U.S Clinical experience

[superoxide]

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Hi there,

I'm currently an MS4 at a decent Caribbean school who is going to participate in the 2009 match. I want to do peds. I've wanted to do peds even before starting med school and that hasn't changed one bit. I can't see myself doing anything else. Adult medicine?

I was just looking at the 2008 match data on the NRMP site and saw that peds (along with everything else) got a LOT more competitive when compared to last year's numbers. Last year there were 1.1 applicants per position for peds, while this year there were 1.46 applicants per position. My guess is that the majority of this increase comes from an increase from FMGs. I'm expecting these numbers to get even more competitive next year. I'm concerned about this because I'm not a very competitive applicant. Step 1: 203/83 on second attempt. Taking CK in May and CS in June. I'm a Canadian citizen, so I'll need a visa (J1). On the + side, I have 2 years of U.S clinical experience and LORs from U.S physicians (I'm expecting a very strong LOR from my peds core rotation) and hopefully have my CK/CS scores before September. U.S clinicals/LORs are the ONLY advantages I have over other FMGs.

I have been researching programs for the last few weeks and there are many programs which mention:

"You must have x number of months of U.S. clinical experience" or
"We require LORs from U.S physicians" or
"You must have passed USMLE on your first attempt"

On the other hand, there are also programs which don't have any specific requirements regarding all of the above.

Now here's my concern: How is this huge increase in applications (mostly from FMGs without U.S clinical experience and/or U.S. LORs...that's my assumption anyway) going to affect me (Someone with U.S experience/LORs)? How much do programs adhere to their own application requirements? Might a program which requires U.S. clinical experience/U.S LORs interview an FMG with 99/99 but with no U.S experience/LORs? (This is probably a very stupid question, but anyways). If the answer is a yes/maybe, then I'm screwed. If the answer is No, then I might be OK, because they wouldn't be competing with me. Should I only apply to programs which require U.S experience/LORs or should I apply even to the programs who have no specific requirements regarding U.S experience/LORs? With the latter option, I'll be competing with the 99/99 FMG.

I'm planning on applying to 40-50 programs.

Sorry if this post is a rambling/confusing/stupid one. Any info would be great (especially from aProg, Winged Scapula or OBP) or anyone else who can shed some light on this topic.

Thanks!

 

[oldbearprofessor]

Hi - You'll have trouble getting experience-based advice here on this issue from program directors in pedi because, to the very best of my knowledge, there are no PD or dept. chiefs in pedi who are SDN members or posters. aPD is in internal medicine and Wingy is in surgery and in private practice. I have no connection with the process you are involved in at all and only minimal knowledge about the issues involved.

My general sense is that pedi programs are much more interested in the person than the Step performance. This will be especially true for community programs and programs that don't always fill. I would apply broadly to these regardless of what they say about US experience. As to whether a program will interview people without US experience when they say they don't, my guess is that most who put that info in their website would stick to it except in unusual circumstances. However, there are no data about this and it's anyone's guess what will happen in any given year. I wouldn't use that to decide on where to apply. Focus on your positives and how you will impress the PD, not what others are doing.

Good luck!

 

[superoxide]

Thanks OBP. I hope you're right!

 

[DarthNeurology]

I might also consider applying to Family Practice which allows you to see all ages of children. Pediatrics match seemed tight this year, the percentage of FMGs/IMGs in peds is much smaller than in FP . . . I think about 70% of residencies in pediatrics are filled with US seniors, and the more desirable ones in university settings are almost 100% U.S. graduates . . . I don't think that pediatric PDs don't care about Step 1, but rather that Peds *was* noncompetitive for US grads, so a lot of them had on the lower range of Step 1 scores, and PDs had to select applicants with lower Steps to fill, and used more subject measures to fill these postions, but now with increased competition, the FMGs/IMGs who succeed will probably have higher Step 1 scores compared to those who don't I would guess. If Pediatrics was as competitive as Dermatology would PDs use >230 as a plus? Of course, all else being equal . . .

 

[superoxide]

I might also consider applying to Family Practice which allows you to see all ages of children. Pediatrics match seemed tight this year, the percentage of FMGs/IMGs in peds is much smaller than in FP . . . I think about 70% of residencies in pediatrics are filled with US seniors, and the more desirable ones in university settings are almost 100% U.S. graduates . . . I don't think that pediatric PDs don't care about Step 1, but rather that Peds *was* noncompetitive for US grads, so a lot of them had on the lower range of Step 1 scores, and PDs had to select applicants with lower Steps to fill, and used more subject measures to fill these postions, but now with increased competition, the FMGs/IMGs who succeed will probably have higher Step 1 scores compared to those who don't I would guess. If Pediatrics was as competitive as Dermatology would PDs use >230 as a plus? Of course, all else being equal . . .

Yeah, that's exactly what I'm afraid of.🙁

I really can't see my self doing anything else besides Peds and it's not like FM is easy to get into either. I believe there were 1.8 applicants per position this year 😱

I'm interested in doing community pediatrics, so I'm looking to get into a community based program. I'll take a lower tier (read: crappy) peds program over a decent FM program anyday.

 

[14022]

Yeah, that's exactly what I'm afraid of.🙁

I really can't see my self doing anything else besides Peds and it's not like FM is easy to get into either. I believe there were 1.8 applicants per position this year 😱

I'm interested in doing community pediatrics, so I'm looking to get into a community based program. I'll take a lower tier (read: crappy) peds program over a decent FM program anyday.

If you apply widely, I think you will be fine. If you look at the match data, numbers of US grads going into peds have not changed, in fact they have gone down a bit. So your increased competition will be FMG's. Advantages for you are that you went to a caribbean school with US clinical experience. You're Canadian, so presumably you speak English fluently. These two things will put you ahead of many FMG's. But do apply widely, and I wouldn't necessarily avoid academic programs, just be judicious over the ones you apply. There are decent academic programs in less desireable cities and even some in desireable cities (e.g, Miami Children's, Univ of Illinois at Chicago) that take a lot of FMG's. Spend time doing research, and look up programs to see where their residents are from. And look at your school's match list to see where your residents have typically gone. Study hard for step 2 as well.

Just out of curiousity, are you applying to canadian residency programs? If not, why not?

 

[DarthNeurology]

Yeah, that's exactly what I'm afraid of.🙁

I really can't see my self doing anything else besides Peds and it's not like FM is easy to get into either. I believe there were 1.8 applicants per position this year 😱

I'm interested in doing community pediatrics, so I'm looking to get into a community based program. I'll take a lower tier (read: crappy) peds program over a decent FM program anyday.

There aren't a whole lot of Ped programs that look "crappy" after this match😉, . . . a lot of students I know find appealing things in a couple different fields, i.e. ob/gyn vs. surgery, . . . why would FP be so unappealing? FPs probably see more kids than pediatricians in the U.S., plus there were/are still some FP slots open this weekend whereas the peds categorical positions are gone, good to have a back-up, and I would say FP is much easier to get for IMGs/FMGs, i.e. the percentage of US med students going in to peds is much higher than FP . . . so the ratios are probably worse for peds and IMGs/FMGs . . . I want to do pediatrics too, but I've had to consider FP as well, (I think I could be just as good a child's doctor as a pediatrician as I read a lot), so I feel your pain!

 

[superoxide]

If you apply widely, I think you will be fine. If you look at the match data, numbers of US grads going into peds have not changed, in fact they have gone down a bit. So your increased competition will be FMG's. Advantages for you are that you went to a caribbean school with US clinical experience. You're Canadian, so presumably you speak English fluently. These two things will put you ahead of many FMG's. But do apply widely, and I wouldn't necessarily avoid academic programs, just be judicious over the ones you apply. There are decent academic programs in less desireable cities and even some in desireable cities (e.g, Miami Children's, Univ of Illinois at Chicago) that take a lot of FMG's. Spend time doing research, and look up programs to see where their residents are from. And look at your school's match list to see where your residents have typically gone. Study hard for step 2 as well.

Just out of curiousity, are you applying to canadian residency programs? If not, why not?

Thanks Scholes! That's very good information. There have been quite a few students from my school who have matched into peds. I'm definitely going to apply to all those programs.

Re: Canadian Residency - In this years match for peds there were just 9 (yes, NINE!) positions for peds in the IMG quota. In the Canadian match, some specialties have a separate quota reserved for IMGs only. The thing is that in order to apply for these positions, you have to be a Canadian citizen/PR. There are no visas available for these positions like there is in the U.S. The ratio of applicants: positions is very high, and since everyone is a citizen/PR, no one really has an upper hand. It might help to do some rotations in Canada and have LORs from them, but it's no guarantee. The sad part is that even after all of this, I probably have a much better chance to get a spot in the United States on a visa than in Canada. The FM match is a little bit less competitive in Canada, but there are way more applicants than spots. I personally know 3 people from my own school who did 12 weeks of FM rotations in Canada and didn't even get a single interview invite, let alone a position in the match. I'm going to apply to the Canadian match as well, but lets just say I'm not holding my breath.🙄

Thanks for your post! 🙂

 

[superoxide]

There aren't a whole lot of Ped programs that look "crappy" after this match😉, . . . a lot of students I know find appealing things in a couple different fields, i.e. ob/gyn vs. surgery, . . . why would FP be so unappealing? FPs probably see more kids than pediatricians in the U.S., plus there were/are still some FP slots open this weekend whereas the peds categorical positions are gone, good to have a back-up, and I would say FP is much easier to get for IMGs/FMGs, i.e. the percentage of US med students going in to peds is much higher than FP . . . so the ratios are probably worse for peds and IMGs/FMGs . . . I want to do pediatrics too, but I've had to consider FP as well, (I think I could be just as good a child's doctor as a pediatrician as I read a lot), so I feel your pain!

I'm planning on applying to FM as a backup as well, although after this years match, FM has actually become more competitive than peds (when you look at the positions:applicants ratio). I just don't find adult medicine appealing. I HATED my IM rotation!! Also, I'm not very good with knowing a "little bit about a lot". I would find FM more of a challenge than peds just because it's such a broad field. You literally have to know something about EVERYTHING! I'm more comfortable with having some focus.

I'm going to do everything I can to get a spot in peds, but if not, I'll be more than happy to get an FM spot. Got to pay those darn loans somehow.

 

[oldbearprofessor]

why would FP be so unappealing? FPs probably see more kids than pediatricians in the U.S.,

The part in bold about pediatric visits is a common myth.

Phillips et al. Pediatrics. 2006 Sep;118(3):1200-6.
Family physicians provide 16% to 26% of visits for children, providing a medical home for one third of the child population, but face shrinking panels of children.

 

[oldbearprofessor]

If you want to be a pediatrician, the only way to become one is to complete a pediatric residency. If one can't match directly into pediatrics, then do something else for a year (or two?) and then try again based on the improved application you'll have. Of course, you could like your other field and choose to stay in it, or you might not. But, I don't believe that a person who wants to only provide medical care for children should not give it more than a one-year shot at becoming a pediatric resident.

We'll follow your saga(s) and see what happens!

Good luck

 

[DarthNeurology]

When you look at Step 1 results 1/4 of matched applicants to a pediatric residency have a 203 or less (203 is 25th percentile), and the median and mean are both 217 for 2007. . . when you look at family practice residents who matched in 2007 1/4 of match applicants had a Step 1 equal to or less than 196!!! and the median was 209!

So I would infer that family practice is less competitive in that pediatrics program seem more competitive and basically fill with much, much more US grads than IMGs, i.e. around 70% whereas more IMGs are found in family practice, so in theory an IMG might find a spot in FP more easily than pediatrics and hence many IMGs apply for FP residencies . . .a lot pediatrics programs I am interested in only rarely take an IMG, (2 in like 5 years) so even though my step scores are very good (96/99) I don't think I will have much of a shot there, . . . I think it is good to apply to pediatric residencies that take IMGs

 

[superoxide]

We'll follow your saga(s) and see what happens!

Good luck

Thanks OBP...Stay tuned!😀

 

[superoxide]

When you look at Step 1 results 1/4 of matched applicants to a pediatric residency have a 203 or less (203 is 25th percentile), and the median and mean are both 217 for 2007. . . when you look at family practice residents who matched in 2007 1/4 of match applicants had a Step 1 equal to or less than 196!!! and the median was 209!

So I would infer that family practice is less competitive in that pediatrics program seem more competitive and basically fill with much, much more US grads than IMGs, i.e. around 70% whereas more IMGs are found in family practice, so in theory an IMG might find a spot in FP more easily than pediatrics and hence many IMGs apply for FP residencies . . .a lot pediatrics programs I am interested in only rarely take an IMG, (2 in like 5 years) so even though my step scores are very good (96/99) I don't think I will have much of a shot there, . . . I think it is good to apply to pediatric residencies that take IMGs

I totally agree with you about it being easier to get a spot in FM, but the bar just got a lot higher this year for all specialties. I'm sure those USMLE mean/median scores for matching are going to go up this year and that's not very good for someone with my stats. All is not lost though. I've read here on SDN about FMGs with similar stats as mine matching this year into some very good peds residencies. Can't do anything about the past, so I just got to do my best and improve my application and hope it works out in the end.

Two words: Pre match...in peds 😍

 

[superoxide]

I want to do pediatrics too, but I've had to consider FP as well, (I think I could be just as good a child's doctor as a pediatrician as I read a lot), so I feel your pain!

With your scores you would be a very competitive applicant at many higher tier programs, even as an IMG, in my opinion. Maybe not the programs you might want, but still. You can apply to some middle tier peds programs as a back up. Why are you applying for FM as a back up? 😕

I agree with OBPs above post. There is no way you will acquire the peds knowledge/training as a FM doc. No amount of reading can replace proper training. You want to take care of kids properly? Do a peds residency!

 

[DarthNeurology]

I totally agree with you about it being easier to get a spot in FM, but the bar just got a lot higher this year for all specialties. I'm sure those USMLE mean/median scores for matching are going to go up this year and that's not very good for someone with my stats. All is not lost though. I've read here on SDN about FMGs with similar stats as mine matching this year into some very good peds residencies. Can't do anything about the past, so I just got to do my best and improve my application and hope it works out in the end.

Two words: Pre match...in peds 😍

That would be sweeeeeet . . . 🙄 . . . you got me daydreaming . . . I never really considered that they could do this for peds, but I guess they could!

I might consider FP if not getting a peds residency (of course I guess as you point out FP is getting competitive too) . . . I don't know if I would wait out 1-2 years for peds, but I sure would feel that I never got the opportunity to become a well-trained pediatrician even if I saw mostly kids I guess . . .

Contrary to popular myth I would say, in my own little world, that outside reading goes a lot further than you would think, if you've read Peds texts like Nelson's or Harriett-Lane, then it helps, as does reading New England Journal and Pediatrics, . . . if I read Gomella's Neonatology during a neonatal elective, read journal articles, you can really push the boundaries of what you know compared to residents even . . . do not underestimate the power of the dark side of the force!

 

[oldbearprofessor]

I agree with OBPs above post. There is no way you will acquire the peds knowledge/training as a FM doc. No amount of reading can replace proper training. You want to take care of kids properly? Do a peds residency!

I agree that reading doesn't replace hands-on training. EXPERIENCE after residency can replace some of residency training. How much depends on the person and their practice environment. Still a pediatrician is uniquely trained in pediatric care and I am very proud to be a pediatrician as well as a neonatologist. The AAP may not be as proud of me because I haven't voluntarily recertified 🙄, but that's a different story. 😛

And, please don't set up a fight with other fields, whether it be Family Medicine, EM, NPs, PAs, etc. All of these and many others take care of kids "properly". But, a pediatrician has a unique role in the care of children and those who wish to provide medical care solely to children and have broad opportunities to pursue specialty training as well as train future pediatricians should consider a pediatric residency. I may not know details about Step 1 scores and residency matching for IMGs, but I am certain that you can get into very excellent fellowship training programs from many many pediatric residency programs, not just the best known ones.

 

[superoxide]

And, please don't set up a fight with other fields, whether it be Family Medicine, EM, NPs, PAs, etc. All of these and many others take care of kids "properly".

I wasn't at all implying that FM docs didn't take care of kids properly. 😳 What I meant was if someone just wants to take care of kids, they are not going to get enough exposure to peds in an FM residency. Anything beyond the bread and butter stuff, I think the FM doc would refer to a pediatrician.

I got nothing against FM, EM, NPs or PAs etc 😍

a pediatrician has a unique role in the care of children and those who wish to provide medical care solely to children and have broad opportunities to pursue specialty training as well as train future pediatricians should consider a pediatric residency.

^^That's what I meant to say 🙂

 

[DarthNeurology]

I agree that reading doesn't replace hands-on training. EXPERIENCE after residency can replace some of residency training. How much depends on the person and their practice environment. Still a pediatrician is uniquely trained in pediatric care and I am very proud to be a pediatrician as well as a neonatologist. The AAP may not be as proud of me because I haven't voluntarily recertified 🙄, but that's a different story. 😛

And, please don't set up a fight with other fields, whether it be Family Medicine, EM, NPs, PAs, etc. All of these and many others take care of kids "properly". But, a pediatrician has a unique role in the care of children and those who wish to provide medical care solely to children and have broad opportunities to pursue specialty training as well as train future pediatricians should consider a pediatric residency. I may not know details about Step 1 scores and residency matching for IMGs, but I am certain that you can get into very excellent fellowship training programs from many many pediatric residency programs, not just the best known ones.

I think, what students are really competing for in a pediatric residency versus a family practice residency is:

1. More face time with pediatric patients, and peds attendings, i.e. much more time in a peds residency goes to seeing pediatric patients. Students find this appealing if they like working with pediatric patients and they believe that they will learn more on a pediatric residency in terms of specialized care of children.

2. Ability to apply for pediatrics fellowships.

3. Being able to say you a doctor who specializes in the treatment of children.

What I think these arguments fail to address is that some of training in family practice augments pediatric training, i.e. taking care of adult patients teaches you general clinical skills that can be applied to children as well as given you a greater breadth of general medical knowledge to use, i.e. more ob/gyn when dealing with teenager pregnancies. It doesn't take in account the learning curve as well, how far up the pediatrics learning curve do family practice residents go? Pretty far I would wager as they do see children and I am sure the FP board covers pediatric care. There are plenty of family practioners (most?) who know more about general pediatric care than peds residents, especially 1st and 2nd year residents who could teach peds residents about pediatrics. It is silly to think that an FP with 20 years experience seeing children wouldn't know more than 99% of all pediatric residents if they were diligent in maintaining their knowledge base. However, it doesn't make sense to say that reading doesn't replace "hands-on learning" everybody in medical school has had "hands-on learning", at least in a pediatric clerkship and then later in residency, . . . Most students don't read up on every single patient, when you do then you get many times more out of "hands-ons" experience, . . . I would wager that if I were a FP physician, and keep up with pediatrics reading then I would be able to know more about pediatrics in general than most pediatricians out there, (>50% flame away!) and could probably sit and pass with flying colors their boards ( I do have First Aid for the Pediatrics Boards so I do know what "they" (peds residents) are trying to learn) . . . it matters if the person is diligent about learning the material and how much you get out of the rotations in residency. I have rotated with internal medicine residents who although they have had more experience than me in months in IM, . . . missed some important things with patients i.e. DDx and treatment issues that I addressed with the attending (in front of bewildered residents) because I had (gasp) read about them in a book, i.e. undiagnosed renal artery stenosis, etc . . . everybody likes the myth of learned scholar who falls on his/her face because they don't have "real world" experience, but I don't think this is the case in clinical medicine where learning about a topic the night before can be immediately applied to a patient's disease that you have never seen at least in workup and initial management . . . gaining "hands on" real world experience is 90% doing things that medical students can do i.e. H and P, admitting, ordering tests, and observing what antibiotics the attending orders and when they get worried about a patient going downhill.

 

[superoxide]

I would wager that if I were a FP physician, and keep up with pediatrics reading then I would be able to know more about pediatrics in general than most pediatricians out there, (>50% flame away!) and could probably sit and pass with flying colors their boards

Uh Oh! I'll let OBP take this one.

 

[TexasRose]

Uh Oh! I'll let OBP take this one.

Or we could just let it go.

 

[riverie]

The part in bold about pediatric visits is a common myth.

Phillips et al. Pediatrics. 2006 Sep;118(3):1200-6.
Family physicians provide 16% to 26% of visits for children, providing a medical home for one third of the child population, but face shrinking panels of children.

I agree. Anecdotally, at my FM preceptor's 10-physician group practice, only about 5% of their busy practice is comprised of pediatric visits.

 

[DarthNeurology]

I agree. Anecdotally, at my FM preceptor's 10-physician group practice, only about 5% of their busy practice is comprised of pediatric visits.

Interesting article quoted by OBP, . . . apparently there may be an oversupply of general pediatricians and family practice doctors competing for child visits!? I.e. the growth of the pediatric generalist population will greatly exceed the pediatric population by 2020 . . . very different from some numbers for internists treating adults. I guess this is not a good time to go into Pediatrics as there is too much competition with people who want to treat kids?

 

[Freibi]

DN, are you leaning towards doing FM, but you feel like people are implying you need to do Peds? At least, if you want to take care of children? Then relax, you can do BOTH adult and pediatric primary care as a family physician, and nobody would rightfully dispute your qualification to do so!

 

[DarthNeurology]

DN, are you leaning towards doing FM, but you feel like people are implying you need to do Peds? At least, if you want to take care of children? Then relax, you can do BOTH adult and pediatric primary care as a family physician, and nobody would rightfully dispute your qualification to do so!

True, now I'm thinking I might want to specialize in pediatrics, and I got to face reality that that is not going to happen in family medicine no matter how much I know, . . . I guess if I don't match I will spend a couple years trying to enhance my peds application, probably with more pediatric clinical experience!🙂 which probably would be better than seeing the 5-15% or whatever that FPs spend of their time with children. .. finding opportunities for pediatrics research and work in a children's hospital is a major pain in the 'ole booty, uh.