A non-US citizen international student's chances of matching in surgery

"Brian," a medical student in Egypt, wrote me about obtaining a surgical residency in the US. Due to space limitations, I have edited the email. He will take USMLE Step 1 soon. He has no green card.

He read a previous post of mine about a US citizen international medical graduate (IMG), but still had several questions.

He asked what qualities separate an applicant matching in a categorical position from one matching in a preliminary position?

"Categorical" means, barring any performance or behavior issues, the resident will complete a full 5-year general surgery residency program.

A college junior wonders if she will get into med school

[Email abridged and edited.] A 21-year-old married woman, who is a junior at a large public university, has always wanted to be a doctor. She had some family and mental health problems (panic attacks, depression) which have affected her grades. She has a current GPA of 2.8, but when recalculated by including grades in repeated courses and deleting the poorer grades as her college allows, her GPA is 3.3. She and her husband have a combined $24K of student loan debt.

She feels very strongly that her family and mental health are no longer issues and is getting A's in science courses that she previously did poorly in. She says, "I seriously feel like a completely different person. I feel capable of getting good grades. However, people keep telling me that I might not even make it into med school because of my low GPA. The thing is though I don't care what I have to do. I am so passionate about learning and helping people. My dream has been to work and eventually have a free clinic on the side to help people who can't afford healthcare. That's why I'm in this. But is there a chance I can even get in? I know that's what I want, but people (peers, degree advisors, and my anatomy professor) keep bringing me down."

This is a very difficult question to answer definitively. I really can't speculate on your chances of being accepted to medical school. Your level of commitment is outstanding.

There is one missing variable—your MCAT scores.

You may want to take the MCAT at the next available opportunity. Great scores would be encouraging. Poor scores would seal the deal. You would have to move on to something else.

Your combined debt is low and you are young, both of which will allow you to spend a little extra time beefing up your GPA.

If you are thinking about applying to offshore medical schools, please do some research. As US medical schools expand their classes and new schools open, there will be fewer residency positions for offshore graduates. If you look at Table 1 on page 2 of the 2013 match data for International Medical Graduates (IMGs), you will see that 2420 US citizen IMGs failed to match to a residency position. It's only going to get worse as I noted here.

Have you considered another option such as becoming a physician assistant? The path is shorter, and PAs are becoming more and more autonomous. It might help you to look at a post of mine from a couple of months ago on "Ask Skepticalscalpel" called "Should I be a nurse practitioneror a doctor?" Read the many comments because they are pertinent.

I hope this is helpful to you. Check back here for comments as they are often more useful than what I write.

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.

A UK Med Student Discovers Surgery, Has Questions

Gareth (not his real name) writes

I came across your blog a few days ago and I have been reading it since. I am a third year medical student studying in the UK. I am writing to you because I would be grateful if I could get some advice. I have always wanted to become a doctor, since I was veryyyyy young, but I never ever considered a career in surgery. Before medical school, I believed that surgeons were like butchers, not capable of any human attachment for the patient etc etc. I believed I would not be able to bear the responsibility to cut someone open given the fact that I am a very emotional person. However, my perspective changed when I was in the OR and saw my first surgery. It was a coronary bypass surgery and I loved it, I loved the idea of making the patient better in such short time and the fact that the surgeon was the one responsible for it, I suppose it must be very satisfying. Therefore, I have started to consider a career in surgery, however, I am still very unsure of whether I have the right personality type and skills to become a surgeon. I still tend to get very attached and moved by patients' stories and experiences and I don't know whether that would help me detach myself from the patient whilst operating. Also, most surgeons seem to be extremely confident and outgoing whereas I tend to be shy and not confident, even though I'm quite good academically. So I am really confused right now. Also, I have never had great hand skills, even though I took some introductory surgical skills courses and they went quite well. I seem to get a bit of tremor when I do practical stuff though, I guess that's because I get nervous. 

I'd like to ask you one more thing. If I do decide to go for a career in surgery, is there any point for me to try and take the USMLE and apply for a US residency after graduation? I heard surgery it's really competitive, I guess many schools don't even accept international applicants?

Thank you very much for your time and dedication. I admire the passion that you show.

Thank you for reading my blog and for writing. I am glad that you have realized what a rewarding career surgery can be.

First let's talk about the "surgical personality." There was a time when most surgeons could have been categorized into a couple of personality types. Those days are gone. Now that 40% of all surgical residents are women it is no longer necessary to be a certain type of individual. I know many surgeons who are quiet, thoughtful and introspective. You need to dismiss any thoughts about your personality type being incompatible with a career in surgery. Also it is not a bad thing for a surgeon to identify with and become attached to his patients.

The next myth is that one must have great dexterity to become a surgeon. In the old days some residency programs use to screen applicants by making them build model airplanes. I don't believe anyone still does that. Now it seems that video game skills are much more important since so many procedures are done laparoscopically. I believe that anyone can become a more than decent technical surgeon through practice. We all get nervous. This is a real person you are operating on. I have written that there is more to surgery than manual skills. It is very important to know who to operate on and when to operate on them as well as who not to operate on.

I have written before about the decreasing chances of graduates from non-US medical schools obtaining residencies in the United States. US medical schools are expanding their class sizes and a new schools are opening. It is not even clear that all us graduates will be able to obtain residency positions in the future. The most recent statistics from the match show that only about 5% of non-US citizen graduates of foreign schools matched into categorical general surgery positions. However, I do not believe you have anything to lose by trying. You will need to get an excellent score on the USMLE and of course, have good grades and recommendations. Although it is difficult, some trainees from the UK have been able to find fellowships in the US. I do not know how easy that will be in the next few years.

Good luck

How can I overcome a low USMLE Step I score?

Nemanja (not his real name) writes: I am a fourth year medical student at a US school. I am planning on applying to general surgery in the next month. I have a few concerns and questions about my application and competitiveness. 

I did very well years 1 and 2, all but one honors. I got a 209 on USMLE Step 1 and a 243 on step 2. The caveat about my step 1 score is as follows. I had a family tragedy 1-2 months prior to taking step 1. In retrospect I probably should have deferred and not taken it but hindsight is 20/20.

After that poor step 1 score, I did well on my clinical rotations. I received a high pass in surgery and honors in 4 other clinical rotations with no grade less than a high pass. I expect to receive strong letters of recommendation from my program director and clinical faculty. I am interested in applying to programs in the northeast portion of the US.

How can I let a program director know about my situation (e.g., in my personal statement, in my dean's letter). Some of the people at my institution have led me to believe that this is an important part of my story and something that may provide an explanation for a below average step 1 score. I am afraid that I will be filtered out due to my step 1 score from many university based programs. What do you think is my best approach to this situation? 

Your question is a good one. I am sorry about your family tragedy. 

I suggest you explain it in your personal statement and ask the dean to mention it in his letter too. You need to emphasize the fact that your Step II score is very good. Strong letters of recommendation will help.

If you search PubMed for "USMLE Step I," you can find a fair amount of information about the weight program directors put on it. One paper says it is the single most important factor used by PDs to screen applicants. Another says that a Step I score of < 200 is associated with a higher risk of failing part I of the general surgery board exam.

Here is a link to a PDF from the NRMP about match outcomes. If you go to page 84, you will find some interesting data about the 2011 general surgery match.

I have some screen shots for you. 

Here's a table listing some summary statistics.

This is a graph indicating that a USMLE Step I score of 209 gives you about a 75% chance of matching in surgery.

But here is a chart showing that a Step II score of 243 gives you a very good chance of matching. No graph was provided.

The message is very clear. Get the PDs to look at your Step II score

You may want to apply to some community hospital-based programs to be safe. I think you will match in a categorical position.

Good luck. Please let me know how things turn out.