Thursday, January 5, 2012


I have a friend, another MiM, who is nothing short of inspiring.

Born in the former Yugoslavia, she was raised in Germany and ultimately went through medical training there. Like all of us, she has stories to tell about her specialty, OB/GYN, that range from hilarious to horrifying. Like us, she has a family - two children, both born in Europe during her medical career. Although training in Germany, as in the US, was demanding, she found the time and courage to return to her home country for a short time during the Balkan War. She worked on casualties in a hospital there while bombs dropped in the distance.

When her husband wanted to accept a job offer in the US about 6 years ago, she didn't hesitate. She dropped everything, including her career, and helped organize the move to a different continent. She supported her children, who didn't speak a word of English at the time they arrived. Since then, their family has thrived. Her son and mine play ice hockey together. We are both now rearing teenagers and commiserating about their lack of frontal lobes!

She did all this thinking that eventually she would resume her career here in the States. To prepare for this, she passed all the USMLE steps and met all the criteria for the match. I remember when, more than 2 years ago, she asked for my help in preparing her personal statement. Having fortunately sailed through my own match as a newly minted American grad, I thought, "Boy, this should be easy - who wouldn't want such a brilliant physician in their program, one with such a broad range of experience?" I'm sure she thought, "I've been through OB/GYN residency, a war, and a move to a different continent - how hard can this be?"

Boy, were we naive.

Since then, my friend has been through two matches without even a single interview. She has done research in an academic GYN lab and is published as a result. She spent a summer in the Himalayas doing medical mission work. Despite everything she tried, she had no success.

I am astonished at what I have learned through her frustrating experience. At the two hospitals where I work, I frequently encounter physicians who are foreign medical graduates (FMG's). Because of this, I assumed there were plenty of opportunities for all comers. Not so.

Speaking to two different residency program directors, I heard the same story. These days, it's all about year of graduation from medical school. If you are more than 2 years out, your application is not even considered. It goes straight to the trash - American or foreign grad.

The other factor is the competitiveness of the market. With the economy in its current miserable state, applications to med school are through the roof. Med schools, seeking extra tuition, are expanding the number of spots available. New med schools are opening in response to the perceived worsening shortage of physicians. However, residencies are not adding positions - they are federally funded, and there is no extra government money for expansions.

This translates into lots of applicants for available residency spots - brand new, shiny American graduates. One program director told me that by 2015, there will be more American med students graduating than there are residency positions to be filled. She said, "At that point, we won't even be looking at Carribean graduates, much less FMG's. If she doesn't find a job by then, she's doomed."

Wow. I had no idea.

We hear a lot in the media these days about the projected national shortage of physicians. We are all concerned about this. How will it affect our jobs? How long will our wait times for new patients become? Who will take care of us when we (or our family members) become ill? How will we divide work with physician extenders?
If this shortage is such a huge problem, why on earth are we shutting out an excellent source of new and yet experienced physicians? There must be hundreds of physicians like my friend, eager to work and already skilled in their fields of expertise. These are intelligent, productive people who will support their communities and pay taxes. If there are not enough residency positions available to accommodate them, why can there not be a parallel program tailored to bringing FMG's into the workplace? Perhaps an apprenticeship model would work...

(I do understand the concerns about FMG's. The American system is different even from Europe's, so it is hard for them to adjust. Language barriers can be significant, even crippling. The quality of FMG's is not consistent, so it is hard to know how much remediation may be necessary on the front end. If a physician has been away from training or practice for too long, the knowledge gap may be large. However, medical training is never easy with any group of students - these concerns are not insurmountable.)

Beyond this, I have concerns about future MiMs in particular. If date of med school graduation is a key factor in residency applications already, this means possibly catastrophic difficulties for women who want to take time off for pregnancies or to care for small children. Admittedly, 2 years is a long time, but it seems to me that even one year off could be considered a serious liability in this competitive climate. Add to that the pressure of student debt. What happens to the med students who cannot match, cannot get a residency position, but owe large amounts? With what means will they pay off that debt?

My talented, courageous friend is the canary in the mine. The difficulties she has experienced with the match process are a harbinger of things to come for many of those who seek to follow in our footsteps.

Encouraging note: My friend is now actively in a preliminary general surgery residency position. We are hoping that this will be the foot in the door that will lead to either a categorical surgery position or a primary care match for her.


  1. Your concerns and comments are exactly what my medical school dean told us when we started the residency interview application process - NO ONE, American grad or foreign, is guaranteed a spot at this point. And, getting your number 1 choice is even less likely. Simply put, when you look at the "Charting Outcomes In The Match," you see a very scary trend - the number of applicants has skyrocketed, but the number of residency slots has stayed almost constant. Lobbying Congress to increase the funding for residency programs should be our top priority.

  2. One more thing to add - this is why so many of us have applied and interviewed at many more programs than ever. For example, my dean told us Ob/Gyn applicants, regardless of our stats, to apply to at least 30 programs, and go on as many interviews as possible. Yikes.

  3. As a medical student graduating in 2015, I'm terrified about the state of residency programs by the time I graduate.

  4. have your friend apply to family med that is ob/gyn friendly!

  5. It's true, many FMGs are skilled doctors but they don't get the chance to practice because of the barriers they have to face (linguistic, cultural, and institutional).
    Hopefully this will change as people realize doctors are what we need the most to care of aging populations and young, obese patients who are susceptible to a host of diseases.

  6. Could there not be an alternative route for FMGs who've completed their training in their home country? As it stands now, one has to complete an American residency to get a medical license. Why? The FMGs could be required to do a probation period and take the relevant boards for their specialty. Wouldn't that be enough (along with their credentials) to determine if they are indeed qualified for a medical license? It would be much, much cheaper than adding more residency spots, surely?
    European licensing does this kind of thing. For example, you could qualify and specialise in the US and then take various exams and work as a specialist in Europe, rather than having to retrain.

  7. Excellent post. I'm a female fourth year medical student (currently finishing up on the interview trail for neurosurgery). At a recent interview, I heard the president of the AMA, Dr. Carmel speak on exactly this subject. He gave us the phone number for the Congress/AMA grassroots hotline. I don't know how we get the word out to everybody in medicine, but it's really important that we all make the thirty second phone call to congress and tell them to increase graduate medical education spending (they've just decreased it by 5% when it really needs to be increased). On the interview trail, I've met some amazing FMGs, some who were neurosurgeons in their former countries and some who have mile long CVs with numerous publications at world class institutes. Many of these folks have just a handful of interviews if even that. Health care reform has completely ignored one big problem--you need doctors to practice medicine. The predicted shortfall of physicians is in the tens of thousands and the 1-3% medical school class size increases won't even touch the problem.


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