure if this is a cross colleges or not) into work groups of 6-7 people. These are the same folks you will be doing group assignments with throughout your first two years.

 
Whatever their recipe for success is, it seems to be working. The school has one of the highest COMLEX pass rates and 90% of their students sit for USMLE Step 1 (and have a pass rate on par with any other med school in the nation).

I know that at some point in time, I would like to be involved in academic medicine. TCOM is a place where I truly would feel comfortable. It is collegial and inviting. One of my interviewers was a “second-career” DO. He was soft-spoken and very encouraging. The interview ended with him saying, “We need to find your husband a job here.”

 

My second interview was even more calming than my first. We sat down and he let me know that he read my file thoroughly. He liked what he read, and told me so. We talked a little about the journey of life. I felt like I was speaking to a kindred spirit.

And that is the greatest love. Finding kindred spirits in life is so rejuvenating. I know that TCOM would be full of them. No, not 240, but enough. Maybe I have settled into a place in my life where connecting with such spirits is easy. Maybe I’ve become better able at trusting my intuition and feeling things out. I like what I felt today. It felt like home. A strange, unfamiliar, comfortable home.

Affordable Care Act Primer for Premeds (Part 4)

I have spent more time on this four-part Primer than I originally intended. Really, I don't know how well something as massive as the Patient Protection and Affordable Care Act can be summarized  in just a few pages. Hopefully, you'll walk away feeling a little more knowledgable on the subject. Maybe you'll even learn something that might surprise your interviewer (though he/she might think you are lying--actually, the thing is so massive, they probably would believe what you are saying is true even if you were lying). 

Title V: Health Care Workforce

This is the part premeds are most concerned with, right? It’s been asserted that the Act will make things better for primary care providers and encourage more students to enter this specialty. Title V directs funds to federally-qualified health centers (FQHCs), the National Health Service Corps, and Community Health Centers. It also increases loan repayment amounts to qualified health professionals. Funds are also set aside to increase graduate nurse education training. (Leadership of nursing associations has been very successful in promoting the Doctor of Nursing Practice as the answer to our primary care shortage.)

Someone told me that more doctors will go into primary care due to the Act redistributing primary care residencies. She probably didn’t realize that primary care residencies have more unfilled positions than any other specialty. Shifting those spots to rural locations probably wouldn’t make them more attractive.

Title VI: Transparency and Program Integrity

This section of the Affordable Care Act puts safeguards in place to keep providers honest and patients safe. Gifts made to physicians and hospitals valued at more than $10 must be publically reported. Though few providers would say that they have ever been influenced by industry gifts, there have been studies to prove otherwise. Human nature makes us friendly to those who have been friendly to us.

Title VII: Improving Access to Innovative Medical Therapies

Have you heard the grievances against Monsanto? Here’s a one-sentence summary: They’ve taken something in nature, patented it, and are now licensed as gods. This section of the ACA puts a path in place for the FDA to license biological products. There are now like other medications with a 12-year exclusivity period before generics can be made. If, by some miracle, I knew that I would live to 150, patent law would be an interesting area to study. Alas, life is too short for me to learn the ends-and-outs of this regulation.

This section also gives special price-breaks for certain clinics serving low-income populations.

Title VIII: Community Living Assistance Services and Supports

This section provided a public option for long-term care insurance. It was repealed.

Title IX: Revenue Provisions

You will be delighted to learn that approximately half of the Affordable Care Act is funded. Honestly, I’m not sure what this means. Taxes and penalties enumerated in this section make the Act (more or less) 50% viable. Where the other funds will come from depends on Congress. At a med school interview, I was asked what I think are the implications of the ACA. My response was that either one of two things will happen. As the system gets stretched in a new direction, 1) we pass a breaking point which will revolutionize the way health care is done in this country with a few insurance plans being casualties of the changes or 2) the system will not stretch like we thought and we will experience a correcting recoil that puts us back to where we were five years ago. Not really that prophetic, but that’s how I see it. Either it will give us dramatic changes or it will give us nothing at all.

Title X: Strengthening Quality, Affordable Health Care for All

This section is known as “The Manager’s Amendment.” It provides guidance and regulations for inter-state health insurance exchanges. It also has a seemingly odd tidbit that reaffirms the Second Amendment. “What,” you may ask, “does the Second Amendment have to do with health care?” Some electronic health records prompt providers to ask about gun ownership to “trigger” (I couldn’t resist the pun) a conversation about gun-safety with children in the home. Wellness programs and insurance companies are forbidden from collecting this data, though providers are not prohibited from talking about safety.

Want to Learn More?

If this series of posts wasn’t enough to satisfy your curiosity, you can read more about the Patient Protection and Affordable Care Act on the following websites:
www.healthcare.gov 
www.healthreform.kff.org 
www.healthpolicyproject.org 

Affordable Care Act Primer for Premeds (Part 3)

Quality Improvement in the Affordable Care Act

The next two sections of the Act focuses on Medicare quality metrics and higher-level public health efforts. It's kind of fun to see the Federal government take an edgy, shake-things-up approach. I'm not sure, however, how well large bureaucracies can effectively function as innovators.

Title III: Improving the Quality and Efficiency of Health Care

In my opinion, this section has the potential to profoundly shift the way care is given in the US. This Title of the Affordable Care Act (ACA) established the Center for Medicare and Medicaid Innovation. Keep in mind: these are innovations, not proven solutions. Basically, the Federal government has recognized that there are big problems in our current system of reimbursements based upon procedures without any regard to outcome. CMI was put in place to discover novel approaches that are effective by increasing accountability.

Innovations that are put in place by Medicare have the potential to cause a huge rippling affect within all health systems (e.g., hospital networks, insurance plans, clinics). You see, Medicare regulations are incredibly stringent. Approved providers have quite a few hoops to jump through for any health plan, and the lower-than-average reimbursement for Medicare just adds to the sting. But there can be an upside to all that regulation.

Here’s the general idea: Health systems will implement changes designed to improve clinically-measurable outcomes such as the percentage of their patients with good blood pressure or whose cholesterol is at an acceptable level. These changes might include using case manager to follow-up with patients over the telephone or getting patients into classes designed to help them manage their chronic conditions. These systems will essentially get a “bonus” from Medicare for population-based improvements. Over time, the carrot will turn into a stick, meaning the bonus will go away and a financial penalty will be put into place. That’s a pretty strong incentive to change. It is thought that system-level changes will not only affect patients with Medicare, but will change how care is given to all patients.

This section also includes details specific to Medicare plans, such as the “donut hole.” The “donut hole” refers to a prescription drug benefit that seemed to be designed to encourage patients to limit the number of medications they took. Patients were required to pay a $300 deductible before coverage kicked in. Above that amount, prescriptions were covered until the annual amount got close to $3,000. If a patient needed more than $3,000 in prescriptions, she would be required to cover the next $3,000 out of her own pocket before “catastrophic” coverage would be in effect. Essentially, it would be possible for a patient who used $7,000 worth of prescription medications to be responsible for about $4,000. (Dollar amounts of coverage varied depending upon the year.) The ACA gradually decreases the amount of out-of-pocket expenses an individual is responsible for.

Title IV: Prevention of Chronic Disease and Improving Public Health

Lots of people believe that the ACA will increase Americans’ health status because of its focus on prevention. While the Act does require insurers to cover preventive services at 100%, there may be a bit of disappointment over the care that is classified as preventive. If your insurance already gives you a no-out-of-pocket-cost annual exam, you will probably not notice much of a change. The services that are covered at 100% are those that have received an “A” or “B” rating from the US Preventive Services Task Force.

Title IV also sets out to create an environment of health promotion through efforts such as calorie labeling at restaurants and wellness programs for older adults. Having worked in health promotion for many years, I think that these environmental approaches can help us turn the tide in the obesity epidemic. There’s more to Title IV regarding improvement in public health, but my brief primer is already too lengthy.

Affordable Care Act Primer for Premeds (Part 2)

The Affordable Care Act is comprised of ten titles that include three focus areas: improving access to care, quality of care, and reducing costs. An overview of the ACA (aka, "Obamacare") was posted on January 24, 2013.

Title I: Quality Affordable Coverage for All Americans

Title I addresses private (also referred to as “commercial”) health insurance plans. It mandates that states create health insurance “exchanges” which are essentially web portal for individuals to comparison shop and enroll in a health plan if their employer does not have affordable coverage options. This portal should also help determine if the applicant (or their dependents) are eligible for programs such as Medicaid, CHIP (for children), or other subsidies. This is designed to increase access by 1) helping people connect with affordable plans and 2) enrolling individuals who are currently eligible for government programs. 

How might this play out? It may lower costs by getting more individuals covered in private plans so that their care is not written off (and thus passed along to everyone else) by hospitals and providers. Conversely, it may raise costs by increasing the number of people who are enrolled in state and federal programs that are notorious for low reimbursement. When providers and hospitals are not getting revenue from one source (i.e., government programs), they simply shift the cost to another source (i.e., private insurance).

Title I is also designed to increase access to care by providing clear regulations for private health insurance companies.  Health plans will no longer be able to refuse coverage to certain individuals or kick them out because they are too sick (read “too expensive”).  This is called “rescission” in insurance lingo.  One of the most talked-about benefits of the ACA is the mandated option for individuals under 26 to remain on their parents’ insurance.  Young adults are some of the least expensive individuals to insure, however, they are often left in coverage limbo because they have not settled into a full-time career with benefits. This provision will be most beneficial to individuals with chronic conditions developed in childhood.

These regulations also mandate insures to cover preventive services as defined by the US Preventive Health Services Task Force (with an A or B rating). These services are to be covered at 100% with members not sharing in the cost.

There are two specific mandates that have been hotly debated: one is the individual mandate and the other is the mandate for employers that have more than 50 employees.  The Supreme Court ruled that the individual mandate penalty is a tax and, therefore, is legal. In 2014, the penalty (aka, tax) starts out at $95. By 2016, the penalty will be $695.  Premium subsidies for individuals with a household income of 100-400% of the federal poverty level are designed to ease the economic impact of getting coverage.  For a family of four in the contiguous US, 400% of the 2012 FPL is $92,200. These subsidies are available for those who purchase through an exchange.

The Small Business Health Option Program (SHOP) creates an exchange for companies that have 2-50 employees. There is no penalty for small businesses who utilize this exchange, but there are also no subsidies.

One of the regulations I find most interesting is the provision that private insurance companies must spend 85% of the money they collect (80% for small markets) on honest-to-goodness health care. Administration and profits can’t be more than 15%. I think that this may lead to more consolidation among the plans as they are force to restructure their business model. My concern is that many plans may discover that they are not viable and quality may suffer or they might simply close down shop, leaving fewer options for consumers.

Title II: Role of Public Programs

This section focuses on Medicaid and CHIP (Children’s Health Insurance Program). The biggest change is an increase in Medicaid eligibility. It is hard to know exactly how this will play out in the market place. Some argue that this will increase the pay to family physicians and pediatricians (the lowest-paid medical specialties) due to the increased number of people able to access care. The problem I see with this argument is two-fold. First, I have yet to meet a family doctor who told me she simply wasn’t busy enough and wished her waiting room had more people in it. Second, Medicaid is notorious for a lower-than-market reimbursement rate. If every provider’s practice was comprised of 10% Medicaid patients, that lower reimbursement wouldn’t have too much of a financial impact. But when more providers begin to feel that Medicaid is more trouble than it is worth, the practices that do take it see their income drop as private insurance becomes a smaller proportion of their business. A friend of mine stopped taking Medicaid when her accountant informed her that she was losing $40 every time she did a certain procedure;  the reimbursement was less than the cost of medical equipment utilized. That adds up quickly—and that was just one procedure.  I’m sure that there will be some clinics that remain economically viable, but I can guarantee that they will need to see an incredibly large volume of patients.

Even though this section focuses on access to care, Title II also sets out to improve quality and control costs through innovation demonstration projects and the creation of accountable care organizations. One example of cost control measures: If a patient’s condition is caused by seeking care (such as a hospital-acquired infection), the services required to remedy the situation must be rendered without payment.

Affordable Care Act Primer for Premeds (Part 1)

Working in public health has been a definite plus for me when it comes to the inevitable Affordable Care Act questions that surface during interviews. Interviewees must have a general understanding of the ACA as its ramifications will impact health care (in what I believe are some uncertain ways) over the coming decade.

The ACA was passed in 2010 as the “Patient Protection and Affordable Care Act” and was dubbed “Obamacare” by opponents. President Obama has encouraged supporters to use that term to remove any negative connotation and to help clarify that they are one in the same. Imagine, if you would, a person who is in favor of the benefits offered under the Affordable Care Act, but is opposed to mandatory coverage under Obamacare. It isn’t too hard to see the confusion that stems from Democrats and Republicans using different names.

I must offer this disclosure: The ACA is extremely long and I have not read it all. What I have read is information from the Center for Medicare and Medicaid Services, a variety of provider newsletter editorials, articles written in the popular press, and documents prepared specifically for public health professionals.  I have also attended multiple workshops on various aspects of the quality innovations and demonstration projects that stem from the Act.

My goal in writing this synopsis is not to persuade you that the ACA is either good or bad, but to help you feel a little more confident about fielding interview questions. Frankly, I think that it is a mixed bag. There are many good aspects of it, but implementation posses many problems. Many, many problems.  Sometimes great ideas can go amiss. In the 1980s, the HMO was seen as a remarkable concept that would save US health care, only to bring us where we are today: one of the most expensive places to get care with some of the most abysmal morbidity and mortality among the developed world.

The Act contains ten “Titles” that fall under the general scope of improving access to care, quality of care, and reducing costs. One of the titles was struck from the act prior to passage, but the numbering remained the same.  Because the ACA is so big, I’m breaking up my posts to reflect the three main focus areas. Stay tuned.

First Interview

I recently attended my first med school interview. There were a dozen other applicants with me that day. Some how, I felt like I was behind on my make-believe timeline with my first interview happening in mid-November. As it turns out, only two other people in our group have had a previous interview, and one of those was earlier that same week.

I must admit, I was surprised with how happy the med students were. We were divided into groups of three for tours given by first-year students. It was casual and informative. Our tour guide stated, repeatedly, that he had "lots of free time" and he felt like it was pretty easy to balance studying with the rest of his life. Lunch was in the cafeteria with a group of second-year students. One of the students seemed like she had a chip on her shoulder. But, hey, sometimes I have a chip on my shoulder, too. Even so, she still was very positive about the school and the level of student support that was offered. Going on campus and talking with students tells you so much more about a school than any website.

Here is my interview schedule thus far:
November: one western school, two Texas schools
January: one midwestern, one Appalachian (WVU's finally came via good ol' USPS)

Med School Application Process

My daughter's a senior in high school. She's already decided on the school she wants to attend. She applied online, paid $30, sent her transcript in, and designated the school on her ACT. This process was moderately stressful for her. Her acceptance envelope came in the mail the next week.

Lots of people tend to think that applying to medical school is just like applying to undergraduate school. When they say to me, "Where are you applying?" I don't think that they are really expecting me to list off all 21 schools that have received a primary and secondary application from me. In July, a few people asked if I was applying for this fall. No, med school isn't quite as "open-enrollment" as the local community college. Here is a brief run-down of the application process.

The MCAT is the greatest obstacle you must overcome on your way to medical school. The colleges classes requisite to taking the MCAT include biology, general chemistry, organic chemistry, and physics. Having taken a physiology course was very helpful for me. Starting in 2015, the MCAT will also include biochemistry as well as social science (psychology) questions. After taking these courses, you need to buckle-down and work through some good study guides. Doing well in these classes is no guarantee that you will do well on the MCAT. It takes devoted study time to review the concepts and work on timing. One of my biggest challenges was working on my "testing stamina." The exam is five hours long. Prep-time for the exam should be around three to four months. Ideally, the MCAT should be taken before May of your application year (the calendar year before you wish to start).

There are three main application systems for medical school. One is for the allopathic (MD-granting) medical schools in the US, another is for the osteopathic (DO-granting) medical schools, and the third is for the eight Texas schools (7 MD, 1 DO). Texas used to be its own country, so it isn't such a surprise that it has its own med school application process. You can create your log-in to these sites in May. You will use these sites as electronic receptacles for a slew of data.

May is a great time to begin requesting letters of recommendation. If you do not have a letter-writing committee at your school, you will need to collect a minimum of three letters from professors. Two of these professors must be from science departments and the third should be from your major if you did not major in science. I had a letter from my physiology professor as well as my organic chemistry professor. For my third professor, I request a letter from my thesis chair for my master's degree (public health).  Many schools have additional, school-specific letter requirements. For instance, some may want a supervisor or someone who can attest to your professional work (if you are currently employed full-time). One school that I applied to wanted a research reference. My thesis advisor was able to address their concerns. Many DO programs request letters from physicians you have either shadowed or work with. All of these letters can be managed on-line so that your writers only need to upload their documents to a single website (or three websites at most). Your accounts with AMCAS (MD) and TMDSAS (Texas) include letter delivery. The DO site, AACOMAS, is run by Interfolio, and Interfolio collects an additional fee for each "packet" of lettes you send out to schools. Managing letters is a nuisance, but the electronic format makes it easier. One of my writers submitted to AMCAS, but not TMDSAS. That left me in the awkward situation of sending lots of reminders. If I had the letter just sent to Interfolio, I could have had only one address to send it to.

In May, you will also want to start ordering copies of your transcripts. You will need your own copy of your transcript--whether official or not--as each application system requires you to manually enter your classes, credit hours, and grades, and then assign each class to a system-specified category. Having finished a bachelor's degree a while back meant that I took quite a few "postbacc" classes. I also had my graduate school courses to enter. I wish I could say that this was the most time consuming part of the application process, but it wasn't. It was tedious and slow, but the narrative writing took me much, much, much more time.

Ah, yes. The narratives. You will write like you are enrolled in an intensive freshman composition class during this process! The most important document is your personal statement. Admission to medical school is riding on it. All three systems require a personal essay on what motivated you to apply to medical school. The essay is limited to 3,800-4,500 characters including spaces. (The character limit is different for each of the three systems.) I did about eight drafts of mine before I felt happy with it. Yes, eight. Most revisions were deciding which elements to trim out.  Additional narratives are allowed for each of the 10-15 extracurricular activities you list. These are about 300 characters each. Much of what you write in one system can be saved as a plain text document and used in another system.

With the best of intentions, it was not until early July that I had all of my electronic applications ready to submit. Letters, transcripts, and writing took a fair chunk of my not-so-free time.

After submitting your application, a few schools will automatically send "secondary" applications. Secondaries generally (but no always) entail any where from two to five additional essays. Rarely can you "recycle" an entire essay, though you may find enough overlap to do a quick revision to tailor the essay to the school's prompt. Secondaries often cost $50-$100 a piece. If you apply for financial assistance, many schools in the AMCAS system waive the secondary fee.

The "complete" application consists of your primary, your letters of evaluation, and your secondary. The admissions committee at the school will begin reviewing your file in the order in which it was complete. Most schools don't begin the review process until July or August. Interview season begins in either September or October, depending on the school.

You are only considered for an interview after your secondary application is received by a school. The complete application usually takes about a month to be reviewed. Sometimes you might hear back from a school in less than a month, but most people do not get interview that quickly. Of course, an interview is not the only possible outcome. In fact, an interview is not the probable outcome. After schools review your complete application, they may reject you or put you on hold. "Hold" is kind of like being wait-listed to interview.  Interviews are always face-to-face. The interview day includes an orientation to the program and a campus tour. Interviews are offered on a rolling basis. Some schools will schedule your interview within a couple of weeks of inviting you, and others may schedule your interview date as far as two months later. Texas schools finish interviewing in December. Most other schools continue to interview for real spots (not just the wait-list) through January or even later. It's pretty nerve-wracking waiting for interview invitations.

It's estimated that about half of interviewees get accepted. For me, that means that five is the magic number. Five interviews roughly translates into 1- (50% x 50% x 50% x 50% x 50%) = 96.875% chance of getting in somewhere. Of course, each schools acceptance rate of interviewees varies dramatically. "Acceptance" rate data is rarely released. In-state versus out-of-state status may translate into slower acceptance times for out-of-staters. Don't be surprised if you don't hear back for a month or more. You might even find yourself on the wait-list until all in-state positions are filled. Again, this varies from school to school.

Once an offer for admissions is extended, you must respond with a deposit to hold your spot. You may hold more than one spot until May 15. Both you, and the schools, must decide who they want by that date. Many people will hold more than one acceptance up to that point, and so there is quite a bit of wait-list shuffling that happens. Schools routinely admit more students than they have space for, knowing that many applicants will wait until this deadline to decide. For instance, Mayo Medical School has only 40 students per class, yet they admit about 70 students knowing that just over half will matriculate. What does this mean? It means your odds for acceptance just might be better than they appear based on out-of-state matriculants.

So far this lengthy process has taken us from May (actually before than for MCAT prep) of one year to May of the next. If you don't already have an acceptance in hand, you might just get a surprise offer in June. Yes, that really does happen. Remember, that is just two weeks after the wait-list shuffle really begins. If you haven't already, it is time to pack up and move. Most schools begin orientation to medicine in early August, though some start in July.