I won't match, depressed.. Advise me

[Clozapine]

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I am an IMG who applied to psychiatry this year (2014-2015), I will start by saying, the season didn’t go well at all. I didn’t expect a lot, but still Its way below my expectations.

Scores: Step 1 (214), Step 2 (219), CS pass .. all first attempts.

YOG: 2011. Medical school performance wasn’t awesome, I had to flunk an year due to family commitments, I wasn’t able to handle the stress.

Visa: Conditional green card. (compromised my chances?)

USCE: Started working with a psychiatrist in March 2014. I was oriented for a week, observed the psychiatrist doing evaluations and following up on patients in his private clinic, and started interviewing patients alone after. Then, started working with him in a community clinic, and a hospital.
At hospital, I interviewed patients whenever the psychiatrist got busy and wasn’t able to make on time. So, I interview 6-8 new patients daily and see others for follow up.
So, to make things short, I am currently working in 3 settings, and I work 40 hours a week at least. Inpatient and out patients. Doing evaluations and writing all notes, writing preparing prescriptions to get signed. This is still ongoing (almost 1 year now)

I am not sure if i did the right choice though, I got a lot of experience, but the learning part was hard, hardly get time discussing cases with him, but did my best and did a lot of reading. Occasionally we discuss cases and treatment plan.

On my eras application, I wasn’t sure how to categorize my USCE, is it an externship? Work? or volunteer? I ended up putting as WORK, as I was paid anyways to cover gas expenses “ Had to drive two hours to reach community hospitals”.

I managed to get 2 interviews. One of them was a prematch and they already rejected me, I strongly believe the reason is not having step 3 done.
Applied to 150 programs !


What did I do wrong?
Is it my PS? I explained why psychiatry, and why I believe that I can be a great psychiatrist.
Was it the fact that I only had one LOR from psychiatrist? (other were from my home country, not psych)
Was my application screwed? my scores? or did I choose the wrong place to do USCE?

I am depressed, and I don’t feel that I will match. I can’t even put a plan for next year. I read threads here, but still confused.

Any advise? anything can help.

 

[splik]

don't give up just yet! You have left it a bit late to ask for advice however! You still have one program to rank (assuming it is in the match) so submit your rank list anyway, you never know. The odds are low, but they are not zero. Also many IMGs submit blank rank lists anyway so they can participate in the SOAP. That is another (again, admittedly limited) opportunity to get a residency spot. Then even after the SOAP there may be some openings potentially, which is another opportunity. It is probably a bit late in the day, however even if you get rejected from places there is nothing really to lose by politely enquiring at a few choice programs letting them know you are available to attend interview at short notice if there are any cancellations and briefly explaining why you are interested in the program and what you have to offer. This is probably more advice for others/later but who knows? Maybe some programs are still interviewing? If you don't match, you can also contact places to let them know you are interested if for whatever reason they have an unexpected opening.

I have no idea what you are doing, but sadly very few people would consider it USCE. It sounds very suspicious. Typically, you want to do your UCSE (which to be honest isn't worth all that much), at a place where there is a residency program. A number of hospitals which have a large number of IMGs have externship programs for IMGs and this will provide an 'in' to a program potentially if you make a good impression and an opportunity to get letters of recommendation.

Although your scores are below average they certainly aren't bad.

I'm not gonna lie, the whole match process can be pretty demoralizing and depressing for IMGs especially if you didn't have any guidance and it can feel very lonely. You invest so much of everything (money, hope etc) with no guarantee of anything. I'm not gonna lie, you're chances of getting into residency this year are very low. But they are not zero. You cannot give up yet - you have multiple opportunities (each of very low potential) to get a residency spot. And if you don't get one then you need to thing of how to improve your application. That means doing Step 3, getting some USCE at a hospital with a residency program, maybe doing some other mental health related activities or writing papers in journals (whcih could inclide letters to editor, case reports, review articles), or presenting at meetings. You could try attending conferences in a field you are interested in and meeting people. You will also need to be more assertive and not necessarily take a rejection as a closed door. Most things in life are negotiable.

 

[Clozapine]

Thanks for your reply, I am really confused about my USCE. Why does it sound suspicious? I really need to know if that is playing against me.
Perhaps I need to explain briefly what I actually do, and I will appreciate any input from the members.
Simply, I am working with a psychiatrist, interviewing patients for him and writing their evaluations, progress notes, and prescriptions so he can sign it, if they only needed a refill. I work in his private clinic, a community based clinic, and a hospital where he is director of the psych department (not an educational hospital). So both inpatient and outpatient.
He recruited me cause of large amount of patients he sees. He reviews my evaluation, interviews patients briefly, and write his conclusion, diagnoses and decides treatment plan.

Thats not considered as USCE? and does it have any value? I am just waisting my time here? 😕

 

[MacDonaldTriad]

I cannot say that I have much experience rating different USCE activities, but if you work with someone who is completely outside of academics, somewhere with no medical school or graduate medical education infrastructure, how would a program know that your “observership” wasn’t with a family friend who agreed to “just help you out”. If you are getting paid, then you can put it down as a job. If you just volunteering, then it may help you make up your mind about the field, but it seems to me there really isn’t any “credit” without accreditation.

Take Part III and publish something. Try this year and having part III will help. Years out of school will be a growing concern so don’t miss 16/17 if you don’t get 15/16. Good luck, it only takes one.

 

[vistaril]

Im usually not a very big proponent of someone needing to take step 3 before they apply, but this is an exception. A passing(and high) step 3 score would help your application out in non-trivial ways. I'd also pick an attainable residency program that has a history of taking non American IMGs(perhaps even from your own country) and work hard to do some shadowing there and really get to know the people. So you could greatly increase your chance at your own program. That's the best way people in your situation get a leg up to get a spot. Seems like some of the nonamerican imgs my residency program took we took because they shadowed and people got comfortable with them being around.

 

[OldPsychDoc]

Clozapine--we reviewed and mostly rejected literally hundreds of applications like yours. Your profile in general is very similar (essentially indistiguishable) from probably 150-200 applications that we might have deemed "acceptable to interview", but we didn't select because frankly, nothing stood out and we filled our limited slots with those whose applications seemed more compelling. Personal statements all start sounding the same, Boards are OK but not eye-popping, LORs are so-so.

Here's what you might do:
1) pass step 3. Having it in hand will set you apart from those who do not, and those who have attempts on the earlier steps.
2) get 1-2 more US letters. Make SURE they are indicating that they know you're going into psychiatry and they're enthusiastic about your abilities in this field. You can still waive your right to see the letter, and I recommend that, but a little coaching to your letter writers will help them reflect more explicitly in their letter that they would highly recommend you for a position as a psychiatrist.
3) zero in on one geographic region. Try to get some in-person contact at a hospital or clinic affiliated with a training program in that area. Whether it's research, volunteering, or a formal observership/externship, it is likely to mean that someone who is a known quantity to local residency program decision makers will know you, and might get you in the door for closer review of the application and an interview. Folks who are living in our area or can demonstrate strong connections here do float to the top of the application pile. Make sure your CV and personal statement show that.
4) do something interesting, even (or especially) if it is not medical. Write about it in your personal statement. It will be refreshing -- believe me, everyone has an aunt with severe depression, a brother with addiction, a grandmother with dementia, a best friend from high school who committed suicide... I'd much rather read about you hang gliding, or sneaking backstage at a rock concert, or meeting the regulars at an all night diner while you're studying for Step 3--anything!

Good luck on the next go around.

 

[crabbypsych]

Did your recommender enlist all these activities? If not, then they are not credited for. Believe it or not, no matter how much hands on experience you have, it is not accounted for if it is a private setting. Legally you are not supposed to do that unless you have additional approved certifications or interviewing patients in a research related activity. That is the big red flag for you.

 

[vistaril]

the other thing of course that nobody is talking about here is the accent. Do you have one? How well can you blend in with an English speaking population and American culture? Even if your English is mindy kaling good, it wont make all your problems go away but it would help you A LOT MORE once you do make some contacts within a residency program you'd like to be at.

Finally of course, what is so bad about practicing psychiatry in your own country? If you really want to be a psychiatrist, I'd consider that.....

 

[Baller MD]

Having one red flag is bad enough. You have multiple. Why don't you want to practice in your home country? Just curious...

 

[crabbypsych]

Whether he/ she wants to study here or his/her own country seems a personal question. He/ She just wants to know how to improve his/her chances.

 

[Clozapine]

Thanks for your replies, appreciate the time you took to post them..
I am trying to gather my thoughts and start planning again. I mean if it is possible, then I will try again.

the other thing of course that nobody is talking about here is the accent. Do you have one? How well can you blend in with an English speaking population and American culture?

I don't have an accent at all, the only accent I am picking up now is texan accent!

Did your recommender enlist all these activities? If not, then they are not credited for. Believe it or not, no matter how much hands on experience you have, it is not accounted for if it is a private setting. Legally you are not supposed to do that unless you have additional approved certifications or interviewing patients in a research related activity. That is the big red flag for you.

I am not sure weather he included my job details or not, it was waived, but I came to ease when one of my interviewers started pointing to some stuff in his LOR and said these are all good things.

Having one red flag is bad enough. You have multiple. Why don't you want to practice in your home country? Just curious.

What red flags are you referring to?
As for reasons for not pursuing psychiatry in country, there are many, but I won't trash talk my country or any other country, lets just say that it is suboptimal, and the society is not ready to accept psychiatrist yet. And there is no way anybody can live there, its just not safe anymore.
Other than that my significant other won't be comfortable living there. I can list reasons that fill pages.

 

[notbobtrustme]

Having one red flag is bad enough. You have multiple. Why don't you want to practice in your home country? Just curious...

why do you think?

 

[slappy]

^ Oh of course you're right. Why else would people want to come to the US. Doctors/specialists don't get paid this highly in countries like Australia or Netherlands.

 

[birchswing]

^ Oh of course you're right. Why else would people want to come to the US. Doctors/specialists don't get paid this highly in countries like Australia or Netherlands.

I would assume there's also a cost savings to get both your undergraduate and medical degree in almost any country that isn't the US. And then there's, as you mentioned, the higher compensation in the US.

This is why I've argued that medical school should be tax-funded in the US. In the US, medical school is for those who can afford a lot of debt. It should only be merit-based, IMO. I think you'd find fewer doctors making a beeline for the specialties that pay out the highest. I think that starting out with so much debt puts doctors in a money mindset. In the US we associate both being a doctor and being able to go to medical school with wealth. That's inherently bad for people who want to be doctors, but I think it's even worse for patients. I think it's particularly a problem for fields like psychiatry that I think remain less competitive and less staffed in part due to compensation being relatively weak.

I do know that even in countries with tax-funded medical school, the medical associations still manage to put a cap on the number of spots open for students each year. So, it's more merit-based than the US which is merit-based after you've funneled out anyone not able to take on debt, but it still stifles competition.

Hopefully the parity portions of the ACA will actually materialize in the next couple of years. It's not that I am sympathetic to the psychiatrists I've seen who are doing well financially, but from a selfish point of view, if it takes more pay to attract better psychiatrists, I suppose I am for it as a band-aid fix.

I lived in Sweden where medical education is tax-funded and healthcare is available to everyone (free for children, very minimal fees for adults). Doctors there are not regarded the way they are in the US. They're not poorly regarded, but it's more like any other service. There isn't a pedestal. Of course Sweden also more generally has one of the most equal income distributions and one of the cultural values is of "lagom" (just enough—it's considered best to be in the middle). The closest American expression I think is "Enough is a feast"--although it's not quite the same, as lagom doesn't just apply to material needs.

 

[notbobtrustme]

^ Oh of course you're right. Why else would people want to come to the US. Doctors/specialists don't get paid this highly in countries like Australia or Netherlands.

The US is the only non-****hole country that doesn't have a quota system for citizens. For example, going to the Netherlands or Australia means you have to wait in line for their citizens to get first dibs on any training spots. If there aren't any left over after they got their picks, too bad. No matter how good your CV is, no matter how much experience you have, you will always take a backseat to citizens as a non-citizen in these countries.

In the US, it's much more based on your application. Most programs prefer US graduates, but they don't require filling all their spots up with citizen graduates before taking on IMG/FMG candidates.

Finally, we have no explicit language requirements. English is one of the most widely spoken languages out there, so many educated people already have a grasp of English. However, in these other countries such as Germany and the Netherlands, you must pass a language test before being considered for placement.

 

[Lattes]

Clozapine--we reviewed and mostly rejected literally hundreds of applications like yours. Your profile in general is very similar (essentially indistiguishable) from probably 150-200 applications that we might have deemed "acceptable to interview", but we didn't select because frankly, nothing stood out and we filled our limited slots with those whose applications seemed more compelling. Personal statements all start sounding the same, Boards are OK but not eye-popping, LORs are so-so.

Here's what you might do:
1) pass step 3. Having it in hand will set you apart from those who do not, and those who have attempts on the earlier steps.
2) get 1-2 more US letters. Make SURE they are indicating that they know you're going into psychiatry and they're enthusiastic about your abilities in this field. You can still waive your right to see the letter, and I recommend that, but a little coaching to your letter writers will help them reflect more explicitly in their letter that they would highly recommend you for a position as a psychiatrist.
3) zero in on one geographic region. Try to get some in-person contact at a hospital or clinic affiliated with a training program in that area. Whether it's research, volunteering, or a formal observership/externship, it is likely to mean that someone who is a known quantity to local residency program decision makers will know you, and might get you in the door for closer review of the application and an interview. Folks who are living in our area or can demonstrate strong connections here do float to the top of the application pile. Make sure your CV and personal statement show that.
4) do something interesting, even (or especially) if it is not medical. Write about it in your personal statement. It will be refreshing -- believe me, everyone has an aunt with severe depression, a brother with addiction, a grandmother with dementia, a best friend from high school who committed suicide... I'd much rather read about you hang gliding, or sneaking backstage at a rock concert, or meeting the regulars at an all night diner while you're studying for Step 3--anything!

Good luck on the next go around.

I've got a question concerning those "interesting things".

Given your experience in choosing candidates for interview, have you ever considered knowledge of foreign languages a valuable skill that would make a candidate stand out among the crowd? Like an IMG able to speak languages that would make it possible not only to better communicate with occasional foreign patients (like spanish or russian), but also languages that would increase access to valuable cultural reading, like being able to speak german and thus having access to Freud's work and other german intellectuals' books for instance, since a "human education" in the field of psychiatry is possibly more valued than in other fields of medicine. If it was ever the case, maybe you could share with us a few examples?

Thanks in advance.

 

[OldPsychDoc]

It's an added plus, but I don't think we'd ever choose someone just because they had a strong second language ability.
I think languages are almost always important as an indicator of how interested in the wider world an applicant is.
Spanish and Russian are more than "occasionally" useful in our context, but in general even native speakers are encouraged to rely on trained interpreters in the hospital.

(Caveat: most of our south asian IMG applicants do report multiple fluencies on their apps, usually their native language and a couple of others. I guess we kind of expect that, and unfortunately, it's not something that will likely make the application stand out or be more interesting, and particularly so as there are relatively few speakers of those languages in our locale, almost all of whom are also fluent in English.)

 

[Lattes]

It's an added plus, but I don't think we'd ever choose someone just because they had a strong second language ability.
I think languages are almost always important as an indicator of how interested in the wider world an applicant is.
Spanish and Russian are more than "occasionally" useful in our context, but in general even native speakers are encouraged to rely on trained interpreters in the hospital.

(Caveat: most of our south asian IMG applicants do report multiple fluencies on their apps, usually their native language and a couple of others. I guess we kind of expect that, and unfortunately, it's not something that will likely make the application stand out or be more interesting, and particularly so as there are relatively few speakers of those languages in our locale, almost all of whom are also fluent in English.)

Yes, sure. I was just wondering if that fits in "do something interesting, even if it's not medical"

 

[wannabie]

the other thing of course that nobody is talking about here is the accent. Do you have one? How well can you blend in with an English speaking population and American culture? Even if your English is mindy kaling good, it wont make all your problems go away but it would help you A LOT MORE once you do make some contacts within a residency program you'd like to be at.

Finally of course, what is so bad about practicing psychiatry in your own country? If you really want to be a psychiatrist, I'd consider that.....

Do accents really matter? Most of my programs had IMG candidates with accents. I'd find it bizarre if I get a leg up as a US-IMG just because of better English and fitting into culture.

If I match this year, I'd feel more confident offering my advice and criticism.

 

[Lattes]

Do accents really matter? Most of my programs had IMG candidates with accents. I'd find it bizarre if I get a leg up as a US-IMG just because of better English and fitting into culture.

If I match this year, I'd feel more confident offering my advice and criticism.

I have no idea, but given you're a US-IMG, it's expected that your accent will be american and your fluency is great, but maybe if an IMG shows great skills in english and a very clean accent, it's more or less a way to stand out during his interviews, who knows.

 

[wannabie]

I've got a question concerning those "interesting things".

Given your experience in choosing candidates for interview, have you ever considered knowledge of foreign languages a valuable skill that would make a candidate stand out among the crowd? Like an IMG able to speak languages that would make it possible not only to better communicate with occasional foreign patients (like spanish or russian), but also languages that would increase access to valuable cultural reading, like being able to speak german and thus having access to Freud's work and other german intellectuals' books for instance, since a "human education" in the field of psychiatry is possibly more valued than in other fields of medicine. If it was ever the case, maybe you could share with us a few examples?

Thanks in advance.

For what's it's worth, I'd love to read Freud, Nietzsche, and Heidegger in German and Sartre, Camus, and Lacan in French! I get the sense reading them that some of the context between their ideas gets lost in translation.

 

[vistaril]

What red flags are you referring to?

huh? you are 4 years out of graduation(red flag) and you flunked a year of med school(red flag). Those sorts of red flags would be enough for an allo AMG to overcome and get in to some program, but not a non-American IMG with basically no strengths(mediocre scores, no step 3, etc).......

You really haven't made the case why you think you deserve an American residency slot.

 

[barzan]

I totally agree yet the Cambridge edition did a great job in translating Kant's work.
would love to read the critique of pure reason in German.

For what's it's worth, I'd love to read Freud, Nietzsche, and Heidegger in German and Sartre, Camus, and Lacan in French! I get the sense reading them that some of the context between their ideas gets lost in translation.

 

[Clozapine]

huh? you are 4 years out of graduation(red flag) and you flunked a year of med school(red flag). Those sorts of red flags would be enough for an allo AMG to overcome and get in to some program, but not a non-American IMG with basically no strengths(mediocre scores, no step 3, etc).......

You really haven't made the case why you think you deserve an American residency slot.

My questions wasn't disapproval with his statement. I just needed to know what are the red flags he is referring to. Graduating in 2011 and getting certificate after a compulsory externship year means 2012... my application was in 2014, most IMGs don't apply at year of graduation.
As for step 3 its an obstacle that you can overcome.
Flunking an year, yes that a red flag. But I never gave exams, had to cut the year short, but that still is a red flag.
I never thought that my application will be better than AMG, they are preferred over IMGs and thats it, was comparing myself with IMGs. As said before, I wasn't expecting much.
I thought that my USCE was good, before getting in, asked 2 psychiatry chief residents (IMGs) and they told me that most applicants at there programs interview don't get hand-on experience in psych, they usually do observerships that doesn't give the same value, didn't know that they HAVE to be in an academic setting to have value, and that was the reason that gave me some hope.

 

[Mad Jack]

I would assume there's also a cost savings to get both your undergraduate and medical degree in almost any country that isn't the US. And then there's, as you mentioned, the higher compensation in the US.

This is why I've argued that medical school should be tax-funded in the US. In the US, medical school is for those who can afford a lot of debt. It should only be merit-based, IMO. I think you'd find fewer doctors making a beeline for the specialties that pay out the highest. I think that starting out with so much debt puts doctors in a money mindset. In the US we associate both being a doctor and being able to go to medical school with wealth. That's inherently bad for people who want to be doctors, but I think it's even worse for patients. I think it's particularly a problem for fields like psychiatry that I think remain less competitive and less staffed in part due to compensation being relatively weak.

I do know that even in countries with tax-funded medical school, the medical associations still manage to put a cap on the number of spots open for students each year. So, it's more merit-based than the US which is merit-based after you've funneled out anyone not able to take on debt, but it still stifles competition.

Hopefully the parity portions of the ACA will actually materialize in the next couple of years. It's not that I am sympathetic to the psychiatrists I've seen who are doing well financially, but from a selfish point of view, if it takes more pay to attract better psychiatrists, I suppose I am for it as a band-aid fix.

I lived in Sweden where medical education is tax-funded and healthcare is available to everyone (free for children, very minimal fees for adults). Doctors there are not regarded the way they are in the US. They're not poorly regarded, but it's more like any other service. There isn't a pedestal. Of course Sweden also more generally has one of the most equal income distributions and one of the cultural values is of "lagom" (just enough—it's considered best to be in the middle). The closest American expression I think is "Enough is a feast"--although it's not quite the same, as lagom doesn't just apply to material needs.

If medical school were tax-funded, then the government would have an excuse to intervene in physician salaries, since they basically gave us our education. That's a large part of the justification for low salaries in Europe. I'd take on damn near seven figures in debt if it meant keeping the government out of my life. Screw your socialism, I want my money. And I could care less about equality and egalitarianism.

/end off topic rant

 

[birchswing]

If medical school were tax-funded, then the government would have an excuse to intervene in physician salaries, since they basically gave us our education. That's a large part of the justification for low salaries in Europe. I'd take on damn near seven figures in debt if it meant keeping the government out of my life. Screw your socialism, I want my money. And I could care less about equality and egalitarianism.

/end off topic rant

I'm not a doctor, so I don't know as much about wages as you. But isn't it the case that the government is already very involved in compensation for doctors who take Medicaid and Medicare?

It sounds like you're theorizing something even beyond how much a doctor can be compensated by public insurance for a service, something like a maximum wage?

I don't quite see how you get from tax-funded medical school education to a maximum wage. The government doesn't control people's wages in exchange for paying for a primary and secondary education. You said the government would "give" you your education. From a philosophical point of view, I've never viewed the government as separate from society. It wouldn't be the government giving it to you. It would be citizens investing in themselves. But on a more practical level state governments license who can and cannot practice medicine. If you're worried about intrusion, they're already "giving" you or denying your right to a profession.

Finally, I know you said you don't care about equality, but what's very interesting is that higher income equality is correlated with a better quality of life among people across the entire range of income distribution.

That is to say, there are better outcomes across almost all measures (infant mortality, life expectancy, literacy) for a rich person in a country with higher income equality.

And that isn't related to socialism in any way. If you look at Japan for example, it has a very high level of income equality that is not achieved through income redistribution. It is achieved through cultural values that emphasize equitable wages. Sweden, on the other hand, also has very high income equality but achieves this more through income redistribution. Some use the word "socialism" for this, but socialism actually looks something much more like a cohesive-capitalist state where the government directs industry. The US is actually more socialistic than Sweden in that way. Sweden allows entire industries to fail, something that doesn't happen in the US so much. Sweden's system used to be more socialistic in the sense of the government heavily cooperating with business but that isn't the case now. I would argue that the US has a very mixed system where government directs and aids business, although much more erratically than a traditional cohesive-capitalist state.

The US even has a neo-patrimonial tinge, which is quite sad.

What creates a flourishing liberal democracy is a commitment to the development of the individual, all of his rights and freedoms, including the freedom to education.

The alternative is a country where a few may prosper in a wasteland of illiteracy and crime, and the wealthy live in compounds and drive bullet-proof hummers. This exists in some parts of the world. Even if you were rich, why would you want to be rich in such a country? A country where you can't send your children to public schools, where you can't trust the electric grid. can't trust that airports will have safety standards, that taxi drivers won't rob you, that the police won't extort you, or that bridges won't collapse. These are the consequences of a country moving toward illiberalism.

 

[Mad Jack]

I'm not a doctor, so I don't know as much about wages as you. But isn't it the case that the government is already very involved in compensation for doctors who take Medicaid and Medicare?

It sounds like you're theorizing something even beyond how much a doctor can be compensated by public insurance for a service, something like a maximum wage?

I don't quite see how you get from tax-funded medical school education to a maximum wage. The government doesn't control people's wages in exchange for paying for a primary and secondary education. You said the government would "give" you your education. From a philosophical point of view, I've never viewed the government as separate from society. It wouldn't be the government giving it to you. It would be citizens investing in themselves. But on a more practical level state governments license who can and cannot practice medicine. If you're worried about intrusion, they're already "giving" you or denying your right to a profession.

Finally, I know you said you don't care about equality, but what's very interesting is that higher income equality is correlated with a better quality of life among people across the entire range of income distribution.

That is to say, there are better outcomes across almost all measures (infant mortality, life expectancy, literacy) for a rich person in a country with higher income equality.

And that isn't related to socialism in any way. If you look at Japan for example, it has a very high level of income equality that is not achieved through income redistribution. It is achieved through cultural values that emphasize equitable wages. Sweden, on the other hand, also has very high income equality but achieves this more through income redistribution. Some use the word "socialism" for this, but socialism actually looks something much more like a cohesive-capitalist state where the government directs industry. The US is actually more socialistic than Sweden in that way. Sweden allows entire industries to fail, something that doesn't happen in the US so much. Sweden's system used to be more socialistic in the sense of the government heavily cooperating with business but that isn't the case now. I would argue that the US has a very mixed system where government directs and aids business, although much more erratically than a traditional cohesive-capitalist state.

The US even has a neo-patrimonial tinge, which is quite sad.

What creates a flourishing liberal democracy is a commitment to the development of the individual, all of his rights and freedoms, including the freedom to education.

The alternative is a country where a few may prosper in a wasteland of illiteracy and crime, and the wealthy live in compounds and drive bullet-proof hummers. This exists in some parts of the world. Even if you were rich, why would you want to be rich in such a country? A country where you can't send your children to public schools, where you can't trust the electric grid. can't trust that airports will have safety standards, that taxi drivers won't rob you, that the police won't extort you, or that bridges won't collapse. These are the consequences of a country moving toward illiberalism.

The government won't just pay for your medical education for free. They'll want something in return. That something is usually service, not cash. Medicare rates too low to pay your expected wages? Oh, well it's okay, we paid your tuition, you wouldn't even be where you are now if not for us, so we'll pay you whatever we damn well please. Right now we have the argument of "we paid for our education in time and with our own cash, so we deserve our high wages." We'd lose half that argument, and the time could easily be viewed as a "sacrifice' for the privilege of being a physician.

Nopenopenope.

And the government has a requirement to educate people, not to train them for a profession. They are very different concepts- one is providing the tools to look at the world (education), the other is providing the skills to do a particular job. Education is a universal right, but training for a profession of their choice is not.

 

[W19]

It seems like the system gives US students a huge advantage over IMG. I know someone at my school who barely passed step 1 (189 when passing score was 188) and she managed to get more than 10+ IM interviews. She probably would have been DOA if she was a US-IMG...

 

[wannabie]

It seems like the system gives US students a huge advantage over IMG. I know someone at my school who barely passed step 1 (189 when passing score was 188) and she managed to get more than 10+ IM interviews. She probably would have been DOA if she was a US-IMG...

A US medical student I used to study with for step 1 failed his first attempt. He had already failed a year of med school. They gave him an extra six months time off to study for step 1 again. He passed it with <195. Last year he applied for pediatrics to programs in the area and interviewed at twelve places. But then in December, he decided he wanted to do EM. He then got seven EM interviews and then proceeded to match at his top choice at the best EM program in my state.

It was such an effortless process for someone so apathetic about medicine and life in general. Remarkably frustrating to me. Nonetheless, I understand and approve the reasons for IMG's (like me) to prove themselves through a more rigorous process.

 

[Doctor Bagel]

A US medical student I used to study with for step 1 failed his first attempt. He had already failed a year of med school. They gave him an extra six months time off to study for step 1 again. He passed it with <195. Last year he applied for pediatrics to programs in the area and interviewed at twelve places. But then in December, he decided he wanted to do EM. He then got seven EM interviews and then proceeded to match at his top choice at the best EM program in my state.

It was such an effortless process for someone who cared little about medicine. Remarkably frustrating to me. Nonetheless, I understand and approve the reasons for IMG's (like me) to prove themselves through a more rigorous process.

I think your friend's experience is not typical for AMGs and more attributable to luck or other attributes (like maybe he's super likable and interviews amazingly well). The match rate for AMGs is dropping, and AMGs with things like failures and repeated years are the ones most likely not to match, especially not in EM, which is pretty competitive at baseline.

Certainly being an AMG is much easier than being an IMG in the match, but it's not quite that easy for most of us.

 

[Baller MD]

I think your friend's experience is not typical for AMGs and more attributable to luck or other attributes (like maybe he's super likable and interviews amazingly well). The match rate for AMGs is dropping, and AMGs with things like failures and repeated years are the ones most likely not to match, especially not in EM, which is pretty competitive at baseline.

Certainly being an AMG is much easier than being an IMG in the match, but it's not quite that easy for most of us.

I'm sorry but you don't know what you are talking about.

 

[Leo Aquarius]

A US medical student I used to study with for step 1 failed his first attempt. He had already failed a year of med school. They gave him an extra six months time off to study for step 1 again. He passed it with <195. Last year he applied for pediatrics to programs in the area and interviewed at twelve places. But then in December, he decided he wanted to do EM. He then got seven EM interviews and then proceeded to match at his top choice at the best EM program in my state.

It was such an effortless process for someone so apathetic about medicine and life in general. Remarkably frustrating to me. Nonetheless, I understand and approve the reasons for IMG's (like me) to prove themselves through a more rigorous process.

What state is that, Alaska?

It's unlikely for anyone to get an interview in EM with a Step 1 score of, say, 194. Something about the story seems off. Maybe he was exaggerating his low score because he actually got something closer to, say, 210 and felt ashamed it wasn't higher and it felt like barely passing to him so he called it 194, or whatever number he threw out.

 

[Baller MD]

What state is that, Alaska?

It's unlikely for anyone to get an interview in EM with a Step 1 score of, say, 194. Something about the story seems off. Maybe he was exaggerating his low score because he actually got something closer to, say, 210 and felt ashamed it wasn't higher and it felt like barely passing to him so he called it 194, or whatever number he threw out.

44 people matched with a score under 200 last year for EM.

And 100+ with a score between 200-210. EM is not competitive dude.

Psychiatry is even easier to match. THEY WILL TAKE ANY ALLOPATHIC STUDENT WITH A PULSE.

 

[W19]

44 people matched with a score under 200 last year for EM.

And 100+ with a score between 200-210. EM is not competitive dude.

Psychiatry is even easier to match. THEY WILL TAKE ANY ALLOPATHIC STUDENT WITH A PULSE.

Lets not get carried away here... If you have multiple attempts for step 1 and you failed classes, I am not sure that your chances are that good even if you are AMG...

 

[birchswing]

The government won't just pay for your medical education for free. They'll want something in return. That something is usually service, not cash. Medicare rates too low to pay your expected wages? Oh, well it's okay, we paid your tuition, you wouldn't even be where you are now if not for us, so we'll pay you whatever we damn well please. Right now we have the argument of "we paid for our education in time and with our own cash, so we deserve our high wages." We'd lose half that argument, and the time could easily be viewed as a "sacrifice' for the privilege of being a physician.

Nopenopenope.

And the government has a requirement to educate people, not to train them for a profession. They are very different concepts- one is providing the tools to look at the world (education), the other is providing the skills to do a particular job. Education is a universal right, but training for a profession of their choice is not.

I very much respect your opinions. I don't come from at the perspective of someone who has something to lose—you've already invested the money and want to protect your position, which is understandable.

I am curious, though, what is the answer to the shortage of psychiatrists?

I have Cadillac-level insurance and there is very little availability and certainly no competition between psychiatrists. I would guess that about 90% of the psychiatrists where I live are both over 50 and from Pakistan/India. And they're all booked months out, even for patients of record.

So it's not just anecdotal I found this:

http://www.newsweek.com/lack-psychiatric-care-madness-244896

To me it seems that tax-funded medical school would increase the total number of physicians (increasing competition and thus quality) and increase the number who go into traditionally lower paying fields because they don't have to recoup their debt and aren't as money-minded as today's medical school students.

I can see why people want to protect the current system if they benefit from it, but what if you yourself needed psychiatric care?

I am open to other suggestions as to how the US could turn around both the shortage of and poor quality of psychiatrists. It's a pretty ridiculous situation for families now who are dealing with the medical equivalent of Indian tech support--and I don't mean that as an insult to Indians. I say it because technical support is disproportionately outsourced due to certain factors: labor cost and a fairly competent education system in India. In the same way there are very specific factors that lead to FMGs coming to the US as psychiatrists: low reimbursement rates (again the labor cost) and having met the qualifications for providing care. But the care is really pretty bad in a lot of cases, and there's no reason the US can't produce more psychiatrists—people who are passionate about psychiatry and not filling in slots due to economic factors that make it a valuable opportunity.

Psychiatrists could get paid more--that's one option. But wasn't that supposed to happen going all the way back to 2008 with the parity act? Are there other reasons Americans don't want to go into psychiatry that could be remedied?

 

[slappy]

I have Cadillac-level insurance

So big, bling, and utter crap?

To me it seems that tax-funded medical school would increase the total number of physicians (increasing competition and thus quality) and increase the number who go into traditionally lower paying fields because they don't have to recoup their debt and aren't as money-minded as today's medical school students.

Your logic is severely flawed. You see poor-quality psychiatrists in the community because psychiatry is generally less competitive. Loan repayment is only part of the reason for that (no one can argue they can't pay off 200-300k in loans with a 200-300k salary given sufficient time). But some people want to make a lot more than that. And you also have to be cut-out for psychiatry, especially if you're looking to do clinical practice.

You don't see poor quality physicians in any specialty in big university hospitals, regardless of immigration status or race. The current Surgeon General of the United States is an immigrant, and Indian by race.

 

[Baller MD]

Lets not get carried away here... If you have multiple attempts for step 1 and you failed classes, I am not sure that your chances are that good even if you are AMG...

If you're that bad of a student then you're probably an outlier.

 

[birchswing]

So big, bling, and utter crap?



Your logic is severely flawed. You see poor-quality psychiatrists in the community because psychiatry is generally less competitive. Loan repayment is only part of the reason for that (no one can argue they can't pay off 200-300k in loans with a 200-300k salary given sufficient time). But some people want to make a lot more than that. And you also have to be cut-out for psychiatry, especially if you're looking to do clinical practice.

You don't see poor quality physicians in any specialty in big university hospitals, regardless of immigration status or race. The current Surgeon General of the United States is an immigrant, and Indian by race.

Well, I think you learn by having ideas and talking about them with people and seeing what others think. It's not an idea I had ever had feedback on before, and I'm not attached to it. The question I have is what are other possible answers? It seems like someone other than psychiatrists will have to take responsibility for psychiatric patients or there will continue to be a need for more psychiatrists.

 

[Baller MD]

Well, I think you learn by having ideas and talking about them with people and seeing what others think. It's not an idea I had ever had feedback on before, and I'm not attached to it. The question I have is what are other possible answers? It seems like someone other than psychiatrists will have to take responsibility for psychiatric patients or there will continue to be a need for more psychiatrists.

Why is having a need for more psychiatrists a problem? I would argue that having an over-saturation of psychiatrists would hurt the field and would dissuade talented students from pursuing psychiatry even more.

 

[birchswing]

Why is having a need for more psychiatrists a problem? I would argue that having an over-saturation of psychiatrists would hurt the field and would dissuade talented students from pursuing psychiatry even more.

Isn't there a reasoning section on the MCAT?

You are the proof that there needs to be more competition and less money-focused people in the field of medicine.

 

[birchswing]

I was thinking about it more, and it’s amazing how much Ricardo’s theory regarding comparative advantage of the factors of production plays into this.

Just as the labor force of the US loses out when wealth gained through return on capital in free trade markets isn’t redistributed, the American public loses out when capital is the means to becoming a doctor.

To put it simply, capital is the US’s greatest resource—just as land and labor are resources. China’s greatest resource since the 1980s has been low-skill labor. US capital in China is cheap (referencing interest rates) just as the fruits of Chinese low-skill labor are cheap in the US. Each has a competitive advantage.

In this theory, all countries have some comparative advantage which will favor the most abundant and efficient factor of production. In general in the western world, capital has a higher rate of return than does labor if you compare them as resources.

In this economic theory, all countries economically benefit when there is free trade because they are theoretically better at one thing than another. Focusing on what they are best at increases their productivity. There are no losers among countries. Within countries, there are always winners and losers. Many people point out that labor is losing in the US. As developing countries enter free trade markets, their scarce factors of productions, such as agriculture, will lose out against other forms of low-skill labor. And of course agriculture is usually the sticking point in international economic conferences—developing countries, some at least, want to protect their scarce factors of production.

The idea among most thinkers is that income must be redistributed in some way among the people in scarce factors of production. So, farmers in Korea must be protected, for example, whereas ideally in the US, labor would be protected. How to achieve this protection is debated. There is the cynical and false idea that the American worker must work harder. It has nothing to do with that. The US economy could be very strong with a fairly high unemployment rate. How the proletariat get their money is somewhat irrelevant at a technical level. It’s already a very mixed system. That isn’t to say that work isn’t important for many other reasons. But it’s to say that how hard a person works and how many jobs they work is less relevant to their outcome than the amount of capital they own.

In the US, within the middle class, wages have only risen for those with post-graduate degrees—not even for those with college degrees. I believe this is partially related to the return on capital being higher than the return on labor. A medical school education is an investment just as setting up a factory in China is an investment—granted on a much smaller scale. Investment of capital has historically proven more valuable than the return on labor. So what if medical school weren’t an investment?

Doctors might behave more like humans rather than like businesses. They would compete more—just as you can see low-skill labor in the US is very competitive due it being a weak factor of production.

Medicine has been a field for the elite—and it should be a field for those who are elite in their knowledge and passion, but not for those who are above all else seeking a return on an investment.

It results in a lack of humanism, a lack of competition, and a lack of providers.

This is my theory. I am open to it being wrong.

 

[Baller MD]

Isn't there a reasoning section on the MCAT?

You are the proof that there needs to be more competition and less money-focused people in the field of medicine.

First, I'm sorry that my OPINION has resulted in you calling me out unnecessarily with a low blow.

Second, me serving as your "proof" that there needs to be more competition speaks volumes of your own reasoning level. I go to a US MD school. Competition is stiff. So much so that MANY other people are willing to go offshore just go get a shot at a US residency spot. If there needs to be MORE competition, it wouldn't hurt people like me, only the people who aren't cut out to get into med school in the first place.

Third, if compensation isn't a factor for people pursuing a field, talented people will wise up and won't pursue it at all. Exhibits: law school and the current trend in radiology.

Random note: people caring about compensation to pay off their high student debt load does not change the fact that they still care about their patient's well-being, in my opinion.

 

[birchswing]

First, I'm sorry that my OPINION has resulted in you calling me out unnecessarily with a low blow.

Second, me serving as your "proof" that there needs to be more competition speaks volumes of your own reasoning level. I go to a US MD school. Competition is stiff. So much so that MANY other people are willing to go offshore just go get a shot at a US residency spot. If there needs to be MORE competition, it wouldn't hurt people like me, only the people who aren't cut out to get into med school in the first place.

Third, if compensation isn't a factor for people pursuing a field, talented people will wise up and won't pursue it at all. Exhibits: law school and the current trend in radiology.

Random note: people caring about compensation to pay off their high student debt load does not change the fact that they still care about their patient's well-being, in my opinion.

I apologize. I was very rude. I've been having frustrating personal experiences resulting from shortages; it is difficult to handle a benzo withdrawal when your doctor can only see you ever 2-3 months and doesn't do phone calls at all. I took your comment the way I did because it seemed like you said you were concerned for the field (although you didn't say concern in which way--so I wasn't sure what you meant), and you said that having a shortage is not a problem. It is a problem for the people who can't get in to see a psychiatrist. Your seeming lack of concern for the patient frustrated me. As for my remark about logic, you didn't say why A=B (why does over-saturation--which is not the premise I proposed--equate to less talented people going into psychiatry)?

As for competition, I meant competition among doctors in the marketplace—not among students. There aren't enough doctors and the ones in psychiatry are often of low quality. Having a way for more Americans to get a medical degree without the impediment of debt might make for more competition among what are less desirable positions (I'm not saying psychiatry should be less desirable, only that it is). There aren't enough doctors in psychiatry, let alone enough good ones. So, increase the market of psychiatrists and increase the competition among them for patients--that is the competition I referred to: competition among practicing doctors based on how competent they are. Competition right now is bottle-necked at the med school level--why not in the market place?

As far as compensation, I haven't proposed lowering pay for psychiatrists. Obviously to some extent the current level of compensation dissuades people from going into psychiatry. I don't know that having a greater number of psychiatrists would lower pay. Cardiologists are reimbursed well and there seems to be more than enough to go around--at least where I live. My psychiatrist gets $50 per session and my cardiologist depending on the type of appointment gets around $200 from my insurance every time I see him. If I have tests done he gets about $400. And I can see him same day if I need to. On the other hand, my wait time for my psychiatrist is 2-3 months. With psychiatry you have a huge demand from patients, not enough doctors, and the compensation is still relatively low. By that logic, compensation should be high, but it's not. So I don't think that increasing the number of providers would decrease pay; I do think increasing the pay would increase the number of providers. And that's what the government has supposedly been trying to do since 2008.

Finally based on how the system is currently, I do think psychiatrists should be paid more. In a more ideal situation, I would think it would be better for all doctors to be paid less, but as long as doctors are so highly paid, I think there should be parity for psychiatrists.

I don't know the mechanics of why psychiatrists are paid less. Does it have something to do with charging for "med checks" rather than regular appointments like other doctors do? I don't know. I am personally willing to pay out of pocket for a better psychiatrist (one I could see more often and who returns phone calls; my current one does not at all).

 

[splik]

hi birchswing - the bottleneck is at the residency level not the medical school level. There are only so many residency spots. There has been a mass expansion the the number of medical schools and places in recent years and yet the number of US students going into psychiatry has decreased. In addition there has been a proliferation of osteopathic schools. This is not making a significant difference to the numbers going into psychiatry. Increasing the number of medical school places is not a solution. We don't have the ability to train more medical students at the same level (quality is definitely going down) and the kinds of people who would want to be psychiatrists if they could get into medical school are wholly unsuitable for the practice of medicine, if they have the interest. While I certainly sympathize with the number of crappy psychiatrists (probably the majority) this does not have anything to do with how foreign they are. I bet you anything the worst psychiatrists out there aren't the foreign ones as the bar is higher for foreign graduates to get a residency (though admittedly not by much).

Also I do not believe there is actually a shortage of psychiatrists. There is a problem with the distribution of psychiatrists and the number who wish to treat the mentally ill. Unfortunately, psychiatry abandoned the mentally ill long ago. If you move to a more reasonable place to live and are willing to pay out of pocket you can see a psychiatrist. I'm not saying I agree with this but such how it is. Even the use of NPs and PAs as physician extenders has not helped much because most people training in these fields do not wish to do mental health work.

To be honest if you were in the UK you probably wouldn't have a psychiatrist. A good GP can usually manage iatrogenic benzo dependence, there are clear national guidelines for the management. In the US a good primary care doctor (not in your neck of the woods) would be able to manage your problems with consultation from a psychiatrist.

Also psychiatrists do not get paid less for using the same codes as a primary care doctor. The issue is one of volume. To bill for a particular visit a PCP could much more rapidly perform the elements necessary to bill than a psychiatrist could. Because we bill the same codes (mostly, we have therapy codes and they have procedures etc) psychiatrists can bill the same, but they typically cannot see patients as quickly and thus may not generate the same revenue. That said psychiatrists are not exactly poor and psychiatrists in a high volume med mx practice could easily make $400k a year. so I would shed any tears for psychiatrists renumeration.

 

[birchswing]

hi birchswing - the bottleneck is at the residency level not the medical school level. There are only so many residency spots. There has been a mass expansion the the number of medical schools and places in recent years and yet the number of US students going into psychiatry has decreased. In addition there has been a proliferation of osteopathic schools. This is not making a significant difference to the numbers going into psychiatry. Increasing the number of medical school places is not a solution. We don't have the ability to train more medical students at the same level (quality is definitely going down) and the kinds of people who would want to be psychiatrists if they could get into medical school are wholly unsuitable for the practice of medicine, if they have the interest. While I certainly sympathize with the number of crappy psychiatrists (probably the majority) this does not have anything to do with how foreign they are. I bet you anything the worst psychiatrists out there aren't the foreign ones as the bar is higher for foreign graduates to get a residency (though admittedly not by much).

Also I do not believe there is actually a shortage of psychiatrists. There is a problem with the distribution of psychiatrists and the number who wish to treat the mentally ill. Unfortunately, psychiatry abandoned the mentally ill long ago. If you move to a more reasonable place to live and are willing to pay out of pocket you can see a psychiatrist. I'm not saying I agree with this but such how it is. Even the use of NPs and PAs as physician extenders has not helped much because most people training in these fields do not wish to do mental health work.

To be honest if you were in the UK you probably wouldn't have a psychiatrist. A good GP can usually manage iatrogenic benzo dependence, there are clear national guidelines for the management. In the US a good primary care doctor (not in your neck of the woods) would be able to manage your problems with consultation from a psychiatrist.

Also psychiatrists do not get paid less for using the same codes as a primary care doctor. The issue is one of volume. To bill for a particular visit a PCP could much more rapidly perform the elements necessary to bill than a psychiatrist could. Because we bill the same codes (mostly, we have therapy codes and they have procedures etc) psychiatrists can bill the same, but they typically cannot see patients as quickly and thus may not generate the same revenue. That said psychiatrists are not exactly poor and psychiatrists in a high volume med mx practice could easily make $400k a year. so I would shed any tears for psychiatrists renumeration.

Very interesting.

I have a great primary care doctor, but he doesn't trust himself when it comes to psych meds. He is amazing. He's very busy like my psychiatrist but unlike my psychiatrist he will do things he doesn't get paid for, which she will not. He e-mails and returns phone calls. Every time I see him, I spend about an hour with him. He also stays late to squeeze people in. My psychiatrist on the other hand does four an hour. She won't even return calls for urgent issues.

Anyhow, I recently had a frustrating/traumatizing experience with my psychiatrist's answering service that was caused in great part by my psychiatrist. It's not something that could be sorted out either since she doesn't communicate between appointments. She'll only relay messages through a secretary, which is like playing a game of telephone, and out of the times I've tried to do that, most of the time she won't even relay a message. This last time was traumatic. And I'm not one of those people who calls a lot or for small things.

I made an appointment to talk to my primary care doctor to ask if he would take over my med management. He was amazingly well versed in my meds and how to do a benzo withdrawal. I told him that he knew more than 90% of the psychiatrists in the area just in that area alone. He told me that if I ever run into a situation where I am between psychiatrists, he'll write my scripts for me. But he said he wasn't comfortable with the responsibility of titrating the doses.

In the mean time, I have been petrified and made mentally sick waiting to see my psychiatrist because she is so unpredictable. She was the best I've found but recently has been traumatizing to deal with. I have tried finding any other psychiatrist but have come up short.

The thing about coordinating the primary care doctor with the psychiatrist is that she doesn't communicate with anyone. I've seen her for about four years and my psychologist said that she in particular, for all of his patients, has never once called him back. I have a release in place, and she is supposed to be in contact with him, but they have never once spoken. My psychologist said that most psychiatrists don't call back, so she's not an outlier.

Again, I don't feel sorry for the psychiatrists in terms of pay. I only mentioned that if within the current system they were paid more it would be to my benefit as there might be more providers.

I didn't know that they make as much as you said. The common trope is that psychiatrists are the lowest paid.

I would discuss my case in more detail and how difficult it has been, but a certain point when you describe the insanity of the world of psychiatry, the patient just comes off looking crazy.

I know people say GPs are the ones who get patients addicted, but that was not my experience. I very much wish my GP would take my case. It would make things infinitely easier. I can understand his hesitancy to some degree. His point was that he wanted "two sets of eyes" on mental healthcare cases. But in my case I don't feel like I've ever had one set of eyes on me.

EDIT: You mentioned the UK. I've said on this board many times that they are ahead of the US in having more awareness and education regarding benzodiazepine dependence. It's not quite on the radar of the government in the US.

 

[PikminOC]

Also I do not believe there is actually a shortage of psychiatrists. There is a problem with the distribution of psychiatrists and the number who wish to treat the mentally ill. Unfortunately, psychiatry abandoned the mentally ill long ago. If you move to a more reasonable place to live and are willing to pay out of pocket you can see a psychiatrist. I'm not saying I agree with this but such how it is. Even the use of NPs and PAs as physician extenders has not helped much because most people training in these fields do not wish to do mental health work.

To be honest if you were in the UK you probably wouldn't have a psychiatrist. A good GP can usually manage iatrogenic benzo dependence, there are clear national guidelines for the management. In the US a good primary care doctor (not in your neck of the woods) would be able to manage your problems with consultation from a psychiatrist.

Also psychiatrists do not get paid less for using the same codes as a primary care doctor. The issue is one of volume. To bill for a particular visit a PCP could much more rapidly perform the elements necessary to bill than a psychiatrist could. Because we bill the same codes (mostly, we have therapy codes and they have procedures etc) psychiatrists can bill the same, but they typically cannot see patients as quickly and thus may not generate the same revenue. That said psychiatrists are not exactly poor and psychiatrists in a high volume med mx practice could easily make $400k a year. so I would shed any tears for psychiatrists renumeration.

Let's also not forget that the midlevels who do prescribe psychotropics also do not work in underserved areas. They saw they want to increase access to care in rural area, but they do not practice there once they finish...

And the malpractice climate in the US vs the UK is very different...