Friday, October 20, 2017

The lost sheep: They’re MDs but can’t find residency positions

I haven’t written about offshore medical schools since this post back in January, but yesterday I received communications from two graduates of those schools which moved me. Both are edited for length and clarity.

This was an email. I read your article on Physician’s Weekly about unmatched MDs. I am a bit down and looking for advice. I graduated from a Caribbean Med school. I have failed attempts and many gaps. Academically I dug myself into a deep dark hole, but my desire to practice medicine kept me going. I recently took Step 3 and just received my scored (failed by 2 points). I do not know anyone in medicine that can help me get a residency. I know I will be a great physician. I am just a horrible test taker.

I didn't apply for the match since I was told that I needed to pass Step 3 to even try to match which would still be almost impossible even with a good score. I know many people who have not matched and have just given up on it. I have so much debt and no way of paying for it. What do you suggest I do? A friend thinks I should just take it again and apply, but I no longer have the funds especially since my chances are so low. I wish there was something more for me.

Any words of advice would be really appreciated.


And this was a comment on the Physician’s Weekly post mentioned above. There needs to be a job market for med students having passed boards but not matched. A PA can work after just 2 years with far less knowledge. I’m a Caribbean grad, unmatched, in debt, depressed, and unable to find work even when leaving MD off my resume. I was top of my class when I graduated but took my Step 1 twice. Now I’m banished to a cave even though I know I would’ve made one hell of a physician. :-( It’s the reality. Five years have passed and I’ve given up. My poor wife works, and I do odd jobs.

How sad. I regret I have no useful advice for both of them and the many others who are in the same situation.

Retaking Step 3 is probably futile. The writer didn't say when he graduated from medical school, but the further away you are from clinical medicine, the less likely you are to match in any specialty. Even if you finally did pass Step 3, you probably would not be able to find a position.

What can they do with an MD degree and no postgraduate training? What kind of job can they get that would enable them to survive while paying off a tuition debt of six figures? How many med school grads are facing this dilemma?

Google “nonclinical jobs,” and you will get 12.8 million hits. But how realistic are the options?

Maybe someone should start an organization to help these people.

Readers, do you have any ideas?



68 comments:

Josh Farkas said...

There are many 3rd world countries with severe physician shortages. These doctors could potentially do an enormous deal of good in such locations. I'm not aware of the rules/regs in such locations, but it might be worth looking into.

Skeptical Scalpel said...

Josh, interesting suggestion, but I have read somewhere that some countries might resent our sending them doctors we don't want. And as you mentioned, they have rules too.

Amartmd said...

I remember talk about Missouri passing a law for people in this situation..."assistant physician " would be able to work under board-certified physician although be paid much less. Also look into military residency programs, talk to recruiter and see if there's a way to get in there.

Gabriel Smester said...
This comment has been removed by the author.
Anonymous said...

Looking abroad is definitely one option.

My first thought was Australia's Skilled Visa Program (www.doctorconnect.gov.au). New Zealand and the UK run similar schemes I think.

Jack Williams said...

Yes I have an idea, the organizations, AAMC & AMA, that are supposed to help the unmatched doctors are against them. Most of the unmatched doctors are not graduates of the AAMC therefore they have different interests. Instead of challenging the plaintiff in the court of law in the anti-trust class-action lawsuit Jung v. AAMC of 2002 which alleged collusion by the hospitals of the AAMC, the AAMC lobbied Congress and got specific exemption in 2004 which rendered the lawsuit moot. The AAMC is powerful organization and when it needs something from Congress it uses the term educate Congress about it as a euphemism for lobby Congress for it.
In situation like this in which these organizations have tremendous influence on Congress while the unmatched doctors have no real political pressure on the politicians the only recourse left for the unmatched doctors is to take it to the judicial branch of the government.
I strongly believe that with an experienced lawyer who can organize a legal team, the unmatched doctors can win class-action lawsuit against the state medical boards in order to practice medicine at least in similar capacity of the PAs on the basis of equal opportunity under the law. The State Medical Boards can only require evidence-based requirements for licensure, the requirements  can't be arbitrary and preferential. If such a lawsuit is filed I would predict that the trial would be a battle between the expert witnesses on both sides and given that the PAs have only one year of medical knowledge and one year of clinical rotations while the MDs have 2 years of medical knowledge and 2 years of clinical rotations I believe that the court eventually would order the state medical boards to do what Missouri did voluntarily. The AAMC and AMA opposed what Missouri did despite the fact that it was a step in the right direction hiding behind that they advocate increasing the residency positions when they know that the political environment doesn't allow that making the good the enemy of the perfect.

Skeptical Scalpel said...

Amartmd, the Missouri law has passed. I do not know how many MDs are in the program or how well it is working. Military residencies are filled via the match just like civilian ones.

Gabriel, do you have any proof that those who take Kaplan and other prep courses do better than those who don’t? I didn’t know that medical errors are increasing and patient satisfaction scores are going down. On what are you basing that statement? Even if errors are up and satisfaction is down, how do you know it’s because of doctors with high USMLE scores and less hands-on experience?

Anon, that’s a useful suggestion if people want to move to Australia.

Jack, I’m not going to defend the AAMC or the AMA. Your theory may even be correct for all I know. It takes money to pursue a class-action suit. Who would pay for it?

Anonymous said...

Perhaps there are too many medical schools/graduates? In Michigan, where I practice, there has been an explosion of both medical schools and class sizes. Presumably this is a great financial boon for the schools, but certainly contributes to the problem of unmatched and overburdened MDs.

William Reichert said...

I am reading a bio of Ulysses S Grant. Turns out that after graduating from West Point , he actually wanted to be a math teacher, was unable to find a teaching slot so he became
a soldier. He turned out, despite some ups and downs, to be a pretty successful soldier. Maybe these gentlemen should join the military. I am sure the the armed forces will find some way to use their education for the mutual benefit of each party.The pentagon seems to have a pretty large budget. Go talk to them.

Unknown said...

You may want to refer them to the drop out club (https://www.docjobs.com/)

I believe it was founded by a student who dropped out of school, or graduated and did not pursue a residency. It's a job and support site for scientists and doctors who want out of the industry. It not only provides job opportunities, but also a fairly active forum to get advice from others in a similar position.

Skeptical Scalpel said...

Anonymous from 10/22/17, there are too many medical schools. A few years ago, I was firmly convinced there was going to be a doctor shortage. Now I'm not as convinced. We are seeing the IMGs being squeezed. At the rate US schools are expanding classes and new schools are forming, the squeeze will affect US grads as well.

William, I did not know that about Grant. The unmatched grads are not all men, but females can do just about anything in the military that men can. It might be worth looking into.

Unknown, thank you for the link. It looks like you have to register before you can read anything, but the topics look pertinent to the issues raised by the unmatched graduates.

SolitaryFlower said...

I have a friend who's talent and interest is in music- he has an advanced degree and produces his own albums. He's decided to only make money via his art, and as a result he was once homeless for more than a year and is constantly broke. I think his decision to not take a "day job" is immature, self-defeating, and pathologically stubborn.
I know what goes into medical school, but I feel the same way about people who fail their Step, don't match, and then still can't/won't make the switch to other jobs. "Odd jobs"?? Why not admin, scribe work, office work?

Jack Williams said...

Scalpel, to your response to anon from 10/22/17, you can graduate US grads as many as you want but unless and until you get rid of the current residency bottleneck you will continue to see a doctor shortage and increase in the number of unmatched doctors. The doctor shortage is a result of the residency bottleneck not the number of graduates.

Jack Williams said...

Scalpel, to your response to my previous comment 10/21/17, I am not a lawyer but as far as I know in a class-action lawsuit the lawyer does not get paid until the lawsuit is successful. Also, there are restrictions on third-party financing the lawsuit but this is not to say that there are not interested parties in the lawsuit who are willing to finance it if allowed to because there are including but not limited to the unmatched doctors themselves, the HHS Department for serving the underserved and rural areas, interested civil organizations and even the taxpayers because if employed, the unmatched doctors will start to earn money and pay taxes, in addition, that will reduce the demand on residency. I think that an experienced lawyer knows how to navigate his/her way to finance the lawsuit.

mvkMDiva said...

Clinical research...or get an MBA and do health administration.

Skeptical Scalpel said...

Solitary, it’s a little more complicated than you make it seem. Other than scribe, most medical school graduates are not qualified for the positions you mentioned.

Jack, please look at the 2017 Main Match Results. There were 35,969 active applicants in this year’s match and 18,539 were active US seniors. The number of PGY-1 positions was 28,849 which means that over 8000 active participants in the match failed to secure a residency position. 94% of US seniors matched while only a little over 50% of US-IMGs and non-US-IMGs matched. If the number of US grads continue to increase, fewer IMGs will match.

As I mentioned before, it is not entirely clear that there will be a shortage of physicians in the future. At best, it is debatable. An increase in the number of unmatched physicians is inevitable because of the unbridled growth of both US and offshore medical schools. The only way that this will not happen is if people stop attending marginal medical schools.

Regarding a class action lawsuit, it is true that the lawyers do not get paid unless they win the suit. However, the lawyers must bear the upfront costs of researching the problem, recruiting the class, finding and paying expert witnesses, and their own and their staff’s time and expenses.

If you think the government is going to pay some lawyers to sue the government in order to finance more residency positions, you are mistaken. If you can find a lawyer to take on the funding of a class action suit, then have at it.

mvkMDiva, clinical research might work, provided the individual has some idea how to do it. An MBA would add more tuition expense which most of these unmatched MDs cannot afford.

Jack Williams said...

Scalpel, with all due respect, I looked at the NRMP 2017 numbers. They're trying to downplay the number of unmatched doctors by using active participants instead of registered applicants. There were 43,000 registered applicants and 31,000 positions meaning there were 12,000 unmatched doctors. I don't know what you mean by marginal medical schools, but as far as I know the unmatched doctors are certified and qualified if you don't trust their medical schools then don't allow them to take the USMLE. With regard to the lawsuit, we are talking about two different things. I'm talking about lawsuit against the state medical boards for licensing the unmatched doctors to practice medicine in similar capacity of the PAs.

Skeptical Scalpel said...

Jack, I used the conservative figures, but I appreciate your bringing up the larger numbers because it illustrates the oversupply of medical school graduates even more. And those numbers are for only one year.

I do not see the glut of unmatched med school graduates changing unless people look at these numbers and stop applying to schools offering a 50-50 chance of matching. It reminds me of those who buy a house near an airport and then complain about the noise.

I think we all know what some of the marginal medical schools are. I hope you don’t believe what you said about me being the person that certifies medical schools and allows people from schools to take the USMLE exams. I have nothing to do with it.

Your previous comment about the lawsuit was somewhat vague. I thought you were talking about a class action suit against the federal government for capping the number of residency positions. A class action suit against each state is highly unlikely to occur for many of the same reasons I cited above plus the need to file 50 such suits.

I would like to end this exchange because we are not getting anywhere with our discussion. You seem to have a lot to say. Why don’t you start your own blog and say all the things you want to say there?

Anonymous said...

I really feel bad for these FMG's. I am equally afraid of a doctor (or person with MD degree) who cannot pass the step 3 exam, which is all clinical. Would anybody feel sorry for the person who gives up 10 years of his life trying to be a professional sports player, only to find out that he just does not have the talent?

Anonymous said...

Can't agree more with the last Anon; if you can't pass step 3, you have no business being a doctor.
I would argue that part of the responsibility of medical schools, since they continue to expand, should be to help in career counseling for marginal medical students. I think this counseling should (much more often) include encouragement to get out before you get in too deep. Didn't pass step 1? I think that's a pretty good sign you shouldn't continue on your current trajectory.

Skeptical Scalpel said...

Anon from 2:04 pm, That's an interesting point.

Anon from 7:32 pm, I agree that the schools do not do much for the marginal students. It's also almost impossible to flunk out of med school. I wrote about this 7 years ago [https://skepticalscalpel.blogspot.com/2010/10/suboptimal-outcomes-for-medical-school.html and http://skepticalscalpel.blogspot.com/2010/08/medical-school-and-surgery.html]

It might have something to do with loss of tuition money, but I know their are students at Caribbean schools who have transferred too US schools at the end of their first or second years.

Unknown said...

it is possible that people may stop going to off shore schools once it becomes clear that there are no jobs for them, something similar happened to anesthesia in the eighties there were no jobs and the residency slots disappeared as no one was applying

Skeptical Scalpel said...

Unknown, it is possible but so far, it has not happened. A new med school is opening in the Caribbean every month or two. They must still be doing OK. Good point about anesthesia. There was a time when they could not attract people at all.

Anonymous said...

The only difference is that they were anesthesiologists, finished residency, and the job market determined that not some program director sitting behind his/her desk.

Skeptical Scalpel said...

Anon, I believe you missed the point. There was an oversupply of anesthesiologists. Medical students recognized that and applications to anesthesia programs dropped so much that several programs closed.

Unknown was likening that situation to what appears to be an oversupply of medical school graduates and wondering why applications to medical school are not decreasing.

Anonymous said...

On point, the initiation point which triggered the chain reaction that reached the medical students was the job market. As you mentioned earlier "There was a time when they could not attract people at all."

Anonymous said...

Sort of blaming the victim and holding her/him to different standards. Step 3 is designed for and required after starting the residency not before. Step 3, typically taken during or after the first year of residency, is not used in resident selection.

Dennis Thiel said...

To Anon above: US grads can't take Step 3 until a PGY-1. Therefore, without at least an internship, one can't complete the process to get a license to practice medicine. However, most FMG's apply to US residencies by different set of rules (5th pathway, etc..). Most all of them do take Step 3 before applying to US residencies.

Sara Bubenik said...

I have been trying to get a residency since 2014. I graduated from OHSU (Oregon Health and Science University) and I was able to take step 3.

Sara Bubenik said...

I am A US grad from a top US school. I did not match because I had trouble with the USMLE. I have been quite vocal regarding the residency bottleneck and the "blame the victim" attitude that medical culture breeds. If a person graduates from medical school AND the ONLY way to practice medicine is a residency, then these should be incorporated in the curriculum. There should be a reserved internship for the small percent that do not match. I took the USMLE step 3 and passed on my first round, but that doesn't matter to PDs if you had trouble on step 1 and step 2. Performance measures should not be the only thing that programs use to give interviews but that is the standard used in our over surplus of medical graduates.

Sara Bubenik said...
This comment has been removed by the author.
Andrew Hennings said...

What other professions guarantee jobs like this? People who study law aren’t guaranteed a job? Why are medical graduates so entitled?

No one is entitled to a profession. If you don’t make the cut for whatever reason you can try another avenue or go do something else. This is how every job market works. I find medical graduates very entitled, asking for privileges not given to other graduates.

Anonymous said...

Thank you Dennis, I did not say that Step 3 could not be taken before starting the residency. Some people do take it on voluntary basis. Many states require some residency training, 6 months/1 year, before taking it even for the IMGs or they have to take it
In different state. But with all different set of rules for the IMGs that you talked about Step 3 isn't required before starting the residency.

frankbill said...

There are other professions that are in high demand. So it is possible to be guarantee jobs at the end of training. Just need to find the right fit for ones talents.

Anonymous said...

Andrew, I agree with you that the job market should determine the employment of the doctors without entitlement. When anesthesiologists mentioned above were laid-off and didn't find jobs some committed suicide but they didn't complain because they were licensed. Your analogy with law graduates is not accurate because there is no cap on them to take the bar exam to get licensed. But what these medical graduates are talking about is the equivalent of the three US major auto companies saying, after lobbying the motor vehicle licensing departments, you can't get driver's license unless you buy one of our cars and moreover we don't have car available for you so stay without driver's license. That's what the special interest groups in the medical establishment, by creating the residency bottleneck after lobbying Congress and state medical boards, are saying to the med. grads. In short, the medical graduates are asking for a reasonable path to get licensed not for a job let alone job guarantee.

Just a thought said...

Entiltled would not be the word I would use. The difference between other professions and medical is the continued hoops and there are many. The residency program is a big difference between other jobs. If you go to law school you are a lawyer, plus a state test ( the bar) , But you can work in a law office and or in a pinch become a politician, if you don’t pass you have options. You can use your degree in the field you studied. Research is not the same thing for a medical doctor and they really can’t have any significant patient interaction.

Also my program just closed a year after I finished so people that were below me did not know if they would be able to stay in there specialty or be able to graduate. Luckily another program picked them up. It was not their fault.

The problem is many fold and entitled is really the wrong term. I have seen many lazy Med students, residents, and attendings, but they are not the majority. Most people that got into and graduated medical school were pretty smart. They have a good work ethic and are driven. So to pass all the hoops and not get to practice is a problem.

Perhaps the medical schools will actually start to care for the future caregivers in medicine instead of treating them like a check. Along with our medical advocacy groups.

There are a lot of things that are unfair in Medicine. Starks laws cripple capitalism in the market place. All the continued government mandates ( why there is an opioid crisis, now there are mandates to try and fix it with more mandates). Yes all professions have their issues, but this a medical blog.

Anonymous said...

Having read 36 comments that are presented, I'd like to point out some things that were not addressed.
1) The public wants physicians that have both intellect & compassion. Many applicants to medical school are too enamored with the money and prestige of an "MD" on the end of their name.
2) Many people go into Medicine with a 40 hour work week ideal...it is not and never has been.
3) Those people going to substandard/below average school without understanding the increased difficulties of those degrees, really have only themselves to blame for not adequately researching the options.
4) the current system came about because decades (maybe centuries) the apprenticeship model of medical education led to incompetence and perpetual ignorance
4) In light of the Anesthesia comment- One must consider what residency programs are being applied for and the need for those specialties. There are many programs where the applicants far outnumber the spots, and others that are struggling to get "good" applicants to accept because of economic inequities between specialties.
5) Who is going to pay for more residencies? Most people don't realize that hospitals rely on reimbursement for a significant amount of money from the Medicare/Medicaid funds to train residents and this can limit the positions available at an individual program.

Finally, everyone knows adults with dreams....doctor. lawyer, athlete, writer, painter. If you do not have the talent, and haven't thought about alternatives the fault may lie with you; not the system. It is not the responsibility of the AAMC or AMA to make sure there are residency spots. Their role is to try to maintain the professionalism and care for the patients in the USA. To think that the schools don't care about their students is crap! I and my colleagues deal with feelings of personal frustration & loss when one of our students flunks out or isn't adequate...that's one of the reasons it is so hard to fail out of medical school.

Anonymous said...

I would like to respond to Anon of 8:56 AM itme 5), The medicare funding for the GME of 1965 was meant to be temporary until the medical establishment could be able to get its act together.
It is clear that the medical establishment failed to wean itself off the medicare funding for the GME. On top of that, the medical establishment has monopoly on training residents and that is why training a resident is expensive. Training a resident is a product that the resident should be able to buy it, or pay for it, from any credible hospital including in Europe just as he/she can buy German or Japanese car. I believe that many residents are willing to pay for it out of their pockets, because it is much cheaper, and to submit themselves to US standard test regarding the training that they got in order to meet reasonable standards for licensure.

Andrew Hennings said...

I think entitled is the right word. No-one has the right to work in the field of their choice. No-one has the right to be a licensed physician no matter how much they have paid to an institution.

Medical students aren't the only people in the world who have invested money and lost it. Bookshop owners and video shops are two easy examples. They also aren't the only people who have invested in training they can't use. Look around you in the US, many people's jobs they have invested long hours training in have moved off shore.

In this day and age no-one is guaranteed anything in the job market. Medical graduates just like all graduates need to be flexible. The best advice these graduates can get is to stay flexible and keep an open mind. Don't dwell on your losses. Maybe being a doctor isn't for you, despite all your sacrifices. If you work hard something else will come.

artiger said...

Wow, Scalpel, good topic. This thread has an Energizer Bunny going, and I'm glad to see the attention this is getting.

I don't hold my breath for more Medicare funding for residency positions, but something I have noticed anecdotally is that medium sized hospitals in underserved (at least to a degree) areas are starting up their own training programs in primary care, and I think maybe in some cases they are funding these residencies themselves. The obvious advantage to this is recruitment; the vegetables that you grow in your own garden are the easiest to obtain, and often the best quality. At least you know what you're getting with them.

Skeptical Scalpel said...

I agree. Increased CMS funding is unlikely. If it happens, it won't be on a large scale. Good point about primary care and hospitals starting and funding residency programs.

Anonymous said...

I agree with Andrew. Calling this "blaming the victim" is mistakenly characterizing the MD who failed to match/pass USMLEs as a "victim" rather than as someone who tried, but failed, to become a licensed physician.

This is inevitable in any competitive job. As someone else mentioned, trying/investing in something and then failing occurs in many careers and fields. These people aren't victims any more than those who started a business or went to law school and then did not succeed are.

Perhaps medical schools should remediate these people or hold them back if they could succeed with additional education? As it stands (and I think someone should look into this) it seems that medical school and residency don't "fail" or hold back many trainees.

Anonymous said...

I guess you missed the point as to why the graduate didn't match. As mentioned above there were 45,000 registered applicants and 31,000 positions. Assume for the sake of the argument that all 45,000 were Harvard graduates and Noble prize holders for physiology or medicine then you would have had 12,000 unmatched Harvard graduates and Noble prize holders. The point is that the reason for unmatching has nothing to do with qualifications but has everything to do with the bureaucracy of lacking available positions.

Anonymous said...

I correct myself, there were 43,000 registered applicants not 45,000. Sorry about the error.

Skeptical Scalpel said...

Anonymous (Jack), the 45,000 Harvard graduates probably wouldn't have chosen a career path that was certain to mean that about 17,000 (38%) of them would not be able to find jobs when they finished school.

Even lawyer wannabees have figured that out. There are now more law school grads than there are lawyer jobs. The number of first year positions in law schools exceeds the number of applicants. As a consequence, law schools are closing or reducing class sizes.

If the number of residency positions increases, more med school graduates will become residents, but I guarantee you there will never be 45,000 residency positions.

Anonymous said...

That doesn't change the fact that the reason for unmatching has nothing to do with qualifications but has everything to do with the bureaucracy of lacking available positions.

Andrew Hennings said...

I don’t understand that point anonymous. The match is merit based. Do you disagree with how they select on merit?

artiger said...

Anonymous/Jack Williams, please know that I share your disdain for the current system and state of affairs, but your arrows are directed at the wrong targets.

Anonymous said...

Artiger, thank you for your comment. Honest people may have honest disagreements. I hope that you elaborate a little bit on the right targets and I hope that they are not the easy targets, namely, the unmatched doctors.

artiger said...

I don't blame the unmatched physicians. I look to Congress to start with, for not providing adequate funding for more residency positions. Next I look at the medical schools as well, the ones that are expanding class sizes and the new ones cropping up everywhere. I would venture a guess (bet?) that very few prospective medical students are being adequately counselled about prospects of residency and not matching. This is something the schools could probably help after the students are accepted but prior to actually starting (i.e., before going into massive debt) by giving realistic expectations of life after the degree is conferred.

Just my thoughts on the matter.

Skeptical Scalpel said...

I agree Congress should find more positions. Whether that will happen or not in this time of tight budgets is questionable. In fact, the opposite may occur. CMS funding could just as easily be reduced.

unknown said...

In India, med school is four and a half years, getting the medical degree requires an additional year of "compulsory internship" which is provided to everyone. Unless you complete the internship you dont get the degree at the same time the degree comes with a license to practice. The rotating internship use to be three months each of medicine, Surgery, Ob-Gyn and Social medicine ( which was essentially primary care in rural setting)It may have changed now.

Skeptical Scalpel said...

Thanks for the info about what goes on in India. A problem that concerns educators in the US is the scarcity of suitable clinical sites sites for student and resident education. I will be blogging about that soon.

Anonymous said...

Hey Scalpel,

Longtime reader here. Felt like I could chip in 2 cents.

I'm currently studying in Israel and applying to the current year match. I knew going in that based on number of interviews offered I'd have a sense of my likelihood of matching. For IM positions last year, I think once you cleared 10-11 interviews you had a 95%+ chance of matching. Fortunately I'm in that group now, and have some offers at academic centers. But getting there required sticking to a plan from day one, which is to say that I knew my board scores had to be pristine. The competition for a residency spot will only get stiffer and if US grads are getting bumped out that's a clear sign to all IMGs that they better come prepared. I studied for Step 1 and Step 2 rigorously, and made sure that my scores were well above the average acceptance for IM. I also cleared my head of the notion that I'd be at a "top 10" program because if one takes a glance at the resident lists on their websites, none of them come from abroad.

I heeded the advice from my upper year classmates. They told me that without boards, you have no chance of matching. I have seen several students flunk a step and get further and further out from school, with less chance of matching each year. I think you were correct in saying that there is no advice to give for these unfortunate grads, because when it comes down to it programs do not have any selective pressure to hire them. When there are so many other candidates who do not have red flags on their applications, why should any program go out of their way to rank a candidate who has gaps in their education or failed board exams?

The best form of treatment is prevention (no I'm not going into primary care but I still believe it). People need to be made aware of the statistics of matching when you attend medical school abroad, and they need to know the very real risk of taking out loans based on those statistics. The reality is that being able to work as an MD and repay 250-300K of loans hinges in part on your ability to perform on two tests (didn't count CS), and I can't see any other way to frame it. I should add that while both step 1/2 are necessary to match, they are not sufficient, as you need good LORs, solid clerkship evals, and good interviews too. Without the board scores though, all else is moot.

Skeptical Scalpel said...

Anon from 11/4, thanks for commenting. I agree with everything you said especially this "When there are so many other candidates who do not have red flags on their applications, why should any program go out of their way to rank a candidate who has gaps in their education or failed board exams?"

MaroonMed said...

I wrote a response to this (and the idea of going to medical school in the Caribbean in general) on my blog: https://www.maroonmed.com/stop-feeling-sorry-for-unmatched-caribbean-mds/

Honestly, we hear these sorts of sob stories all the time and I don't see why we should feel sorry for what is essentially a pattern of self-inflicted wounds.

Skeptical Scalpel said...

Maroon, your blog post is harsh, but perhaps it should be read by all who consider going to Caribbean schools. It will either make them rethink it or make them more determined to prove you wrong.

SolitaryFlower said...

I know this is an old discussion, but I saw it on your 2017 roundup and that reminded me of it. I did some research into the jobs I originally mentioned- admin and office work (data entry). Industry standard for those jobs is a Bachelor's degree or some college, basic knowledge of Excel and Word, and excellent communication skills. So unmatched MDs can absolutely do these jobs.

Skeptical Scalpel said...

True, but the problem is they won't be able to pay their student loan debt on a data entry person's salary.

SolitaryFlower said...

Obviously it's not an ideal situation, and not a solution at all. I'm just saying that there really is a better option than 'odd jobs.' Frankly I can't imagine how disappointing and frightening the whole situation must be.

Skeptical Scalpel said...

I agree it's a terrible situation. That's why I am trying to warn people about the reality of MDs without job prospects.

Anonymous said...

A residency should stop being thought of as a job and be seen for what it actually is - a continuation of medical education/training.

In other words, the US should adopt a system similar to what Unknown from 11/3 (1:29 PM) spoke of. The odds that this actually happens? Near impossible considering how entrenched the current system of medical education is in the US.

The current system is the equivalent of finishing an undergraduate program and being told by your college, "Congratulations on earning your bachelor's degree, you are now ONLY eligible for jobs that require a high school diploma!"

A bachelor's degree grants its owner the right to apply to a broad scope of jobs that require a certain level of education. A medical degree should qualify you for more than just the right to apply for a residency.

There needs to be a viable way for these unmatched graduates to utilize their degrees outside of clinical medicine. OPTIONS, that is all these unmatched grads are asking for. As is, a medical graduate without a residency is seen only by employers as someone who spent 4 years not gaining any work experience or applicable skills.

Medical schools and the AAMC should help the unmatched by loudly and proudly advertising how their knowledge and skills might be useful to employers in other realms such as business, politics, technology, etc.

Sadly, it seems that medical schools and the AAMC only try to sweep these people under the rug and abandon them when they are in their greatest moment of need.

Skeptical Scalpel said...

The problems with what Unknown on 11/3 suggested are as follows.

1) How many people would be included in the mandatory internship program? There were 8000 unmatched grads in 2017.
2) Would it be open to all US and non-US IMGs? If so, who would pay for this?
3) Where would these internships take place? US med schools are already concerned about the availability of suitable training sites. [See http://skepticalscalpel.blogspot.com/2017/12/chronic-shortage-of-training-sites.html]
4) For the non-clinical jobs, how would you get employers with those jobs to accept med school graduates?

Anonymous said...

Your first three points are precisely why I don't think Unknown on 11/3's system would ever be feasible. I was only making the point that it is a system that makes more sense; where residency is treated as a part of medical education and earning an MD, not separate from it.

The US is trillions in debt and Medicare is already one of the leading costs, which makes raising additional funding to place those 8000 unmatched residents extremely unlikely.

In regards to non-clinical jobs, I don't think it's asking too much for the AAMC or for schools to act as brokers between grads and employers. In the same way that an undergrad college holds job fairs or helps place students/grads into internships or entry positions, I think med schools and the AAMC could do the same. I just think it's a shame that so many educated minds seem lost or reduced to "odd jobs" or jobs where they are grossly overqualified.

Were these grads the best students? Probably not, but the fact that they graduated and passed step 1 and 2 of the USMLE illustrates a noteworthy level of work ethic, discipline, and yes, knowledge.

Understand that there was once a time where the number of residency positions outnumbered the amount of graduates and simply passing these exams meant you could move forward to the next step in training. This led to an environment where hospitals would compete between themselves for the best students and would even try to offer residencies to top students after only 1 or 2 years of medical schools. This eventually culminated in the formation of the Match, which put an end to this system and let all hospitals offer residencies at the same time.

Many of today's older physicians have told me that when they were students they only needed to worry about passing their board exams and that scoring high was a secondary concern. They basically knew that if they had at least passed their exam, that they would be offered a residency. However, as soon as the number of graduates outnumbered the amount of residency positions, the USMLE became a competition between students rather than a bar for ensuring a standard of retained knowledge. How many of those capable and successful physicians would not have matched if they were stuck in the same competitive system that today's unmatched grads are? It's impossible to say, but it's food for thought.

Skeptical Scalpel said...

I agree that no one is going to fund residency positions for 8000 unmatched graduates.

Your suggestion that the AAMC try to help graduates find jobs is probably worth pursuing. However, what we do not know about the approximately 1500 who went unmatched, withdrew, or did not submit a ranked list is why they did so.

It is possible that some went straight from medical school graduation to pursuing a PhD, an MPH, a job in a tech startup, or another endeavor of their own choosing.

You can bet the AAMC is not going to help the over 8000 unmatched US citizen IMGs find jobs nor do I think their schools will help them.

It’s true that the USMLE exam is being used in a manner for which it was not intended. A recent opinion piece in Academic Medicine discussed the situation at length but did not come up with any solutions to the problem. I have not heard of any reasonable alternatives for screening the hundreds of applications that residency programs receive.

Skeptical Scalpel said...

In reading my above comment, I notice I should have said in the second paragraph "approximately 1500 US seniors who went unmatched..."

Matched, the 2nd Time Around said...

I was one of the horrible horrible unmatched grads. a few of you have referenced on here. I was not a successful match during my first entrance into the cycle. I had an issue with my first board exam and should have applied more broadly geographically. I'm currently a resident so you can correctly assume I made it on my second go. Yes, I am a US MD.

During my time off I spent quite a deal of time thinking over this process. Yes, I did fail my Step 1 and retook it successfully. I subsequently aced my Step 2 and Step 3. Life got in the way of my first Step and nearly killed my career but should it have? I worked my ass off. Sacrificed years and money and it could have all been for nought.

If things are to remain the way they currently are I would like to see curriculums across the US make preparing for the boards sole priority. So many times I've heard, "I do not teach for the test, I teach for life." spew out of some EdD or PhD. To them I say, ridiculous. If the test wasn't the soul of the match then I might take their words with more weight.

If things are to change we need to cap medical school sizes and do it fast. There are too many grads. and not enough spots. On top of that we need to nix import of FMGs and IMGs altogether.

Since it appears there will not be anymore residency programs opening in the near future we need to cull the hoard now. This extends out to Caribean grads. Now I know many many great Caribean MDs but they like other FMGs & IMGs need to hit the chopping block the hardest. Priority should remain and always be for US Grads at US residency programs. I see no point in importing talent or semi-importing it (Caribbeans) when we have more than enough US grads here all the same. Medicine should not be treated as a pathway to immigration, I say that as an immigrant myself. I look at my own institution with disgust at times. So many of the residency programs are packed to the brim with FMGs and IMGs while they simultaneous ask us to "apply at home" and stay. Admnistration begs them each year to admit more of us but it never occurs. I could probably name the amount of people from North America in the combine programs on 1 hand.

Skeptical Scalpel said...

Matched, thanks for your interesting comments. As long as they continue to make money, Caribbean schools will stay open. Unfortunately, many graduates will not find residency positions.

US schools will continue to expand their class sizes as they hop on the "impending doctor shortage" bandwagon. You might want to read this December 2017 post on the expansion of US medical schools http://skepticalscalpel.blogspot.com/2017/12/chronic-shortage-of-training-sites.html.

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