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Discuss.
The NRMP should allow people to register for SOAP as a separate thing, rather than combining it with the Main Match...
I think they did it this way because back when it was the Scramble, there were thousands of IMGs that would only participate in the Scramble without even setting up an ERAS or making a rank list. I think ERAS wants people to at least funnel through them before the SOAP so they aren't inundated with applicants who just want to try to SOAP. Plus, it gets them more money too...
The NRMP should allow people to register for SOAP as a separate thing, rather than combining it with the Main Match. It would make it more organized and also, they should simply allow people to apply on the first day to 60 places and see what happens in a week. That would give programs more time to go through the applications and interview more people.
Other than that, I don't think the process can't be changed much. The only way we have less people match is if we create more spots for the numerous amounts of physicians that want to be part the US medical system. Unfortunately people talk about not having enough physicians, maybe they should realize there is a simple solution/investment to that problem.
Based on my experience with SOAP last year, I don't see why the entire process must be compressed into 4-5 days. Why not stretch out the experience to 2-3 weeks? It would give the PDs time to fully review applications and give considered looks at applicants rather than judging them by their raw numbers alone.
One major difference in Canada is that we have designated IMG spots in the first iteration, such that IMGs are not eligible for the vast majority of spots in the overall match. The second iteration is, however, open to everyone. I support this kind of arrangement, at least insofar as Canadian students - who on average applied more times to get into med school than IMGs! - should have first dibs. At a certain point, it is simply impossible to make any kind of health human resources plans by taking into account the 1500 or more Canadians who choose to study abroad, a sizeable proportion of which never even bothered to apply to Canadian schools.
It is not in any way parochial to argue that US residency positions should be allocated primarily to AMGs, though of course AMGs always have the advantage either way. I don't know how much more the Canadian example has to offer unfortunately - Canadian residency programs are organized at the university level, so all programs are coordinated by the Postgrad Office of each medical school. There are only 17 of them in total, and of those 3 are purely francophone.
I think an AMG favored first match (even more heavily favored than now) would be ideal.
I think an AMG favored first match (even more heavily favored than now) would be ideal. And a second match free-for-all makes sense at that point. Medicare = tax-payers money, and as such we should be taking care of the children of tax-payers and also favoring the schools they go to in U.S.A. because the faculty who are paid with our tuition are also paying taxes. If there are left-over spots afterwards then we can take in IMG's who are probably more than happy to have any shot at a residency in the U.S.
Its not a free market when there is one payer, the citizens of the U.S., for the majority of residency positions, thus my protectionist stance on the residency market. If hospitals funded their own positions then by all means let it be by a pure meritocracy, but the american tax-payer invests 200k in each students loans and then 150-200k per year for each resident. When push comes to shove with limited residency positions I think matching AMG's preferentially will help keep the brightest students in the States interested in medicine.
Its not a free market when there is one payer, the citizens of the U.S., for the majority of residency positions, thus my protectionist stance on the residency market. If hospitals funded their own positions then by all means let it be by a pure meritocracy, but the american tax-payer invests 200k in each students loans and then 150-200k per year for each resident. When push comes to shove with limited residency positions I think matching AMG's preferentially will help keep the brightest students in the States interested in medicine.
Full disclosure - I matched through the main match into a competitive residency position, but I hate watching my classmates, who would be very competent clinicians, struggle through the SOAP.
As much as my heart goes out to those who did not match, whether they are AMG or IMG I do agree with you.
I think the Canadians have the right system and we should follow it. Our neighbors to the North certainly make no exceptions to wanting Canadian students placed first. Why are we not doing the same?
I also think that while it may be difficult to deal with at first, it would save a great deal of pain and frustration. As Margaret Thatcher would say, Yes the medicine is harsh. (I think she said that?)
Anyways, look at it this way - if you knew as a graduating undergrad that if you went to a Caribbean med school you would only have say a 25% of matching- do you think most people would do it? Probably not. And if people knew that only as an AMG you would get first picks of residency, with say less than 20% of remaining spots to be battled among anyone who is not an AMG in the 2nd round would people still go to med school abroad? Probably not.
The reality is that with the increase in American med schools, Caribbean ones are more and more becoming obsolete, and a money grubbing system that leads nowhere. Sure some people match but many don't and they end up in a huge financial hole.
Just like with everything not everyone can get into certain professions, certain schools, certain specialties. Not just in medicine but every field. Not everyone can get a Harvard MBA and some people may have to settle for a different program for example.
So reading the story of someone like the plastic surgeon from Romania yesterday who says he's depressed because he can't practice plastic surgery in the East Coast and he doesn't want to do FM is not very heart wrenching to me. I've had colleagues who have not matched to plastics who are stellar, and I've had AOA classmates who have gone to FM bc they love it. Why does the Romanian plastic surgeon "deserve" a plastics spot in the US?
The reality is that as a nation, we give everyone handouts and while it would be great to have everyone who wants something get it, the reality is that it won't happen. Given that it makes sense to reserve spots for those who are from here first, and then open up spots to others. We need to take care of ourselves first and the reality of the matter is that Carib med schools should be closed because they bring more pain, frustration, and financial disaster than the few who do make it. That's my take. And progressively, I think threads like this will become more and more prevalent.
If I was graduating undergrad now and I could not make it into an American med school, and my only choice was to go Carib I would probably choose a different career altogether.
I think the Canadians have the right system and we should follow it. Our neighbors to the North certainly make no exceptions to wanting Canadian students placed first. Why are we not doing the same?
There was a really good point made that AMG's don't even consider applying to the type of places IMG's match at. If AMG's applied as broadly across tiers of programs as IMG's do there match rate would move even higher in fields outside of the uber competitive ones like Ortho, Urology etc.
How many AMG's who apply to IM apply to smaller, community programs that no one has ever heard of? Places like this would jump at the chance to take an AMG but the AMG's don't apply.
Part of the issue is geographic mobility. If you are in the US and have put down roots, maybe married someone with their own career or have kids in school, you might be more limited in terms of residency choices than the person who did his med school offshore and his rotations at a half dozen sites across the country. So yeah the offshore guy has fewer roots and can apply to that community hospital in the middle of no where.
But right now the match rate for US seniors is historically around 94%, with another 3-5 or so percent finding things in SOAP/scramble. Im not sure how much more AMG friendly it needs to be. As the number of US seniors continues to increase over time, assuming these percentages hold true, you will see the offshore crowd pushed out of the picture in fairly short order.
As much as my heart goes out to those who did not match, whether they are AMG or IMG I do agree with you.
I think the Canadians have the right system and we should follow it. Our neighbors to the North certainly make no exceptions to wanting Canadian students placed first. Why are we not doing the same?
I also think that while it may be difficult to deal with at first, it would save a great deal of pain and frustration. As Margaret Thatcher would say, Yes the medicine is harsh. (I think she said that?)
Anyways, look at it this way - if you knew as a graduating undergrad that if you went to a Caribbean med school you would only have say a 25% of matching- do you think most people would do it? Probably not. And if people knew that only as an AMG you would get first picks of residency, with say less than 20% of remaining spots to be battled among anyone who is not an AMG in the 2nd round would people still go to med school abroad? Probably not.
The reality is that with the increase in American med schools, Caribbean ones are more and more becoming obsolete, and a money grubbing system that leads nowhere. Sure some people match but many don't and they end up in a huge financial hole.
Just like with everything not everyone can get into certain professions, certain schools, certain specialties. Not just in medicine but every field. Not everyone can get a Harvard MBA and some people may have to settle for a different program for example.
So reading the story of someone like the plastic surgeon from Romania yesterday who says he's depressed because he can't practice plastic surgery in the East Coast and he doesn't want to do FM is not very heart wrenching to me. I've had colleagues who have not matched to plastics who are stellar, and I've had AOA classmates who have gone to FM bc they love it. Why does the Romanian plastic surgeon "deserve" a plastics spot in the US?
The reality is that as a nation, we give everyone handouts and while it would be great to have everyone who wants something get it, the reality is that it won't happen. Given that it makes sense to reserve spots for those who are from here first, and then open up spots to others. We need to take care of ourselves first and the reality of the matter is that Carib med schools should be closed because they bring more pain, frustration, and financial disaster than the few who do make it. That's my take. And progressively, I think threads like this will become more and more prevalent.
If I was graduating undergrad now and I could not make it into an American med school, and my only choice was to go Carib I would probably choose a different career altogether.
This doesnt really solve the problem, again the FMGs (non US citizens, non Carib) are a bigger group. Why close the Carib med schls, and still allow the FMGs from random other non US schools to still be able to apply? Lets look at the bigger picture, and put it all in perspective.
Part of the issue is geographic mobility. If you are in the US and have put down roots, maybe married someone with their own career or have kids in school, you might be more limited in terms of residency choices than the person who did his med school offshore and his rotations at a half dozen sites across the country. So yeah the offshore guy has fewer roots and can apply to that community hospital in the middle of no where.
But right now the match rate for US seniors is historically around 94%, with another 3-5 or so percent finding things in SOAP/scramble. Im not sure how much more AMG friendly it needs to be. As the number of US seniors continues to increase over time, assuming these percentages hold true, you will see the offshore crowd pushed out of the picture in fairly short order.
I think the Caribbean schools are more troubling to the AAMC because they aren't set up to train physicians for a local national population, but instead are just backdoor vehicles for people who want to practice in the US. As a result they are essentially US oriented schools not meeting any LCME standards an oversight. There is no US recognized governing body involved, but the whole point of these programs is to send people to the US. So everything these schools do is with an eye toward getting into US residency, doing whatever window dressing appears necessary, but not necessarily educating based on approved standards. This is different than a med school in, say, Germany, where the focus would be to actually to train physicians to take care of the local population, and the school couldn't care less how their application might ultimately be regarded in ERAS. So I think the powers that be would be content driving the offshore schools out of business and gobbling up a chunk of the students that would have gone offshore into LCME governed US programs.
Im sure lots of Caribbean students and grads will complain and say that they are US citizens and paid taxes and as such should have the same access as US grads since their taxes pay for Medicare which subsidizes residencies. Problem is, that you didn't go to an accredited US med school and that is on you. Instead of taking the time to improve your CV you copped out and took the easy route to med school admission.
In terms of FMGs vs. IMGs, I tend to favor FMGs since as Law2Doc noted, they went to schools that often had their own national accreditiation rather than the for-profit, doctorate factories of the Caribbean.
First, with the increase in med school seats, the number of students with 3.7 GPAs and 34 MCATs not getting into US med schools are going to drop. The difference in accountability is that US grads went the accredited route, something Caribbean grads did not. Just as importantly, there is no reciprocity here. The US took FMGs/IMGs to fill unfilled spots from US grads. If there are enough US grads, then Carib grads are no longer needed. Most other countries do the exact same thing in protecting their own graduates as they went through accredited schools and met the baseline requirements of graduation.
I have no interest in punishing IMGs, I have friends that went to the Caribbean that are thriving in practice now. What I am interested in is making sure that all US grads are taken care of with residency positions since that was the way the system in this country was initially designed and the way other countries run. If a US grad can't get a residency in the US when they are done, there is really nowhere else for them to get PGY training. To me there is essentially a covenant that if you get into and complete US med school, there should be a residency at the end of the rainbow. Since US grads are completing nationally accredited training, it stands to reason that the AAMC should work with the ACGME to make sure that the number of spots available allows for all US grads to have residencies. Two national accreditation organizations working together to match education and work force needs based on graduates from the country. Canada's system is similar and a new US system could account for all US grads and then open the remaining spots to IMGs. Caribbean grads don't have those protections because they don't go to US accredited schools.
I didn't say that IMGs dont turn out to be qualified physicians. THe problem is there is an upcoming bottleneck and we need to protect US grads just as other nations protect theirs. I am quite aware of the information from the link you noted; that being said, I dont take much solace that St. maarten, Saba, grenada, etc. accrediting these schools because they have no skin in the game. The receive money for having these schools there but arent then obligated to offer post-graduate training so to them its not really an issue.
I'm shocked that a Caribbean grad would promote that the US-IMGs should be lumped in with AMGs.
If you value caribbean accreditation, then you can go to Caribbean residencies. Hmmm, small problem there. Caribbean island accreditation does not equal AAMC accredtiation, the guideline you posted notes "comparable" but this is not an AAMC determination.
Sorry, meant LCME not AAMC (was using AAMC data on future matriculants to US med schools). My point with ACGME is that the two (LCME, and ACGME) should work together to match US grads and # ofspots. ACGME accredits residencies, creating the number of spots we now have. Matching output from US schools with training numbers makes a lot of sense.
Ah..you would like to see evidence. Here it is:
Evaluating The Quality Of Care Provided By Graduates Of International Medical Schools
http://www.ama-assn.org/resources/doc/img/0810-health-affairs-imgs.pdf
I quote:
"We also found that there were fewer in-hospital deaths among the patients of non-U.S.-citizen international graduates than was the case for patients of either U.S.-citizen international graduates or U.S. graduates. The difference between non-U.S.-citizen and U.S.-citizen international graduates was striking. Although this finding may be unique, it is not surprising, given previous research. U.S.-citizen international graduates have lower scores on the cognitive portions of the licensing examination sequence, lower ratings from training program directors, and lower rates of specialty board certification."
A rather damning report, if I may say so. In the light of this, may I recommend that we remove Carribs from consideration for the match and restrict it to AMGs and the best of non-US IMGs - exactly what some top residency programs do.
We need to do this because of a few things:
1) I am in a pretty competitive specialty (rad onc); in the last few years, I have seen some superb students with no red flags who weren't reaching, top of the top, not match because of the competitive nature of rad onc. They were advised not to have a back up besides an internship which is what I was still telling students until the All In policy, since it allows them to get spots that open up during the year. They had to go through SOAP/scramble and it wasn't easy, they got offers and spots but there were often spots that they would have taken in things other than rad onc that were already filled through the match with IMGs/FMGs. This would protect students like them.
2) Even for those students that have had problems/red flags as you note, the reality is they got into a US med school and deserve the same protections as a grads at the top. This is what plenty of other countries do, and for good reason.
I think the idea of the switch makes sense now and in 3-4 years. Better to be pro-active in protecting in US grads. You still haven't answered, why shouldn't the US do what the vast majority of other countries do in protecting their own graduates? Canadian system works well, whats the issue?
I think the transition to the SOAP process has been an improvement. Unlike before where students had to manage multiple phones/fax machines and it often came down to the SCHOOL and it's secretaries now the applicant has much more control. I like the process although fortunately never had to participate.
Survivor DO
likewise i am shocked that the AMG doesnt want accountability for AMGs in med school
isnt it more concerning to you to just promote by default if an AMG is under-performing in med school? this type of thinking is what got our current educational system in this country is such disarray.
why is it hard for you to realize that 99.5% of AMGs would match if they applied broadly to programs like IMGs have to do by default and rank less ideal programs as backups. there.... problem solved.... without needing to change the rules.
1. There is no guarantee that a huge number of programs will go unfilled. Based on a system similar to Canada's system, a certain number of spots would be open to IMGs/FMGs to fill out the number deficient from US seniors. All other spots would be matched in the primary or scramble/SOAP after the fact.
2. The problem is taht you are neglecting the fact that the reason FMGs/IMGs were included in the national match was because there weren't enough US grads (only about 50% of needed based on NRMP data). Now that we are approaching parity, you seem to be advocating for a system that says since we let the flood gates open when we neeeded to, we shouldn't be able to close them when the need is no longer present. That absolutely goes against how we have practiced busineess and immigration in this country. If we don't have a need for foreign graduates, there is no need to give them residencies.
"PDs have a program to run and they want it to run smoothly without problems. which has more risk for the program and patient care?" Any data to support that an IMG does better than an AMG? There is accountability in the US system in the from of a pass/fail licensing exam (USMLE), tests in M1-4, and once in residency in service exams, licensing exams. This is not a good ole boy's club, but it should be one that protects the interests of the schools it is paying for and that it accreditates.
You can give me that this is the US BS but the reality is in 2013 we live in a globalized society. We face competition daily in every industry from developed and developing nations and as such need to modify things to stay competitive; there is no ability to be mobile for US grads as such we are obligated to protect them and the investment. The same can't be said for US citizens who forgo standardized medical education to go to school outside the country in unaccredited schools. I am the child of an FMG and know that i wouldn't have the life I have today without the opportunity given to my family; that being said, my family came over because of a shortage of residents meaning the residency spot was a benefit to my family and the country. When we start changing that cost/benefit analysis such that it benefits the student but not the country as some of its own are being left out, things need to be re-evaluated.
"PDs have a program to run and they want it to run smoothly without problems. which has more risk for the program and patient care?" Any data to support that an IMG does better than an AMG? There is accountability in the US system in the from of a pass/fail licensing exam (USMLE), tests in M1-4, and once in residency in service exams, licensing exams. This is not a good ole boy's club, but it should be one that protects the interests of the schools it is paying for and that it accreditates.
1. How would that filter more IMGs? Say we have 25k spots and 22k US grads; one solution is that in advance of ERAS, 3k spots would be open to IMGs/FMGs and US grads with all other spots limited to US grads only. PDs within the 3k spots could interview IMGs/FMGs and US grads all others US grads only. Once the match is done and SOAP for US grads complete, odds are only a handful of spots would remain.
2, Once we hit true parity, my expectation is that the ACGME and the LCME due to political pressure will close the initial match to non-US grads until all US grads match; cant let students go to US med schools (many of which receive government funding) only to not have training possibilities (which are also governement funded) because foreign grads (IMGs/FMGs) are taking spots. Why bring in foreign grads (IMG or FMG) if you have enough supply in house.
I don't agree with your assessment of medical education for the 1st 2 years; having had friends who went to SGU/Ross, etc. we compared 1st 2 years of classes and they were nowhere near the same. Caribbean students were taught more about what to know for the Step 1 and less about the systems as a whole. When you look at board scores, many of IMG colleagues told me that large numbers of their classmates took 3-6+ months studying compared to AMGs who usually get 3-6 weeks. Third/Fourth year- though both take steps, my understanding is that Carib rotation sites can often be non-university/academic rotations with little impetus for poor grades as the proctors are being paid and can be replaced easily unlike US schools where the school and hospital are affiliated. I am in an academic institution so I am familiar with what PDs face; many PDs will also look ath the fact that Carib students took the easy way out compared with their AMG brethren who may have had to re-apply once or more but did it to go to an accredited school.
You and I will never see eye to eye becuase you favor protecting a class of students who rather than making the sacrifices necessary to pursure accredited edcuation in this country, took the simpler path to an MD and then expect to come back and have access to spots that were only intended for them when there was a surplus. Me, I favor protecting those students who went to accredited schools in this country and for whom the match was created. Protecting US grads is not akin to looking away from the flaws of some US grads- obviously those with red flags will find it difficult to get into competitive specialties. However, since they met the graduate requirements (objective measures for tests/USMLE/etc and subjective measures) they deserve the opportunity to pursue residency in this country (where there education was accredited). If they wanted to pursue education in another country, they would face the same difficulties that IMGs/FMGs face and then some. US-IMGs have a far bigger red flag in my opinon than the ones you mentioned; as such they are welcome to pursue post-graduate training in the countries their schools are accredited in (good luck with that) or try to return. If they return, they should face the same scrutiny that US grads would face trying to go elsewhere.
you and I will never see eye to eye becuase you favor protecting a class of students who rather than making the sacrifices necessary to pursure accredited edcuation in this country, took the simpler path to an MD and then expect to come back and have access to spots that were only intended for them when there was a surplus.
1. There is no guarantee that a huge number of programs will go unfilled. Based on a system similar to Canada's system, a certain number of spots would be open to IMGs/FMGs to fill out the number deficient from US seniors. All other spots would be matched in the primary or scramble/SOAP after the fact.
2. The problem is taht you are neglecting the fact that the reason FMGs/IMGs were included in the national match was because there weren't enough US grads (only about 50% of needed based on NRMP data). Now that we are approaching parity, you seem to be advocating for a system that says since we let the flood gates open when we neeeded to, we shouldn't be able to close them when the need is no longer present. That absolutely goes against how we have practiced busineess and immigration in this country. If we don't have a need for foreign graduates, there is no need to give them residencies.
"PDs have a program to run and they want it to run smoothly without problems. which has more risk for the program and patient care?" Any data to support that an IMG does better than an AMG? There is accountability in the US system in the from of a pass/fail licensing exam (USMLE), tests in M1-4, and once in residency in service exams, licensing exams. This is not a good ole boy's club, but it should be one that protects the interests of the schools it is paying for and that it accreditates.
You can give me that this is the US BS but the reality is in 2013 we live in a globalized society. We face competition daily in every industry from developed and developing nations and as such need to modify things to stay competitive; there is no ability to be mobile for US grads as such we are obligated to protect them and the investment. The same can't be said for US citizens who forgo standardized medical education to go to school outside the country in unaccredited schools. I am the child of an FMG and know that i wouldn't have the life I have today without the opportunity given to my family; that being said, my family came over because of a shortage of residents meaning the residency spot was a benefit to my family and the country. When we start changing that cost/benefit analysis such that it benefits the student but not the country as some of its own are being left out, things need to be re-evaluated.
Im confused about what you are saying and where this came from?
You think PD's dont agree with me; if that was so, why do AMGs with 200s get in over IMGs with 240s. The red flag I raised is not because of their inferior undergrad stats but because they went the path of not going to an LCME accredited schools. That is a big red flag particulary when that accreditation the school does have comes from a Caribbean island compared with accreditation from the UK, etc. Please re-read my sentence, I dont think IMGs have an easy road, particulary for matching. I said they took the easy road to an MD which going to Caribbean is compared with re-dedicating yourself, improving your CV, and taking the chance of failing again in my opinion.
There are any number of reasons to admit a DO over a FMG, number one on the list being financial. Admitting an FMG over and osteopath means the program loses several 100k.
4 years from now will be interesting. for the past 5 years, there has been harping a lot for increased class sizes. this is now happening as well as the expansion of new allopathic schools and DO schools. what happens is suddenly there become more AMGs / DO's than residency slots?
The interesting question will be what happens when the number of DO students increase to a point that THEY start to affect the AMG match rate?
Gotta feeling that at that time there will be call to limit the spots to just US citizens that are allopathic students...that those DO students should have worked harder to get into an allopathic school and not take the easy way out and choose to go to an osteopathic school...
The interesting question will be what happens when the number of DO students increase to a point that THEY start to affect the AMG match rate?
Gotta feeling that at that time there will be call to limit the spots to just US citizens that are allopathic students...that those DO students should have worked harder to get into an allopathic school and not take the easy way out and choose to go to an osteopathic school...