A medical school graduate recently published an account of the financial disaster she is facing due to a failure to match into a residency program two years running. After attending OHSU, where she ran up a $400,000 tab despite resident tuition, fees, and insurance of under $45K per year, she was unable to accomplish her dream of practicing medicine. While she didn't post her transcript, board scores, essays, and letters of recommendation, reading her account brings up a lot of concerns and even more questions. She is clearly frustrated (who wouldn't be) and bitter (again, who wouldn't be after 5-7 years in the pipeline) but multiple parties failed here.
Failures All Around
First, she failed. Medical school isn't easy, and residency is harder. She failed Step 1. Every medical student is well aware of the importance of that test. The goal isn't just to pass it so you can graduate from med school, it's to rock it so you can get into a good residency program. Passing it is generally taken for granted by most medical students. She failed at the residency matching game (i.e. applying to enough programs that might realistically take you to match into one of them)…twice. It's not like there is one person out to get her. 200 program directors, presumably some of whom are desperate to fill their class in their new, on-probation, or failed-to-fill-last-year programs, and including her home program, took a pass on her. I suspect these issues were also reflected in her letters, essays, and interviews. There are many other things to criticize about her past decisions and writing, but that's not the point of this post so let's leave it there. The point is med school is hard, and it takes a lot of hard work, smarts, “ability to pass tests,” and the ability to communicate well and interact well with others. No matter how the system changes or how medical schools change their policies, some people are going to fail. However, many docs are surprised (I was) to learn how high these statistics are. Just looking at the US MD Match, these are the stats:
| Failure to Match | Category |
| 6% | US MD 1st time |
| 56% | US MD 2nd time |
| 21% | US DO |
| 29% | Canadian MD |
| 47% | International MD (US Resident) |
| 51% | International MD (Non-US Resident) |
Second, her school admissions committee failed her. For some reason, the school felt she should be in that class of med students. Who knows exactly why, but they felt she was academically “good enough” (despite an MCAT of 24) and could contribute something to the class. In retrospect, they screwed up. She wasn't academically “good enough.” She couldn't pass step 1 (the first time.) She couldn't make up for it enough elsewhere to match (despite reportedly applying to 200 programs.) Now, OHSU has her money and she has debt that will, at best, be forgiven 10 years from now. Medical schools should be required to provide these sorts of statistics to their applicants. At least then they'd know what kind of a gamble they were making before they plunked down their $400K (as you can see it's a real gamble for most international schools.) The real task for a medical student isn't to get an MD, it's to get a residency spot. Neither students nor schools should ever forget that. While I suppose I expect DOs in the MD match to have a lower match rate (at least they have the DO match as a back-up), and international medical grads usually know they're gambling a bit, even 6% is way too high and 50% after hundreds of thousands in tuition is insane! When a student gets an MD but not a residency, both student and school have failed. Maybe half the tuition ought to be refunded or something aside from very prominent disclosure of these statistics. Too bad there isn't some insurance product out there that schools could purchase to at least wipe out some or all of the debt for their non-matchers. They could market it as “guaranteed match or $100K back!” If med schools are going to be “for-profit” they might as well run them like any other business.
Third, the system failed her. She is absolutely correct in her criticism of the system. 1,000 US med students a year and 2,400 US Citizen IMG med students each year don't match. They have the same debt as anyone else, but don't have the income. She advocates for more residency spots to help the “doctor shortage.” Maybe that's part of the answer (probably not for her though, since there were apparently programs willing to not fill rather than take her.) Maybe it's fewer med school spots or tighter academic admissions standards. Maybe it is to allow residencies to pay the best candidates more and to allow the worst candidates to pay for the privilege of training and let market forces solve the issue. I don't know. But I do know there are 3,400 people a year coming out of med school with hundreds of thousands of dollars in debt they won't be able to pay back, and that's a problem. Each of those doctors has a personal financial catastrophe to deal with.
Dealing with a Medical School Catastrophe
Now, let's talk about what can be done in this type of scenario. The best thing to do is to prevent it. Any med student who is paying attention should see this type of risk at least a couple of years out. If you are failing multiple classes, failed Step 1, or were held back in medical school- you are at high risk to not match. That means you are very different from those surrounding you and should recognize that when it comes time for the match. Dermatology is not for you. Family practice, internal medicine, perhaps a general surgery preliminary internship, etc are the specialties you should be looking at. Sure, they might not be your dream, BUT YOU NO LONGER QUALIFY FOR YOUR DREAM. Be realistic. Next, you need to apply to more programs than is typical, even if you have to take out a loan to do it. 10 isn't enough. 50 probably isn't enough. I know of med students who wanted to match into EM so badly that they applied to ALL the programs. Certainly if you are a very weak applicant, you should be sure to apply to all the safety programs you can find- programs on probation, programs that are brand new, programs that didn't fill last year, programs in crappy locations etc. Completing any residency program is so preferable to completing no residency program. Heck, even completing an intern year at least opens an opportunity to practice independently in most states and you can build your practice from there.
If you start seeing the writing on the wall early on, you need to be even more frugal than most medical students. It's one thing to pay back $200K in loans on a $200K income. It's entirely different on a $50K income. If you fail 5 classes in your first year of med school, GET OUT NOW! If you know you're on the bubble to match, don't take out a dime more of student loans than you possibly need. And start working on skills and connections you may need to get a job if you have to go to plan B.
Also, don't do anything else that could hurt your application. Limit your “red flags.” If you bombed the USMLE, make sure your grades are good. If you didn't honor the rotation in your desired specialty, be sure you find the person who liked you the most to write you a letter of recommendation. If you're an IMG, make sure you don't bomb the USMLE too. Don't reveal any social issues (mother dying, upcoming divorce, wanting to get pregnant etc) you're facing- program directors want to know you're 100% committed to the program. Life happens, and discrimination is illegal, but people are people. Don't even give them the chance to discriminate against you if you can help it. I literally vomited in one of my interviews, and I think things turned out okay (I'll never know, as I ranked them third.) But when you need someone to take a chance on you, don't ask them to take two chances.
Some people just don't see it coming. All of a sudden they unexpectedly didn't match. Perhaps they aimed too high. Perhaps they were sunk by a bad letter of recommendation. Perhaps they didn't apply to enough programs. Perhaps they had a few bad interviews. Whatever. Assuming you don't get picked up in the Supplemental Offer and Acceptance Program (SOAP) or the scramble, you've got a year to kill.Your second year is a second chance. Granted, failing to match adds another red flag to the list of red flags you already have, but at least this time around you have (hopefully) more realistic expectations of how you appear to program directors and can do a better job applying and interviewing. You may even be able to do another rotation or two in your specialty, or do some research that will get you some new letters and strengthen your application. Remember that while 6% of US grads don't match, almost half of them will match the next year. Make sure you're in that half. It only takes one program director willing to take a chance on you.
Now, let's assume that whatever you did in medical school or while applying to residencies was so terrible that you just cannot match anywhere no matter how many times you apply. You applied for two years and no dice. It's time to enact a back-up plan. This particular doctor has a nursing degree. That's a great back-up plan. Shattered dreams? Perhaps, but it still provides a better than average income. The back-up plan may be sales, research, entrepreneurship, using the undergraduate degree (biologist, chemist, teacher whatever,) or going to yet more school (law?) Maybe it's marrying one of your fellow med school graduates! At any rate, settling for a terrible job when you have 8 years of education seems silly, even if you can't be a practicing physician.
Also, keep in mind there are many people who get to the end of med school and CHOOSE not to even enter the match. There are other careers out there besides clinical medicine. The path isn't nearly as straightforward as proceeding into residency training, but there are some doors there assuming you have some other skills (sales, communication, teaching, research, etc). Welcome to how the rest of the world outside of medicine gets a job. You take what you can get, you work your butt off, and you move up as best you can.
What do you think? Do you know of medical graduates who were unable to match? What advice do you have for them? Comment below!
Unfortunately this situation is increasingly common. As a graduating medical student, I had a few friends who didn’t match. Every situation is unique, but in specialties like ortho/ENT/plastics/derm, a 75% match rate is the norm among graduating medical students despite self-selection for these specialties. Even good applicants need to have a viable back-up plan heading into match week.
Many years ago I knew a family friend who didn’t match and he is now the global head of pharmacovigilance for a major pharmaceutical company. So his MD certainly didn’t go to waste and I presume he doesn’t miss practicing medicine either.
This story is all too familiar to me. I am an IMG doctor, so naturally have so many friends who have lost out of the game b/c they couldn’t get into residency. I also was at some point, a clinical tutor at one of the international medical schools in the Caribbean and I have two students from there, who to this day, have not been able to match (actually they have no further hope of matching). They are both US citizens and have >$400,000 of student loan debt, mostly private loans. It’s really scary. One of the students told me recently that she will never be able to pay her loans off and she is currently working as a research assistant. The stories are gloomy. Sad!
As someone who also has had friends and acquaintances who went the Caribbean med school route – I have to say that I have yet to meet one who failed to match or flunked out that should truthfully have ever been there to begin with. At the risk of sounding elitist, medical school is not for everyone. If you struggled through college with mediocre grades, poor study habits, or multiple confounders that made it hard to excel, then those things tend to be magnified in medical school rather than go away. Far too many of the ones I knew/know of had wealthy parents who just couldn’t accept the fact that their child would be anything other than a doctor and they demanded/insisted/encouraged that they go there despite the fact that they had no means to succeed.
I find those foreign medical schools to be somewhat akin to for-profit colleges in that they are very complicit in the massive accumulation of debt for people that have no means of ever paying it off. While there are a few reputable foreign medical school aimed towards US citizens, the overwhleming majority are simply out to make a profit and could care less whether the students they “accept” have any chance of succeeding. Acceptance at these school is really whether your tuition check cashes. Shameful.
I absolutely agree with you. The medical school where I taught were having about 400 students in one class when I was there. Now, I hear there are about 800 to 1000 medical students in one class. It cost about $50,000 per semester then. Most of the Caribbean medical schools are very complicit. They are mostly there for the money and sadly, these students mostly qualify for only private student loans. I actually think it’s a ponzi scheme going on there…
It’s no different than the for-profit law schools I suppose. It’s just a big gamble. You could just walk in the first day, look to your left, look to the your right, look in front of you, and realize that 2 of the 4 of you aren’t going to match after 4 years and $400K. $50K a semester is insane.
What happens when you have student loans and you fail medical school?
You’re still responsible for them. So the best bet is usually find a job that qualifies for PSLF and stay there for a decade.
You need a reality check if you believe the US medical schools do not engage in the same business model. Take a look!
To be fair. I know two graduates of Caribbean medical schools. One spent a big chunk of his childhood in the islands and the other I assume went there because they accepted her. Both are very good physicians and one in particular is exceptional.
Great point and I so glad I not in medicine while my dad is. Glad I never was forced into pursuing medicine or else I would have disowned my family or committed suicide.
Are there any foreign medical schools in Europe for usa citizens with top quality and that are free or charge little.? I hear Europe is a magnet for free or less costly tuition.
I heard some good things about Irish medical schools this weekend.
Great post. At least the good news is that the demand for the bottom half of MD’s is still greater than any other field in the world. A similar analysis for business school, law school, etc…would be even scarier. But at least people are starting to talk about this more, which is a step in the right direction.
You’re right. Law in particular has been very scary.
WCI, an intern year only allows you to practice in 2 states, not the majority. This is an excellent post and students who have ‘doctor dreams’ don’t realize the hard work and perseverance it takes to become and MD. I have a ton of friends who didn’t match into residency and I’m grateful that I have an opportunity to practice medicine. I’m a foreign MD.
Only 2? Do you have a source for that info? I know for certain Arizona and Alaska allow it. This article says 33 states for MDs and 37 states for DOs:
http://thedo.osteopathic.org/2014/02/practicing-after-one-year-of-gme-is-it-feasible-should-it-be/
Dang, I guess it depends on if you are img vs us trained. For a foreign doc like myself; it’s only 2 states; the vast majority need at least 2-3 years of post graduate training. You are right if you go to a US medical school………..but for foreign grads it’s only 2 states; north carolina and wisconsin I believe.
I don’t know what the number is, but 2 is not correct. My father in law has practiced in 3 different states (neither being Arizona or Alaska) in the past 6 years with only and MD/intern year and his MD is from Puerto Rico. All legally, practicing for the federal govt.
Puerto Rico is a US Territory and most of the med schools there are LCME accredited, so their grads are not treated in the match or licensing process as IMGs but as AMGs.
The 6% number is misleading… once you factor in SOAP and the scramble, the actual amount of 1st time US senior applicants who don’t land a residency job is more like 1-2%. From what I understand, the 6% number is people who don’t match before SOAP and scramble are taken into account (but please correct me if I am wrong). At match day a couple years ago, there were a handful who did not match at our school, but they had found a residency program by the end of the day or end of the week.
Statistically there should be a portion of applicants who don’t get in to med school, accepted students who don’t graduate, students and M.D. graduates who don’t pass USMLE, residents who don’t complete residency, residents who can’t find a job or get their license. Otherwise either the tests, licensing etc. are pointless and not serving their intended purpose, or there is some bottleneck and they are turning away qualified individuals at some earlier point in the line. There are better and worse doctors, better and worse students, and at the fringe there are anomalies that manage to squeeze by at each phase but are otherwise incompetent.
The blogger seems to think that she is entitled to a license and a residency position simply because she went through the motions. Unfortunately it looks like OHSU gave her a medical degree for doing just that. With such a defeatist attitude and absolutely no hope, she should probably consult an attorney regarding bankruptcy protection.
Bankruptcy doesn’t make student loans go away.
I’m not sure how much the figure drops via SOAP/Scramble. I think it might include the SOAP/Scramble- that’s all part of the match isn’t it? It seems the numbers are getting a bit worse over time. In 2012, just 4.9% of US med students didn’t match. I only saw data going back to 2011 though, and there isn’t a clear trend in just 4 years.
It can, with enough hopelessness 😉 Granted, it is not as easy as discharging credit card debt, but there have been many cases of student loan debt discharge. Again, an interested individual should consult a bankruptcy attorney.
Match results and SOAP results are broken out separately. The scramble is not NRMP organzied and is essentially done manually school to residency program.
From table 18 of the 2014 NRMP report: “An applicant is eligible for SOAP if the applicant is 1) registered for the Main Residency Match, 2) eligible to enter graduate medical education on July 1 in the year of the Match, and 3) fully unmatched or partially matched (i.e., with only a preliminary or an advanced position). http://www.nrmp.org/2014-results-data-book-available/ Also on p.1 of the introduction it discusses how a higher match rate leaves a smaller amount of residency positions for SOAP.
No idea if it makes any difference – never heard of discharging student loans in bankruptcy – but she says on her blog she has already been through bankruptcy before.
The USMLE is an American standards, number of failures or successes determined by the state also an American standard. Everything is standardized. A Faustian pact with the devil so to speak. If you fall within the curve low or high end of it then you’ve paid your dues how you do in a residency or real life with patients is an entirely different story.
The blame here isn’t on a woman who followed a path she felt was meant for her. It’s on the money making cartel. If All your standards as paid by my tax money falls solely on the shoulders of those who received a score of 240 or above then by all means make the standards only 240 or above simple.
[Removed for profanity-ed]
The only standards we’ve to go by is her USMLE a US AMA standard she did pass it….[ad hominem attack removed-ed]
She earned it by the way abd thousands like her she wasn’t sitting on the couch waiting for a govt. handout she worked [hard.]
This is the ugly flip side of affirmative action programs’ effect in medical school admissions. There is essentially no way a white, or especially Asian, applicant would get in with a 24 MCAT… and, guess what? MCAT performance does have a correlation, albeit not a perfect one, with future performance inclusive of matching.
While I really don’t want to have a debate about affirmative action policies with regards to medical school admission on this website (and if this goes too far down that road I’ll just delete all the comments related to it) I think it is important to point out that there certainly is a way that a white or Asian applicant can get into medical school with an MCAT of 24. In fact, the data shows that the acceptance rate for whites with an MCAT of 24-26 is 18.7% and an MCAT of 21-23 is 5.7%. Here’s the data if anyone really cares to look it up:
https://www.aamc.org/data/facts/applicantmatriculant/157998/mcat-gpa-grid-by-selected-race-ethnicity.html
Acceptance rates are lower for Asians, higher for whites, higher for Hispanics, and highest for blacks with a 24. Whether those rates are too high, too low, or just right is a political question that can be debated elsewhere, but I thought it important to at least provide the facts after a comment like that.
and just to be clear, this woman is white
She actually claims to be “mixed heritage”. I think we can chill a bit on the race identifiers.
Thank you, WCI, for your response to Toshi. I have a lot of respect for your truth telling.
I’m not sure Toshis point is really invalidated. WCI implies a 24 on the MCAT isn’t up to par. Someone who claims to be on an admissions further in the comments says her MCAT shows she shouldn’t go, and over half of black matriculants have scores in that range. Something is broken about that.
MCAT 24-26
Black 56.5%
White 18.7%
Asian 12.2%
Hispanic 40.7%
What about income based repayment plans or pay as you earn? While politically many may not agree, are they not an option for this type of individual? Or even using her nursing degree in a critical area and having loans forgiven after 10 years.
https://studentaid.ed.gov/repay-loans/understand/plans/income-driven
Absolutely, and that’s exactly what she should do.
There is clearly way way more to this story then the author is telling us. If you can’t match or scramble into a family med residency something is seriously wrong.
I would also say I don’t think this actually is a system failure. From what info we have the system succeeded – this woman should NEVER be an independent physician, in any field. OHSU may have failed her by not intervening sooner, she failed herself, but the system didn’t fail her.
But what I find more concerning is the fact that it sounds like this woman knew she wanted to do rural medicne from the get go. And we know that the reimbursement is poor. And then she still borrowed $400k in loans!!!
Complete lack of insight by this woman. If you are going into peds, fp etc go to a cheap state school.
Agreed.
The “system” succeeded by protecting the public from an incompetent physician. However, the system (OHSU) failed her by accepting her and not failing her at several stages through med school, and arguably the system (federal student loan program) failed her by giving her the money to do it, or by allowing schools to accept and pass poorly performing students.
Yes. The big disconnect is saying a person is a good enough doc to graduate but not good enough to match. It’s one thing to fail. It’s another thing to be hundreds of thousand in debt with no possible way of ever paying it off without PSLF.
I agree. Also finishing school is really only 1/3 the battle if you ask me. I learned way more in residency than I ever would in school. Even if she had done poorly in school I got to think graduating at least deserves a spot at an intern year. Maybe she’s better with people than books (psych?)
i have a hard time supporting the notion of “gold stars for everyone” and giving someone an internship simply because they graduated from med school.
as someone who sits on an admissions committee, this woman showed very demonstrably that she has no business being a doctor. she doesn’t have the intellectual capacity, which she demonstrated through mcat, usmle, and class grades. but more worrisome is her lack of professionalism.
Then she needs to be issued a full refund or her debt need to be wiped clean. She loses but the people still wanna win? So her debtors are still expecting their money? Please. If I was her, I would act as if I didn’t owe a dime. If she loses, everybody loses.
I find it absolutely disgusting that you claim to be on an admissions committee. Do you know what they call the person who graduated at the bottom of the class in medical school? DOCTOR
Not sure why someone would claim that if they were not on a committee. Having been on one, it’s mostly a coalition of the willing.
A med school graduate may be called “DOCTOR” but that doesn’t mean they will match into a residency (fewer and fewer do each year) nor that they will be a skilled and compassionate clinician.
Some brilliant minds aren’t standardized consider that perhaps someone like Newton with Asperger or Einstein who was kicked out of school would have also flunked the USMLE. A test implemented in the nineties I wonder how many practicing physicians who’d graduated prior would actually pass it first go with flying colors. Their own training subpar in comparison to today. It’s always easy to blame the victim it makes it more bearable and less a human story that anyone can be subject to. Shoulda, woulda coulda.
[I tried to find something useful that contributed to the conversation in that long, difficult to follow diatribe, but it was mostly a personal attack directed at me, so it has been severely cropped.-ed]
I hear what you say, but have you considered the reality that in fact there are many people who are utmost sincere, compassionate and hardworking with top interpersonal and bedside skills yet do poorly on classroom tests or not good with grades?
In reality, there are some people who usually study harder and longer than their peers, but do not know how to study smart or efficient as sadly our schools never teach to how to study efficiently or smart and instead say to study hard. These people sadly do their best and many have no disability, but just learn differently.
Universally, “grades or test scores” never determine one’s worth as a professional or person as most important qualities as common sense are character, integrity, interpersonal skills, work ethic and passion for the work.
The other side of the coin is easily demonstrated when you run into a doc who clearly isn’t that bright. It takes a certain minimum amount of intelligence to do this job well, and you drop below that level at the peril of increased morbidity/mortality. If you ask most docs, the first characteristic they want from their doc is competence.
Craig is right, the rate of not matching is much less than 6%. I had two in my class that scrambled, ironically into radiology. I read the post from this individual; she really does not seem to take accountability for what happened, and is rather blaming on a number of factors, including ADHD, coming from a poor family, the system etc. I’ve known people who failed step 1 but all of them ended up matching the first time around. To get passed up on the match twice after graduating from a very good medical school, despite ‘strong letters of rec’ from all these big wig doctors and the chief of surgery at OHSU (despite their program not even wanting her) sounds like she has SEVERE lack of insight. I imagine there are major red flags on her application, far beyond failing step 1. Its unfortunate that the school didn’t do more for her, and took a huge risk taking her with an MCAT of 24.
I know plenty of good doctors with MCAT’s around a 24. Its not great but that isnt’ that huge of a risk. The MCAT is a pretty poor test to determine future ability as a doctor. It correlates with matching slightly but that is about all. At the school I went to 24 was usually the cutoff. If you were exception with a 23 you probably got interviewed but most needed a 24 to have a chance.
This post makes me feel old. I just don’t recall classmates not matching. I would be interested to see the percentages over time. On the flip side, this lady has put a lot of energy into her blog. Have you asked for a guest post submission? It seems the younger readers (and older readers who now have college kids) could benefit.
I think her story would be much more interesting a year from now when she tells what she ended up doing with her life.
You are right. And she is getting direct phone number contacts for jobs in the comments of her post. She is not toast yet.
And… Please give more info about your personal vomit story! A couple weeks ago, an internal candidate spewed during interviews. You are not alone; go ahead and give some details.
Not much to it, just bad cheesecake the night before at the dinner. I literally had to ask the interviewer for his trash can. They did give me some zofran.
One of the things that generally characterizes this blog and the Bogleheads discussions is a belief that we are individually responsible for our financial futures, and that we need to make the necessary efforts to make sure they will be good ones. I’m afraid that’s what is lacking in this person. If you read her blog and Reddit almost all the blame and responsibility is directed externally. So yeah you can blame her medical school and the system in general, but ultimately the solutions to her problems lie in the mirror.
This brings back memories from MATCH. My first year of dental school was brutal, and although I did ok, my professor who I was talking to about specializing said that I needed to pick it up in order to MATCH. He didn’t sugar coat it, and looking back probably was a little overkill, but it got a fire underneath me. Did well on the national board part 1, grades went up, party due to having more clinical classes and being very good at those, and I got involved with service groups, lobbying groups, and became the president of my dental school specialty group. Even got to meet with the Secretary of Health and Human Services for an hour. (That alone was a huge bonus on the applications.)
The year before I graduated 13 applied and no one matched. Freaked me out! So I applied to 25 schools, which is a lot for dental, most do 6-7, interviewed at 10, turned down the 11th, and made my list. Ended up matching with #2, but would have been very happy at anything down to #3. #9 was the safety net where instead of getting paid, you had to pay 50K a year in tuition.
I agree with WCI and some of the comments from the outside links/posts. The letters of recommendation are a integral part. I never got to read the one from that professor I mentioned at the beginning, but every interview commented on it. (I almost took a peak at it while I was chief resident since I had access to the files, but didn’t).
Anyways, I feel bad that it didn’t work out for this doctor, that’s rough. But it’s tough to say the system failed, when we all play the same system. I understand the debt too, we had the same at graduation, only difference being that my school was way more expensive, and I had a couple kids. I can’t imagine 400k of debt with low tuition etc. That is a tough spot to be in though and I feel for her.
I feel bad for her. I’m not sure why she decided to go to medical school. If she wanted more practice independence in primary care field, becoming a nurse practitioner would have made more sense – shorter training time and lower cost, not much income difference at the end, especially taking her age into account, and fewer working years remaining.
She already was as a nurse with 10 year work experience, she had to have a decent salary at that point.
There were two posts in early February about 16 reasons why it sucks to have a High Income and 16 reasons why it sucks to have a Low Income. This rant is getting off the topic of this post completely, but I have an idea for a future post that I would like to read (but not write, as I don’t have personal experience in this) – about why it is great to have a mid-range income, especially in nursing (or teaching, or working for almost any large employer with nice benefits). One has income high enough to be able to contribute to employer sponsored retirement plans, to his/her own TIRA or Roth IRA, one bottoms out their taxable income this way, then still has all the deductions – child credit, dependent care, earned income credit, favorable time off and other benefits with large employer, savers credit, various child education credits, credits for healthcare (if one is self employed ), student loan deduction, lower taxes on capital gains, no standard/itemized deductions phase out, not being slapped with AMT, extra 0.9 earned income Medicare taxes, extra 3.8 investment income taxes, marriage penalties, you name it. Then the magic of compound interest is added to this – starting to work at 22, instead of post-medschool/ post-residency/ post-fellowship.
There has to be the income vs taxes vs compounding interest sweet spot to hit – and I seriously doubt it’s the MD route. It seems that spreading income and taxes over a longer time more evenly would be more advantageous than a decade to a decade and a half of poverty followed by few decades of outsider-perceived decadence. It would especially apply if one wanted 2-3 decades and not till death do us part (from work). Imagine flying the whole life under the federal tax radar for many if not most future and present taxes targeted at high earners or prodigious savers (ex: RMDs in the present, some sort of success tax on IRA or 401k high balances or distributions in the past – now permanently repealed).
Why would one give that up for 400k of loans and heart-breaking disappointment?
While I don’t disagree that this particular doc made a lot of bad choices, and that NP school made a heck of a lot more sense financially, that income bracket has issues as well-especially if self-employed. You’re out of the earned income and retirement savings credits and you’re still paying full rate on SS tax. That flattens the tax code considerably.
Why not go NP. 20 states now let them not only practice without supervision but also need supervision for only their first year and can be by another NP. Nothing like being trained only by the next best person…. Starting pay is 80-100K.
Just FYI, but most NP schools require 3 years of nursing, 1 in critical care, 600-800 hours of didactic training and 800-1500 hours of clinical training most of which is shadowing.
For a comparison a family physician (most NP’s do primary care) will have approximately
2000-2500 hours of didactic
4500-7000 hours of shadowing combined in MS3 and MS4
10000 hours of direct patient care under physician supervision in PGY 1-3
But if 20 states we are equal except in our ability to write for percocet….
I oversee NP’s and thankfully mine are pretty good but it scares me how many think that they are even remotely as well trained or experienced.
I have 2 separate friends with MD’s that never did a residency. One is a very successful entrepreneur and the other is successful in biotech industry. There is a way, but I think they planned it this way and someone that went into medicine wanting to see patients would have to dramatically change their vision…tough story to read. I agree will be interesting in a few years to see how it is dealt with. – Jon
Docs lose many yrs of compounded interest by starting many yrs later than we poor dentists. I started the game at age 25. LOTS OR DOUBLINGS, rule of 72, especially with the returns in the 80’s and 90’s. Docs should maximize retirement befor loan payback as Jonathan Pond suggests-Lots of nice pieces at WEALTHTRACK-a show on PBS weekly
The number of people who are going to be wildly successful after failing to match is just not going to be that high. My guess would be 1-2% if that. Consulting firms aren’t looking for people who barely made it through med school and just have an MD.
I am faculty at a very good med school. From the time I graduated (ca 2009) until now it’s been fascinating to see the transition in the leadership attitude.
2005: we’ll get you through no matter what b/c it looks bad for us if we don’t
2015: let’s identify M1s in first semester who we should strongly suggest they do something else.
I completely agree that medicine is not a birthright. I’ve never bought into this idea that a person can struggle in undergrad, struggle on the MCAT, struggle in med school, struggle on Step1, struggle in clinicals but somehow come out the other side an amazing physician. Too many medical students look at academic difficulty and convince themselves that this is somehow adding to their compassion abilities. I just don’t think that overcoming personal obstacles adds that much to your bag of tricks as a doc.
I am glad that you brought up the change in mindset of the medical school leadership. In my opinion, it is unconscionable, possibly actionable, that a medical school allows someone who has a high likelihood of not succeeding on the other end to take on a financial burden approaching $500,000, without the ability to pay it back. Perhaps the med school should have some skin in the game, too, either in the form of loan forgiveness or assistance with payments for those who are unable to garner a residency.
It’s not a terrible idea but it will never happen. Esp with the match getting harder a school is not going to want to put itself on the hook for every student who doesn’t match.
I think what is really unconscionable is
a) the marketing campaigns of Caribbean schools
b) that fact that the AOA is allowing all these new DO schools to crop up
What I would hope is that in the near future becoming a practicing doc becomes seen as something that you can’t get to just bc you can get into medical school. In much the same way that not every law student can expect $150k from a big firm.
I agree with WCI not to turn this into a discussion of admission standards, but some of these students just should not be in medical school. You rock a 23 on the MCAT and I’m supposed to be shocked when you don’t get a spot? Surely there has to be a discussion about this sort of thing.
[Ad hominem attack deleted]… A PCP fulfills simple processes which she can easily do.
I really feel bad for anyone in this situation. I worried about the amount of debt I was going to take on way before I ever set foot in medical school. I know not everyone thinks about it and it doesn’t help that all the financial counseling you get is…sign here, and take your loans.
Having said that, once you’re in, you really need to take advantage of the resources available. I had plenty of friends who thought they “knew” everything they need to know about applying to residency because they talked to a “friend” about it…there’s plenty of misinformation out there (I know someone who applied to 50 programs in family medicine, because his roommate was applying to 50 programs in Urology…he figured that’s just the number that you’re supposed to apply to). The person you need to listen to is your med school advisor. Personally, I talked to the residency program director at my school (for the specialty I wanted). It’s really easy, just call his/her secretary and schedule an appointment. Ask all the questions you want, and ask for an honest opinion. They can tell you if your grades/USMLE scores are competitive or not, and how broadly you need to apply (and maybe which programs might be willing to take you if you’re not a great candidate). If they tell you to apply to more programs, for the love of christ, apply to more programs! It’s better to get accepted to your last ranked program than have to scramble.
I’ve also been on the other side of the selection process. You have a few just AMAZING applicants, plenty of middle of the road applicants, and then some not so good applicants–the percentages vary by year. Because of the not so good ones, I’ve really questioned the med school selection process. And it’s not just people with poor grades/scores…some of these can make good residents. If they’ve done an away rotation at your program, you can tell if they are “trainable” (it’s a word I like to use). The ones I really worry about are the ones who seem like they just don’t “get it”. It’s hard to describe, but you can’t seem to talk to them. They say the oddest things, and can’t seem to grasp simple concepts. It makes you wonder how they finished med school…some with pretty good grades too (? Rain Man). I’ve had applicants tell me straight out (first thing out of their mouth) that they won’t be able to take any call, that they can’t work certain days/hours, that they really don’t know if this is the specialty they want, that they really don’t want to come to this program. All I can do is furrow my brow…
I also happen to know someone who got in after 3 years of applying (he was an international student). During those 3 years, he did research in the department he wanted to do his residency in, he networked and got to know all the attendings and residents (including myself) and basically did every dang rotation (as a “student”) that a resident would do in the program. He proved that he’d make a good resident, and got accepted. Took a whole lotta work though.
At the end of the day, you can’t be “passive” at any step along the way. Being a doctor doesn’t just fall in your lap…that’s my 2 cents anyway.
I am always shocked at how many medical students don’t take advantage of all the opportunities available to help them with the match process. most don’t even sit down with the chair or residency director of the department they are applying to.
the number 1 piece of advice i give our medical students is that this is YOUR match. you have to take responsibility and ask for help when needed. and look at programs that are a good fit for you. if you aren’t getting an interview at your #1 place, call and ask for one. sit down with and ask your department chair for honest opinions regarding different programs.
if you sit on your hands and expect the world to come to you, you will find yourself disappointed come match day
So just a few comments on your thoughts
1) The DO match rate is lower for multiple reasons
– they tend to take A LOT more non traditional students which often don’t have the same qualifications and often not the same scores either
– The DO rate includes 2nd and 3rd year non matches which significantly raises it (whereas the AMA divides out those groups)
– There are a LOT less DO residency spots then applicants so if they want to go to a demand specialty and don’t match, many would rather try to match in the AMA match to a specilaty then take a rotational spot in the AOA match. (The AOA is several weeks before the AMA for this reason). While I was military I did apply to a few AMA residencies as backup. I didn’t even consider any AOA residency spots.
2) I agree that this girl is in a bad situation but I’m willing to bet she brought some of it on herself. It says a lot that programs would rather have empty spots than take her. Especially considering most programs are almost always willing to bring on a person as a transitional year unless they just don’t trust them. Not matching indicates to me huge issues (as does not passing step 1). I also suspect that most residencies would be more willing to except the bottom of the barrel in first applicants than someone that failed to be picked last year (You apparently get 2nd chances in life if you play pro sports but not if you are an aspiring Dr.)
3) I love your idea about med schools offering some sort of guarantee and a discussion of cost upfront but we haven’t seen that with any college or law school yet either. Think medicine is bad…. look at the number of unemployed lawyers
4) I find it hard to believe she actually applied to 200 programs. I don’t know any program that would accept a resident without an interview and most want that interview to be in person. Even though I knew I was likely matching in the military I did 2 in person and 1 phone interview (with plan for in person follow-up) with AMA programs.
Your last two paragraphs were gold. Excellent stuff
Addendum, I realized that your 21% for DO’s was strictly related to the AMA match so please disregard the third “bullet” above.
However I do find the number pretty exceptionally high from experiences with classmates. My school of 200 has only a few non-matches but based on the numbers should have had about 20. I suspect that the “DO” rate includes a large number of 2nd and 3rd attempts. Still I knew several programs that flat out told me they wouldn’t take DO residents regardless of ability. Including an attending who berated DO schools to me without even knowing if I was MD or DO.
Having the military involved significantly reduced anxiety but I wonder how many programs I would have applied to had I not been military? Of course had I not gone military I probably would have picked a different specialty as well.
One consideration is personality. I’ve had a chance to come across a couple of folks in training who were just bizarre people. This may not be the case of this woman’s situation, but there are candidates who interview very poorly and are personally off-putting. There are also candidates who look phenomenal on paper but are “functional idiots”. One such resident had exceptionally high scores, was a Rhodes Scholar, and had a masters degree in a related field. At the same time could not grasp the basic concept of how to present a patient (i.e. “this is a 78yo white male with history of diabetes and hypertension presenting with…”) as a PGY2! That despite remedial help.
My point is there are serious personality issues that may affect one’s ability to function as a physician. (Although serious personality disorders are sometimes a prerequisite for department chairmanship.)
I was surprised at the tone of this article. The writer comes off as arrogant (paternalistic?) and spends most of the article chiding this complete stranger. A more interesting & relevant post may have been to focus on the financial aspect of such a big debt & little income, and to expand on topics such as forbearance, various payment plans, estate planning, etc… Also it would be interesting to tease out student loan & bankruptcy such as how this law came about & what other debts cannot be discharged.
What about encouraging folks to get 2 full time jobs, avoid buying home & car, and to knock the debt out like other americans that aren’t doctors. There’s still a chance of being debt free in 10 years. Overall, very negative post aimed at people who likely aren’t feeling great after not matching. I hope to find more hopeful, encouraging, positive posts in the future.
I thought this post touched on a new topic specifically. PSLF and loan repayment has been written about many times here. The fact that there are over 1000 graduating doctors who don’t match every year…with nearly half a million dollars of burden… that is a big story and one that is appropriately discussed here.
You can defend this girl and her feelings all you want but WCI gave some info that shows she isn’t alone in her predicament. And the economics of it is scary.
“get two full-time jobs and knock the debt out like other Americans [who] aren’t doctors”…. Uh, yeah, I haven’t seen any non-docs with this student loan amount. What two full-time jobs do you recommend for this mother of two?
When I wrote the article I was very worried about the tone. So I had two people read it prior to publication and made dramatic changes, all of which were to avoid coming off as arrogant, paternalistic, and chiding the stranger. Entire paragraphs and multiple sentences were deleted to hopefully focus this on what people who don’t match can do. I guess I wasn’t completely successful. If you think I’m bad, you ought to read what people are saying about her on Reddit, Sermo, and the other places this is being discussed on the internet.
It’s very hard to be encouraging to someone who has $400K of debt growing at 8% a year (interest alone of $32K a year.) Payments on this type of a debt are basically the equivalent of the gross salary of the average American household and it can’t be discharged in bankruptcy. The only hope really is PSLF or someone getting a six figure job. Even so, this debt won’t be “knocked out” any time soon. Without PSLF, it’ll be decades before she can scream, “I’m debt free” on Dave Ramsey’s show. Just avoiding buying a car and home or getting a second job isn’t going to do it. Sorry you find that fact discouraging. I do also.
If you would like to submit a guest post on student loan/bankruptcy, forbearance, estate planning etc, here are the guidelines: https://www.whitecoatinvestor.com/contact/guest-post-policy/
Do you have a link to the reddit? I did a quick search and I couldn’t find it.
It’s in the post. Second link I think.
Are you a program director? I have spoken to several about different “red flags” prior to 2nd year, because we have had a handful of students who have faced tragedy or other issues who failed and bounced back. Not everyone has a back up or parent to step in to fix things. I have spoken to several program directors who have said that they look at how a student responds to a failure more than the original issue itself. Failed step 1? How did you do on the re-take? Took a year off for extenuating circumstances? What else did you do in that year? What was learned? How was that applied. While failure may seem like dire circumstances for you, don’t go spewing false information. There are always exception and ways to show you have grown from circumstances. You have to be willing to apply yourself, apply anywhere and replace your failures with successes.
No.
If you were a program director who had a choice between someone with no red flags and someone with red flags who seems to be overcoming them and someone with red flags who does not seem to be overcoming them, how would you rank them?
I’d rank them first, second, and third and I suspect most directors in competitive programs feel the same way. If I can fill my class with a bunch of residents who have no red flags at all, great! The less competitive the specialty and the program, the less likely that is, in which case I’d move on to the second group.
You don’t mention where you’re at in life, but I suspect based on your comment that you’re a student with some red flags that you’re working on overcoming and you found my post discouraging. I’m sorry for that and hope that by overcoming them you’re able to match into your desired specialty and program. I find it important to provide an important blend of encouragement and realism, and that was the aim of this piece written 3 1/2 years ago. Given the increase in medical school enrollments with much less change in residency positions, the problem outlined by this post can only have become worse- i.e. more med school graduates that aren’t matching.
I didn’t find the tone that way, but it’s a tough subject to talk about without someone feeling offended. How can you tell someone that what they have done for the past few years was insane and they might not be able to get out of it for a decade, if the loans can be forgiven, in a nice way? I don’t know it it’s possible. I can only imagine what Dave Ramsey would say. I listened to him about a month ago and a dentist graduated with 400k, wanted to buy a practice and a home and Dave about had a heart attack. Gave her a what’s coming, took a break to regain his composure, then continued on about how this decision means that they have to live small so they can live like no one else etc. And this was someone who graduated and was headed out to work.
It’s tough, but adding more debt that’s impossible to bankrupt is not smart without a clear, executable plan.
I am in PGY 24 (that is, 24 years beyond graduation), and knowing what I know now, I do not think I would consider that amount of debt to become a doctor. IMO, it is just not worth it.
In any case, a life lesson that is well-illustrated by this case is the need for a back-up plan (Plan B). This is something we should think about when embarking on a complicated interventional radiology procedure, when going to the mall to buy a pair of shoes, and, yes, when we are taking on hundreds of thousands of dollars worth of debt.
For the benefit of the individual in question, I think that she is a good writer and may have a career in medical writing. She may have grounds for a lawsuit. Telling (and retelling) her story in the media may have some monetary value. Does her husband not have the ability to earn a living–put him to work. Fast track to Nurse Practicioner? Start a blog for MDs and DOs having trouble finding a residency spot and helping them cope with various related issues? (she is off to a good start with that one!)
And even without a discrete plan, I have found that when one door closes, another one is opening up somewhere else. You just have to keep your eyes open to see it and walk through it. The woman seems like a bright and decent person, and I wish her well.
Thanks for reading and replying to my comment. The comments and your replies are just as interesting as your articles. Keep up the good work.
Thanks for injecting some sense into this. I am appalled at the mass hysteria of the same sort that ensued in the comments. These individuals are posing as physicians?
The body heals itself much of medicine is a big cartel no different than any other sterile institution whose main concern is making money if not a down right scam (oncology) we’d go take compassion classes in the hospital where I work and referred to the patients as customers seeking their satisfaction. I’d rather a personable physician who makes an honest effort than a condescending Pygmy with godlike syndrome.
I followed the link in your first sentence and read the original blog post. My intuition tells me this is a person who’s not quite right in the head. I’ve encountered people like this at various stages of the schooling process, and the tone and content of the article sound exactly like what I would hear from a crazy person. I could be wrong, but I bet I’m not the first person to have these impressions.
I am not going to agree or disagree with your premise, but in a hypothetical environment, if a med student is mentally unbalanced, IMO, the medical school has an even greater obligation to not bury the individual with debt and false hopes. Again, unconscionable, maybe actionable, as I indicated elsewhere.
also went back and actually read the post.
i love this argument that performance on our LICENSING EXAM should not be taken into account when assigning residency spots.
ever notice how everyone who struggles in med school winds up getting diagnosed with ADHD? doesn’t ever seem to be the case that people just can’t cut it….
How many medical students that previously filed bankruptcy do not match in any residency?
Who are you expecting to have that data?
Lenders
As an aside, I have learned a great deal about the match process from reading this. As a military student I wasn’t to worried. I had decent numbers and rotations and I knew I had a 95% likelihood of matching to the military (especially given I was FM).
I only had 3 other interviews setup. I imagine had I not matched I would have been scrambling to apply to a ton of programs before the AMA match. (I wasn’t interested in any AOA spots, probably because I don’t do OMT and most of my rotations were in AMA locations.
Very interesting and I imagine much more nerve racking to go the other way.
I’m curious how many people end up at spots they didn’t rotate or interview with given the high number of applications to each program.
Very few end up with spots they didn’t interview at. I was probably overly paranoid about the whole process. I went through the military match- interviewed at both programs in my specialty/service (flew to Texas to tell them I didn’t want to go to their program but please please please let me go through the civilian match) and managed to go through the civilian match. Applied to 30, invited to interview at 28, went to 19 interviews (the less competitive ones call first, so you put them on your calendar, and then you have to decide whether to stop and interview or just drive through town and not interview) and by the time the ones I really wanted invited me, I had a crazy number of interviews to go to. Most of December and January and even one in February as I recall. If I had it all to do over again, I’d definitely do fewer interviews, but there is little reason not to apply to tons of programs. That doesn’t take much time or money all things considered. By the time I got to my number one choice, I had already practiced at 20 other interviews! No wonder I matched there.
Wow, little surprise that WCI went the overkill route. Could you imagine not matching at any though? Just unfathomable.
My horror story was getting a phone call from a residency director who placed me at the top but that I put much less lower. It was a total scream-out crazy thing that I “let their program down”. (Had been a medical student there).
Matched at #1…never rotated there but had a very formal & thorough 3-day interview with all applicants.
I went full paranoid similar to WCI during my residency application process. Applied to 97 orthopaedic programs, received 25 interviews went on 16 interviews, ranked all 16. I was 250+ Step 1 and Step 2, AOA with almost all clinical honors, top-10 medical school. Don’t mess around when you are fighting for your future. What’s a few couple grand extra to pass the biggest hurdle left in your training?
I agree that many career disasters occur from not applying to enough med schools or residencies. That said, you and I both now recognize we were a little paranoid. I wouldn’t have gone to so many interviews but they were literally lined up on a road trip across the country. I could either drive through Pittsburgh or Kalamazoo or Syracuse and interview or not interview. But I still probably would have done 12 even if I had known which ones were going to give me an interview from the very beginning of the process.