Match Farce

[NotAProgDirector]

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All sorts of interesting thoughts here. The thread has drifted from the match, to med ed in general.

As far as the match is concerned, it's a great solution for a student who isn't certain where they want to be, or is less competitive for the field they are applying to. If a student knows exactly what they want, or is certain they know where they want to be, then some sort of direct apply / get position system is better -- cheaper and faster.

One of the problems with the match is that it takes all of the emotional excitement / energy of getting a position and compresses it into a 5 minute window. In a normal job application process, it gets stretched out over weeks. Whether you "like" that or not depends on your personality. Many of my PGY-3's are currently applying for jobs., and find it incredibly frustrating that they don;t know how long this will take, when they will hear back, etc.

One comment above was that if you don't match, that a stigma gets attached to you and you will never match. That's not really true. If you apply for a competitive field (let's say ortho) and don't get a spot, if you apply the next year to something less competitive and simply state the truth (that you're pursing a different field), you'll get plenty of invites. The problem is that people that are not competitive for a field then apply the next year and get less invites -- then the issue is that they simply weren't competitive and probably wouldn't get a spot regardless of the system.

Great Britain experimented with a no-match system a few years ago. They had everyone apply, and then had a uniform offer date where programs could offer spots to applicants, who could then choose what spot they wanted to take. It's very similar to the way SOAP works. What happened is that 20% of the applicants got 90% of the offers up front, and many, many good applicants got no offers. They finally did get offers (since the top candidates only could take one of their many offers) but this created a bunch of problems.

If we really wanted to change the system, I agree that getting rid of the academic year would be needed. Some european systems used to be based on "attachments" -- instead of a 3 year program, you'd sign up to work for 3-6 (or more) months at a single program, then search around for a new attachment. Since they can start at any time, it takes the pressure off starting on July 1. This system had plenty of problems also, and whether it is better or worse than what we have now isn't clear (and varies based upon how you look at things).

As far as changing the entire med ed system, it certainly could work. I could imagine a pre-med degree that if you don't make the cut, you get diverted into another pathway that generates a standard BS/BA degree instead. This could shorten training time, and make it cheaper. No argument that the whole process is ridic expensive. It does add a bunch of new problems -- like the MCAT becomes a do-or-die event (which perhaps it is already). I do think that some sort of rotating 3rd year experience needs to be done before people choose their fields, for the reasons stated. 4th year could change into 3 months of school (i.e. sub I, etc) and 9 months of work of some sort, where you get paid -- EMT, research, etc, etc. You'll need some sort of 4th year to apply to programs.

 

[thefritz]

The part about undergrad being a waste, I completely agree with for the most part. The only issue with a 'pre-med' degree is that if students get that degree without having the scores required to get into medical school, they have pretty much wasted 3-4 years of undergrad. At least if you get a Biology (or even Art History) degree, you have the potential to put that degree to use in getting a job outside of medical school. You likely don't remember much about organic chem or physics, but the knowledge is likely still there in the back of your mind, and you could re-pick it up much easier if you needed to. If you stay a doctor, then it's not necessary, but not remembering something != not learning it.

That's not quite what I meant. Ideally, there would be no medical school to get into. You do 5 years of college then 1 transitional year, then residency.
Year one college: Basic gen ed stuff math english etc, bio
Year two college: chem, cell bio, physics
Year three college: biochem, upper level basic science electives. Required shadowing.
MCAT-like test required for progression to year four
Year four college: anatomy lab, microbiology, path and pharm. Required shadowing.
Year five college: integrated systems-based courses. Required shadowing. Take step 1-like exam. Apply for residency
Confer MD
Begin transitional year at health system your residency program is at. Take step 2-like exam
Re-apply if you really hate the residency you applied for and are willing to wait a year to do something else.
Begin traditional residency.

No "medical school" needed.
In college, people "pick" their major and course of study after only a few semesters and this is usually their career. There's no reason why a student, after four years of being in a true pre-med/medschool type program can't just also "pick" something. The idea that you need to do rotations to figure it out is a little silly. You can figure it out from a few shadowing sessions (which is really all third year is anyway) if you're immersed in the program and have a basic understanding of the subject matter and the physician's function. They just make you do 30 sessions instead of 2 to get credit. My system would have you do a few provided shadowing sessions in your later years in every specialty. It's not like you think surgery is awesome for 7 weeks, then all of the sudden in week 8 you're like OMG they have to wake up at 4AM, I can't do this forever. No, you get a big enough picture early on. Enough to help you decide what you want to be when you grow up anyway. And of course there will always be some that change their mind. But that's in any system and we don't need two and a half years of full-time clerkships to do this.

 

[Raryn]

The idea that you need to do rotations to figure it out is a little silly. You can figure it out from a few shadowing sessions (which is really all third year is anyway). They just make you do 30 sessions instead of 2 to get credit. My system would have you do a few provided shadowing sessions in your later years in every specialty. It's not like you think surgery is awesome for 7 weeks, then all of the sudden in week 8 you're like OMG they have to wake up at 4AM, I can't do this forever. No, you get a big enough picture early on. Enough to help you decide what you want to be when you grow up anyway. And of course there will always be some that change their mind. But that's in any system and we don't need two and a half years of full-time clerkships to do this.

Just curious: What year medical student are you?

 

[thefritz]

M4.

 

[NotAProgDirector]

That plan certainly has some merits. It's much shorter/faster, and hence much cheaper. Most medical schools in the US are already part of an undergraduate university (since the 4th and 5th years as you decribe above are basically the 1st and 2nd years of medical school as it is today).

But, it trades those benefits for possible problems:

1. Getting into "a medical pathway" as above would become completely dependent on your MCAT score. (One could argue that's the way it is now anyway).
2. The only pathway you could get into is your undergraduate school. If you went to a school that didn't have a pathway like this, you'd be out of luck (although an alternate pathway could be created to address this).
3. Most importantly from my viewpoint, the "doctors" coming to my internship would basically have the skills of early 3rd year students. In other words, they would be completely useless. One has to wonder whether residency training would just get longer in response. And would you expect to get paid for this 3rd year equivalent?

I would argue that you should:
1. Put the 3rd year back into the training pathway.
2. Shorten years 3 and 4 to 18 months (many medical schools have done this already).

This creates a 6 year pathway -- 3 years of traditional college, 1.5 basic sci years, 1 year of 3rd year clerkships, and 6 months of 4 year type experiences. This still has the problem of addressing when you would apply for residency -- if it was after completing the whole pathway, then we'd need to change residencies to start in January (or you'd be applying in the middle of your clerkships).

Note that there are several 6 year BS/MD programs that are similar to the above, just 2 + 2 + 1 + 1 instead of 3 + 1.5 + 1 + 0.5.

 

[evilbooyaa]

That's not quite what I meant. Ideally, there would be no medical school to get into. You do 5 years of college then 1 transitional year, then residency.
Year one college: Basic gen ed stuff math english etc, bio
Year two college: chem, cell bio, physics
Year three college: biochem, upper level basic science electives. Required shadowing.
MCAT-like test required for progression to year four
Year four college: anatomy lab, microbiology, path and pharm. Required shadowing.
Year five college: integrated systems-based courses. Required shadowing. Take step 1-like exam. Apply for residency
Confer MD
Begin transitional year at health system your residency program is at. Take step 2-like exam
Re-apply if you really hate the residency you applied for and are willing to wait a year to do something else.
Begin traditional residency.

No "medical school" needed.
In college, people "pick" their major and course of study after only a few semesters and this is usually their career. There's no reason why a student, after four years of being in a true pre-med/medschool type program can't just also "pick" something. The idea that you need to do rotations to figure it out is a little silly. You can figure it out from a few shadowing sessions (which is really all third year is anyway) if you're immersed in the program and have a basic understanding of the subject matter and the physician's function. They just make you do 30 sessions instead of 2 to get credit. My system would have you do a few provided shadowing sessions in your later years in every specialty. It's not like you think surgery is awesome for 7 weeks, then all of the sudden in week 8 you're like OMG they have to wake up at 4AM, I can't do this forever. No, you get a big enough picture early on. Enough to help you decide what you want to be when you grow up anyway. And of course there will always be some that change their mind. But that's in any system and we don't need two and a half years of full-time clerkships to do this.

Ah, OK. I mis-understood you. What you're describing is very similar to 6/7 year BS/MD programs (which I whole heartedly support) and/or the UK system of medical education.

I still think we should be forced to do at least 1.5 years of rotations + Step 2 prior to getting an MD (as aPD stated). I'm OK with 1 year of 3rd year and 6 months of 4th year. I do NOT feel like shadowing was enough to pull me into my field choice. Sure, shadowing a specialty for a couple days made it relatively easy to eliminate from contention, but in non-surgical fields, there is such a variety of stuff even within a general field that it would be hard to get a decent sample size just through shadowing.

Also, I'm not sure where you did your MS3 rotations, but I would say less than 10% of my time was spent shadowing (AKA just watching the resident/attending do his thing). I'm terrified about going into intern year as is, but I couldn't imagine being responsible for patients' lives without the experience of MS3.

 

[mvenus929]

The idea that you need to do rotations to figure it out is a little silly. You can figure it out from a few shadowing sessions (which is really all third year is anyway) if you're immersed in the program and have a basic understanding of the subject matter and the physician's function.

Also, I'm not sure where you did your MS3 rotations, but I would say less than 10% of my time was spent shadowing (AKA just watching the resident/attending do his thing). I'm terrified about going into intern year as is, but I couldn't imagine being responsible for patients' lives without the experience of MS3.

This. I did far more than shadowing during third year, which is why my school feels that it's completely okay for fourth year students to precept (albeit in a limited way) first and second year students, and even some third year students, in terms of H&Ps and note-writing. Fourth year probably doesn't need to be as long as it is (then again, at my school it's extremely long, so maybe others will feel differently), but I still think both third and fourth year are valuable. Maybe you could change the way third year was done by having different 'tracks'--those who knew they wanted more of a medicine type specialty could do more limited surgical rotations, while those who wanted to do more surgical stuffs could do less medicine, and those who wanted to do something involving less patient care (radiology, pathology, etc) could do their own thing. If you found halfway through that you wanted to be in another track, there could be some flexibility built into the system to allow that.