Tuesday, March 18, 2014

Help! My friend didn't match in orthopedics ... again

Maicon [not his real name] writes

My friend wanted to be an orthopedist, but his grades and USMLE scores were just average for medical school—Step 1 was 215. He applied last year, got some interviews but didn't match. He started a research fellowship in ortho at an academic center and re-applied. I tried to tell him to defer applying until he finished the fellowship so he could have something to show for it other than, "I started a fellowship and working on blah blah blah." This year, he got fewer interviews and failed to match again. During all this, I had advised him to also apply to general surgery, but he always resisted. He now has decided to try for an unfilled general surgery preliminary position.

I realize this is an elaborate discussion however you would be doing a major service for many applicants of this kind who have nothing to go on other than delusions or conspiratory paranoia.

Sad to say, but this happens every year.

The advice to do a year of orthopedic research was misguided. He has just wasted a year of his life.

I'm not sure what goes on in orthopedics. However, in a recent post on how general surgery program directors select residents, I noted that previous research experience was extremely low on the list of criteria as was having done a preliminary general surgery year.

I wonder how many who do a research year succeed in getting an orthopedic residency position. My guess would be less than 5%, if at all.

He should be honest in his application for the general surgery non-designated preliminary position. The program directors will know the truth anyway. The good news is that there are over 450 unfilled positions this year and not enough bodies to fill them.

The bad news is that these positions can be dead ends in many cases. That is, your friend could do a year or two of preliminary surgery and then have no access to a third-year categorical spot. Another issue is that in some programs, non-designated prelims are treated like second class citizens by being given all the scut rotations.

There is some hope though. Here's a paper that found an amazing rate of success for non-designated prelim surgery residents obtaining categorical positions, but it's from Mass General. Abington Memorial Hospital reported surprisingly good outcomes. Yale's results weren't quite as good. UC-Denver also had some mixed results. There could be some publication bias here. Programs with dismal records of placing prelim trainees may not have chosen to report their experiences.

If he does obtain a preliminary spot, he must work very hard and do very well on the general surgery in-training examination in the hope that someone drops out or is cut from a categorical position and that he will be selected to replace that individual. If not, he will chalk up one or two more wasted years.

A backup plan for a different specialty career should be in mind in case he is unable to eventually secure a categorical general surgery position.

My feeling is that if an applicant doesn't match in a dream specialty, he should forget about a year of research, scrap that dream, and move on.

As always, comments are welcome.


  1. Surgery Coordinator, TXMarch 18, 2014 at 2:04 PM

    I feel that medical schools try to prepare these students but it is often too late. The ortho dream should always have a fallback career plan, the same goes for ENT. There should be a mandatory faculty development course at all academic institutions to help train advisors on how to guide students and deliver the truth about scores, increased class sizes, limited slots at programs and alternate options. Perhaps implement specialty specific advising at the end of 1st year and then more intensely along the next 2. We have to help them.

  2. How often do categorical general surgery residents drop out? I've known a few, but I assume past the internship year it must be rare.

    The late drop-outs I know of never went into internal medicine specialties. They went into anest., path, radiology. One ortho resident joined a hair transplant clinic. A neurosurgery resident liked his neurorad rotation so much he switched to Rays.

  3. I am a 2nd year student. At my institution students have to show a list of their choices to the Dean's office prior to submitting rank lists. That said they are not required to show the actual rank lists and the Dean's office knows this. They try to burst our bubbles pretty early (As 2nd years we've heard the speech twice already and I'm sure the volume will get turned up as we get closer to the whole process). In spite of this there are a few ortho/ent/plastics/urology bubbles burst.

    What about the fellowship route after General Surgery? Any word on how fellowship options may sway someone to "put up" with Gen surg for 5 years?

    For the record: It's early but my goal is General surgery

  4. Surg coordinator, you have some good ideas. They make a lot of sense. That's why they never will be adopted by any medical schools.

    Anon, the attrition rate for general surgery residents is about 20%. It's not that rare past the first year either. I have written about it.

    qtipp, there are always people who have unrealistic expectations. That is why those 450+ non-designated preliminary slots get filled every year.

    1. Can you please link to your attrition rate post? 20% sounds astoundingly high. I wonder where Gen surg ranks in attrition vs other specialties...

    2. I don't know how attrition in general surgery residencies matches up with other specialties.

      Here are links to a post I wrote about attrition and a paper by people at the American Board of Surgery who reported the 20% figure.

      http://skepticalscalpel.blogspot.com/2012/06/why-is-attrition-rate-of-general.html and http://www.ncbi.nlm.nih.gov/pubmed/20739854

  5. Specialty selection is a largely random affair made by inexperienced medical students. It is also unfortunately a very inflexible process, with those who do not get positions being completely blacklisted from that point onward. Something is wrong with this.

    1. Anon, you are correct. Students sometimes have to decide on a specialty after taking rotations of one or two weeks. It's ridiculous. Shortening med school would only exacerbate the problem.

      I don't think people who don't match are really blacklisted. However, I think they are viewed as damaged goods by many program directors. It's sad but true. That's why I advise people who don't match to think about transferring to a less competitive specialty, which is often just as fulfilling as what they originally thought they could not live without.

  6. Nope. We're blacklisted.

    I got blackballed, didn't match, ended up in one of the lesser fields, slogged through the residency, tried to leave on multiple occasions but could not, and I hate it. No fulfillment. My goal has become making enough income to retire early. It's a dead end.

    My life has fallen apart and all I have to look forward to is the day I never have to set foot into work again. How pathetic. Fuck the match.

  7. I am truly sorry to hear your story. I wish I could somehow make it better for you. I'm not going to try to defend the system. Maybe you should consider some counseling to help you get through all of this. I wish you well.