Thursday, August 18, 2016

Audition electives, applying to programs, and interviewing

By now most rising fourth-year medical students have chosen a specialty and are busy preparing residency applications. A paper from October of last year in Academic Medicine sheds some light on the process.

Researchers from Mass General and the University of Vermont surveyed 2884 fourth-year students from 20 US medical schools in 2014; 1367 (47.4%) responded—52% of them were female.

Just over half of the students applied to internal medicine, pediatrics, or surgery residencies.

While the average number of programs applied to was 36.4, those seeking surgery applied to a mean of 58.2 programs, significantly more (p < 0.001) than those applying to any other specialty.

Except for radiology, for which applicants averaged 16.9 interviews, all other specialties including surgery had a mean of about 12 interviews per applicant.

Of those who answered the survey, only 71 (5.2%) did not match in the specialty they wanted.

Thursday, August 11, 2016

You failed the written boards: What to do now

I graduated this July and took the QE (written general surgery boards) on July 19th. I got my results today and I failed. Not only did I fail but my score placed me in the 5th percentile. Needless to say I'm disappointed. You hear stories about CE (oral exam) failure but never about QE failure. I never blew the ABSITE out of the water (50, 29, 20, 34, 38), but I never would have expected to perform so poorly. Rather than search for blame I'd like to form an effective strategy so that I pass the second time around.

I am sorry to hear of your misfortune. I can’t imagine how you must be feeling.

In your time as a PD did you have a resident or residents fail the QE? Several residents failed the QE. The most notable was a guy who never got below the 60th percentile on the ABSITE. To this day, I cannot understand how that happened.

What became of these people? You will be happy to learn that nearly everyone eventually passed. Patients never ask you how many times it took you to pass the boards. They don’t know about that sort of thing. As far as I know, failing the boards on the first attempt has no long term ramifications except for your program which is judged by the percentage of residents who pass the boards on their first attempt.

Any advice on how to avoid another failure? In order to help you answer the last question I will tell you that I went through SESAP 15 once. I listened to the audio as well. I stuck to high yield sources and UpToDate to supplement SESAP. I avoided reading any formal textbooks but I did read Cameron front to back during residency.

I have found that everyone learns in different ways. There is no single path to success.

One thing you said caught my attention. “I avoided reading any formal textbooks…” I think that would be a good place to start. You need to get a basic full-sized surgery textbook and read it carefully all the way through. I would advise you to take notes, make flashcards, or whatever else you think might help you to remember important points. Cameron is a great book but in my opinion it is more suited to studying for the oral boards because it is more clinically focused.

SESAP is geared more toward surgeons doing recertifying exams and is probably not worth spending time on for the QE.

Many of my residents used books of practice questions which may help, but only after you have done a lot of reading.


After you have studied your textbook and are feeling fairly comfortable, you should think about taking an intensive review course a few weeks before the exam. That may help solidify your knowledge. Taking a review course without studying beforehand probably won’t work because it is so much information over a short period of time that you will not be able to retain it all.

Study hard because the last thing you need is to fail the QE again. That would put tremendous pressure on the third attempt. You don’t want to be in that position.

I hope this helps. Good luck.

Wednesday, August 10, 2016

Can a US IMG with a marginal USMLE Step 1 score still match in surgery?

A US IMG with a USMLE Step 1 score between 200 and 210 wrote me with several questions.

Disclaimer: This is my opinion which may not be shared by the majority of surgical program directors. The questions are italicized.

Is there a way to find programs that don't have Step 1 cut offs? No.

Should I email them my 230 on the USMLE practice test? That would be of no use.

Should I explain my situation or will that seem like a sob story? I've had bad luck but just a string of it and I feel like it would sound like I was making too many excuses. As I read your story, it did sound like too many excuses. The problem for you is that there are numerous other candidates out there who don’t have these issues and have better scores.

Should I strategically book rotations during interview season and hope they decide they want me (does that happen and do you have any tips on this)? The value of so-called “audition electives” is controversial. I never put much stock in them, but I think many program directors do. If you decide to do some audition electives, you should focus on smaller community hospital programs. Many programs list where their residents went to medical school on their websites. You should pick places that have taken US IMGs recently.

Friday, August 5, 2016

Shortage of doctors in the future? Maybe

Shortage of residency positions for international medical school graduates in the future? Yes.

Google “shortage of doctors” and you’ll find that almost everyone believes what the Association of American Medical Colleges (AAMC) says—that we will need 90,000 to 130,000 more doctors by the year 2025.

There are a few naysayers such as Gail Wilensky, a health economist and co-chair of the Institute of Medicine panel that found no evidence to support those estimates and Princeton health economist Uwe Reinhardt, who says it’s in the best interests of the AAMC to predict a shortage.

A 2012 survey found that one-third of US physicians planned to retire by 2022. According to a study by the Kaiser Family Foundation, there are just over 900,000 active physicians in the US, meaning that if the survey is correct, about 300,000 doctors will have stopped practicing by 2022.

The AAMC says that about 18,000 medical students graduated from US schools in 2015. Will that be enough to replace those who say they are quitting? The number of residency positions available for med school graduates was 27,860 in the 2016 match.

If you multiply 27,860 residency slots x 10 years (between the years 2012 and 2022) you get 278,600, which approaches the projected number of 300,000 retirees lost.

No matter which side of the debate is correct, international medical graduates (IMGs) will be adversely affected. Here is why.

Wednesday, August 3, 2016

What has society come to?

A medical student who corresponds with me wrote the following. It has been edited for length.

She was shopping at a mall with her husband and their children.


As I walked underneath the escalators, I heard a horrific sound. I looked up and saw a body cartwheeling down. I ran to front of the escalator to push the stop button. An 80 or 90 year old gentleman was lying partly on and partly under his walker. He seemed unconscious with blood all over the place. I said "Sir, sir," saw his fingers move, and called 911.

A black man from the top of the escalator made eye contact with me and came running down to see how he could help. He hesitated, his face and body language screaming fear, but he came over. He knew he had to once we made eye contact because I was the only one actually doing something.

A security guard who was heading to work arrived. He had no gloves, no radio, nothing. Why wasn't anyone from security coming? What's the point of security cameras? Wasn't there anyone watching? I turned around to see who else could help. About a dozen people were just standing there with their cell phones taking pictures and videos. Not a soul asked me if they could call 911. In fact when I called 911 a second time, the dispatcher asked me if there were more people with me because I had placed the only two calls.

Tuesday, July 26, 2016

What are the residency prospects for graduates of offshore medical schools? 2016 update

Since I blogged about this two years ago, there is new data that may help clarify the situation for those who graduate from non-US medical schools. That post has had over 44,000 page views and 91 comments, some of which are responses from me to reader questions.

The National Resident Matching Program (NRMP) has published a 290-page summary [Characteristics of Applicants Who Matched to Their Preferred Specialty in the 2014 NRMP Main Residency Match (5th edition)] of the 2014 match, the latest year for which complete information has been analyzed.

The number of US graduates participating in that year's match was 17,374 compared to 16,896 graduates of other schools including non-US IMG's (7334), US IMGs (5133), DOs (2738), US graduates from previous years (1662), fifth pathway students (15), and Canadian grads (14).

From the Main Match Results Data for categorical general surgery in 2014:
One way to look at these numbers is that if you are US senior applying for a categorical surgery position, you have a 922/1274 or a 72% chance of matching. If you are in the "others" category, it's 283/1108 or a 25.5% chance of matching.

Wednesday, July 20, 2016

In-Training: Stories from Tomorrow’s Physicians

A new book, In-Training: Stories from Tomorrow’s Physicians, is a collection of essays by medical students that originally appeared online. The book’s editors, Ajay Major and Aleena Paul, created the In-Training website as a place where students could express their thoughts and feelings about life in the pressure cooker that is medical school.

The 111 essays are brief and as is true of any collection of writings from diverse individuals, are of somewhat uneven quality. Some are good. Some are fair. Some are meh.

One of my favorite pieces was one by a doctor who had received his diploma 10 days before a flight home. During the flight, a woman collapsed—prompting the dreaded “Are there any physicians on board” announcement. The new grad was the only responder. Having experienced this myself a couple of times, I had no trouble identifying with the author who described his predicament well.

I learned something from another of the essays which described a novel intervention for wandering patients with dementia.

A unique feature of the book is that every story is accompanied by a few “reflection questions” prompting the readers to think about what they just read. The questions add value and could serve as the basis for stimulating group discussions.