IMGs and the Match: What are my chances?

Much more than US students, IMGs have a much harder to time figuring out a satisfying answer to the “what are my chances?” game. If you haven’t already read it, I’d strongly recommend reading the “Charting Outcomes in the Match for International Medical Graduates” available at http://www.nrmp.org/match-data/main-residency-match-data/.

For an example of IMG board score considerations:

Overall, matched U.S. IMGs had mean USMLE Step 1 scores of 224.5 (s.d. = 17.0) and matched non-U.S. IMGs had mean USMLE Step 1 scores of 233.8 (s.d. = 17.1), both well above the 2016 minimum passing score of 192.

Overall, matched U.S. IMGs had mean USMLE Step 2 CK scores of 232.6 (s.d. = 15.0) and matched non-U.S. IMGs had mean USMLE Step 2 CK scores of 238.8 (s.d. = 15.6), both well above the 2016 minimum passing score of 209.

This tells you a couple of important things right off the bat:

  1. Being a US citizen makes a big difference for an IMG. Needing a visa or having your English proficiency called into question requires a bump in your Step scores.
  2. Successful IMGs have higher scores than US medical graduates, but as you can see, not by as much as you might guess.

That being said, averages can be misleading. The average IMG is typically applying to less competitive fields on the whole, so within many specialties, the requirements will be substantially higher.

IMGs will doubly benefit from an “in” or personal connection at a particular program. For better or worse, IMGs have historically been funneled into high-need fields like family medicine and psychiatry. They also make up a disproportionate fraction of residents at less competitive community programs.

Note that there are some exceptions to the need to complete a residency in the states in order to practice in America. For example, radiology has an IMG alternative pathway, which is four years of fellowship at a US institution after completing residency training in a foreign country. While this is functionally equivalent to a radiology residency in duration, the competitiveness is different, as you are applying for generally less-competitive fellowships and not residency spots. See https://www.theabr.org/ic-img-dr.

Ultimately, no one online (definitely not me, and not even most residency consultants, I’d venture) can likely give you a great answer for your particular circumstances. Chances are your school and former classmates know the track record and what their luck has been in recent years. That’s probably your best bet.

With new medical schools opening while residency spots staying flat, competition is such that more and more programs aren’t even reading international applications except on a case by case basis for exceptional (hello research) applicants.

Broad application strategies and backup plans are a must.

How to start a website

Despite the widely publicized demise of the blog, personal websites continue to exist, and writers like myself continue to publish them. I’ve also received a steady stream of requests for background information and approaches to maintaining a “successful” long-running website over the past decade, so here are my thoughts. What follows is most definitely my (long) personal opinion and is not necessarily prescriptive:

 

Motivation and Content

While most people have questions about the mechanics of choosing a platform and maintaining a website, those are ultimately the easier problems to solve. The content is ultimately the critical challenge.

You have to enjoy the writing, and you need to either pick a niche you really like or give yourself the flexibility to adapt. If your goal is traffic and money, you’ve probably already lost.

The vast majority of new personal websites (i.e. blogs) are abandoned within months.

There are a lot of reasons for the high blog mortality rate, but one of the ones I think people don’t anticipate is pigeonholing yourself into a niche that is overly narrow or unsustainable. When you choose doctoreatinghealthy.wordpress.com or howIgotthroughmedschool.blogspot.com (not real sites, I think?), what do you do when you’re tired of posting about steel cut oats or graduate? How can your site grow with your interests?

Of course, the flip side is that you also need to find your voice. Just rewriting things other people have already said won’t keep you interested for long and probably won’t bring a lot of readers either.

 

Platform and Hosting

It’s worth discussing what both software you’ll use for your site and what hosting you’ll need vs. purchase at the same time because neither choice lives in a vacuum. The most important question that determines what suits your needs is the level of control you want. There are good fully-hosted turnkey solutions that allow you to create a website with minimal fuss and no technical skill and just get to writing. And then there are DIY options that require a bit more effort up front but leave you with the power to change every detail of your site and take it to new directions in the future.

You don’t need to learn to code to design and run a website anymore, no matter which avenue or platform you choose.

Several years ago, I would have recommended that anyone serious about running a website use WordPress.org and set up their own hosting. WordPress is a CMS (content management system) that can basically do anything and runs almost every site on the internet. It’s great, it’s easy to use, and it’s free.

The turnkey options were too inflexible to create what I would have considered a “good” site. You could always tell who was using an out-of-the-box platform or design with the handful of near-universal themes, the laziness of the free wordpress.com URL, the bylines that would say “posted by Admin” on every single post (of a single author blog). It was depressing. With everyone posting more and more on Facebook and Twitter, no wonder people thought blogging was dead.

Over the past few years, advances among web platforms coupled with a general trend toward clean, minimalist design have really leveled the field.

Options

For web hosting, there are plenty of options. I have always used Dreamhost, which has one-click WordPress installation with automatic upgrades and a simple backend. You can purchase and manage new URLs and host multiple sites on the same cheap plan. I’ve paid $7 a month to host multiple sites with unlimited bandwidth and storage for over a decade and serviced millions of hits with basically 100% site uptime.

If you sign up here for a year of the shared unlimited hosting at $7.95, you get $50 off. Unlimited means unlimited websites, storage, traffic, email, etc. You’ll also get a free domain registration thrown. You’ll also have an optional free SSL certificate (that you’ll need if you ever want to sell anything). It’s an awesome deal that I took advantage of over a decade ago, and I’ve never looked back.

Bluehost is another common WordPress host. You’ll hear about them on basically every “how to start a website post” because they offer a really popular affiliate program. While their program doesn’t include a reader discount, their packages are a couple dollars cheaper than Dreamhost (except they don’t always include the increasingly important SSL certificate unless you pay more, depends on the shifting specials). Both companies offer various tiers of server upgrades if you find your site grows and you need more power.

If you don’t use the WordPress.org platform, you basically won’t need to pay for separate hosting, because the other reasonable options are full-service and the hosting comes included. One easy solution is to use WordPress.com (either for basically free or upgraded to a better plan as you need it), which is the commercial arm of the free WordPress CMS software: less control but more support. Personally, if I wasn’t into DIY, I’d pick Squarespace, which is a reasonably priced CMS with an excellent interface and nice clean themes. If you want to start a low-fuss online store, then go for Shopify.

Whatever you choose, just pay enough so that you don’t have lame corporate branding on it (like you often see with Wix sites).

URLs

Buy a real URL, even if you haven’t started yet or are not sure if blogging is for you. It costs about ten bucks a year. If that seems too steep, then you aren’t taking the idea of writing seriously. Please just buy a real URL, preferably .com (but .net or .org or probably .co is fine).

Every paid hosting option, whether WordPress via Dreamhost or Bluehost, Squarespace, etc will throw in a new domain registration if you sign up for a hosting package. Two birds with one stone, no excuses.

Part of running a successful site is being searchable and navigable. Your URL should be easy and memorable, and every post and page you write should be available at the same spot FOREVER. You aren’t going to build up link-juice from search engines by having crufty gross super-long URLs that you’ll need to completely change in a few months or years when you finally get serious. I know it’s not free, but again, if taking your project seriously isn’t worth forgoing a coffee or two a month, then why are you even contemplating it.

 

More Thoughts on Content

Far be it for me to give advice on what you (or anyone else) should write about. I write a poorly monetized personal website that meanders around a variety of topics including medicine, technology, writing, and personal finance, and it’s changed a fair bit over the past decade.

That far-ranging scope and the permission I’ve given myself to convert the questions and quests of my journey in medicine (and, to a lesser extent, writing and indie publishing) are what have kept me coming back to write for an audience of strangers here year after year.

On the flip side, a narrow scope may get you a more laser-targeted audience. If you want to make money, a narrow niche is much easier to sell to advertisers, pivot into a monetizable newsletter, or to target with upsells like the gazillions of e-courses you’ve seen cropping up online.

If it’s part of a business for which you might be willing to pay for traffic, a well-carved niche will also be easier to target for ads to attract the right kind of visitor and get a return on those sketchy sponsored Facebook posts.

But a narrow scope is also the fastest way to find yourself spinning the same handful of ideas into repetitive permutations and fluffy listicles. This–along with depression about having no traffic–is why so many people abandon their blogs. Most sites never make it to their one year anniversary.

I was happy to write about medical school stuff for a number of years. And I still do so on occasion when I think I have something valuable to add, but as I get more and more removed from that time of my life, it would be hard to imagine continuing to write here if the site was something that had “med school” somewhere in the title or where I felt constrained to stay on topic. However, starting from scratch with a new site or totally rebranding instead of just iterating and evolving would also be lame.

Now that’s in part the difference between starting a personal blog and a true business. If the goal is to make money, then sure, you can try to build up an audience and credibility while you have the energy and then later on try to sustain or grow the enterprise by bringing in outside writers, publishing lots of guest posts, etc. Just be aware that most people with this goal fail, and again–I can’t stress this enough–you should want to write.

Frequency & Activity

Many people try to drive traffic by publishing frequently. It is indeed true that search engines like to see a well-maintained, active site. And, it’s also true that if you post everything you publish to social media, you will likely get a greater number of clicks, and those clicks may even be a critical driver of the traffic you do see.

But that pressure results in a lot of people writing a lot of things that even they don’t care about. I don’t personally want to write the same thing more than once or twice, and it would be a debilitating killjoy to feel compelled to churn out trite, Madlib-like combinatorial garbage, throwing it against the wall week in and week out and hoping it sticks.

In my experience, organic search traffic comes from “high-quality” writing, especially that which gets linked to from reputable websites. I’ve never attempted to see if listicles perform well in the medical education niche, and frankly, I’m happy to remain ignorant.

Topical vs. Evergreen

Most personal sites probably function best at the outset when a significant portion of the posts are evergreen (meaning they stay relevant over the course of years). Current events and commentary are fun and keep things fresh, but the effort required to stay topical typically exceeds the staying power of the writing. When you have a lot of readers like Kottke.org or Daring Fireball, high-volume posting and topical commentary are basically the whole point. But for most people who are starting out writing part-time, your topical writing has no staying power and is mostly lost in the ether of the Internet. Make sure to take your time to write some really helpful stuff. Topical writing is more fun when you have an audience.

I believe that there is an inherent tension between writing for a periodical website like many blogs and writing to communicate ideas. Most informational sites should be generating content like a serialized novel, a larger overarching work split into manageable chunks and small sections. Instead, most sites meander through the same topics again and again like a pendulum swinging through the center. Where does a reader start? Why should a reader keep reading?

If you’ve ever read Lifehacker, you’ve seen this firsthand: the staff writers will often post the same hacks almost verbatim, apparently not even realizing that they’ve posted the same exact thing on multiple occasions before. Big successful websites do this and get away with it because even lame posts get clicks and clicks mean money.

You can do that too, of course, but if the goal is to build something you both enjoy doing and can be proud of, I’d argue for quality over quantity.

If you do end up writing an unruly tangle of posts about the same thing, then it becomes even more important to have strong site design/organization/navigation as well as to assemble your greatest hits into easy-to-find lists that help new readers really “get” what you have to offer. (Note: I’m 100% guilty of not following this advice.)

 

Good luck!

I think the internet is better off with more people owning their own content and maintaining their own presence online. Ceding our collective voices to Facebook has sped up the pace and volume of discussion, but it definitely has not made the world a better place.

I’m always happy to help.

PSLF & Double Part-Time Employment

Qualifying employment is a critical component to the PSLF formula:

Eligible Loans
+ Qualifying Payments
+ Qualifying Work
x 120 months (10 years)
= Public Service Loan Forgiveness

But most folks haven’t considered a nuance in the PSLF law that currently applies to very few people but could easily apply to more. Part-time work counts, so long as you have enough of it to make a “full-time” equivalent.

From the official PSLF FAQ:

I’m working for more than one employer during the same period of time, but I’m not employed by either on a full-time basis. Will my combined employment be considered full-time for PSLF?

Yes, as long as the combined number of hours you work for each employer equals at least 30 hours per week. Each employer must be a qualifying employer for the employment to be included in determining whether you are employed on a full-time basis. For example, if you worked for one qualifying employer for 10 hours per week and you concurrently worked for a second qualifying employer for 20 hours per week, this would meet the 30 hours per week requirement.

 

That combined 30-hour threshold is a key facet. Because normally (emphasis mine):

For PSLF, you are generally considered to work full-time if you meet your employer’s definition of full-time or work at least 30 hours per week, whichever is greater.

If you are employed in more than one qualifying part-time job at the same time, you may meet the full-time employment requirement if you work a combined average of at least 30 hours per week with your employers.

 

There are plenty of folks working 30 hours or more per week but who are still considered “part-time” by their employer. An 8 or 9-hour workday with a 5-day work week is 40 or 45 hours respectively. A part-time employee working 80% at four days a week might work a 32 or 36 hour week: already enough hours to theoretically qualify for PSLF.

This suggests that a lot of people working part-time for a nonprofit employer may still qualify for PSLF if they can find a small amount of additional part-time work to get themselves over the 30 hours per week hump.

Put another way, not everyone who needs to or wants to work part-time needs to abandon PSLF.

And, not everyone needs to work “full-time” in order to achieve loan forgiveness.

Token efforts

To double down, if a person’s main “part-time” work is already 30 hours per week, then literally any paid employed qualifying position should automatically make the person qualified because they already have the raw hours they need.

Of critical importance, there are no specific compensation stipulations regarding what constitutes qualifying part-time employment. It is the number of hours worked in a paid position that matters, not how well (or poorly) paid you are.

At this point, the gears may be turning in your head, and it’s worth noting: this is not actually a loophole. But it is a potential gamechanger for how people look at both their main job and evaluate potential additional opportunities.

On a related note, there is also no rule in the PSLF law that states that you can’t also have a for-profit job. What you need is to have enough qualifying nonprofit work. These are not mutually exclusive.

There’s also no rule that both positions have to be related in any way. You could be a doctor and also work at a food bank.

You need either a full-time qualifying job or any combination of 2 or more jobs that hit 30 hours/week worked.

Too much money?

Ultimately, the more money you make, the more money you pay toward your loans within an income-driven repayment plan and thus the less money you will have forgiven after your 120 payments. If you’re constantly in a negative amortization scenario, then it probably won’t matter, but if IDR repayments were already making good progress in paying down your loans, then sometimes extra work can change the calculus.

Double employment is a great way to pursue an unsatisfied passion while essentially having the government pay your salary indirectly through loan forgiveness. But if you are fortunate enough to work at a well-funded non-profit and earn too much money with your second endeavor, it may make loan forgiveness more expensive than just paying off the loans yourself.

Start your own non-profit

You could (theoretically) even create your own qualifying nonprofit organization and work for it part-time to get over the hump (you could also theoretically do that full-time too obviously). Surprisingly, the barriers to creating your own 501(c)(3) organization are actually not that cumbersome, and the PSLF rules even say that it is OK to certify your own employment eligibility if you’re the only person who can do so.

Again, from the FAQ:

I’m the only official who can certify my employment. Can I certify my own qualifying employment?

Yes, you may certify your own employment if you are the only employee of the organization who can do so. However, we will request additional documentation concerning your employment, such as earnings statements, IRS W-2 forms, your application for tax-exempt status, or any other documentation required to be filed with the IRS on a periodic basis regarding the activities of the organization.

Note that if one were to try this potentially super shady solution, it would be highly prudent to also keep extensive records including a detailed time log to document your work hours and output. People absolutely should not be trying to convert their for-profit personal businesses into fake non-profits, but it does mean that you can be rewarded for making the world a better place.

Nonetheless, while there are clearly honest and legitimate ways to do this and achieve PSLF; it’s undoubtedly ripe for abuse. I think it’s safe to say that anyone who plans on certifying their own qualifying employment–even in conjunction with a more traditional job–is setting themselves up for a lot of questions and some serious bureaucratic hassle. Annual certification forms would be an absolute must. Running a real non-profit is a must. And frankly, given the number of people who are likely to be caught with fake paper-only nonprofits created for personal gain, it’s probably not a great idea.

A hypothetical example

I work as a neuroradiologist full-time for a non-qualifying employer, but for purposes of discussion, let’s say I worked 80% at a qualifying academic institution. In this scenario, I would easily surpass the 30 hours/week needed for PSLF, but since I’m part time, my main job won’t qualify on it own.

Conveniently, since 2009, I’ve been quietly editing and publishing the longest-running exclusively Twitter-based publication for fiction in the world. It’s called Nanoism, and it’s a literary magazine that even pays “professional“ rates to authors. This effort costs money and time and doesn’t earn me a penny. It’s already functionally non-profit in the sense that the only time money changes hands is when I pay writers or run contests to benefit charities (which I admit I haven’t done in a while).

Literary organizations like this are perfectly suited for 501(c)(3) nonprofit status and there are tons and tons out there, and though it would take some nontrivial hassle to file for this, I could do so. With official nonprofit status, suddenly the spare time I’ve been spending running a strange little Twitter-based literary venue would actually go toward loan forgiveness, which could help me redouble my efforts, expand the organization, plan more educational outreach, run more charity fundraising events, finally publish the anthology I’ve been promising for the past decade, etc. It would go from an unusual hobby to an unusual hobby that indirectly secures my financial future.

Since (in this example) I work enough part-time hours already anyway, a massive additional time commitment is unnecessary. Just enough that my organization is a real, functioning non-profit (which–let’s face it–would probably still end up a massive additional time commitment, but you see what I’m getting at here). Making a legit would also probably entail bringing in more people and growing the organization. A one-member non-profit might look mighty suspicious to the government with hundreds of thousands of bucks on the line.

If you have a skill or a craft and are on the cusp of a qualifying gig for PSLF, I’m not necessarily suggesting that starting your own non-profit is the way to go, because it’s not. For most people, really, it’s almost certainly not. But I am suggesting that you look for ways to use your skills for deserving organizations if it might make all the difference. You don’t need a big salary; you just need to be a paid employee.

Take home

A non-profit side-hustle could be more profitable than you’d think.

For people working full-time just for PSLF, keep in mind that you may not be quite as tied down as you might think.

When antibiotics equals ratings

A new study published in JAMA last week (summarized by NPR) is another great example of the obvious negative externalities of prioritizing patient satisfaction scores (i.e. the Yelpification of medicine). It analyzed a large number of telemedicine visits for URI:

Seventy-two percent of patients gave 5-star ratings after visits with no resulting prescriptions, 86 percent gave 5 stars when they got a prescription for something other than an antibiotic, and 90 percent gave 5 stars when they received an antibiotic prescription.

In fact, no other factor was as strongly associated with patient satisfaction as whether they received a prescription for an antibiotic.

The outsized and misplaced importance of patient satisfaction scores is a perfect embodiment of Goodhart’s law, well-paraphrased as “when a measure becomes a target, it ceases to be a good measure.”

If you make patient satisfaction scores a critical target—and they are—you will see consequent mismanagement. This is so blatantly apparent when it comes to urgent care and pain management that, if anything, high satisfaction scores are likely a more meaningful signal of poor care (like in this study when patient satisfaction scores positively correlated with patient mortality).

I used to know a bunch of residents who would moonlight at a doc-in-the-box for-profit standalone urgent care. They were, apparently, told to make the patients happy and provide antibiotics for most URI visits.

Even outside of quality metrics, you need patients to make money, and the “customer” is always right.

 

Yes, PSLF is really happening

People often ask if I personally know anyone who has gotten their loans forgiven via PSLF since the first crop of folks became eligible in October 2017. It’s a reasonable question, but it’s also the wrong one.

Because, despite the legitimacy of the PSLF program, there are very few people who could have actually benefitted in the initial crop. This stems from the fascinating(ly terrible) way the program was rolled out to discourage the older generation of folks who were already in repayment to utilize it.

Nonetheless, the proof that PSLF is real has arrived. The Federal Student Aid office recently released their new student loan report (conveniently summarized here):

The Public Service Loan Forgiveness (PSLF) Program, which was established under the College Cost Reduction and Access Act of 2007, permits Direct Loan (DL) borrowers who make 120 qualifying monthly payments under a qualifying repayment plan, while working full-time for a qualifying employer, to have the remainder of their balance forgiven. October 2017 was the first month that borrowers could potentially qualify for loan forgiveness under this program, provided they met all program requirements since the inception of the program.

As of June 30, 2018, approximately 28,000 borrowers had submitted almost 33,000 applications for loan forgiveness under this program. Of the approximately 29,000 applications that have been processed, more than 70 percent of them have been denied due to not meeting the program requirements (such as having eligible loans, 120 qualifying payments, or qualifying employment). In late May 2018, FSA initiated outreach efforts to those borrowers who may potentially qualify for the Temporary Expanded Public Service Loan Forgiveness (TEPSLF) opportunity, which provides limited, additional conditions under which borrowers may be eligible for loan forgiveness if some or all of the Direct Loan payments were made under a non-qualifying repayment plan for PSLF.

Another 28 percent of PSLF applications were denied due to missing or incomplete information on the form. These borrowers have been advised to submit a complete application so a determination of their eligibility can be made. Almost 300 applications have been approved by the PSLF loan servicer as meeting all program requirements, resulting in $5.52 million in processed discharges for 96 unique borrowers.

99% rejection sounds terrible, but it’s actually exactly what you would expect if the feds were honoring the specifics of the program as advertised. Recent graduates—who essentially all hold qualifying loans—tend to focus on the qualifying employment aspect of the rules. But for the folks who would theoretically have been eligible in 2017, the lynchpin was really qualifying loans and, to a somewhat lesser extent (see below), qualifying repayment plans.

Allow me to explain.

The PSLF formula:

Eligible Loans
+ Qualifying Payments
+ Qualifying Work
x 120 months (10 years)

= Public Service Loan Forgiveness

 

The Loans

“Eligible loans” means Direct Loans. Direct loans are given “directly” by the government, which is what all recent students use who don’t take out additional private loans. Back in 2007, that wasn’t the case. Students received loans from private banks that were “guaranteed” by the government under the FFEL program. During the financial crisis in 2008, the government stepped in and used the Direct Loan program to provide most educational funding. The FFEL program was completely shuttered in 2010.

Anyone in repayment during the late 2000s or finishing school near 2007-8 would not have had eligible loans without taking additional steps to consolidate them into a Direct consolidation loan. No one who didn’t hear about the program back then and read the fine print would have done the right thing. Huge swaths of people who thought they were eligible and applied for PSLF were denied for exactly this reason. They were never eligible.

If any of these folks had filed a single PSLF employment certification form, they would have found out the news and been able to change course accordingly.

Take home point: loan forgiveness is too important to not plan.

 

The Payment Plans

This is the second reason for denial, but at least some of these folks will win out eventually.

“Qualifying payments” are full, on-time, payments while utilizing a qualifying repayment plan: IBR, ICR, PAYE, REPAYE, or Standard. The Extended and Graduated plans do not count. IBR, the first of the new generation of income-driven repayment plans, started in 2009. So again, by definition, the folks making payments toward PSLF back in 2007 and 2008 couldn’t have even been using it yet (the lucky ones were using ICR). Unfortunately, many applicants were on the graduated or extended payment plans, which—again—do not count. 

Luckily, Congress decided this technicality was too cruel and passed a temporary $300 million PSLF expansion to help people denied for this on a first-come-first-served basis.

In order to benefit from the new law, you need to apply to PSLF and also file a TEPSLF request.

Since the government doesn’t actually hold the FFEL loans, there is essentially no chance of them extending anything extra to the folks denied for having the wrong kind of loans.

 

The Future

The initial disappointment and underwhelming numbers from the initial stages of PSLF were an inevitability.

Over the next few years, the numbers of successful applicants will skyrocket. Not accounting for undergraduate borrowing, medical students graduating in 2012, for example, would almost universally have qualifying loans and been using qualifying repayment plans. Lawyers from 2011, some masters degree holders in 2009 and 2010, etc. Folks whose schooling began ten years ago will be part of a cohort that didn’t require the same big steps to have been made correctly early on that these initial failures succumbed to.

We’ll see a small uptick this year and then big rises thereafter. This is only the beginning.