Two Unmatched-Doctor Advocacy Groups Are Tied to Anti-Immigrant Organizations

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    The point the article's making is that these advocacy groups are tied to groups arguing against things from the H1B to 14th ammendment (birthright citizenship). Tons of leadership in these groups that help unmatched residents have authored hundreds of blogs for outright white nationalism websites. It seems to lead down the rabbit hole of white nationalism/Trump/etc. and while it seems crazy, it's all pretty well outlined. Good article to whoever wrote it.

    1. Attached is a chart basically outlined explaining the concreteness of these ties.

    2. Here is an excerpt that describes the essence:
    July 2020, at the height of the covid pandemic, Lynn (founder of one of these groups) sent a letter to then-Senate Majority Leader Mitch McConnell asking him not to allow a bipartisan bill that would allocate unused green cards to foreign health care workers into the next covid stimulus bill, and instead prioritize unmatched U.S. doctors. That effort was publicized in Breitbart News, a right-wing publication that shares the anti-immigrant view. The bill died in the Senate. The SPLC also reported that Joe Guzzardi, a writer for Doctors Without Jobs, has previously written more than 700 blog posts for a white nationalist hate website.

    ----
    I don't know about all of you but there have been people mentioning on SDN/ Reddit/Discord/Spreadsheets talking pretty openly about prioritizing US graduates. I just want to have a more sophisticated discussion about what exactly we all think.


    I for one think the following:

    1.) IMGs are not taking spots Americans want for the most part, but there are cases where they in competitive fields which is enough to ignite the flame.
    2.) Residencies are US-taxpayer funded (medicare), but then those who graduate from US residencies usually stay and practice in the U.S. To counter that though, one can say U.S taxpayer money funds some US medical schools so we prioritize US graduates. Then there's the part that some IMGs take part in programs where their countries pay the hospital for XYZ spots so medicare funding isn't what's being used in some cases.
    3.) Most importantly it's important to be honest with our viewpoints but to stick to the facts and not let tribalism/political leanings divide us.
    4.) I have noticed some SDN/Reddit sentiment on disdain of non-Western country medical schools (i.e South Asia, Africa) in passing.

    I think it's important when we make these arguments to be specific as to what we exactly mean so that our viewpoints aren't associated or used in instances like this.

    Thoughts?
     

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    mjhunt103

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      I think it is important to remember that several members of these group are, in fact, immigrants (Saideh Farahmandnia) or children of immigrants (Faarina Khan, Rani Esther Paulina Raja, etc.) . I think Doug Medina's father was from Nicaragua.

      People like to paint this organization as xenophobic, but it really is a self-interest issue. They believe they are capable of being good physicians and program directors are rejecting them for illegitimate reasons. They think their chances would be higher if program directors were not allowed to consider anyone who is not a citizen or LPR.

      And, really, who can blame them given the debt and how much sacrifice they put in?
       
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      Mad Jack

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        The point the article's making is that these advocacy groups are tied to groups arguing against things from the H1B to 14th ammendment (birthright citizenship). Tons of leadership in these groups that help unmatched residents have authored hundreds of blogs for outright white nationalism websites. It seems to lead down the rabbit hole of white nationalism/Trump/etc. and while it seems crazy, it's all pretty well outlined. Good article to whoever wrote it.

        1. Attached is a chart basically outlined explaining the concreteness of these ties.

        2. Here is an excerpt that describes the essence:
        July 2020, at the height of the covid pandemic, Lynn (founder of one of these groups) sent a letter to then-Senate Majority Leader Mitch McConnell asking him not to allow a bipartisan bill that would allocate unused green cards to foreign health care workers into the next covid stimulus bill, and instead prioritize unmatched U.S. doctors. That effort was publicized in Breitbart News, a right-wing publication that shares the anti-immigrant view. The bill died in the Senate. The SPLC also reported that Joe Guzzardi, a writer for Doctors Without Jobs, has previously written more than 700 blog posts for a white nationalist hate website.

        ----
        I don't know about all of you but there have been people mentioning on SDN/ Reddit/Discord/Spreadsheets talking pretty openly about prioritizing US graduates. I just want to have a more sophisticated discussion about what exactly we all think.


        I for one think the following:

        1.) IMGs are not taking spots Americans want for the most part, but there are cases where they in competitive fields which is enough to ignite the flame.
        2.) Residencies are US-taxpayer funded (medicare), but then those who graduate from US residencies usually stay and practice in the U.S. To counter that though, one can say U.S taxpayer money funds some US medical schools so we prioritize US graduates. Then there's the part that some IMGs take part in programs where their countries pay the hospital for XYZ spots so medicare funding isn't what's being used in some cases.
        3.) Most importantly it's important to be honest with our viewpoints but to stick to the facts and not let tribalism/political leanings divide us.
        4.) I have noticed some SDN/Reddit sentiment on disdain of non-Western country medical schools (i.e South Asia, Africa) in passing.

        I think it's important when we make these arguments to be specific as to what we exactly mean so that our viewpoints aren't associated or used in instances like this.

        Thoughts?
        I want the most qualified doctors in training, not the most American ones. I do also agree that the positions of these groups are largely about self-interest more than anything, and letting self interest take a priority over getting the best doctors we can is not very good for the system as a whole
         
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        mjhunt103

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          I want the most qualified doctors in training, not the most American ones. I do also agree that the positions of these groups are largely about self-interest more than anything, and letting self interest take a priority over getting the best doctors we can is not very good for the system as a whole
          I want economic security for Americans as a whole. Good healthcare has little value without that. That requires that if U.S. citizen doctors have a good level of competence (all USMLEs passed, ECFMG certified, etc), they must be chosen over non-U.S. citizen doctors.

          That way, we recoup federal student loan money and give our citizens a chance at a good economic future.

          There are numerous posts here about networking being an important factor in getting residency. It follows that those chosen are not necessarily better, just luckier.

          I recognize there may be some MD's who shouldn't be doctors, but there many unlucky ones who could be.

          You surely know that many residency programs already only consider LPR or U.S. citizens (including the one Faarina Khan MD matched at recently). If all were forced to follow that policy, they would adapt.
           

          Mad Jack

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            I want economic security for Americans as a whole. Good healthcare has little value without that. That requires that if U.S. citizen doctors have a good level of competence (all USMLEs passed, ECFMG certified, etc), they must be chosen over non-U.S. citizen doctors.

            That way, we recoup federal student loan money and give our citizens a chance at a good economic future.

            There are numerous posts here about networking being an important factor in getting residency. It follows that those chosen are not necessarily better, just luckier.

            I recognize there may be some MD's who shouldn't be doctors, but there many unlucky ones who could be.

            You surely know that many residency programs already only consider LPR or U.S. citizens (including the one Faarina Khan MD matched at recently). If all were forced to follow that policy, they would adapt.
            A highly qualified IMG may have incredible research experience, outstanding clinical skills, and a depth of experience that a bottom of the barrel US grad lacks. Turning them away in favor of xenophobic policies could cost us both lives (which often also costs us money) and research talent (which can again, cost us money). US grads that don't match typically have a reason for such, be it marginal scores, board failures, or applying to programs in which they had no business applying to begin with. To take one of them in place of a far more qualified applicant is a slap in the face to meritocracy and to the patients we are supposed to serve. The purpose of medicare funding for residencies is to provide the best care possible to the Medicare population of the United States. Doctors are not in any way the focus of the funding that allows you to train, patients are. They, and the economy, benefit from having the most innovative and qualified physicians possible filling those positions.
             
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            mjhunt103

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              A highly qualified IMG may have incredible research experience, outstanding clinical skills, and a depth of experience that a bottom of the barrel US grad lacks. Turning them away in favor of xenophobic policies could cost us both lives (which often also costs us money) and research talent (which can again, cost us money). US grads that don't match typically have a reason for such, be it marginal scores, board failures, or applying to programs in which they had no business applying to begin with. To take one of them in place of a far more qualified applicant is a slap in the face to meritocracy and to the patients we are supposed to serve. The purpose of medicare funding for residencies is to provide the best care possible to the Medicare population of the United States. Doctors are not in any way the focus of the funding that allows you to train, patients are. They, and the economy, benefit from having the most innovative and qualified physicians possible filling those positions.

              Meritocracy is a fiction. That is not how the world works in medicine or anywhere else. Nepotism is the main factor in employment in both in residencies and every other field in life.

              Networking means sometimes one equally qualified graduate matches and another doesn't. Thus, it logically follows that there are many well-qualified graduates who are chronically unmatched with very low-quality lives. What is hard to understand about that?


              None of what you stated about the purpose of residency funding does changes the fact that the purpose of government itself is to provide economic security for all its citizens. Assuming it even matters, the answer to help U.S. citizen AMG & IMGs gain whatever clinical or other experience you claim justifies choosing non-citizen doctors. Investing in our own citizens is what ensures an economically prosperous future.

              What's hard to understand about that?

              I question whether not matching necessarily indicates an important reason.. Dr. Seth Koeut is an AMG (albeit from a Puerto Rican school) and graduated in four years, indicating at least reasonable academic performance.

              Yet, he still failed to match five times. He won his bankruptcy battle and his loans were discharged (falling back on the taxpayers, as it must), but his life was still destroyed. Unless, he can borrow more money for retraining (and my understanding is he will never be able to), he is trapped in a cycle of poverty forever. That is disgusting. It should be easy to see why so many unmatched doctors are suicidal.

              Do you deny that many residency programs do not consider anyone who is not a citizen or LPR? They seem to do just fine. If others must follow suit, they will find enough well-qualified Americans.

              In case you're wondering, I don't currently work in healthcare at all. I just want a good standard of living and want to have as many high-paid jobs as possible to choose from.
               
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              Mad Jack

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                Meritocracy is a fiction. That is not how the world works in medicine or anywhere else. Nepotism is the main factor in employment in both in residencies and every other field in life.

                Networking means sometimes one equally qualified graduate matches and another doesn't. Thus, it logically follows that there are many well-qualified graduates who are chronically unmatched with very low-quality lives. What is hard to understand about that?


                None of what you stated about the purpose of residency funding does changes the fact that the purpose of government itself is to provide economic security for all its citizens. Assuming it even matters, the answer to help U.S. citizen AMG & IMGs gain whatever clinical or other experience you claim justifies choosing non-citizen doctors. Investing in our own citizens is what ensures an economically prosperous future.

                What's hard to understand about that?

                I question whether not matching necessarily indicates an important reason.. Dr. Seth Koeut is an AMG (albeit from a Puerto Rican school) and graduated in four years, indicating at least reasonable academic performance.

                Yet, he still failed to match five times. He won his bankruptcy battle and his loans were discharged (falling back on the taxpayers, as it must), but his life was still destroyed. Unless, he can borrow more money for retraining (and my understanding is he will never be able to), he is trapped in a cycle of poverty forever. That is disgusting. It should be easy to see why so many unmatched doctors are suicidal.

                Do you deny that many residency programs do not consider anyone who is not a citizen or LPR? They seem to do just fine. If others must follow suit, they will find enough well-qualified Americans.

                In case you're wondering, I don't currently work in healthcare at all. I just want a good standard of living and want to have as many high-paid jobs as possible to choose from.
                Your lack of experience in graduate medical education explains your myopic views on the matter.

                For the most part, people landing residencies aren't doing it because of nepotism or cronyism. If you're on an adcom and an application from someone you know comes up, you have to recuse yourself. Nepotism can help you get letters and the like, increasing your chance of matching, but at most institutions it isn't much of a factor, if one at all. Most of the people getting those positions from connections are Americans to begin with.

                American graduates that don't match almost always have a reason for it, from poor boards to major red flags to personality problems to picking residencies that they are in no way competitive for. Someone with a 199 on Step 1 that took five years to finish school with multiple fails but happens to be an American or candidate with a 255, a pile of research papers that make them promising for starting new businesses or developing innovative drugs/devices (businesses that would remain overseas or never manifest entirely if they remained overseas), and a perfect academic record but who happens to be from overseas, who would you pick if you happened to be a program director? Which one will ultimately bring more economic activity to the United States? Which one is more likely to develop devices, procedures, and drugs that save lives? A US grad first policy is penny wise and pound foolish.
                 
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                NotAProgDirector

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                  Nepotism and networking play a very small role in AMG matching. Might play a bigger role in IMG matching.

                  A huge problem with "US citizen only" is that there are more GME spots than US grads. There are probably more spots than US citizen applicants. So you'd need to have a policy of all US citizens first, then allow non-US citizens. That's really difficult -- when you get to the last 50 US citizens, who presumably have issues else they would have matched, programs will be strongly tempted to wait -- rather get a good IMG than a problematic AMG. Are you going to force programs to take these applicants? How would that work?
                   
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                  FutureInternist

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                    I want the most qualified doctors in training, not the most American ones. I do also agree that the positions of these groups are largely about self-interest more than anything, and letting self interest take a priority over getting the best doctors we can is not very good for the system as a whole

                    Does a higher score on an exam make one more qualified?

                    What about the fact that FMGs (like Caribbeans students) study for months while US students may get 6 weeks.

                    There is a lot of stuff that even the most barely passed USMLE/COMLEX doc can handle and I do think there should be some “take care of our own” mentality that allows for FMGs only once all US students have either matched or decided to wait a year.
                     
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                    Mad Jack

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                      Does a higher score on an exam make one more qualified?

                      What about the fact that FMGs (like Caribbeans students) study for months while US students may get 6 weeks.

                      There is a lot of stuff that even the most barely passed USMLE/COMLEX doc can handle and I do think there should be some “take care of our own” mentality that allows for FMGs only once all US students have either matched or decided to wait a year.
                      Higher scores correlate with board pass rates. Board pass rates keep your program from ending up on probation. That's why board scores matter.
                       
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                      FutureInternist

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                        Higher scores correlate with board pass rates. Board pass rates keep your program from ending up on probation. That's why board scores matter.

                        Right… so not better docs just better test takers.

                        I’m still in the “ get all US students a spot and then fill up remaining with FMGs” camp.
                         
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                        mjhunt103

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                          Your lack of experience in graduate medical education explains your myopic views on the matter.

                          For the most part, people landing residencies aren't doing it because of nepotism or cronyism. If you're on an adcom and an application from someone you know comes up, you have to recuse yourself. Nepotism can help you get letters and the like, increasing your chance of matching, but at most institutions it isn't much of a factor, if one at all. Most of the people getting those positions from connections are Americans to begin with.

                          American graduates that don't match almost always have a reason for it, from poor boards to major red flags to personality problems to picking residencies that they are in no way competitive for. Someone with a 199 on Step 1 that took five years to finish school with multiple fails but happens to be an American or candidate with a 255, a pile of research papers that make them promising for starting new businesses or developing innovative drugs/devices (businesses that would remain overseas or never manifest entirely if they remained overseas), and a perfect academic record but who happens to be from overseas, who would you pick if you happened to be a program director? Which one will ultimately bring more economic activity to the United States? Which one is more likely to develop devices, procedures, and drugs that save lives? A US grad first policy is penny wise and pound foolish.
                          You don't need to know someone to know what country they are from. It is obvious that many internal medicine program directors give massive preferences to their countrymen.

                          Then again, maybe the real reason is that visa holders are more likely to tolerate abuse:


                          I reject all your analysis about innovation and economic activity and other stuff. Mostly, it's all a scheme to funnel more money to already rich people, future H1B visa holders, etc. It's not economic activity that is likely to benefit the average person.

                          In any event, the chance that any given high-scoring FMG will make any important discovery is so miniscule that it is not worth throwing away the lives of huge numbers of American medical students, even if it would benefit the average person.

                          If this is an argument that visa holders should receive equal consideration to U.S. citizens, I am even more adamantly opposed.

                          Then again, that is not the current policy. I have read that over 90% of AMGs match the first time and most of the rest match the second time. I also read that 99% are practicing medicine 6 years later, so it is clear that there is effectively an AMG-first policy.

                          And, by the way, I have never been to medical school. I have contemplated health professions in the past, but that is not the path I took. Make no mistake. If I were an unmatched MD, I would not harm my mental health by coming here.
                           

                          mjhunt103

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                            Nepotism and networking play a very small role in AMG matching. Might play a bigger role in IMG matching.

                            A huge problem with "US citizen only" is that there are more GME spots than US grads. There are probably more spots than US citizen applicants. So you'd need to have a policy of all US citizens first, then allow non-US citizens. That's really difficult -- when you get to the last 50 US citizens, who presumably have issues else they would have matched, programs will be strongly tempted to wait -- rather get a good IMG than a problematic AMG. Are you going to force programs to take these applicants? How would that work?
                            After I think about it, you do have a point. Here is one issue I have been thinking about:

                            Do you think there might be cases where program directors would rather not fill at all than take them?

                            Here is a story on reddit that makes me ask that question:


                            This person took almost seven years to graduate. He must failed huge numbers of classes along with failing step 2 CK twice. That story is sad, but it may not be safe to let him practice medicine.

                            But, if I found the right linkedin profile, he ended up as a Clinical data coordinator, which could be a good job. So, maybe the ending is not too sad.

                            HOWEVER,

                            I just have to believe that SOME currently unmatched doctors could be good physicians if given a chance and I want to see change to make it happen.

                            After all, they have to be as knowledge as many NPs and PAs, right?

                            I might explore capping programs at 50% (or another number) visa holders, which would hopefully induce programs to take more competent U.S. citizens (including IMGs) without inducing them not to fill.

                            And, I would like to see Assistant Physician programs in Missouri and a few other states become more common to offer the chance for real clinical experience in a supervised setting.
                             
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                            Mad Jack

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                              Right… so not better docs just better test takers.

                              I’m still in the “ get all US students a spot and then fill up remaining with FMGs” camp.
                              Unboarded doctors have been proven to have inferior outcomes, and those with lower board scores are less likely to pass their boards, ergo... And this is aside from the fact that probation is a nightmare for programs to deal with and can ultimately lead to closure
                              You don't need to know someone to know what country they are from. It is obvious that many internal medicine program directors give massive preferences to their countrymen.

                              Then again, maybe the real reason is that visa holders are more likely to tolerate abuse:


                              I reject all your analysis about innovation and economic activity and other stuff. Mostly, it's all a scheme to funnel more money to already rich people, future H1B visa holders, etc. It's not economic activity that is likely to benefit the average person.

                              In any event, the chance that any given high-scoring FMG will make any important discovery is so miniscule that it is not worth throwing away the lives of huge numbers of American medical students, even if it would benefit the average person.

                              If this is an argument that visa holders should receive equal consideration to U.S. citizens, I am even more adamantly opposed.

                              Then again, that is not the current policy. I have read that over 90% of AMGs match the first time and most of the rest match the second time. I also read that 99% are practicing medicine 6 years later, so it is clear that there is effectively an AMG-first policy.

                              And, by the way, I have never been to medical school. I have contemplated health professions in the past, but that is not the path I took. Make no mistake. If I were an unmatched MD, I would not harm my mental health by coming here.
                              Some program directors will have a bias toward schools internationally that are a known quality, just as those inside the United States may have a preference for students from some US schools. Again, you're looking at things from the outside and have never actually been involved in the process, so you're making assumptions that are untrue at best and ridiculous at worst. As to past research success being indicative of future research success, well... That's just a fact. It isn't even up for debate.
                               

                              mjhunt103

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                                Unboarded doctors have been proven to have inferior outcomes, and those with lower board scores are less likely to pass their boards, ergo... And this is aside from the fact that probation is a nightmare for programs to deal with and can ultimately lead to closure

                                Some program directors will have a bias toward schools internationally that are a known quality, just as those inside the United States may have a preference for students from some US schools. Again, you're looking at things from the outside and have never actually been involved in the process, so you're making assumptions that are untrue at best and ridiculous at worst. As to past research success being indicative of future research success, well... That's just a fact. It isn't even up for debate.
                                As far as passing boards, I am pretty sure most unmatched MD's have passed Step 3, the last USMLE exam. That is the standard advice if you don't match first time, isn't it?

                                As far as FMG's, they can do any research they want in their own countries. The issue that is the purpose of the U.S. government is to invest in its own citizens and help them build whatever research or clinical or other skills are necessary. That means Program directors who give preference to any foreign school are acting against our national best interest and must be forced to stop or leave, which program directors who have preference for U.S. citizens are furthering that interest.
                                There will always be some room for exceptional FMGs in the U.S, but the national interest requires that they be limited.
                                 
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                                Mad Jack

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                                  As far as passing boards, I am pretty sure most unmatched MD's have passed Step 3, the last USMLE exam. That is the standard advice if you don't match first time, isn't it?

                                  As far as FMG's, they can do any research they want in their own countries. The issue that is the purpose of the U.S. government is to invest in its own citizens and help them build whatever research or clinical or other skills are necessary. That means Program directors who give preference to any foreign school are acting against our national best interest and must be forced to stop or leave, which program directors who have preference for U.S. citizens are furthering that interest.
                                  There will always be some room for exceptional FMGs in the U.S, but the national interest requires that they be limited.
                                  Bringing the brightest minds to the US to live here and perform research here is how we have maintained our status as a research powerhouse for the better part of a century. The purpose of the US government is to uphold the Constitution of the Republic, and nothing in our Constitution or the finding principles of our Republic come even close to the values you espouse. Programs have been created to do certain things through representative democracy, and the Medicare program was designed to care for Medicare patients, not to financially or academically enrich US citizens. Doctors aren't widgets, and there are genuine capability differences between individuals, and given the choice between scraping marginal US candidates and exceptional foreign ones, you're probably going to be better off for programs and patients with the latter.

                                  Now with regard to boards, people who barely passed their basic boards may very welk struggle to pass their specialty boards. If you don't pass your specialty boards you're functionally unable to practice in almost all settings in many fields, as insirance will not accept you to panels and hospitals will not give you privileges. Boards are only offered once a year in most fields, so every failure costs a lot of money and beyond a certain point a lot of time in practice
                                   

                                  mjhunt103

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                                    Bringing the brightest minds to the US to live here and perform research here is how we have maintained our status as a research powerhouse for the better part of a century. The purpose of the US government is to uphold the Constitution of the Republic, and nothing in our Constitution or the finding principles of our Republic come even close to the values you espouse. Programs have been created to do certain things through representative democracy, and the Medicare program was designed to care for Medicare patients, not to financially or academically enrich US citizens. Doctors aren't widgets, and there are genuine capability differences between individuals, and given the choice between scraping marginal US candidates and exceptional foreign ones, you're probably going to be better off for programs and patients with the latter.

                                    Now with regard to boards, people who barely passed their basic boards may very welk struggle to pass their specialty boards. If you don't pass your specialty boards you're functionally unable to practice in almost all settings in many fields, as insirance will not accept you to panels and hospitals will not give you privileges. Boards are only offered once a year in most fields, so every failure costs a lot of money and beyond a certain point a lot of time in practice

                                    Bringing the brightest minds to the US to live here and perform research here is how we have maintained our status as a research powerhouse for the better part of a century. The purpose of the US government is to uphold the Constitution of the Republic, and nothing in our Constitution or the finding principles of our Republic come even close to the values you espouse. Programs have been created to do certain things through representative democracy, and the Medicare program was designed to care for Medicare patients, not to financially or academically enrich US citizens. Doctors aren't widgets, and there are genuine capability differences between individuals, and given the choice between scraping marginal US candidates and exceptional foreign ones, you're probably going to be better off for programs and patients with the latter.

                                    Now with regard to boards, people who barely passed their basic boards may very welk struggle to pass their specialty boards. If you don't pass your specialty boards you're functionally unable to practice in almost all settings in many fields, as insirance will not accept you to panels and hospitals will not give you privileges. Boards are only offered once a year in most fields, so every failure costs a lot of money and beyond a certain point a lot of time in practice
                                    I don't care what you say about finding principles of the Republic or the constitution. I care about what creates the society I want to live in. I want financial security and government policies that further that.

                                    Anything that decreases competition for high-paying jobs, whether in medicine, technology, or other sectors, is a good thing, because it increases my chances of financial security. What could be easier than reducing or eliminating H1B and other visas?
                                     
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                                      I don't care what you say about finding principles of the Republic or the constitution. I care about what creates the society I want to live in. I want financial security and government policies that further that.

                                      Anything that decreases competition for high-paying jobs, whether in medicine, technology, or other sectors, is a good thing, because it increases my chances of financial security. What could be easier than reducing or eliminating H1B and other visas?
                                      Took awhile but we got there.

                                      The truth of this is that US grads currently have a huge advantage over FMG/IMG as is. If you're a US grad who didn't match, its 99% because you did something pretty badly wrong. It makes no sense to radically change a system that's already heavily weighted in your favor just to get the relatively small number of US grads who don't match every year.
                                       
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                                      NotAProgDirector

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                                        Do you think there might be cases where program directors would rather not fill at all than take them?

                                        This person took almost seven years to graduate. He must failed huge numbers of classes along with failing step 2 CK twice. That story is sad, but it may not be safe to let him practice medicine.

                                        But, if I found the right linkedin profile, he ended up as a Clinical data coordinator, which could be a good job. So, maybe the ending is not too sad.

                                        HOWEVER,

                                        I just have to believe that SOME currently unmatched doctors could be good physicians if given a chance and I want to see change to make it happen.

                                        After all, they have to be as knowledge as many NPs and PAs, right?

                                        I might explore capping programs at 50% (or another number) visa holders, which would hopefully induce programs to take more competent U.S. citizens (including IMGs) without inducing them not to fill.

                                        And, I would like to see Assistant Physician programs in Missouri and a few other states become more common to offer the chance for real clinical experience in a supervised setting.
                                        In the case you've quoted, we're missing lots of data so it's hard to assess. As you mention, the person took 7 years to graduate. Even with the one extended year mentioned, that suggests another 2 years of extensions. We also don't have any assessment of their clinical skills -- doing poorly on exams but then great on clinical work is one thing, doing poorly on all of it is another.

                                        I also get the sense in their description that they are trying for psych, with a "backup" of IM or peds. That's a poor choice -- with a performance like that, they are not going to get a spot in psych. And if they do lots of things to try to improve their chances in psych (i.e. SubI, the psych observer program mentioned, etc), that will only decrease other field's interest.

                                        99% of US grads end up in some training program. So we're not talking about thousands and thousands of chronically unmatched US grads. There are some, and it;'s usually very poor performance like this that causes the problem.

                                        Capping programs at only 50% (or any other number) visa applicants isn't going to work well. Some programs fill with 100% IMG's. Unless you're going to force programs that currently take all US grads to somehow take IMG's, there aren't enough US grads to fill slots. Plus some of those IMG's are US citizens and don't need visas.

                                        Assistant physician programs are probably not the answer. They were created in MO to allow internationally fully trained physicians a pathway to practice -- the assumption being that they won't need all that much help getting started. To take a medical student with no training and place them into something like this -- unless they are going to provide the oversight at the same level a residency program does, it's going to be a disaster. Also, one of the important ways to learn how to be a good physician is to work with a bunch of people and pick up skills / processes -- if you're only working with one person, it's very easy to learn their bad habits as "normal".

                                        Although news articles make it out like there are zillions of US MD's who never match, in fact there are very few. Yes, there are >1000 US MD's who don't match in NRMP every year, but most of those match the next year or find a spot outside the match. The chronically unmatched are a small number. Although I can't be certain, I expect more are from carib schools than US schools.

                                        A two stage match (with US citizens / GC first) won't really work -- the weak US grads would end up in the seocnd round competing with the stronger IMG's and unlikely to prevail. Neither will any limit on visas -- first it would be very difficult to know what number of visas to limit to, and more importantly you get a visa after matching so what would happen is more people would match than visas available, and then there would be some sort of scrum to get the remaining visas, it would be a real mess. And when someone gets squeezed out of a spot because of lack of visa, it's unlikely that program would be willing to consider the unmatched US MD's you're describing. What a 2 stage match might actually address is the ~1000 unmatched US grads who want a spot this year rather than waiting for next -- since there would still be spots open, they could apply in that second round. But that's a different problem then the one you're discussing.

                                        The solution to this problem is loan forgiveness. If a student doesn't match for 2-3 years in a row, they should have the option to discharge their loans. The school should be on the hook for part of the cost - perhaps 50%, or even 100% if you'd like. And, in doing so, the student would forgo all future GME funding so they would be unable to discharge loans and then get into training. The number of students in this situation is very small, it's not going to make a difference to the "doctor shortage" (if there even is such a thing).
                                         
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                                        Redpancreas

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                                          The solution to this problem is loan forgiveness. If a student doesn't match for 2-3 years in a row, they should have the option to discharge their loans. The school should be on the hook for part of the cost - perhaps 50%, or even 100% if you'd like. And, in doing so, the student would forgo all future GME funding so they would be unable to discharge loans and then get into training. The number of students in this situation is very small, it's not going to make a difference to the "doctor shortage" (if there even is such a thing).

                                          This is the solution. To address a semi-related point...

                                          Schools need to be accountable to some extent for the outcomes they create and I think footing 50% of the tuition is reasonable as students obviously have the a large level of accountability for their failures. Maybe it will start putting pressure on administrators to actually starting looking for the root causes of issues in students in medical school instead of the shotgun approach of sending them to counseling, making them write a progress journal, etc., and document their shortcomings in case they have to cut ties.

                                          Once students match, medical schools think “out of sight/out of mind”. That's usually OK as a large majority of US MDs did most of the right things and are fine but the issue becomes when schools (i.e. administrators) try to push students to accept something they don’t want to do or just pass everyone because all it does is kick the can down to residency. I am tired of seeing medical schools doing the bare minimum providing lectures to M1/2s (that are inferior to commercially and exponentially cheaper sources btw) and then setting their students free in M3/4 to just wander around the hospital clueless with no curriculum or structure aside from shelf exams they have report to. There is no accountability schools currently have for the M3/M4 clinical education and a good amount of students come into residency knowing USMLE CK stuff but not much practical stuff. This would be all well if everyone was in the same boat but they're not. Some categorical classes get filled with a mix of IMGs who have at minimum completed a year of internship (equivalent to PGY-1 here) if not more (ie-some have been attending physicians in their own countries). Then there's US grads who sometimes transition from other fields and make it into other fields. That means in some programs, only 50% of the residents are truly new to residency-level experience. Amongst that group, supposed 10% come from med schools that are not getting the education they needed in M3/M4. While 10% seems like a lot, in this scenario it's 5% because of the other 50%. Take 5% of 20 person residency class and that’s 1 student. If one student out of 20 has a problem no one is going to bat an eye and that student’s screwed. I think the US clerkship system is failing some of us and currently there's really no incentive for schools to re-examine it.
                                           
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