Thursday, February 12, 2015

Cautionary tales about the matching process

Within the next two weeks, anxious fourth-year medical students will submit their residency choices to the National Residency Matching Program. I have written many posts about how to investigate residency programs and the workings of the match.

Here are a couple of stories about deception and disappointment. The first appeared as an anonymous comment on a post I wrote about how to rank surgical residency programs.

I am the spouse of a surgical resident halfway through their residency. When I hear of the idea of "vetting" the residency program as med school graduate, it makes me laugh and cringe. It's not really possible.

We were extremely concerned about not getting stuck in a malignant or toxic program. But these people must have been aware of how bad the program was, we thought the place had the happiest, friendliest people. What a facade.

So now what? We struggle. If it gets too bad I suppose we will try to switch to a new surgical program. Maybe the switch is to a different discipline altogether. Time will tell.

The take-away is perhaps make sure you are lucky, because if you are not, life is hard, and options to fix it are even harder.
[I wish I could tell you how to make sure you are lucky.]

In the mean time we will show up at each and every required recruitment dinner. We will smile, we will follow the script and lie our asses off. Why? Because if we don't we will be labeled a "problem" resident and never get a recommendation from the PD to another program. So the cycle continues. Does the program kick out good surgeons, perhaps, but how many do they lose or worse ruin? Luck of the draw.

The second, also by an anonymous writer, appeared on the KevinMD website. At over 1700 words, it is too long to reproduce here. But it echoes the theme. Here are a few excerpts.

Within only a few days of starting my residency, I was called “retarded” and referred to with homophobic slurs. Women were commonly referred to with misogynistic labels.

After one semester of training, I was told that I had not been studying enough because I didn’t do well on the national in-service examination, a test given nationally used to measure your performance versus residents at other programs. I was threatened with academic probation and warned that I needed to read more.
[Do you think the writer might be a surgical resident?]

He describes his increasing despair at the lack of teaching and respect. He failed to obtain a fellowship and speculates about possible reasons.

Today I remain discouraged, jobless, and deeply regretful of the decision I made as a medical student to choose the residency program that I did. I try to remain hopeful that someone will give me a chance and renew my interest in practicing medicine the right way, but it is hard to remain optimistic.

My goal in writing is that as this year’s match day approaches, I plead with the newly graduating doctors out there to please do your homework. Do ask about board passage trends, do try to find out why questionable programs don’t always fill with applicants in the NRMP, and do not assume that an appropriate educational plan is being offered at a program simply because it is accredited. The ACGME and the NRMP publish listings of programs that are on notice, so avail yourself of these listings. Your residency program is a place where you will work very closely with what may amount to be only a small number of supervising doctors, and you only really get one chance to make the right decision.

In my case, there were red flags that I did not pay close enough attention to. During my interview, the residents gave very short and incomplete answers to my questions, and several of them seemed downright unhappy. I had just assumed that the faculty were part of a medical school which was never the case, and I failed to do any research with respect to the effect that program size might have on education. Don’t make the same mistakes that I did, and best of luck to all of the new docs out there. 

I don’t think the match depends on luck, nor do I think that the size of a program makes a difference.

There are two sides to every story, and we will never hear the other sides of these.

However, do not completely discount these anecdotes just because the writers are anonymous. You can understand why the writers did not reveal their names.

I hope all of you did your due diligence, but as these stories show, sometimes it is not enough.


Anonymous said...

I'm a current resident out on research now so I've had a little bit of time to consider my training.

I wasn't pleased on Match Day when I opened my envelope. Where I matched was lower on my list than I wanted (or even expected) to go but ultimately it satisfied the broader picture of the type of program I wanted.

After a few years training, it's been very obvious to me that surgical residency is very difficult but I'm also thankful that my program overall doesn't make it harder than it has to be. Sure there are rotations here or there that are outliers with toxic personalities but I think the overall culture of the program is good.

I never would have thought about how much culture matters in medicine before I started. You learn, soon in your intern year, how the culture from one nursing floor differs from another. How the culture in one surgical sub-specialty department differs from your own. If you cross paths with residents from other programs, you learn how the culture of their program contrasts with your own. If you ever rotate through a VA you learn a culture you never knew could be so painstakingly slow and inefficient.

When I think back to the interview day for my current program, I didn't like the culture at all. I think I found myself interacting with a few of the more outspoken personalities and I walked away disliking the program. It was only after I spent some time in the program that I learned that that wasn't representative of the whole.

My advice to medical students agonizing over the rank lists is to consider the important things (board passage rates, fellowships, etc) that many people touch on as being professionally crucial. Then, once you're done doing that, try to think about all of the people you met, from the administrators to the leadership of the program to the current categorical residents you interacted with, and try to understand the culture of that program.

The culture is the only thing you'll notice when you find yourself working harder than you ever had before. The culture on a bad rotation is what you'll curse as you head into the hospital before dawn. The culture is what will support you if you run into trouble or need help. You overall feelings on your program and your ability to put yourself in the right mental head-space to show up for your job, and to do your job well, all depend on the culture that you'll experience for those years of training.

I don't know if I could have accurately predicted the culture of my program from the interview day I had. But I also know that I didn't even know to consider it.

Skeptical Scalpel said...

Thanks for your very thoughtful comments. Your points are spot on. I hope that this year's group of applicants considered the importance of culture.

Anonymous said...

My advice to the med student: you had better get a good mentor. Also, do "away rotations" as much as possible, at well-chosen locations. People can fool you on interview day, but I doubt that they can keep up the fa├žade for a month. (However, you had better work your tail off on those away rotations, or you will shoot yourself in the foot.)
I was never able to find a mentor in my 4 years of med school; I had no medical people in my family -- consequently, I was nearly clueless when it came to the whole match process. Surgical residency was a continual school of hard knocks for me. It took everything that I had just to make it through. I could have done a lot better, if I knew then what I know now

Anonymous said...

Anonymous Europe: As I read this post and the comments my old days when I was prepping for the USMLE in the US came back... Back at that point I was really wanting to go and be a surgeon in the US, then I changed my mind and came back to Europe. Why?
1. I was 27 at that time. I knew that will all the USMLE+matching stuff, even if everything had gone well, I would hit the OR when I am 30... If I scored well.....
2. The 80+hours working week was also kind of scary.
3. Taken that if I succeeded my life would not have consisted of anything else but work.
4. Taken that I do not have US citizenship I would have most likely landed a place somewhere in Podunk not some big city.
What I would advise is: 1. Find a discipline that you really want to do and find someone who is sympathetic to you and would teach you with patience. Medicine should not be military. Medicine needs discipline but it should be taught with respect and love, not fear and humiliation.
2. Work on other continents too, even if it is only research, because the experience you gather will make you all the more valuable, someone with international experience.
3. If the US does not work out for you, go to Canada, or come to Europe.

Skeptical Scalpel said...

Two Anons, thanks for you input. Good advice.

Anonymous said...

As the first physician in my family, I had little background or advice for choosing a surgical residency. I ranked my match list based on perceived academic prestige first, and location second. I matched to my second choice - which turned out to be a brutal surgical program in a lovely city, where I still reside today. The program's cache opened a lot of doors for me, in terms of fellowship and job opportunities after training was completed. I met two very strong mentors in my surgical program, one a chief resident when I was an intern, and another was the program director. Somehow I managed to graduate as a chief resident, despite having horrible Absite scores a couple of years, some emotional and relationship problems, and probably some burn-out. Life is better now, but those 5 years in General Surgery were a tough toad. My advice : match to the best program you can, get a mentor or two, and avoid getting married until you're done training. Work your ass off.

Skeptical Scalpel said...

Good advice. I'm not sure about the avoidance of marriage. If you find the right person who can help you get through training (as I was lucky enough to do), marriage can be an asset.

Anonymous said...

The more I read, the more I think that I shouldn't go into surgery.

I would be crushed in a malignant program, and it sounds like the probability of choosing a malignant program is noticeably higher in gen surg than others.


Skeptical Scalpel said...

202, I don't know about that. This post involves two programs. I think it's possible to identify programs like this if you are careful.

artiger said...

I picked up on 202's post a little late, but I agree with Scalpel. Malignancy still exists in general surgery programs (as well as in other specialties), but it's going the way of the dinosaur. Along with work hour limits, the tyrannical, childish, bullying behavior of the past is simply not tolerated like it once was. And it shouldn't be.

Anonymous said...

Artiger, with all due respect, it is tolerated in my area. I mean hugely, they diaper these surgeons. We're the biggest metro area in the state. This isn't the programs, this is regular work hours with patients. I've been on the receiving end of tantrums, and I do mean slamming a PICC line in the sink type of thing. When I finally got tired of the mess one too many times, I said, CAN I GET A WORD IN EDGEWISE PLEASE? The surgeon physically jerked back. The rest of the visit, the surgeon at least stopped himself and said go ahead when he *still* kept interrupting me. Ye Gods ...

Anonymous said...

I wish the malignancy was gone...i finished surgery residency - barely; some of the senior residents were rewarded for making residents in other disciplines cry...there were some with 100s of complaints from the floor, nothing was done. and do NOT make a complaint - oh no - the repercussions! however, i still love surgery and lived through residency to get where i am. but the last time i worked as an attending in the academic world (a "high end" name) the residents were told to lie about hours, treated staff poorly, and although they almost all get into fellowships, it was because they had no real training (since they were competing with fellows there).

Skeptical Scalpel said...

Sounds like a really bad experience. Made residents in other disciplines cry? Geez.

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