By Dr. James M. Dahle, Emergency Physician, WCI Founder
There was an interesting article in the New York Times a while back called: “I am Worth It”: Why Thousands of Doctors in America Can't Get a Job.
The lead-in to the article involves a doc from Alabama who enrolled in a medical school in Barbados.
Then came an unexpected hurdle: A contentious divorce led Dr. Cromblin to take seven years away from medical school to care for her two sons. In 2012, she returned for her final year, excited to complete her exams and apply for residency, the final step in her training.
But no one had told Dr. Cromblin that hospital residency programs, which have been flooded with a rising number of applications in recent years, sometimes use the Electronic Residency Application Service software program to filter out various applications, whether they’re from students with low test scores or from international medical students. Dr. Cromblin had passed all her exams and earned her MD, but was rejected from 75 programs. In the following years, as she kept applying, she learned that some programs filter out applicants who graduated from medical school more than three years earlier. Her rejection pile kept growing. She is now on unemployment, with $250,000 in student loans.
Caribbean Medical School Residency Match Rate
There are apparently 10,000 “chronically unmatched” doctors in this country. While a 94% match rate seems really high, 6% of a large number of people is, well, a large number of people. But a 94% chance seems like a gamble worth taking.
Attending a medical school in the Caribbean is a different story for several reasons.
The average match rate there is approximately 61% according to the article, but that's 61% of those who graduate AND actually get an interview. Many students drop out along the way and there are plenty of those who don't even get an interview. Among graduates, the real match rate is only 50%. Among enrollees, it's even lower.
That's right. Even if you graduate from medical school, you have:
- A 50% chance of fulfilling your dreams and becoming a practicing physician AND
- A 50% chance of owing $250,000-450,000 and wasting 4-10 years of your life chasing a dream
That is one heck of a gamble.
Apparently, there are people attending med school in the Caribbean who were not aware of this gamble when they rolled the dice, so let's get the word out there. In the words of my partner who sent me this article:
IF YOU GO TO MEDICAL SCHOOL IN THE CARIBBEAN, THERE IS A 1-IN-2 CHANCE YOU'LL END UP $250K IN DEBT AND UNMATCHED!
The other problem with going to school at some Caribbean schools is that, even as an American citizen, you can't get federal student loans. You end up paying higher interest rates, you don't qualify for IDR programs, and the PSLF or IDR forgiveness escape hatch to fall back on in the event you don't match doesn't exist. Here is a list of schools eligible for federal loans.
At least if you go to Ponce (the Puerto Rico medical school) you can get federal student loans, but match rates are still substantially lower than you would see at a mainland MD school (82-89%). Speaking of Ponce, here's a heartbreaking story from a Ponce graduate who did not match either:
San Diego-based Seth Koeut was born to Cambodian refugees who came to the U.S. when he was a child and later pursued a medical degree in hopes of becoming a doctor. After he failed to obtain a residency role—a required part of the transition from medical school graduate to licensed medical professional—Koeut ended up working menial jobs before filing for chapter 7 bankruptcy in May 2012 while holding $440,465.66 in federally-backed student debt.
In 2015, Koeut filed an adversary proceeding to discharge his student loans as part of his bankruptcy. After the adversary proceeding was dismissed, Koeut filed an appeal in 2018. In October 2020, arguing against a discharge of the loans, the Department of Education (ED) contended that he had “not given his best effort to find better employment.”
Born in a Cambodian refugee camp in Thailand, Koeut came to America in the 1980s. His family “lived in extreme poverty,” the filing stated, “collecting cans from the trash to supplement the family income.” Koeut did well in school and earned a bachelor’s in marine biology and Spanish from Duke University in 2002 before moving to Bangkok to study clinical tropical medicine.
He did not earn a formal degree and began working part-time jobs in retail before attending the for-profit Ponce School of Medicine in Puerto Rico, finishing in 2010 and passing all the medical board exams. However, over the next five years, Koeut was unable to secure a residency placement. The loans he took to finance medical school, meanwhile, started coming due. Koeut selected an income-driven (IDR) program in October 2010 with a monthly payment of $0, according to an ED loan analyst who testified in his case. He also went back to working retail, including jobs at Bloomingdale's, Crate & Barrel, Banana Republic, and even as a dishwasher in a Mexican restaurant.
Koeut repeatedly deferred payments while unsuccessfully attempting to obtain a spot in residency. As of 2020, according to court filings, Koeut claimed that his total assets amounted to less than $5,000. Mr. Koeut's attorneys argued to the court that Koeut had applied to 5,000 jobs after graduating from medical school, trying in different fields using his language skills and even working unpaid jobs at universities and other organizations to improve his resume while living in his parent’s kitchen to avoid paying rent. And while ED contended he did not try hard enough to find employment, the court stated: “A medical school graduate who works as a parking attendant and dishwasher cannot be described as lazy.”
This story had a bit more of a happy ending than the first. Not only did this doctor qualify for $0 IDR payments, but he actually had his loans forgiven in a bankruptcy proceeding, a rare but increasingly common event despite the mostly true “Student loans don't go away in bankruptcy” dogma.
There are literally thousands more of these sorts of stories every year. Here is another from the New York Times:
At some point, Dr. Saideh Farahmandnia lost count of the number of residency rejection emails she had received. Still, she could remember the poignant feeling of arriving in 2005 at Ross School of Medicine in Dominica, thinking she was “the luckiest person in the world.” She had grown up in a religious minority community in Iran in which access to higher education was restricted.
After medical school, she spent two years doing research with a cardiothoracic surgeon at Stanford, thinking it would make her residency applications more competitive. But she applied to 150 residency programs, from rural to urban community hospitals, and received 150 rejections. She kept applying every year until 2015, when her mother died suddenly and she took a break to grieve. “You leave your family to follow your passion and promise you’re going to help the country that adopted you,” Dr. Farahmandnia, 41, said. “At the end, you’re left with $300,000 in student loans and a degree that took so much of your life and precious time with your mother.”
They're not all from Caribbean graduates either:
Dr. Douglas Medina, who graduated from Georgetown University School of Medicine in 2011 and has been unable to match, says he pays at least $220 each month in loans, though some are now paused. “Just a couple of weeks ago I tried to decide between student loans or a stroller for the baby that’s coming,” he said. “It’s not just our careers being ruined, it’s our families.”
But many of them are, and at some point, they all come face to face with this issue:
“When I graduated, I got the cold smack of reality that all my credentials don’t matter, because you’re not getting past that match algorithm,” said Kyle, an international medical school graduate who asked that only his given name be used because he is reapplying for residency after an initial rejection.
The financial lives of all of these doctors were completely ruined by going to medical school. What are the solutions to that problem?
What Happens If You Don’t Match
Four Solutions to the Unmatched Problem
What is the problem, really? Well, there are several, but the main one is the huge mismatch between medical school spots and residency spots. This is basically the same problem law school graduates face. There are far more attorneys than good lawyering jobs. For-profit law schools stuff their classes full and pump out graduates that nobody wants. It's not quite as bad in medicine, but it is increasingly becoming a problem. Medical schools are increasing class sizes and new, for-profit medical schools are popping up all the time.
And that doesn't even include the old, for-profit medical schools in the Caribbean. Every year there are more medical school graduates, but no more residency slots than there were the year before. There are four solutions to the problem, and each of them should be implemented:
#1 Stop Lying to People
Honestly, this is no different for pre-meds than it is for high school students. Too many guidance counselors and even parents are telling young people to chase their dreams without regard to the cost. Guess what? Going to a really expensive college and borrowing the entire cost of education to get a degree in English, journalism, or other fields that don't lead to high-paying jobs is not going to work out well financially. Sure, a few of those folks are going to go to medical school or law school or start a great business, but most of them are going to be in a middle-class job saddled with doctor-like loans and never really dig out. As a society, we need to quit giving such terrible financial advice.
When it comes to medicine, the problem is a little more hidden. Yes, we still have pre-med advisors, bloggers, podcasters, Twitter accounts, and college instructors encouraging students to go to medical school no matter their qualifications. They continually trot out somebody who struggled in college, got into a single Caribbean medical school, matched into neurosurgery, and is now a world-renowned surgeon who separated conjoined twins in a grueling 36-hour surgery and now the twins are both playing for the Mets! What they don't do, however, is give these students realistic expectations of what is likely to happen in their case.
We all know a great doctor who struggled with the MCAT or the USMLE or who had a relatively low college science GPA. We all know great doctors who are DOs, IMGs, or FMGs. It's no longer politically correct to say that standardized tests have any usefulness whatsoever. Certainly passion, compassion, hard work, and attention to detail are at least as important to a successful career in medicine as intelligence and raw ability. But we need to quit telling people that raw ability and intelligence don't matter at all.
Yes, some people are smarter than others. Just like we all know great docs who may have “lesser credentials,” we also all know some docs who just aren't all that bright and who we wouldn't let anywhere near our family members. Lower that bar too much, and there will be a lot more of those docs around.
Pre-meds also need to be aware that some steps in acquiring their dream career do not work the same way as getting into a college or even a medical school. Schools love to have diverse students with incredible background stories and a broad array of talents and interests. They have real motivation to demonstrate that they are accepting students with all kinds of gender, racial, socioeconomic, and academic backgrounds.
However, as you leave school, that focus changes. When you interview somebody for a residency position or a real job, you're trying to decide whether you want to work with this person day in and day out for the next few years or decades. You want to know they're not going to sign out a mess to you. You want to know they're going to take good care of your patients when you sign them out or they are on call for you. You don't want this person increasing your own medicolegal liability or requiring you to do a ton of extra “academic rehabilitation” work. Frankly, you couldn't care less if their family is from Cambodia, Nigeria, Guatemala, or Canada. Nor do you care whether they studied music or molecular biology in college.
I sat on a medical school admissions committee. I've served as faculty in a residency. I've been hiring attending docs for more than a decade. It's not unusual for us to have 50 CVs for a single position. Those CVs mostly all look the same except for the names of the schools, residencies, and publications. We may only interview four or five of those docs. Guess how we screen them? That's right, mostly on the perceived quality of the residency with a little bit less emphasis on the perceived quality of the medical school. We all know that the acceptance rate at a Caribbean medical school is 10 times higher than at a mainland MD school.
Residency programs have similar issues. They get thousands of applications. They have to cut them down somehow. What is the easiest way to do it? They screen by USMLE scores (although they soon won't be using Step 1 scores), by GPA, and by perceived quality of the school. There are hundreds of residency programs across the country that have never taken a Caribbean school grad and likely never will. The truth is that there are fewer open doors for you when you choose to go to school offshore. Pre-meds need to know that. They also need to know about the downstream consequences of owing $400,000-500,000 in non-federal student loans without a job that will ever pay them off. Even if they match, chances are good that they will have a higher student loan burden than most of their peers and they'll be matching into a specialty that pays less than average. You don't get a pass on math just because you're chasing your dream.
Not everyone agrees with me. More from the Times:
Dr. William W. Pinsky, the chief executive of the Educational Commission for Foreign Medical Graduates, which credentials graduates of international medical schools, said residency directors who down-rank medical students from abroad were missing out on opportunities to diversify their programs. “I understand program directors have to do what they have to do,” Dr. Pinsky said. “But if they put on a filter to leave out international graduates, they’re cheating themselves.”
Maybe the programs are cheating themselves, but Dr. Pinsky is asking residency programs to take a bit of a gamble that they don't have to take. For the most part, Caribbean students went to those schools because they couldn't get into a mainland school. So they started out a step behind. Then they often suffered through substandard preclinical education, being forced to teach themselves medicine and then prepare for Step I on their own. As 3rd and 4th years, they usually have to line up their own rotations, which often are simply not as good as the ones for students at a typical mainland MD school. So you're taking a less capable individual and putting them through an inferior process and then expecting someone evaluating them for the next stage of their career to somehow ignore all that? That's not very realistic, despite the fact that there are some incredible individuals who can become great doctors through this pathway. While it can happen, it isn't the way to bet.
#2 More Responsibility on Medical Schools
OK, rant over. Obviously, it is important for people to take personal responsibility for their actions. However, some of this responsibility also falls on the medical schools. They simply must maintain sufficiently stringent admission criteria that ensures their students can graduate and pass their boards AND match into residencies and get good jobs afterward. If they don't do this, they should pay at least part of the price. For example, if a student doesn't match within two years of graduation, perhaps the school should have to refund 1/4 or even 1/2 of the tuition paid. It wouldn't completely solve the students' financial problem, but it would certainly incentivize schools to be careful who they admit and to maximally support their struggling students. These sorts of incentives are even more important at schools with low match rates. I have no idea how this would be enforced on a school in another country, but perhaps the match could do so. It could simply not allow a school's graduates to enter the match until the school implemented this sort of a policy. Maybe that would do more harm than good, but how are these schools any different than other institutions regarded as predatory? Maybe we need to take a hard line against them.
#3 Increase Residency Slots
This mismatch between medical school graduates and residency positions has always been around, but in recent years it has worsened. There is a doctor shortage, particularly in primary care (although maldistribution appears to be the larger problem). So more schools open up and more students are enrolled. But that wasn't the bottleneck. The rate-limiting step was residency training. Without more slots for residents (primarily paid for with federal Medicare dollars) you might get more doctors, but you don't get more practicing physicians. Boosting this funding solves both problems.
Some doctors are actually against opening up more residency slots. They want to control the number of practitioners entering their field to keep incomes high. Fine. Then just increase residency slots in the specialties where there are shortages. Right now APCs like PAs and NPs are plugging holes in the system, mostly in primary care fields. Doctors wring their hands about this encroachment and the loss of turf battles in state legislatures. But lower cost/higher profit isn't the only reason APCs are hired. They're also hired because a doctor can't be found.
The article says this process has begun:
The pool of unmatched doctors began to grow in 2006 when the Association of American Medical Colleges called on medical schools to increase their first-year enrollment by 30%; the group also called for an increase in federally supported residency positions, but those remained capped under the 1997 Balanced Budget Act. Sen. Robert Menendez, Democrat of New Jersey, introduced the Resident Physician Shortage Reduction Act in 2019 to increase the number of Medicare-supported residency positions available for eligible medical school graduates by 3,000 per year over a period of five years, but it has not received a vote. In late December, Congress passed a legislative package creating 1,000 new Medicare-supported residency positions over the next five years.
But let's be honest: It's too little, too late. A thousand spots isn't even close to what is needed to solve this problem. It's off by an order of magnitude.
#4 Assistant Physician Legislation
One of the best solutions is the concept of an Assistant or Associate Physician. This is a medical school graduate who has not completed (or even started) residency training. Two states (Arkansas and Missouri) now offer this licensing, but legislation has been introduced in Georgia, Virginia, Utah, Kansas, Oklahoma, Washington, and New Hampshire, as well. An assistant physician, like most Advanced Practice Clinicians (APCs), practices under the supervision of a licensed physician. However, despite having twice the training (and training at a higher level) of an APC, they make half as much. At least, though, the APCs are getting some valuable training out of it that will soon lead to the “big bucks”. That's not the case for an assistant physician. In fact, assistant physicians should probably qualify for a PA license if nothing else.
It has often been said that medicine eats its young. Medicine also eats its wounded. We need to quit ignoring the unmatched doctor problem. Changes need to be made at the individual level and college level (better education about the costs and financial risks of attending medical school), at the medical school level (balancing the need for training competent doctors with developing a compassionate, diverse workforce, and limiting enrollment until more residency positions are available), at the federal level (more residency positions), and at the state level (assistant physician licensing). As practitioners, we need to consider converting what are traditionally APC slots into assistant physician positions. As things stand now, you get twice the training at half the price.
What do you think? What do you see as the solutions to the problem? What advice do you have for Caribbean graduates struggling to match? Comment below!