FAQ#14: Being an average medical student with financial difficulties

This was an email I received from M a while back. One of the first challenge to overcome when deciding to take the USMLE is self-doubt. The second challenge to overcome is the concern that their dreams are more than what their finances can handle. The third challenge to overcome is to forget all the anecdotal evidence of those who have failed while remembering those who succeeded.

Dear Dr. Jamie,

Hello. I've researched on USMLE and came across your blog. You are truly aspiring! I am a Malaysian medical student, studying in XXX.

I am wondering if you think I should apply for USMLE, given that my syllabus back in XXX is more of a problem-based learning system (and not lecture based)? I am always worried that my medical knowledge is not on par with the rest of my fellow classmates. Furthermore, I am not exactly the top scorer of my class. I dedicated a lot of my time studying, but will only score fairly (sometimes just passing, sometimes above average). Even so, do you think I should take USMLE? 

I know you mentioned that with time & motivation, one could compensate for the lack in memory & intelligence, but I'll be starting clinical rotations at the start of January, and I am quite worried I would be burnt out after my rotations and wouldn't dedicate as much time as I should. 

I wasn’t a top student as well when I started out with my USMLE journey. During my first two years of medical school, looking back at the percentile, I was actually below average. In my second year, I decided that I really wanted to go to the U.S. I started focusing 60-70% of my time in medical school studying for the USMLE. I realized that having good scores would get me a ticket to the U.S. I also realized that scoring well in medical school doesn’t mean much. In the end, anyone who passes, top scorer or not, gets to work as a doctor in Malaysia. However, doing well in the USMLE will allow me to get immediately into a specialization training program in the U.S. Fast forward many years later, I was thankful for the decision I made back then. While the top scorers in my medical school are still waiting for the government to offer them Masters position (which has more to do with connections, duration of service and racial quotas than merit), me, the below average student, is going to start subspecialization training.

Like you've mentioned in your blog, financial issue is a big factor and would deter us from taking the exam..it is indeed true. As an international medical student, I am paying alot more than the locals and other government sponsored students. I am worried that if I take the exams, my results would not be as good (below average/fail) & would make me feel that I've wasted my money. Or even if I did well in USMLE, I might not secure a spot in residency as well. My lecturer emphasised that it is getting tougher and tougher each year and not everyone could successfully matched in their residency program. I knew of a Singaporean senior who achieved 270 in USMLE Step 1 and still did not match. 

Not everyone would match. In terms of foreign applicants, there are around 12,000 each year, and you have to be better than 50% of them in order to match. In addition of USMLE scores, getting a position also depends on interview skills as well as specialties, which you choose. In the U.S., everything is almost transparent. Every year, the match statistics are released, and it reveals valuable information such as the number of applicants, probability of matching based on score and so on.

Looking at the chart below, you can see that for Foreign-trained physicians, the number of applicants has been around 12,000 per year. The probability of matching remains the same at around 50%, meaning that if you are in a class of 10, you will have to beat the other 5 to match.

This is another chart, which shows the probability of matching based on USMLE scores for a NON-US medical student in light green. I scored 240++, and I stood an 80% chance of matching. After receiving my Step 1 results, I immediately started my Step 2 CK preparation and also made more detailed plans to get into the U.S.

The reason I'm interested in USMLE is because there are more and more medical students all over the world, with very limited training slots/internships/residency places. Like everyone else, medical school is expensive and I am paying a large sum for tuition fees & cost of living. Inevitably, I would like to have a good job prospect to repay my student loan, etc. but I'm really worried about my future and the direction I'll be heading. Please kindly advice and I am sorry to bore you with such a long email.

Around 6-7 years ago when I made the decision to head to the U.S. I took the gamble and studied hard for the exam to improve my odds of matching. I knew that nothing was a 100% and no one can guarantee my entry into a training position. I justified paying for the exams by thinking that the cost of the USMLE process is peanuts compared to the cost of my medical school. However, the difference between being able to enter the U.S. specialization system and entering the Kementerian Kesihatan Malaysia workforce is huge.

If one of your main hesitation to take the USMLE is due to financial reasons, I would suggest that you consider taking one of the steps first. If you do really well in that step, take it as a sign that you should proceed with other steps. If you do poorly in that step, then stop your pursuit of the USMLE but be satisfied to know that at least you have tried.

FAQ#13: Questions from a Paediatric Medical Officer with MRCPCH

I apologize for the long hiatus, being caught up in residency training program. I will be completing my residency program in a few months, and have also been accepted into a subspecialty fellowship program. Life has been great here in the States to the point that I am second guessing my decision to move back to Malaysia at the end of my training. Perhaps I may decide to just stay on and work here in an academic institution, and only go back to Malaysia once a while to help conduct training courses for my fellow Malaysians.

I have received tons of questions via email, but was not able to respond to all of them. I will try to respond to some from now onwards. I received this email from a medical officer who is really dedicated towards his/her own training.

Hi. I m medical officer working in XXX.  I had previously email you as a houseman at the final year. I chose to stay in Malaysia and came to sarawak after completion of my housemanship.  I sat for mrcpch and passed the first 2 parts within 1 year. During that time, I was not ready to leave Malaysia. However, only after I started as a medical officer, I does not seem to be satisfied with the training here. It does not make me to be confident to work as a paediatrician in the future. And, there are a lot of issues of medical officer overloaded, followed by the previous issue of houseman overload.
It made me to rethink whether decision of staying back is correct.

I had few questions. 
1) After I completed my housemanship, I will be exempted from licensing exam in Ireland. I realised that work overload issues at Ireland are obvious and economic state in Ireland are unstable. 
My aim is to be trained better. Going Ireland is within my choices. Mrcpch Is not recognised in Ireland. I need to take mrcp paed Ireland beginning from part 1.

Second choices that I has is stay back at Malaysia and finish my last part.
The mrcpch will be clinical.


Thirdly,
I start to wonder whether I shall consider US residency as one of my other options. Can you interpretate the pros and cons of choosing this option? I start to consider migrate to oversea as I really disappointed with Malaysia health system.

I am not familiar with the training program in Ireland, and how does the Irish training program work. In general, the questions you would have to ask are (1) Will they accept you immediately into a pediatric training program and guaranteed to complete it as a consultant pediatrician? (2) Will they accept you into a pediatric subspecialty training program? (3) Will they discriminate against your nationality when it comes to competing against locals?

I think you should not thinking of going to the U.S. for training having to be a permanent endeavor. You can always return to Malaysia as a subspecialist, or head to Singapore. I also feel that you should think beyond general pediatrics. You would want to be able to contribute more, beyond general pediatrics to the community. Think about this: (1) if you were to stay in Malaysia, will you pursue pediatric subspecialty training? (2) will you be satisfied with the pediatric subspecialty training and become a confident subspecialist? (3) will you be okay with staying in the KKM system for an additional 8+ years? This is because you have to complete your MRCPCH, undergo gazettement, apply for Masters for subspecialty training, undergo Masters training, get bonded.

The best part about training in the U.S. is that you get trained as a pediatric subspecialist really quickly with no bonds. I am now a third year medical resident, and will start as a subspecialty fellow in a fellowship training program soon. When I complete my fellowship program, I will be a subspecialist and am free to choose to either work in an academic institution in the U.S., work in a private hospital in the U.S., return to Malaysia, head to Singapore, head to Australia, and many other choices.

Another thing about the application is that U.S. is not like some other countries where perhaps those with citizenship will be accepted first, with foreigners taking the leftover spots. I have been accepted into a pretty competitive fellowship program. Four, including myself, in my class, applied for this specific fellowship. Based on merit, myself and another classmate got the fellowship. The other two did were not as good, did not get the fellowship, although they were Americans. Here in the U.S., as long as you work hard, you will be judged almost equally.

2) second question, am I too old to start as a resident at us? Going to  be 28 this year

When I started my residency (1st year), the average age of the class is around 29-30. The oldest in my residency class was 35. This is because the American medical school is a graduate entry program. Furthermore, many Americans usually do some other work before deciding that medicine is for them.

3) do Ielts a must to proof my English proficiency? I sat once. But writing component was too poor despite of overall mark of 7.5

IELTS is not required. Passing the USMLE Step 2 clinical skills exam gives the programs the assurance that you can communicate well with patients.

4) let say, If I decide to go for usmle, which part you would suggest me to start first? Any link on application process that you could share with me?

I would suggest you go with USMLE Step 1 first. It has been awhile since you were exposed to surgery, psychiatric etc. Therefore, just take it step by step. Furthermore, completing part 1 MRCPCH would probably give you some good basic science knowledge to tackle Step 1. Looking into USMLE Forums would be a good start.