Friday, April 11, 2014

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

A year ago in a post about law school applications decreasing, I speculated about whether a similar phenomenon would occur with medical schools.

In that post, I commented on the impending problem of too many medical school graduates and not enough residency training positions. I cited an article that appeared in the New England Journal of Medicine in 2011 in which the CEO of the Accreditation Council for Graduate Medical Education predicted that by 2015 or sooner there would be more graduates of US medical schools than residency positions leading to specialty certification.

The data for the 2014 residency match have not been released publicly so the outcomes for graduates of US med schools are unknown.

However, the Educational Commission for Foreign Medical Graduates says [here] that of the 26,678 residency positions offered, only 53% of US citizen graduates of offshore medical schools (US-IMGs) and 49.5% of non-US citizen offshore grads matched.

A look at the websites of two of the more prominent Caribbean schools, St. George's University and Ross University, shows that most of their graduates who matched ended up in non-procedural specialties like internal medicine or family medicine.

St. George's lists 760 graduates and Ross 783. [They take two groups of enrollees per year at different starting times.] St. George's matched 22 (2.8%) and Ross 18 (2.3%) in categorical 5-year general surgery positions. To look at it another way, of some 1200 categorical slots, 40 (3.3%) graduates of the two most well-known Caribbean schools are on track to become general surgeons.

Neither school listed the number or percentage of unmatched graduates.

The ECFMG pointed out an important fact which is that as of 2013, hospitals were forced to commit to either filling all of their residency positions via the match or none of those positions via the match. This has resulted in an increase of 2672 positions available through the match and implies that there were that many fewer positions available outside of the match this year.

The exact a number of US-IMGs and non-US citizen IMGs who obtained first-year positions in the 2014 post-match supplemental process or later is also unknown, but at least in surgery, about 450 positions that were available after the initial match results were released consisted of nearly all preliminary slots good for only one or in some cases, two years of general surgery training. That amount of training is insufficient for obtaining board certification, but some prelim residents do progress to 5-year positions as I noted in a recent post. 

A harrowing account of one US-IMG's quest for a residency position can be found here. He is fortunate to have obtained a preliminary surgery spot after both the main and supplemental matches.

Excluding ones in Cuba, there are about 40 medical schools in the Caribbean that cater almost exclusively to US citizens as well as some similar schools in Mexico.

Some key questions arise. How many international medical graduates, both US and non-US citizens, do not currently have residency positions? What will those without residency positions do to earn a living? How will they pay back their student loans if they are unable to practice as physicians?

If you go to an offshore school, the best case scenario is that you'll have about a 50% or perhaps slightly better chance of matching to a residency position in any specialty and about a 2.5% to 3% chance of matching in general surgery. These odds may be worse if you choose a lesser-known school.


Anonymous said...

Thanks for the stats. If these top 2 Carribean schools are churning out 750 grads a year each, then it is obvious they are diploma mills. Few US schools push out that many.

Are all these off-shore schools not private businesses? So at least a few people have done well.

Since few prelimimary surgery interns go on to a full surgery program, where do they end up? Anesthsiology and pathology are moderately competitive these days, and I assume internal med and ER programs would require them to start anew.

Anonymous said...

The pluses and minuses of off-shore schools are easier to assess now with all the online resources available. so I expect the number of applicants to decline. However, I don't think the number of grads to go down for a while. Some of these schools pay US hospitals big bucks to take in their students for clinical rotations, and cash-strapped inner city hospitals find the arrangement attractive.

The 50% chance of being a US doctor after spending 4years and 200k is prob. still attractive to many undergrads who all of course believe they are above average. nevermind GPA and MCAT. When young, we all live in Lake Wobegon.

Anonymous said...

I think although this is a good article to give many prospective students a reality check, it should not be used as a reason to NOT pursue ones dreams in the medical field via the carribean. There are a good amount of students in the carribean that are more than US medical school caliber, but due to unfortunate circumstances have had to turn to this route. Whether it was one college class that torched their GPA or due to the simple fact that the instate medical colleges surrounding their particular area were extremely competitive; there are more than enough examples and reasons.

At the end of the day, if you put in the work to get good board scores AND make connections, you will have a great shot at getting your residency choice. And if you talk to some of the top surgeons at hospitals, they will tell you the carrbibean surgery residents they do have are the hardest working because they know they are the underdogs.

Skeptical Scalpel said...

I'm not sure what happens to all the prelim surgery residents. I wish I knew. More of them than one might think find categorical general surgery positions because the attrition rate of GS residencies is about 20%.

I agree that there is big money to be made in the med school business and that I doubt applications will fall off much for a while. You have only to look at the third anonymous comment above to see that hope springs eternal in the human breast.

artiger said...

Quite true Scalpel. I transitioned from a prelim to a categorical spot. In my categorical program, there were two guys who said "Enough" a few months in their second years. Although they looked great on paper and were conscientious physicians, they both said that they simply could not hack it (back then the call ranged from every other to every third night, depending on the service). Grades and test scores aren't everything, so if the desire is truly there, the prelim route is about the best shot. If time and money are not factors (not sure who would fall into that category), one could do a residency in, say, internal medicine, then reapply for a categorical position. I know that every day I wished I knew more medicine.

I still think the best thing would be to have everyone do a general intern year, rotating through the basic services, and then deciding near the end on a specialty. I know, not going to a happen.

Anonymous said...

Re Anon 3:

Working hard is good in any field. But....

The top 2 Caribbean schools graduate 750+ *each*, while no American MD school even puts out 250 a year.

Although it does not come up in polite conversation, it is a given that an off-shore grad is a result of not getting in any one of
thousands of American MD and DO spots. Contrary to popular opinion, it is not all that difficult to get into medical school
The current acceptance rate for MD schools is around 40-50 %.

If you didn't get into an AmericanD or DO school, a prospective student should just go do something else and get on with life. There are plenty of financially comfortable,
rewarding careers ourside of medicine.

Anonymous said...

For anyone interested, I think this is the data:

As a brief summary:

Total surgery (categorical) positions offered: 1,205
Total US Seniors: 1,274 applied / 922 matched
Total Applicants: 2,382 applied / 1,198 matched

For the international scene:
Total US-IMG applicants: 5,133 applied / 2,722 matched to a PGY-1 position though no data is given regarding whether these were categorical or prelim positions

CB said...

^^lol just stepped in on this convo and that was quite a ridiculous comment. Not everyone can afford to apply to all these schools you speak of. Most students I know in the Carribean tried their luck at the few local schools they thought they had a shot at and if all else failed, went offshore (since theres even less of a chance out of state). While there are many failures, there are also many success stories from offshore grad students, all you have to do is look.
I hope the ones you refer to as needing to just go get on with life are the same students who outperform you in the future sir.

Skeptical Scalpel said...

Artiger, thanks for illustrating the point that it is possible to transition from a prelim to a categorical position in surgery.

First anon, your comments are a bit harsh. It's OK for people to pursue their dreams as long as they know what they are getting themselves into.

Second anon, thanks for the link.

CB, there are many success stories, but I think it is useful to be aware of the odds.

-STEPHANIE said...

Anon: As the wife of an off shore grad, I can personally attest to the fact that some students that are plenty capable of being great physicians just don't get accepted to US med schools. Your comment seems a bit harsh and I doubt that all the physicians out there practicing that attended off shore schools would appreciate hearing that they should have "just gone on with life" after not being accepted in the US. However, as the author stated, students who attend offshore schools should be aware of the odds and the fields in which most off shore applicants end up in so as not to be shocked by the reality and stigma of being an IMG.

Skeptical Scalpel said...

Stephanie, thanks for commenting for writing the post about the difficulty your husband overcame to eventually secure a surgical prelim spot.

drinkingfromthefirehose said...

I tried my best to provide some specific information from my small corner of the world for neurosurgery applicants. Perhaps the general approach (and some of the suggestions) are relevant to your general surgery readers as well ...


Skeptical Scalpel said...

Thanks for the comments and the link. Most of what you wrote is applicable to IMGs wanting to be general surgeons too except for your suggestion that a year of research might help an IMG who didn't match. That may be true in neurosurgery, but I don't think it will work for general surgery. A year away from clinical medicine doesn't enhance a GS applicant's chances in most places.

drinkingfromthefirehose said...

I completely agree, generally, regarding the limited value of research. But there is a paucity of alternatives.

The challenge is how to become a "known quantity" in a program once one has failed to match. Since we do not have preliminary spots, and since most of our "pre-residency fellowships" are disappearing (and of dubious value), I don't know of any way other than research. I completely agree that doing clinical work is superior - but only a few general surgery programs will allow preliminary residents to rotate on neurosurgery, and only for a limited time.

Another option, which I did not think of earlier, would be to backup or scramble into a related specialty (radiology, neurology, even anesthesia) which requires a separate preliminary year. Then if one could do the preliminary year at a university hospital with neurosurgery residents, perhaps a highly motivated applicant could maneuver to have a month on the service and attempt to parlay that into a job if one were to open up at that program. Quite a few "if's"...

Either way, the path from FMG/IMG to neurosurgery (and, as you mentioned, general surgery) is too tenuous. My best advice is that one should work tremendously hard early on to gain admission to a US MD medical school if one wants to be a neurosurgeon in the United States.

pamchenko said...

Since going thru residency, I've worked with a lot of prelims. I give them all the same advice which is to seek opportunities outside surgery. Still a lot of them insist on pursuing "the dream."
that kid with the wife blogging for him still has the deck stacked against him. What he doesn't realize is that he will be competing in the match again nxt year against a brand new set of American medical school grads. he doesn't realize that there is a stigma against even American school grad prelims. Its like marrying someone with kids. another reason he's in a bad position is that he will have difficulty getting meaningful letters of recommendation or more importantly a phone call. the most important/influenential people will be working with chief residents. its not like in medical school where you can tag along with one chairman/chief of division and suck up all day to get a letter. his job as an intern will be to do mindless paperwork, discharge summaries, blood draws and basic floor management. intern work = PA level work and its hard to assess who will be a good surgeon from that level. granted you can tell about someone's work ethic, level of drive, ability to eat s**t which is important. another important thing is the ABSITE. interview offers are given before the absite is even taken. absite performance is crucial. he will be competing with indian kids (see AIMS) and foreign practice surgeons who are bred to take tests.
he is happy to gotten this prelim spot? its not really a blessing. I see it as very high risk.
his likely outcome will be fighting for a prelim two spot. he can always hope that one of his co-residents leaves for research (as long as one isn't slotted to come back). then again, he will need to have the best absite score/work ethic. after the prelim two year you are looking at research years which are by no means guarantee into surgery.
and the better of a surgeon he wants to be, the less he is going to see his wife and kid. he will be staying late to finish up tasks. he will be fudging workhours to show desire. he will be studying and reading for the ABSITE instead of spending time with his family.
ultimately he's playing catch up. you gotta pay the piper at some point. he went to St George's which had lower standards of admission. he needs to demonstrate that he's as good as a kid from AIMS with a 99 absite and ridiculous work ethic or a kid from an American medical school who just didn't match ortho.

scott ross said...

Who is their right mind would want to go to any med school today. Just have a peek at the website which shows what your physician gets paid from medicare. For example if you bill for say a pneumonia patient- 250 office visit, 90 bucks for IV rocephin, 65 bucks for EKG, 85 bucks for chest x ray, 45 bucks for oxygen therapy, 45 bucks for nebulizer treatment, 100 bucks for IV s and monitoring, 35 for pusle ox , time spent on patient 4 hours. 35 bucks for cbc with diff, 125 bucks for CMP. total billed- 1610. Now lets see how medicare rapes you..Office visit level 4 reimbursed 124 bucks, iv rocephin 1 dollar, EKG 12 dollars, chest x ray 12 bucks, O2, pulse ox and neb treatments, iv fluids, 0 bucks, cbc 12 bucks CMP 3 bucks for drawing and handling, total reimbursement- a big 164 bucks. Their you go guys. Not even close to covering your overhead. The dwindleing reimbursements will become the norm in the future. the cheaters seem to be the only ones that get paid well. Anyone that has gotten paid well is under investigation and will probably be moving into a jail cell. The students/grads that don't get a residency may be the lucky ones.

Skeptical Scalpel said...

Pamchenko, you have said it a little more explicitly than I. It is indeed a tough situation. Most of the prelims I know who have moved into categorical slots have been very lucky. Some do make it. Your advice about working hard is correct.

Scott, I agree with much of what you said. Here's an interesting statistic from October of last year. The number of applicants to med school in 2013 was the highest it has ever been. I think that they just don't know what they are getting into. They will find out.

Skeptical Scalpel said...

I meant to include the link to the story about med school applications. Here it is

pamchenko said...

as a surgeon I really don't rely on luck. I try to bet on likelihoods and weigh the pros and cons of every kind of decision I make. he's more likely to get a spot outside of surgery than a categorical position in surgery. ultimately that prelim needs to ask himself what is most important. most likely having a family, paying for wife/kids/home/lifestyle/kids sports/kids college/keeping up with the jones will be more important than whatever career he does. I know that's what's happened to me. you do what you need to do to pay the bills and take care of your family.
the smart thing to do would be to use that hard work ethic and try to get an anesthesia or radiology spot where he can get the money he needs to pay for his family. my friend in IR makes double my salary.
he continues to chase this dream, it will cost years of earning potential.
at least once a month I seriously regret being a surgeon and wish I was in finance.
if he is lazy or doesn't pan out, he can always go into PM&R and then match some noncompetitive pain fellowship and do injections all day, make surgeon type money and have a much better lifestyle where he can watch his kids grow up.

Anonymous said...

@scott. Almost all physicians still earn 6 figures, and some make 7 figures every year, as detailed in recent NYTimes articles.

@pam. Wow. Some surg. prelims do make it to a full residency, usually when some junior in their progam drops out late in the year. I agree that anyone starting a prel.year should immediately start looking into other specialties.

But, what are the numbers? How many prelim. GS get into a full residency in GS or ENT or urology or ortho?

What other specialties would accept a surg. prelim as a full year in their requirements? Anesth and path, maybe radiology, are the only ones that come to mind.

Regarding neurosurg, I have worked with many IMG neurosurgs. including an American Carribean grad. It may be tough, but it is doable. Isn't neurosurg a less competitive residency than ortho. rays. ENT, urol and derm? I don't know anymore since leaving academics 10 years ago.

Anonymous said...

@pam. That's kind of cruel.

Yes, general surgeons are poorly paid, but it is still 200-400 k for most. Radiologists earn more, which is prob. why it is a highly competitive residency.

The fact is that as an unmatched American IMG, an applicant is marked as damaged goods. Radiology, and to a lesser extent Anesthesiology, are competitive spots, so are not just automatic for GS rejects.

What struck me about the blogger's post was that the husband applied to 100 GS spots, but not even one alternative specialty.

Skeptical Scalpel said...

Almost no non-designated prelim resident, which is what these unfilled positions are, gets into ortho, GU, ENT etc. Designated prelims are those who have already matched into a categorical ortho, GU, ENT etc position. Neurosurgery is still very competitive.

Yes, the blogger's husband put all his eggs in one basket. He definitely needs a backup plan now.

-STEPHANIE said...

@Pam We are very much aware of the situation we are in. However, it is certainly a blessing to have a paycheck coming in this next year vs. not. Josh was silly to not have applied to back up programs in IM or FM where he likely would have easily matched. He will not be making the same mistake twice and while he hopes to stay in GS, he most definitely will be applying to back up specialties for the 2015 match. We have no choice but to try and see the glass as half full. The GS program at UMass took one of their prelims from SGU last year into their categorical program this year and the PD who interviewed him assured him that they take good care of their prelims in order to help them move forward in whatever field they choose. Sure, it could be BS, but we hope it isn't. As you stated, what is most important is taking care of himself, his wife, and his child which is why he took the prelim position to begin with. During the SOAP, he would have been happy with anything, but post SOAP, this was the only option he was given.

Skeptical Scalpel said...

Stephanie, thanks for following along with the other comments. I'm glad you have a plan in case the prelim spot does not lead to anything further in general surgery. I hope Josh gets a categorical position. With some hard work and the support you are giving him, who knows?

Good luck.

Anonymous said...

For any prospective/current Caribbean students out there who want to be surgeons, it is an uphill battle, in the wind and snow. I went down to the Caribbean to pursue my dream of becoming a surgeon and matched into a categorical 5 year general surgery spot at a University program this year. People will look down on you and doubt you, but, in my opinion, hard work trumps prestige.
@STEPHANIE: Keep the faith

Skeptical Scalpel said...

Anon, thank for the comment and congratulations. Would you mind telling us what your grades and USMLE scores were? Did you have any letters from well-known surgeons? Will you be graduating from one of the 2 schools I mentioned? Thanks.

Anonymous said...

Dear Sir,
My scores on STEP 1/STEP2 were 250/248. I had letters from the CVTS PD at a large university program and a letter from another senior faculty member at the same institution. While on that rotation, one of the faculty admired my work ethic and called his friend, the PD at the institution where I matched, and was an advocate on my behalf. That being said, this was a visiting rotation that I had set up on my own.
Additionally, of the top 5 positions on my rank list, 4/5 were "manufactured runs" where I had either sought out programs to do a rotation there or had people within the programs who were my advocate. I did not attend one of the previously mentioned schools and would prefer to remain anonymous. I did, however, do my 3rd year clinical rotations in the UK which was an awesome experience and a good talking point in my interviews. Hope this helps!

Anonymous said...

Oh, grades were OK, 3.25 GPA but Honors in all but one clerkship...

Skeptical Scalpel said...

Thanks for the information. This should help other students very much.

The USMLE scores were outstanding.There was excellent support from what seem to be influential mentors.

Anonymous said...

Why are unmatched medical students considered "damaged goods"?

Skeptical Scalpel said...

Anon, that is a good question. I can only speculate about the answer. I believe many program directors feel that the fact that someone did not match is proof that there must have been something wrong with that individual. Of course, we all know that isn't true, but the stigma has prevailed for many years. I could be wrong about this.

Malik Soudah said...

Caribbean medical school is best platform and nice and informative….. Successful communication is key in every successful business…. Understanding your subject and having good knowledge on your blog topic is always essential for a successful blog… Thanks for this post…..

Skeptical Scalpel said...

Malik, thanks for commenting and for the link to your school's website. I was able to find some other links that might help prospective students. Here they are.

Leah said...

Interesting read- My boyfriend just left 2 days ago for Saba University School of Medicine. His father, (who's an MD as well, graduated from Sackler in Israel, and is an anesthesiologist) seemed to support his decision to go there. He wasn't able to get into the US due to his undergrad GPA. (It's a 3.3, bad freshman year, recovered over the next 3 years), yet he got a 35 on the MCAT. I know his case is completely unique, as he's not the traditional Carib student. To me, that score is very, very good!

I've been researching his school a lot, and since it's smaller, it's been hard to find any info regarding their match rates, quality of education, clinical rotations, etc. I guess I'm just worried that he went and took out a ton of student loans, only to get screwed over in the end. Maybe you have some insight into this school I'm missing?

Skeptical Scalpel said...

Leah, there's a good reason why you can't find the info on match rates. They probably aren't very good. The clinical rotations in these schools change frequently. Many of them tell their students to arrange their own clinical rotations. Your boyfriend will be able to find out some of these things by word of mouth now that hes at the school.

Anonymous said...

My girl friend studied at University of medicine and health sciences - St.Kitts in Caribbean.She is very hard worker and studied well. All of my savings gone and extra bank loans adds ups. No match, no residency and no more hope. Applied for Medical lab tech and my opinion IMG is not an option, try local medical schools and if not try something else

Skeptical Scalpel said...

Thank you for commenting. I am so sorry to hear this.

I looked at the UMHS website ( and counted 59 graduates who matched in 2014. What I can't find out is how many UMHS students were in the class. Do you happen to know that figure?

Anonymous said...

Thanks Skeptical....................Not really know how many , there were 3 graduation per year and not sure how many applied

Skeptical Scalpel said...


Anonymous said...

Hi, I am a former Cuban medical student. In Cuba I did five years of medicine school and came to the United States. I'm 26 and I intend to continue my studies here. I met with the president of a university in the Caribbean (USAT Monserrat). They have a campus in Miami and they don’t require the MCAT. Only with my transcripts of 5 years of medical school in Cuba I can enroll, 3 year after I’m a FMG. The school website is a joke and the admission process is very informal. They came to Miami only a week monthly and you need to get the clinical practice hours by you own. I want to be a pediatric or general surgeon, and I don’t want to spend years of sacrifices and money for nothing.
On the other hand if I make the college (3 or 4 years), and medical school (4 years) I'm afraid that my age when applying to a surgical residency (34 years or so) will be an impediment to achieve my goals. Any advice will be welcome.

Skeptical Scalpel said...

Anonymous former Cuban med student, thanks for your comments. First, please re-read my post and pay particular attention to the parts about the chances of matching for a 5-year position in a surgical program. Notice that even the offshore schools with good reputationps are matching a very small percentage of their graduates in surgery. The school you mentioned is not well-known. To be honest, I'm not sure you could match in any specialty with a degree from there. Ask them what percent of their grads match in any specialty. Ask them for the names of some recent grads so you can verify the information. Please research all of this carefully. I would advise you to gather as much information as you can. It will be hard as a 34-year-old to start a surgery residency, but it may be the better choice. Good luck.

Anonymous said...

Thanks a lot for the advice

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