“Number of medical students pursuing surgery specialty drops by half”

That was the headline in a September 10 Becker’s ACS Review article. The first sentence of the piece was more specific, “Only 4 percent of medical students surveyed in 2018 said their chosen medical specialty is general surgery, compared with 8 percent in 2016, according to Medscape's Medical Student Life & Education Report 2018.”

This caused some consternation among general surgeons on Twitter. I tweeted, “Interesting. Lifestyle is finally catching up to us. I think it will get worse.”

2018 Residency Match Update

The National Resident Matching Program Advance Data Tables for the 2018 Main Residency Match again show an increase in the number of first-year positions offered, going from 28,849 in 2017 to 30,232 this year.

Of the 18,818 seniors graduating from US allopathic medical schools, 17,740 (94.3%) matched, 1078 (5.7%) did not match, and 474 withdrew or did not submit a rank list. The 5.7% who went unmatched was identical to last year’s figure.

The 1511 graduates of US allopathic medical schools from previous years did not fare as well with 43.8% matching and 56.2% going unmatched—slightly worse than the 2017 percentages.

What were attrition rates in surgical residency programs 25 years ago?

Last month I blogged about the 20% attrition rate of general surgery resident over the last 25 years, and a recent paper presented at a national meeting that found after following the general surgery resident class of 2007, 20% had dropped out for one reason or another.

A reader who calls himself Artiger commented on that piece asking, “Is there any data on resident attrition prior to 1992? Just curious if this has been a problem for more than the past 25 years.”

I responded that I wasn’t aware of any such studies but I would try to find out.

Most of the few papers written about attrition back in the day focused on one residency program or one medical school’s graduates.

Until the middle of the 1990s, many surgical residency programs were pyramidal—that is, they took more categorical first-year residents than they had chief residency positions. For example, when I began my training in 1971, my program had 12 first-year residents, decreasing to 8 in the second-year and only 4 chiefs.

Can a med student who flunked Step 1 still become a surgeon?

I received these emails (italics) recently. The writer gave me permission to publish them. They have been edited for length and some details have been changed to protect his anonymity.

I'm a third year medical student at an allopathic state medical school. I've always wanted to do surgery. My problem is I failed USMLE Step 1 the first time and got a 207 on my second attempt. I hadn't failed anything else throughout first and second year, with the majority of my grades being my school's equivalent of Bs.

My surgery shelf exam was a week after I received my Step 1 score and, despite studying hard, my low score on that exam got me the equivalent of a C in surgery even with very good clinical evaluations. The rest of my third year has been good with most evaluations saying I'm well-liked and a team player.

Should I give up and go into a different specialty with better odds of matching? Apply to prelim surgery programs and categoricals? Or even apply to all of those things at once? I'm in a large pickle, paralyzed with indecisiveness, and would immensely appreciate your advice.

Disclaimer: This is my opinion. I do not presume to speak for all program directors. I'm going to be honest.

Surgical fellowship match results for 2017

Two weeks ago, I reviewed the preliminary results of the 2017 main NRMP match. Data for the specialty match, also known as the fellowship match, recently became available. Here are the outcomes for the subspecialties of general surgery.

For abdominal transplant surgery, 36 of 58 programs filled, comprising 51 of 74 positions. There were 75 applicants with 24 going unmatched. The number of transplant programs has dropped from 69 in 2013 with a concomitant decrease in the number of available positions from 84 to 74. Applicants numbered 116 in 2013, and except for a slight upturn in 2016, interest has steadily declined. Consistent with the previous four years, US grads filled 31% of the positions in 2017.

Colon and rectal surgery filled all 56 programs and all 95 positions; 35 of the 130 applicants failed to match. Colorectal has filled 100% of positions available in three of the last five years. US grads filled 75% of the slots which is fairly consistent with previous years.

Pediatric surgery’s 44 programs filled all but one of the 45 available positions. This is the first time in the last five years that pediatric surgery did not fill 100% of its slots through the match. There were 96 applicants this year, and 52 of them did not secure a position. US grads filled 80% of the slots which is a slightly lower percentage than previous years.

Brief summary of 2017 residency match data

Here are some snippets from the NRMP Advance Data Tables for the 2017 Main Residency Match.

The number of PGY-1 positions offered was the highest total ever. US allopathic medical school seniors in the match numbered 18,539, which is also a new high. Only 5.7% of US seniors failed to match. That was a slightly lower percentage compared to 2016 and 2015.

The numbers were not as good for previous graduates of US allopathic medical schools with only 46% of 1472 applicants matching. Osteopathic graduates fared better with 81.7% of 3590 applicants matching.

I have blogged about the prospects for international medical school graduates. Of the 5069 US citizen graduates of international medical schools, 54.8% matched—a rate consistent with the totals for the last four years.

Breaking residency placement fever

 By Francis Deng* and Skeptical Scalpel

A recent opinion piece entitled “Residency Placement Fever” in the journal Academic Medicine by Gruppuso and Adashi noted a recent intensification in the volume of residency applications submitted and interviews offered/attended per applicant.

For keen observers of the Match process, this trend is neither a secret nor a surprise. The Electronic Residency Application Service (ERAS) has seen an increase in applications filed per US medical school graduate from an average of 30.3 in 2005 to 45.7 in 2015.

Inflation of residency applications is getting out of control these days. Time for a limit in ERA$ pic.twitter.com/AsRn8c3fgd

— Francis Deng, MD (@francisdeng) October 31, 2016

The prospects for switching to a different specialty

Could you comment on how an applicant switching into general surgery compares to one that applied directly from medical school would be viewed? I had a very difficult time choosing between specialties and have been regretting my decision not to apply into surgery. I am currently in a prelim year in medicine and am currently matched into radiology. I want to reenter the match process this year but am nervous to give up my guaranteed radiology position at a top program for an unknown where I can go unmatched or matched into an undesirable program. I graduated from a US med school. My USMLE Step 1 score was 235, Step 2 252, and I have published 2 articles in a surgical sub-specialty field.

You are what is known to the National Resident Matching Program (NRMP) as an "independent applicant" (graduate of a US med school going back into the match).

Go to the NRMP website, download the PDF "Main match results and data 2016" and look at Figure 6, you will find that 52.2% of independent applicants in general surgery failed to match compared to only 9.9% of US seniors.

 

This holds true for most specialties. Note that 43% of independent grads did not match in neurology.

Your USMLE scores are quite good, and the fact that you have published to articles will probably help a little. However, the reality is that you probably have about a 50-50 chance of matching in general surgery.

I wish I could explain why this is. All I know is it has been this way for years.

I can't tell you what to do. I suggest you give this some serious thought. It is probably not ethical for you to reenter the match and not tell your anesthesia program that you are doing so, but I suppose that is an option. If you don't match in general surgery, you would still have your anesthesia spot, but if you do match, you will leave your anesthesia program high and dry.

If you decide to apply to general surgery, you should go with mostly community hospital programs and send out lots of applications. By lots, I mean more than 50 or as many as you can afford.

You will be able to better assess your chances as you see how many interviews you are offered.

Good luck with your decision and please let me know how it turns out.

 

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.

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.

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.

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.

So you got into medical school… Now what?

"So you got into medical school… Now what?" is a book written by Dr. Daniel R. Paull, a recent med school graduate. His aim was to inform newly matriculating medical students about what to expect and how to survive. For the most part, he succeeds.

The first four chapters are a bit on the dry side because Dr. Paull tries to simplify such complex things as how to live with anxiety in the first two years of medical school. He also spends a bit too much time on how to study. I agree with him that studying in medical school differs from studying in college, and that sticking to a schedule is a sensible way to organize time. However, I think that most people will figure out what works best for them on their own.

The book picks up steam starting with Chapter 5 on how to prepare for USMLE Step 1. I get a lot of questions about USMLE, and with no recent experience, I sometimes find them difficult to answer. Dr. Paull takes care of that quite nicely.

The remaining chapters offer plenty of practical advice on transitioning to the clinical years, clerkships and how to arrange them, studying for the two parts of USMLE Step 2, the fourth year of medical school, and finally how to arrange and succeed in the all-important residency interview process.

Regarding clerkships, Dr. Paull wisely recommends that students ask their residents and attendings for feedback during the rotation instead of waiting until the end to find out that their performance was not up to par. He gives some specifics like asking for feedback about H&P's and presentations and how to improve on them.

The pros and cons of away rotations are discussed in some detail and should help any student who is conflicted about whether to do one or not.

He explains how the National Resident Matching Program works and offers some hints about ranking programs which echo similar comments I have made on this blog.

The book is in trade paperback format and inexpensive at a list price of $19.95. It's also available in a Kindle edition.

My only other criticism of the book is that Dr. Paull relies a little too much on an alarm clock about to go off or going off as a way to introduce a challenge he is trying to help students deal with.

Why should we believe anything Dr. Paull says? Well, he has a bachelor of science degree in physics from New York University, graduated from the University of Miami School of Medicine, and is currently an orthopedic resident at the University of Toledo in Ohio. In case you hadn't heard, orthopedic residencies are highly competitive.

Also, I have read the book myself and think most med students will find value in it.

Disclosure: I received a complimentary copy of the book from the author.

2015 Match Review

Continuing grim news for international med school grads and some US grads too

There were a lot of happy faces on March 20th as depicted in this brief video of the excitement on the campus of the University of Rochester School of Medicine. Similar scenes took place at every US medical school because 93.9% of the 18,025 graduates of US allopathic medical schools matched in a specialty.

But for the 1093 (6.1%) US graduates who didn't match things were not so bright. These applicants had to go through the Supplemental Offer and Acceptance Program (SOAP) which connects unfilled programs with unmatched students.

Because there were over 8600 unmatched graduates from schools all over the world vying for about 1200 unfilled first-year residency positions, even some US med school grads did not secure a position. One of these unfortunate souls tells her story in this blog.

The 7400 or so new MDs left out in the cold will not be able to pursue their careers. They will not progress into any specialty, nor will they be able to obtain licenses to practice medicine anywhere in this country. Those with substantial tuition debt will have no way to pay off their loans.

The percentage of unmatched US graduates has been relatively stable over the last five years, ranging from 4.9% to 6.3% while the number of first-year residency positions offered has steadily increased by nearly 4000 from 23,420 in 2011 to 27,293 this year.

Graduates of osteopathic medical schools didn't fare quite as well. Of the 2949 osteopathic school applicants, 610 (20.7%) went unmatched, but this percentage has steadily declined from a high of 28.3% in 2011.

International med school grads were much worse off; 2354 (46.9%) US citizens and 3725 (50.6%) non-US citizen graduates of international medical schools did not match. Both of these groups also had declining percentages of unmatched applicants. In addition, about 1900 US citizen graduates of offshore schools either withdrew or did not submit a rank list compared to almost 2700 non-US citizen international graduates who did likewise.

Reentering the match next year is an option, but spending a year outside of clinical medicine greatly reduces one's chances of finding an accredited position.

If you factor in the number of applicants who either withdrew from the match for did not submit a rank list. graduates of international medical schools have well below a 50% chance of matching.

In previous posts here and here, I have warned about the risks involved with attending an offshore medical school. If you are considering attending such a school, I urge you to look at the numbers and think long and hard about your decision.

Source: Advance Data Tables 2015 Residency Match

A medical student says to abandon the match

A blog post entitled "How a Nobel Economist Ruined the Residency Matching System for Newly Minted MDs" appeared on the Forbes website. In it, Amy Ho, the medical student author, lists all the things she considers wrong with the National Resident Matching Program (the "Match").

I would have commented about this on the site itself except that I have a lot to say, and in order to post a comment, I would have had to agree to allow Forbes to post tweets in my name. No, thanks.

The title of the post is misleading. As the author noted, the Match as been around since 1952. It was established to make the process of finding a residency position fair for all graduating medical students. Alvin Roth, the economist who shared a Nobel Prize based in part on his work with the Match algorithm, simply refined the process in the 1980s and 1990s to make it even more fair. Roth didn't ruin the Match; he made it better.

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

Note: I updated this information in a new post on 7/26/16.

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 match-day lament: "We will rank you very highly"

A medical student and I were discussing his experience with this year's resident matching process. He told me he had interviewed at 18 programs and ranked 17 of them. He matched to a categorical five-year general surgery position at his sixth choice hospital and was satisfied.

His assessment of the situation was that his somewhat below average USMLE Step 1 score might have affected his chances at his first five choices. [See my previous post on how residents are selected here.]

Then he said, "I was a little surprised as I had some really positive correspondence with programs at the top of the list with one even telling me they were ranking me very highly."

Even though he had been warned that this type of thing might happen, he said, "It is so hard to not fall into the trap. It feels so good to hear 'you're ranked highly.'"

He was disappointed that a program would tell him this and not follow through. He planned to tell future applicants to beware.

"I almost wish there was a 'no contact' policy," he said.

Other than hurt feelings, no real harm was done. The match algorithm favors the student. The fact that a program director would tell an applicant that he was ranked highly and then not do so does not affect the way the match process works.

The applicant's rank order list is queried sequentially by the computer until the first unfilled program that ranked him is identified, and that's where he will end up.

Having been out of the program director business for a few years, I'm sorry to see that this sort of thing still goes on.

It works both ways. On numerous occasions, applicants would call or email me to say they were ranking my program highly, only to go elsewhere come match day. I assume that these applicants thought their chances would be improved and I might rank them higher if they expressed greater interest. After being burned a few times, I learned to disregard any such statements.

I agree with my young friend. There should be no contact after the interview including the obligatory waste of time "BS" thank you email from both sides. If there is contact, both parties should take whatever is said with a grain or two of salt.

Rite of Passage for Some Medical Students: “Scramble Day” Explained

UPDATED on 2/25/13: As of the 2012 match, "Scramble" no longer occurs. The NRMP instituted a much more orderly process, which I'm told worked well.

Ironically, this year the "Ides of March" marks the annual rite of passage for fourth year medical students known as “Scramble Day.” Graduating student participate in a matching program that links them to residency training positions. Throughout the fall and winter, students take electives and go on as many as 20 interview trips seeking coveted residency positions. They then submit a list to the National Residency Matching Program [NRMP] ranking the programs they want. Likewise the programs rank the students. A computer crunches the two lists and the next several years of a graduating med student’s life are revealed.

Unfortunately, some students, usually one or more from every US medical school and hundreds of students from international schools, do not “match” and today is the day they find out. Starting at noon today, they “scramble” to find residency training positions with programs that have unfilled slots.

The process is painful for both the students and the residency program directors. Unmatched students, whose predicament is usually the result of ranking programs “out of their league,” having some blemish on their record or simply being from non-US schools, have to quickly get over their embarrassment and disappointment and face the reality of scrambling to find a job for the coming academic year. Program directors [PDs] have unfilled positions either because their specialties are not in favor with graduates, their programs have problems or there are too many positions to fill.

General surgery has a unique issue in that so called “categorical” or full five-year positions are in high demand, but there are far more“ preliminary” [one-year] slots available than there are takers. These one-year positions are meant for those entering subspecialties like orthopedics or ENT. Due to the needs of the programs to staff their hospitals, there are some 400-500 preliminary slots in excess of the number of one-year positions actually needed by the subspecialties.

At noon today, phones will be ringing off the hook and fax machines will be overheating as the scramble gets underway. Residency program directors will have to decide which applicants to take based on brief telephone interviews, and the students face the same under-informed decision process. For US students, associate deans often act as agents trying to explain why their anxious student didn’t match. International students are on their own.

Many interesting deceptions take place. The records of some students, who didn’t match because they are crazy, lazy, just not too smart or all of the above, are buffed up by their deans. International students always claim to be at the top of their classes, and the information is impossible to check. Students who had their hearts set on orthopedics and didn’t match have to now say they wanted to be general surgeons all along.

It is the epitome of a “crapshoot” for both parties.

Thankfully for me, I am no longer a participant in this nightmare, but I empathize with both the PDs and the students. Good luck.