Should residency program directors look at applicants’ social media activity?

Please take a look at my new post on Physician's Weekly: My thoughts on whether residency program directors should review applicants' social media activity.

“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.

Chronic shortage of training sites worries medical schools

The Association of American Medical Colleges (AAMC) says many of its members are worried about a shortage of training sites for students and residents.

The AAMC’s 2016 Medical School Enrollment Survey found that 80% of schools were concerned about the number of available clinical training sites. There were also issues with the numbers of primary care and specialty preceptors.

The graphic below shows that these problems are not new, but in general seem to be worsening. [Click on the figure to enlarge it.]

The situation is exacerbated by increasing competition for clinical sites from osteopathic schools, offshore medical schools, and nurse practitioner and physician assistant schools.

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.

How to fix the problem of general surgery resident attrition

Over the last 25 years, about 20% of general surgery residents have failed to complete their five years of training. This compares unfavorably to other specialties such as orthopedics, obstetrics-gynecology, and medicine with attrition rates of < 1%, 4.5%, and 5%, respectively.

A paper presented at the American Surgical Association in April looked at the factors associated with attrition in one year’s resident class. In 2007, 1047 residents began their training and after 8 years of follow-up, 80% had become surgeons. How many non-finishers left programs by their own choice is not clear.

Some highlights of the research are as follows:

24% of women and 17% of men left general surgery training.

Size mattered because 23% of men and 25% of women left large programs compared to both sexes leaving smaller programs at a rate of just 11%.

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.

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.

Caribbean medical schools: A look inside

Did you know that several Caribbean medical schools provide postgraduate premed courses so students can complete their science requirements? At least one school’s nearly year-long premed curriculum includes 8 hours per day of classroom work, rudimentary general chemistry and organic labs, and a physics lab with 40-year-old equipment. The fee is more than $30,000 cash, no loans. That's a lot to pay for courses that are not accredited and credits transferable only to other Caribbean schools.

The goal of these premed programs is to prepare students to take the Medical College Admission Test (MCAT). However, some schools require only that applicants take the MCAT but do not reject anyone on the basis of their scores. 

A former student said, “Little did I know that a [Caribbean school] acceptance was the equivalent of a lottery ticket. They actually attempted to weed us out of the small (and unaccredited) pre-med class! It took me a month to figure it out.” One of his professors told him the administration said not to pass everyone in the premed course into the first year of medical school.

He struggled through the premed requirements and wound up at a different school. The dean at that school spoke to the students about USMLE testing and what to expect in the clinical years. Many times during the talk, that dean referred to the school’s “top students” in a way which implied that only the best students were likely to match to a residency position.

Another school administrator told him that some residency programs would not even look at his application if there was an F on his transcript. While most program directors would probably verify that statement, it was not widely known among the students at his medical school. Some had even failed a course but were still planning to become surgeons.

Regarding his struggles in the second year of medical school, the student said the volume of material was overwhelming, everyone in his class was stressed, and approximately one-third had dropped out. He observed that students who were doing well were “type A personalities who had some measure of prior academic success…and could make it through any US or Canadian program with ease.”

He barely made it through the first year with mostly C grades. During his second year he dropped two courses and had to repeat them.

After eventually withdrawing from that school, he applied to another and was turned down.

He warned that those who are thinking about going to school in the Caribbean don’t understand how many don’t make it through.

Dropouts and accurate figures on what percentage of each graduating class passes all USMLE steps and matches to a residency program are unknown.

Meanwhile tuition debt keeps accruing and doesn't go away. The student has over $200,000 to pay off and will be doing so without the benefit of a physician's income. He is now trying to get a job related to his undergraduate major—business.

Regarding the offshore medical school experience, the student had the following observations:

The schools accept many students who they know will not make it through to fill up the class and make a lot of money in the process.

I didn’t find the material in medical school to be all that difficult; it’s the volume of the material and the time constraints that are the problem.

I could not figure out why my studying was only yielding C's when some people were getting the A's and B's. I'm starting to believe people are born smart.

I am not a good test-taker. I make the process harder than it is. The right answer might stare me in the face but I'll always second guess it.

I was informed that residency programs look at more than STEP scores. I was actually under the impression that no matter what red flags I had on my transcript, my STEP scores would decide my future, but I was told by other students that residency programs will look at pre-clinical grades and I even heard from one student that an IM program asked for college transcripts! If that is the case, I would never stand a chance.

I wanted to be a primary care physician. Was all this stress worth it to go into primary care?

I keep reading that the match will continue to get harder and harder.

I have blogged about the decreasing number of residency positions available for international medical graduates.

Despite the recent ban on immigrants from certain countries, I do not expect the situation to change much for US citizen IMGs.

If it comes to a decision about whether to attend an offshore school or not, do your homework. Talk to people who have been there. It's not all palm tress and sunsets. 

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.

FAQs from IMGs about applying for surgery training

Here are some of my responses to common questions from international medical graduates (IMGs) looking to match in categorical general surgery residency programs.

1. Which programs should I apply to?

You should apply to a number of second and third tier programs, especially if you USMLE Step 1 scores are not outstanding.

2. What would you consider second and third tier academic programs?

There is no short answer to this question. I suggest you go to Doximity’s residency navigator and look at their list of surgery programs. You should start at the bottom and work your way up. Doximity’s list is not perfect, but it is better than any other one I have looked at.

3. How much of a level playing field is the interview process?

I’m not sure what you mean by this question. The object is to get some interviews. Most programs will not waste their time interviewing people they have no interest in. If you are offered an interview, you should obviously make the best impression you can.

4. What about observerships?

Should I become a general surgeon?

One of the rewarding things about blogging is receiving many emails from high school, college, and medical students asking about general surgery as a career.

I try to answer every one of their specific questions and direct them to posts that I've written on the subject.

A recent inquiry stimulated me to review all of my posts and put most of the questions about becoming a general surgeon in one place. They are about 500 words each. I hope you enjoy them. Here they are.

Is the solo general surgeon a dying breed?

What is the future of open surgery?

In what specialties can a surgeon be autonomous?

An applicant worries about the future of general surgery

Will automation affect surgeons' skills?

Going to medical school and becoming a surgeon when you are older

A medical student from the UK discovers surgery and has questions

Is it possible to live a full life as a surgeon?

Choosing a medical specialty is difficult

A med student asks, “Is surgery the right careerfor me?”

Which type of surgery residency should I choose?

Medical school and surgery

Choosing a Medical Specialty Is Difficult

On the shoulders of giants

The following was sent to me by a professor who sits on the admissions committee of a medical school in the United States. Here’s what he asks prospective students during interviews.

Sir Isaac Newton said, “If I have seen further, it is by standing on the shoulders of giants.”

If you want to become an astronaut, I’ll bet you know who Neil Armstrong is. If you want to become a rock-star, you likely know who the Beatles were or who the Rolling Stones are. If you want to become President of the United States, you know who Barack Obama is. But you want to become a doctor, right? That’s why you’re here.

So, who are those giants of medicine? What famous scientists or doctors who have advanced the science of medicine can you name?

The following would not be acceptable:

Mehmet Oz, MD
Sanjay Gupta, MD (Medical reporter)
Phillip McGraw (“Dr. Phil”)

Here are some names that would count: Drs. Watson, Crick, and Franklin

You wouldn't believe the answers I get. For example:

Another Caribbean med school graduate needs advice

I did not attend St. George's, Ross, or Saba. I chose my school because it has a premed program which leads to an MD program. My USMLE Scores on Step 1 and Step 2 CK are above 230.

I did not apply for the 2015 match because I did not have my step 2 CK results until November. It would have been too late. I could have rushed my step 2 but I wanted to get a good score and be a solid applicant. Also I would not have been able to complete my surgical electives in time to get letters of recommendation. At some point, I will be doing research at [a very well-known medical school]. I felt that for these reasons this would make me a better applicant the next year.

Since graduating I have been trying to find a medical related job (scribe) but have had no success. I have reached out to many institutions regarding research opportunities but have come up dry. I may be able to secure a volunteer research position by next month. Do you have any suggestions for me? I knew I would hate being out of the medical field for this long but this was my best bet. Does this gap hurt my chances?

I am concerned that despite your excellent USMLE scores, taking a year off from clinical medicine may cause your application to be rejected immediately. I do not know if a 9 week research elective, even at a premier med school, would be enough to offset your lack of clinical experience over the entire year. Acting as a scribe would not be considered clinical experience.

Another issue is what is the record of your school regarding matching graduates into surgical programs? Since you didn’t tell me your school’s name, I cannot give you any insight into that situation. Even if I did know the school’s name, it may not have published its match results.

To answer your specific questions:

How many gen surg programs should I apply to? I was thinking ~100. That seems reasonable. You should be able to gauge your chances better after you see if you receive any offers for interviews from the 100 programs.

During a gen surg interview, should I be open about my backup specialty? I would advise you to say that you would take a preliminary spot in general surgery if you didn’t match in a categorical position. Admitting that you would do internal medicine is often seen as a lack of commitment to surgery.

Most hospitals I am looking to apply are IMG friendly. Which means the surgery and medicine programs are both IMG friendly. Would it be a bad idea to apply to different specialties at the same hospital? I think it would be a bad idea. I suggest you wait and see if you get interviews from the general surgery programs. If you don’t, then there would be no problem applying to internal medicine at the same place. I doubt very much that the two services would talk about any specific applicants. Most surgery programs get hundreds of applications and those applicants who are not offered interviews are not remembered.

Some readers may have other opinions. I hope they will comment.

A medical student in Cuba is looking for advice

Someone writes: I am trying to help a friend's brother who is not a US citizen and currently a medical student in Cuba, and I came across your very informative web site. The brother most likely is going to be able to come to the United States in the fall.

My friend is wondering if he should complete the last year of medical school there in Cuba or come here and continue on. It seems like there is no benefit from completing med school in Cuba, given the difficulty to be licensed in the U.S. And the difficulty in getting a residency position.

Does any of the course work from his studies in Cuba transfer over to U.S? Is it likely that he'd have to get a bachelor's degree here before ever going to a U.S. Med school? My friend says that he has an outstanding record in the Cuban medical school, speaks excellent English, does well on tests, etc. Any advice you could give?

As far as I know, no medical students from Cuba have transferred to a med school in the United States recently or possibly ever. Regarding your questions, I can only give you my best guesses.

I doubt very much that a course from the Cuban medical school would be accepted here in the US. US med schools that accept a few transfers from Caribbean schools like Ross or St. George's usually take those students at the beginning of the third year of medical school.

A few schools are doing combined BS/MD degrees in five or six years, but I don't know of a single US school that would take a student directly out of high school into a 4-year program.