The Hell of Becoming a Doctor

The Hell of Becoming a Doctor
MidJourney: "A woman doctor on fire"

To preface this post, I want to make it clear that I am not part of the healthcare industry and do not purport to be an expert in the field. My insights stem from a deeply personal perspective, having been with my wife from her pre-med years through to residency. I've witnessed her transformation from an enthusiastic young woman aspiring to become a doctor to someone worn down by a journey spanning over a decade, with more than two years left to navigate.

The Financial Burden

Assuming the average cost of a four-year graduate degree is $45,000 and medical school expenses hover around $200,000, the typical resident physician faces an educational debt of around $250,000 before even starting a residency and this is without factoring in loans for living expenses. Medical school's demanding training load makes it nearly impossible to take on even a part-time job. During this time, interest on loans accrues, except for the COVID-related pause on loan repayment. It's crucial to consider the weight of this debt burden on medical residents navigating a system that appears to be designed to push them to their limits. Prior to the SAVE student loan repayment program, my wife would have had to either defer her loan or manage repayment plans costing up to $1,800 per month. Resident salaries often start at approximately $60,000 per year which can make for a very tight budget for some residents.

The Human Cost

Given my wife's medical training, specializing in a non-surgical speciality, many individuals in her life are also doctors in training. She has openly admitted that if given the chance to turn back time, she would choose not to pursue a career in medicine—a sentiment shared by the majority of her co-residents and friends in the field. Unfortunately, for those who have reached residency, turning back is no longer an option. With debt loads approaching $300,000 for some, dropping out of medicine to pursue a lower-paying career is financially unfeasible. This debt essentially entraps them in the system. It's no surprise that numerous medical residents grapple with depression, burnout, and, tragically, some take their own lives. A glimpse into the residency subreddit reveals the stark reality of abuse and exploitation, with countless examples marked by vent and serious tags. It is a disappointing reality that, even escaping residency doesn't guarantee relief from depression, as some statistics indicate that between 300 and 400 physicians take their own lives each year.

Lighting the Match

MidJourney: "Matchstick on fire"

If residency is considered hell for a significant portion of medical residents, then the National Resident Matching Program or Match is the entrance to this inferno, but I will need to take a few paces back to explain how prospective residents even get to that Match.

Throughout medical school, students engage in a combination of classroom-based learning and clinical rotations, which typically commence in the third and fourth years of their program. Alongside these experiences, they must also complete two pivotal examinations: the United States Medical License Examinations STEP 1 and STEP 2, commonly referred to as USMLE STEP 1 and STEP 2. In addition to the STEP examinations, there are also shelf exams, which are clinical assessments conducted during the third and fourth years, coinciding with clinical rotations. There are seven of these examinations in total. Students may not move on to further rotations until these are passed.

While the shelf exams are mandatory to complete medical school it is those STEP examinations that are of paramount importance and will determine the future of the medical student. They are typically administered during the second year and the third or fourth years of medical school. It's worth noting that the STEP exams are exceptionally challenging. The mental investment in these exams is incredibly high and the gravity of the implications of a low score is anxiety-inducing. Achieving a passing score does not guarantee admission into a residency program.

Now that I got that out of the way, I want to take us back to "The Match" which is a proprietary system that all medical students must utilize to apply to residency programs across the country. Through a single portal, a prospective resident will submit their letters of recommendation, a personal statement, and a resume with any research completed in medical school. Oftentimes, it is advised that residents apply to several programs, at least ten but oftentimes residents will apply to twenty or more, each incurring a cost. Prior to the COVID-19 pandemic this would also require prospective residents to fly out and interview onsite. The residency will also have access to their STEP 1 and STEP 2 scores.

According to the NRMP, which manages the Match, In 2023 there were 42,952 applicants for 37,425 first-year residency positions.

While the letters, resumes, and personal statements are all important, the STEP score separates everyone from the most desired to the least. From there, residency programs will either pass on a prospective resident or they will offer them an interview. Those individuals will produce a ranked ordered list of residencies they interviewed at and the residency programs will do the same in regards to which residents they wish to have in their program. The Match then runs its algorithm, which is not known to the public, and will “Match” residents to a program on Match Day, which is the third Friday of March each year. Everyone gets paired up to a program and everything is great, right? Absolutely not.

There is a not insignificant portion of prospectives who do not “Match” and they will have to go onto the next process called the SOAP or Supplemental Offer and Acceptance Program. This program is for residency programs who did not fill all of their residency spots. This often requires those medical students who did not match to scramble for interviews in hopes that they may get placement. According to the NRMP, which manages the Match, In 2023 there were 42,952 applicants for 37,425 first-year residency positions. There were also 2,950 second-year residency positions available as well. Overall, 81.1 applicants were matched into a first-year position at a residency program (NPRM). Those who did not match into a program had to enter the SOAP. Anyone who did not SOAP must wait another year. This can be exceptionally devastating and can make it more difficult to Match the following year.

Residency, the promised land. The portion of training that medical students have been working towards to at a minimum of 8 years at this point. Think about that for a moment. If someone enters pre-med right out of high school, by time they reach residency they would be between 26-28 years old, and they are still looking at a minimum of 3 years of residency, but more often than not they are looking at 4 years or even more if they elect to do a fellowship. So you are looking at a group of people who will be into their 30's before they are board certified and are no longer "in training".

Residency programs are not designed to be anything favorable to the resident.

So, whats the big deal? Its just 3 to 4 more years if they don't elect to go into fellowship, and don't doctors make a lot of money? Why can't they just toughen up and bare it for a few more years? If you have to ask that question, I invite you to go back to the top and read some of those reddit threads I linked above. However, in a general sense, residency programs are not designed to be anything favorable to the resident. There is no recourse for abuse and bringing up anything to the program is often met with gaslighting, denial of reality, remediation programs and some residents will just be seen as being too problematic and are then let go. There is also the very real issue that plagues residencies at large and that is around sexism and racism.

The Old White Hands Grip on Residency

Residency leadership, in general, is largely older white males. This demographic composition becomes a more significant concern in the context of medical residency, where program directors, vested with absolute authority, are the centralized figures overseeing all aspects of a residency program. Now I can go way off the rails here and go into fragile male egos and society rewarding narcissistic white men with leadership positions, but hell hath no furry like a program director thinking they are scorned. My own wife, a minority woman, faces sexism and racism on a semi-regular basis with attending physicians and program leadership. She is also a strong woman who does not comport to the societal framework foisted on women and carries herself with confidence which can be quite intimidating to men in power, especially when they are in the wrong. It's disheartening to witness the systemic challenges she faces as a minority woman within the medical field.

I want to bring attention to two specific instances of abuse within residency, recognizing that these are just glimpses into a broader issue. Many individuals, fearing repercussions, choose silence over speaking out against the prevalent abuse. The extent of power that a single person holds over residents, impacting not only their professional lives but also reaching into their personal spheres and families, remains largely underestimated by the wider community.

A Program Director's Fragility

I invite you to read this case file (warning, PDF) on Dr. Bahnson and his egregious abuse of power over three urology residents. TLDR, the urology program director retracted recommendation letters from three residents, thereby denying them the opportunity to sit for their board examinations. The repercussions were severe—no board examinations meant no license, and without a license, the affected individuals could not practice medicine.

The case file unveils a series of disturbing instances, including abuse, toxic behavior, gaslighting, and denial of reality. Standing up against such maltreatment resulted in the program director effectively blocking these residents from realizing their dream of becoming doctors. Reflect on the gravity of this situation: over a decade of commitment, accumulating significant debt, and having one's future hinge on the arbitrary decisions of one individual.

While the program director's actions were eventually reversed through litigation, the emotional toll endured by the affected individuals cannot be understated. It's a stark reminder of the vulnerability that aspiring doctors face when their dreams are subjected to the whims of those in power.

Doctoring While Black

I encourage you to search residency pages online, maybe some local institutions in your city or state. Residency pages are often public and you will get to see all of the residents ranging from the PGY1's up through the fellows. It's noteworthy that a significant majority of these residents are white, with some representation in the Indian and Asian communities.

Considering the Supreme Court's recent actions virtually eliminating affirmative action and the constant challenges faced by Diversity, Equity, and Inclusion (DEI) efforts, this demographic skew may worsen. I'd like to highlight a blog post written by Robert Ray Jr., who shares his experience as a Black man in residency. Rather than recounting his story here, I believe it's essential to read it from his perspective. His narrative sheds light on the toxicity prevalent in residency programs and not bending to the residency, they will break you. All the while, the burden of hundreds of thousands of dollars in debt looms over individuals heads. A constant reminder that the toll has yet to be paid.

To What End?

Completing residency often feels like stepping out from one fiery lake into a less fiery one. I intend to delve deeper into this aspect in a future piece, but witnessing my wife, a resilient and strong woman, grapple with the burdens of residency due to constant gaslighting and abuse has left me feeling helpless. There's a profound sense of powerlessness when you realize that all you can do is listen and provide support, as there's no internal system for residents to seek the help they desperately need.

They bought into the ideal of becoming doctors to help people, yet they find themselves navigating a system where there's no support for them.

It's disheartening to witness young residents expressing regret for choosing a career in medicine, with some contemplating an exit from the profession as soon as possible. A significant portion of my wife's co-residents sought therapy, a response to the harsh realities of enduring years of abuse. Some have even admitted to feeling passively suicidal or sinking into depression. This prompts reflection on the initial motivation—they bought into the ideal of becoming doctors to help people, yet they find themselves navigating a system where there's no support for them. Instead, they are left to help themselves and conform to the demanding whims of residency. In such circumstances, one may wonder, what else can they do?