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!