Cristina Valentín-Rivera, M.D.
Some of us have to overcome more challenges than others in order to get where we need to be.
I entered medical school with an MCAT score that was higher than approximately 50% of accepted medical school applicants in the nation. While these scores are supposed to be the best predictors of Step 1 performance, my case proved to be unique-- my passing, low score in Step 1 was almost at the bottom fifth percentile. That Step score is not indicative of poor test-taking skills—rather, it reflects my struggle with untreated ADHD throughout medical school and the subsequent depression that resulted in failure to match into a residency position. Twice.
My first crisis occurred during my first year of medical school, over the course of a weekend. Throughout a post-exam ski trip, I experienced dizziness and severe nausea. It persisted for days, brought me to the verge of tears, and prompted me to leave class and small group conferences. When the doctors in the ED found nothing wrong with me, I concluded that I was depressed.
I decompensated. I continued getting depressed for different reasons and became too sad to study. Even when I did not feel completely miserable, I found myself staring at the same page of study material without being able to read it. When I finally managed to finish a paragraph, I could never recall its contents. Even reading for pleasure was challenging. I barely passed my next exam, and my symptoms worsened until I failed the final exam of the year.
I immediately took action. Right after my visit to the ED, I confided in a close friend and reached out to our school’s behavioral health practitioner, who agreed that I was depressed and proceeded to prescribe medication. The first antidepressant did not help, nor did the second. It was difficult to tell whether the third one had any effect, as I continued to struggle academically. In order to improve my mental health before third-year clerkships, I took an academic leave, completed an enrichment year, and continued therapy with our school’s psychologist. While my psychologist and I suspected that depression did not explain all my symptoms, we never discovered what we were missing. By the end of my enrichment year, I sensed that I was in a worse position to begin clerkship rotations. I communicated my misgivings and was reassured that everything would be fine.
Everything was not fine. The business of the clinic helped distract me from my sadness and I was able to perform well during the day. I would read up on the next day’s patients to write down lab values and find the main issues to discuss. I arrived early, prepared, and started seeing patients before the doctors arrived. As soon as the workday was over, however, I was alone with my emotions again. I continued to have difficulty getting started with tasks and processing the scant study material that I managed to go over. I failed nearly every clerkship exam for the first half of my third year.
Eventually, I found the help I required. One of my school deans recommended a new psychiatrist, who evaluated me from scratch. He revisited my working diagnosis, astutely identified details that uncovered predominantly inattentive ADHD, and started me on Ritalin. After I received the correct treatment, I started studying better. I began to feel more alert, productive, and organized. People close to me could tell I looked better, and the effect on my academic record was none short of miraculous. Fail, fail, fail, fail—5mg Ritalin—pass, pass, pass, pass.
The entire experience was overwhelming. Every exam failure was an additional stain on my transcript, which I feared may all but completely preclude me from serious consideration by any residency program, despite a strong resumé. I remained proactive, voiced my concerns, and sought guidance from faculty. You will be fine. One step at a time. You will Match. I plowed ahead, sent my application for the Match, and received very positive feedback about my interview performance--including the closing statement: I have a feeling you will be a very competitive candidate this cycle. This spring, for the second time, I received the dreaded e-mail from the NRMP: We are sorry, you did not match into any position.
The repercussions of failing to match are numerous. The stigma of being a reapplicant and the added red flag of being a year out of graduation makes the second attempt to Match even more difficult than the first. In fact, less than half of US MD graduates succeed in finding a position through the Match. To overcome these odds, medical graduates invest thousands of dollars to participate as observers in one-month rotations, or volunteer full time in other externships. We feel forced to decide between a paying job that could support us during our gap year vs an educational, clinical opportunity that would improve our likelihood of matching. I continue to be riddled with guilt after my parents withdrew money from their retirement funds to support my required clinical experiences. I traveled from state to state in pursuit of the next educational opportunity. Leaving my home program’s state meant losing my health insurance, and constant travel prevented me from establishing care with a new psychiatrist. I survived without medication for most of my gap year, up until the week I started working on this piece.
I wonder what my medical school journey would have been like had I been diagnosed with ADHD when I first sought help. Maybe I would not have failed all of those exams, if any. Perhaps my ERAS applications would have yielded interviews at a rate higher than 4.64%. I might have been halfway through residency training by now. Alas, one year after my first failure to match, life is still on hold. I had been looking forward to remaining in one location for the next four years, eager to establish care with a psychiatrist and primary care physician near my new home. More than anything, I craved the relief and elation that would follow after finally being able to close this chapter of my life. This has not yet come to pass, but this story is not over.
I will eventually find success. I am a person whose resolve inspired her peers to go into medicine, who mentored others during their path to medical school and helped them get scholarships. I helped lead a new organization in my medical school, used my grief to design a T-shirt to raise $3,770 for Puerto Rico after Hurricane María, and helped advocate for standardized Medical Spanish education in medical schools. I joined regional and national leadership positions to improve communication between medical schools, help Latino medical students feel supported, and provide our membership with more resources to pursue our mission of serving marginalized communities. Most importantly, I am a compassionate future-healthcare provider who earns the trust of her patients and uses her background to become a more insightful and empathetic physician. I am good. I would be an asset to any program and an advocate for the patients I will serve. I just have to wait for that time to come. In the meantime, I will continue to learn from my experiences and apply for the Match again. I hope the third time will be the charm.
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