Retort of the week

Do you have any idea how many bullets I pull out of corpses weekly? This isn’t just my lane, it’s my [expletive] highway.

Pathologist Dr. Judy Melinek, responding on Twitter to an NRA tweet admonishing doctors to “stay in their lane” and stop discussing gun control.

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.

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.

 

Explanations for the 2017 Official Step 3 Practice Questions

Here are my explanations for the 2017 version of the official USMLE Step 3 free question pdf. This is a constant reader request, so enjoy my take on these 137 questions.

You can find my thoughts on preparing for Step 3 here. In short, I think the free materials and UWorld should be enough for most folks. If you want books recs, they’re in that post. If you need another question source, I haven’t tried any of them, but you can get 10% off BoardVitals if you’re interested by using code BW10.

As for this free practice exam, Blocks 1 and 2 are “Foundations of Independent Practice” (FIP). These should take up to 1 hour each. Blocks 3 and 4 are “Advanced Clinical Medicine” (ACM). These should take up to 45 minutes each. Total practice time should be no more than 3:30 if taking under test-day conditions.

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NYU and the slow coming wave of “free” school

A couple of weeks ago, NYU announced that they were making medical school tuition free for every student. Dean Robert Grossman stated, “This decision recognizes a moral imperative that must be addressed, as institutions place an increasing debt burden on young people who aspire to become physicians.”

My first thought on this news was, Man, Harvard is going to be so pissed that they weren’t first.

The idea of free tuition has been discussed and debated in multiple contexts across Ivy-type schools for years. These institutions are not immune to the burgeoning reality that their educations are financially untenable for most people and crippling for others. With many such schools fostering endowments numbering in the tens of billions of dollars, actual tuition dollars are no longer the bedrock of a healthy world-class institution. Over the past ten or so years, Harvard has often led the way on increasingly generous undergraduate financial aid, and many similar schools have made corresponding efforts to make undergraduate education more affordable, but until now, no one has taken meaningful steps to fix graduate schools, many of which are now considered mandatory for advancement across many industries. Even this move is largely a token effort, as every other extremely expensive NYU school will still keep its top-dollar cost in the shadow of this brilliant PR stunt.

As an illustration of the numbers involved in making one small school free:

The annual NYU med tuition was an exorbitant $55k per year, and there are 442 total active medical students, which gives a total cost of $24 million per year. “Paying” this requires (according to NYU) an endowment of $600 million because the school is utilizing the famous 4% rule that would make this massive endowment essentially guaranteed to last forever based on historical stock market returns.

Numbers aside, I do agree with the words of the dean (though I would expand them). There is a moral imperative to fix the cost as well as the delivery of medical education. The length, cost, and inefficiency are all otherwise mutable strong arms that are breaking healthcare and squeezing the joy out of young doctors in training from coast to coast.

NYU will not be the only school to offer free tuition. Other rich schools in and outside of medicine likely have been and certainly will be shoring up their endowments to join the club as is feasible. I anticipate this is the first in a salvo of private schools slowly making various programs free, and this will speed up if/when PSLF is eventually canceled, as the program is basically the only justification for charging otherwise unmanageable amounts of money to students who are destined to never be able to actually service their debt. Beleaguered state schools with their chronically strapped budgets will struggle.

 

My second thought is that free tuition will now make NYU about as affordable as the best-priced state schools (because the cost of living in New York is otherwise so high). Four years of living expenses will never be cheap, and it’s much harder to scrounge time to be gainfully employed during medical school compared with college. Clinical rotations are inflexible more-than-full-time jobs.

This will also result in, I imagine, a huge increase in applications to NYU. When my wife and I applied to medical school, we only applied to state institutions back in Texas where we were still residents while away for college. We were not keen to spend as much in a single year as we could on the whole package. People like me may now decide to add NYU to the list, especially since NYC is glamorous.

 

So, good on NYU for being the first to pull the trigger. I hope more schools join their ranks, and I hope most of all that this well-publicized confrontation of medical training costs will lead to a paradigm shift that allows schools and hospitals to rethink the whole process. We can do so much better, for our doctors and for our patients