By Dr. Jim Dahle, WCI Founder
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!
It’s just selecting for intelligence. honestly if someone got a 24 and then failed step 1, they’re probably not intelligent enough to be a physician. Everyone wants to be nice and be a “yes man” but at the end of the day, some people just don’t have enough intelligence to do it. Essentially the only two things these standardized tests measure are a) your determination and effort b) your intelligence. If you don’t have enough a+b to get a decent score, well then you probably shouldn’t move on to the next phase.
In regards to not matching, just as many if not more people don’t match due to being illogical. Like ranking 2 programs. I’d also call this a form of intelligence. Nearly all (99.99 %) of US MDs will match if they rank enough programs. However there are some truly delusional people out there who only rank like 5 programs and guess what? They end up unmatched.
^ this phenomenon is the definition of insanity IMO. Not matching makes you almost an outcast to programs in terms of your chances the next year, so why people can’t spend an hour looking up stats, so they can be sure they have a job after taking 200+ K in debt seems truly insane to me. All the NMRP data is extremely easy to read and interpret, probably could read through the general stats and a couple specialties data in 30 min. Meanwhile these people that have worked for 4 years to graduate seemingly can’t find the time to do that. I’d call that a lack of intelligence. Probably the most ” high yield” thing you could possibly do for your career is just being honest and aware of the current landscapes in both your desired fields and the residency application process in general.
I agree this is a terrible situation and there must have been other circumstances that she doesn’t reveal.
I do want to make note of multiple comments that single out her 24 MCAT as an early warning sign of decreased changes of succeeding. It may be worth looking through this article below from AAMC that correlates MCAT scores with USMLE pass rates, med school graduation, etc. Per the article, 90% of people scoring in her bracket of 24-26 passed USMLE Step 1 on the first attempt which is only 4% off the average pass rate of 94%. Though MCAT is an easy way to weed through applicants I don’t know that what many people consider a low MCAT score is a strong predictor of decreased medical school/USMLE success. I remember internally thumbing my nose at some of my classmates with significantly lower MCATs in M1 but come M4 we were all headed to competitive residencies.
https://www.aamc.org/students/download/267622/data/mcatstudentselectionguide.pdf
It doesn’t look so bad when you consider that stat, does it?
I’m currently a 4th year medical student. I took the MCAT and scored a 25 on it. After the basic sciences I scored a 230 on my step 1 and then later a 249 on step 2. Turns out I was better at medicine than the physics tested on the MCAT.
i don’t think the MCAT thing is the whole story. my points are more about when someone has a pattern of struggling. in most cases the MCAT is an early indicator.
the problem is that some students honestly feel that they should be judged based on effort and intention rather than performance and results. as a prof i see this a ton. everyone expects honors just for showing up. many students who are having academic difficulties just fold it into “this is just going to make me a better doctor” because they have this horrendous misconception that being a great doc has nothing to do with knowledge but all compassion. i see this time and time again.
The article does have a critical tone reflecting on reasons why some applicants don’t match. I think this critical tone is what has generated 70+ comments. In United States, particularly for a student who had enough academic achievement to get into medical school, criticism does not exist. It is always praise. That kind of an American way of raising our kids and how education system is.
No one ever sits down with these students and tells them how it is. So the students keep going through their degrees, struggle, graduate and guess what they continue to struggle. I’m talking about a small percentage of students.
What is concerning is the high cost and inability to discharge loans in bankruptcy. The way the system is set up you simply don’t get a way out of it.
Here is an irony that I thought of while reading this:
This woman is a doctor with 400k debt, and no income. Probably she is marginal in terms of capabilities (no offense, just reading between the lines)
Had she become a “noctor” instead (which probably she is qualified for and would have done reasonably well at) she would have far less debt and $150K income.
Why, in the current environment, would ANYONE go for an MD degree? Ego – yes, but financially it is stupid.
Really? You are a financial advisor, right?
You realize that debt can be wiped out in a year, I hope.
I think you are off-base in your conjectures.
I don’t think he’s an adviser. I’m curious what type of specialist you think can wipe out $400K in loans in one year.
The benefit of being a PA/mid-level is you spend 2 years training (instead of 7-11), have a lower debt burden, and have easier academic standards, yet still have a pretty good income. Many mid-levels have better incomes than poorly paid physicians. I think his thought that this woman should have been a mid-level (since she already had an RN with 10 years of experience and was apparently pretty weak academically) was spot on.
“noctors” don’t make 150K. At least not starting. Average is about 80-120K. That being said, I agree she made some really poor financial decisions in my mind.
PAs are being hired at 160k in town.
Happy Easter, WCI. I was thinking of you listening to a story about perilous rock climbing today.
My reply was in reference to this line: “Why, in the current environment, would ANYONE go for an MD degree? Ego – yes, but financially it is stupid.”
Your response made me laugh and think of this: http://www.zdoggmd.com/specialty/
Grateful to the great Jehovah for a 365 day debt payoff.
It’s a tough position for her, no doubt.
I won’t do anything aside from mention the low MCAT, likely lower GPA or poor medical school performance.
A pet peeve of mine is how people live way above their means.The usually very conservative COA for schools can be greatly undercut.
At our middle-cost school my classmates stayed at the apartments that cost 900 a month. I lived at an apartment that was slightly less nice but 400 a month. Both apartment complexes were managed by the same management company; again little difference in quality. Other similarly-minded students with an eye toward frugality lived next to me.
That’s real money. 500/month is 6k a year and 24k over 4 years, without including interest. Add other ways to save like buying food on sale (100/month) and the like and you can cut costs by tens of thousands over 4 yrs.
But some classmates are driving mercedes c class cars (base 37k) or have watches that cost 1,400.But my people were poor rice farmers, we know how to get deals with little effort.
This woman’s story reminds me of my time on the Progress Committee at the med school where I did my residency. Basically, any med student who was deemed a risk for failure due to academic performance or professionalism problems was brought before the committee and we interviewed them. We would discuss with them what they thought their deficiencies were, and we would review their grades, review the comments in their evaluations, and sometimes interview the faculty who had recommended they be brought before the committee. We would usually work with them to come up with a plan of action to get them on track, but we had the ability to recommend that they not progress to the next year of med school, essentially we could expel them.
The one universal trait shared by all the students brought before the Progress Committee during my tenure: lack of self awareness. Not one of them could understand the bad decisions that had lead them to the point where they were being considered for expulsion.
We asked one woman why she thought she had failed 2 classes during second semester of her first year. She said she hadn’t been able to study much because she was preparing for a medical mission trip she’d be going on that summer. When asked why she would continue to plan for a summer mission trip when her grades were failing, she said that she couldn’t afford to pay back family members who had donated $2000 for her to go on the trip. She couldn’t see that $2000 (and some embarrassment telling her family she was no longer going on the trip) was small compared to the $20,000 in wasted tuition (and the bigger embarrassment of telling her family that she had lost a year and would have to join the next year’s class of med students).
We had another student who was brought to the committee because he was chronically late or absent during his clinical rotations. He would show up for rounds at 11 am without apology, and if asked why he was late or absent would reportedly give lame excuses like “I overslept.” How he’d made it so far in life is a miracle. We asked him how he thought he could improve, and he suggested that he go to a leadership retreat for high level executives (he showed us the brochure). If anything he needed a better alarm clock.
I was consistently flabbergasted by the lack of self awareness and introspection in these people. And this poor woman in the blog you reference sounds like she’s in the same camp.
Didn’t read her whole post, but her noting that perhaps having a new baby and nursing/ hauling family to interviews worked against her… she should have (since discrimination, even the illegal kind, happens) ensured that it was invisible to her interviewers that she was nursing, or had a child, or had brought the family on the road with her. Not the time to save on hotel bills by asking the interviewing scheduler if they can put your family up for the night you’re in town, nor to say you have to fit the interviews between feedings for the baby.
And if she mentioned the trials of bad cheap hotels, bad sleep with a nursing/ cranky traveling baby, trouble getting to/ getting ready for the interview due to all of those etc. in the interview then she’s an idiot; Either she missed the social truth that most people (especially those interviewing you for residency) will count it against you that you planned poorly not pity you and help you, or she’s so selfcentered and unaware that she lost her composure and vented her frustration about her challenging life in the interview. (Of course as a 50 something I’m so composed professionally- let’s not discuss at home with family!- that I only ‘lose my composure and vent my frustration’ as a staged act to demonstrate- not always effectively- that things need to change (eg the drug seeker needs to give up hoping he has a chance with me, the staff needs to realize I’m about to quit if they don’t improve…)
just found out i didnt match. grades were bad. i passed both usmles the first time around (224 and 226). I will be a US grad. PS and LORs were really good–I got a ton of positive feedback on these during my interviews. I know I wasn’t the strongest applicant, but the bottom 6% of US med students? Wow.
Womp. Womp.
What an expensive disaster (time and money).
Wish me (and my fellow un-matchers) luck with the SOAP!
Advice to anyone out there who needs it: keep your head in the game. don’t cry over anything that doesn’t cry over you.
Thanks for coming and sharing. Seems like you still have a strong chance. What were you trying to match in?
Good luck. Hopefully you can scramble into something and reapply for next year.
I was in a similar situation last year. I had low but passing board scores and no clinical honors. Unlike this story I came in with a good MCAT score (a 33) and good undergrad gpa but struggled a lot in med school with finding a way to cram all the information in, though I never failed or was borderline. Still did decent on rotations, earning mostly HP’s (my school was pass, high pass, honors), though if i’m being honest I never could figure out how to consistently do honors work either. I applied to a specialty that in retrospect I really had no business applying to (ER) and did not match after getting only a few interviews. Perhaps it was my fault for not doing more research but my advisors all told me that even with the lower boards I was “40th-50th percentile” and should be fine. I wanted to trust their judgement. Everyone to my face told me I was “excellent” clinically. I did not get anything in the SOAP, although I only tried for categorical IM and prelim IM spots, didn’t bother for a prelim surgery, and all my dean had to say to me at the end was “We’re kind of puzzled, most people in this situation have a red flag somewhere.”
They were decent enough to let me extend my graduation a semester so I could do some extra sub-I’s and try again. I did 3 additional IM rotations since I felt I should be competitive for that and ended up excelling at all 3. I applied broadly (70 programs), got 11 interviews, ranked all of them, and matched this cycle.
It was an absolutely soul-crushing experience, and I sympathize with anyone who has gone through it, even someone like the lady in this article. While I think it is always important to maintain insight about yourself and look for ways to improve, education is a two-way street I feel. In the same way students should seek out good feedback and advice, teachers and mentors should give it and make it a priority to be knowledgeable about the process. Like everyone else I get the impression that this lady really needs to step back and take some responsibility, but I also get the impression that her faculty did a lousy job giving her guidance. Perhaps they did and she didn’t listen, but I know at my school there was a tendency for faculty to write students they didn’t like or felt were underperforming off as simply dumb or lazy, only giving them that much-needed feedback in the written eval when it was far too late for them to improve. Speaking both from personal experience and what I’ve seen happen to classmates. Not to mention what a huge loss it is for the school to invest so much in this girl and now she has a mountain of debt she may never fully pay off.
[You sir are a troll and won’t be posting here any more. Have a nice life. -ed]
Bummer that those comments were read by my child on my email.
*sigh.
The solution would be for US medical schools and Carribean medical schools to change to the international/british model of medical education where it is 5.5 years (4 years of schooling and 1.5 years of house surgeon) whereby upon graduating from medical school you can practice family medicine without doing a residency program. Nurse practioners in the us essentially practice medicine with far less training.
Earlier, it was stated student loans cannot be discharged in bankruptcy. But, there is a recent news article showing that is not necessarily true. It is difficult, but sometimes possible.
Seth Koeut was in precisely the same position as referenced in this article.
https://www.yahoo.com/now/medical-school-graduate-440000-student-loans-discharged-151422886.html
https://casetext.com/case/koeut-v-us-dept-of-educ-in-re-koeut
Of course, we will have to see if other courts follow this.
I included that article in this month’s newsletter. Pretty unique case. Either way, you don’t want to be in that situation, even if you do get your loans discharged in bankruptcy.
I think it’s always been very rare but possible and I don’t think that’s changed. Better to work under the assumption that you can’t get out of them in bankruptcy.