M&M Rounds: Didn’t Match for a Residency

During M&M rounds, we will examine some fictitious cases and evaluate the facts and consider some solutions to these problems.

Mark Ashes is a 32-year-old Hispanic male presenting for not matching to an exotics/wildlife medicine specialty for the third time through the VIRMP.  He has wanted to be a veterinarian being paid to work with charismatic megafauna since he entered vet school.

Mark went on a trip to Africa during his undergrad years and was immediately smitten.  He decided he wanted to be a wildlife veterinarian.  He applied to veterinary school and was accepted on his second application cycle.  During vet school, he participated in all the exotic/wildlife club activities and elective courses offered.  One summer during vet school he went abroad to help in a wildlife capture program.  His grades were fair because his focus was on non-traditional species, so he didn’t have a lot of patience for learning “regular” medicine.  He had a class rank of 40/130.

In his senior year, he did multiple externships at zoos and exotics practices throughout the US.  He applied for exotic animal internships through the VIRMP with letters of recommendation from three exotics specialists.  He did not match on the first go-around, did not Scramble, and decided to enter into private practice where he would get to do a fair bit of exotics work.  He applied the next year for an exotics internship through the VIRMP and was accepted.  Thereafter, he applied for an exotics/wildlife residency but did not match.  Since then, he has continued working in small animal/exotics practice and applying to exotics/wildlife residencies.

My treatment for Mark is very much my own opinion, and others may differ- I welcome your comments!  My treatment is for him to find a zoo where he can volunteer to work with them and drop his dream of being paid a decent salary to work with charismatic megafauna.  This would achieve his goal of working with those animals while acknowledging the reality that he is very unlikely to get a residency in wildlife medicine.

The match rate for wildlife medicine is one of the lowest of any specialty – 3% for exotics and 9% for wildlife as of 2021.  Wildlife medicine had 97 applicants for 9 positions and exotics had 83 applicants for 3 positions.  Not impossible, but statistically poor, particularly for someone who has already failed to match.

I think the learning issues for Mark’s case focus on what you do during vet school and how you choose your specialty.  Mark didn’t do any research, and his grades weren’t great because he was so focused on his species of interest.  If he had focused on being a more general veterinarian, he may have done better.  Pursuing a rotating internship before a specialty internship may also have improved his application.  Specialty choice is also incredibly important.  Obviously, you want to do what you enjoy doing, but I believe most people would be happy doing a wide variety of disciplines.  I wanted to be an orthopedic surgeon and I am incredibly happy in anesthesia.  One of my colleagues trained to be an equine internist and is very happy in anesthesia.  There are many routes to happiness.  If you focus too closely on a single outcome, you may be limiting your options for happiness.  Consider the match rate for your specialty.  If you aren’t one of the absolute top candidates in the country, you may never be able to get that residency.  Another path may bring you greater happiness.

M&M Rounds: Didn’t Match for an Internship

During M&M rounds, we will examine some fictitious cases and evaluate the facts and consider some solutions to these problems.

Ivey Sprigs is a 27-year-old Caucasian female presenting for not matching into an internship through the VIRMP.  Her eventual professional goal is to do a cardiology residency, so an internship is virtually essential as a first step towards that.

Ivey’s history is that she came to vet school planning to do mixed animal practice and return to the small town where she grew up.  She was an average student through vet school, focusing more on learning the material than grinding for a grade.  Her class rank was 50/130.  She did some research during the summer between freshman and sophomore year but it did not lead to a publication.

During her junior year, she began to think that she might want to specialize after vet school, but wasn’t sure in what.  In her senior year, she did an amazing job on clinics.  She arrived before everyone else and left after everyone else, was enthusiastic, was humble, and applied all that she had learned in her pre-clinical years while her classmates were just focusing on the next test.  She particularly enjoyed her cardiology and internal medicine rotations, and decided that she wanted to be a cardiologist.

When Ivey applied to internships through the VIRMP, she only applied to highly competitive academic internships, since she felt these would be more likely to lead to a cardiology residency.  She had her mentors review her letter of intent and had a letter of recommendation from an internist, a cardiologist, and a pathologist.  Because she did well on clinics, they wrote her strong letters of recommendation.

The treatment for Ivey is both simple and complex.  The simple part is that she now needs to Scramble to get SOME kind of reasonable-quality internship.  While she could enter private practice and try again next year, I think it’s harder to get back into the academic system once you have gotten out.  The complex part is that she needs to make herself a more competitive candidate during her internship year.

Unfortunately, that’s going to be hard to do.  Her class rank is probably adversely affecting her for some institutions, particularly if they have other stellar candidates with a better class rank.  She can’t do anything about that, though, so let’s look elsewhere.  While she has some research experience, she doesn’t have a publication.  Getting a publication during the intern year is hard, but not impossible.  Telling the faculty at the start of the program that doing research and getting a publication is of top importance may be helpful.  But remember, the internship is a year for clinical training.  Very few interns successfully complete a research project or write a case report.

Ivey is probably going to have to do a cardiology specialty internship to be competitive for a residency.  To that end, finding an internship at an institution that has a cardiologist during the Scramble will be key.  Another alternative may be to enter a PhD program in physiology or pharmacology and then finish that program while getting good grades in it.  That is a very long road but, if Ivey can’t get there through the internship/specialty internship route, that may be the only option available to her.

There are a lot of lessons I think are important here.

  1. Sometimes, grades do matter.  However, learning the material matters MORE in my opinion.  Being an RFHB is even more important than that.  Don’t neglect your development as a person or as a clinician just to score good grades.
  2. The competition for high-quality academic internships is fierce.  You would not believe what the applications I read look like.  Multiple peer-reviewed publications, letters of reference with them in the top 1% of candidates, incredibly well-written letters, a wide variety of experience, and letters of recommendation from people in core disciplines.  Ivey could have done a few things differently:
    1. Follow through her research to a publication (or make sure she worked with someone who would enable her to do so).
    2. Applying to less-high-quality positions but rank them lower.
    3. Get a letter from a surgeon rather than a pathologist.
  3. Working hard counts for far more than almost any other variable.  However, your hard work is not remarkable.  It is EXPECTED that any intern applicant will work hard.  So, unfortunately, putting in the hours is the minimum baseline to be considered for an internship.  You have to somehow go above and beyond, like Ivey did- being humble, knowing what is clinically relevant, and being pleasant to work with.

If you don’t match for an internship, it’s not the end of the world.  There’s always the Scramble.  However, this is why I advocate that you apply and rank anywhere you think you COULD be happy, not just the high-quality positions.  Because I think it’s far better to get a mediocre internship than to go into private practice if you’re keen on specializing.

M&M Rounds: Expensive School

During M&M rounds, we will examine some fictitious cases and evaluate the facts and consider some solutions to these problems.

Jasper is a 26-year-old Caucasian female presenting for just getting accepted into an expensive veterinary school.  She has been struggling to get into vet school since she graduated from undergrad, and so finally decided to apply to private schools to increase her chances of acceptance.

Jasper’s history is that she has wanted to be a veterinarian since she was 5, when her family’s Golden Retriever got sick and Dr. Martin helped him feel better.  Although she shadowed vets and had plenty of hours of experience, her grades throughout undergrad were fairly poor.  She has been working at veterinary clinics since graduation, and has applied to her state school and other inexpensive schools every year since.  She has never even gotten an interview, so she applied to a private school this year and got in.

As tuition will be upwards of $60,000 per year, she will owe at least $240,000 at graduation.  This does not include living expenses, books, and anything else that might happen, like a car breakdown.  So let’s add $120,000 for those, for a total of $360,000.  Unfortunately, if her debt:income ratio is greater than 2:1 (that is, her debt is $360k and her salary is less than $180k), she will never be able to pay this amount off without Public Service Loan Forgiveness (PSLF) or income-driven repayments (IDR).  Let’s break down why.

Let’s assume Jasper gets the mean income for a new 2019 graduate in small animal practice of $90,000.  How much debt accumulates on that loan amount every year?  At a 7% interest rate, Jasper has $25k in interest she will need to pay off, in addition to the principle.  If Jasper pays just 15% in taxes, that’s another $13k.  If Jasper can live very frugally, maybe her expenses are $30k a year.  That leaves $22k a year to pay down debt and contribute to retirement.  Forget about contributing to her future kid’s college savings.  Let’s say she gets an employer match up to $10k for her retirement, so she contributes $10k to retirement, leaving $12k for her student loan.

How long does it take to pay off $360k at $12k a year?  $360/$12 = 30 years.  Jasper will be 60 years old, won’t have contributed to her kids’ college savings, and will have lived a very frugal life for 30 years.  No buying a house, no buying a new car, no vacations, no eating out.  Do you really want to have gone through vet school to live life on $30k a year?  The debt is too large for the potential income.

The treatment for Jasper is simple, but it isn’t easy.  The treatment is two fold.  One, borrow as little as possible by living extremely frugally during vet school.  Two, get a very high paying job on graduation in a low cost-of-living area.  Working ER in Phoenix and taking 26 shifts a month is an example.  If Jasper only spent $20k on living expenses during vet school, rather than $30k, her debt would be down to $320k, making her payoff time 21 years.  She’d be 51 by the time she pays it off.  Still not great.  If she also gets a high-paying job, let’s say $110k, her payoff time would be 9 years.  That still involves living a very frugal life for that time.  She will be making a six-figure salary but living like a student for 9 years.

Going with PSLF would mean her debt is paid off in 10 years AND she doesn’t have to pay taxes on that payoff.  Academia is looking pretty good now.  Internship and residency years can count for this (if they are in a state or 501c3 institution), so that’s only 6 years earning a faculty salary to be debt-free.  Income-driven repayment (IDR) is also an option, but it will still take 20-25 years for the debt to be gone and she will have to pay taxes on the forgiven amount.

Going to an expensive school will affect every decision you make for the subsequent 10-30 years of your life.  Is that really the route you want to take?  I think students go to expensive schools because they don’t run the numbers.  Or maybe they have an idealized dream of, “But I HAVE to be a vet, no matter the cost!”  Frankly, I think that’s a child’s sentiment.  Adults should make better decisions.

I think there’s only one lesson here: DO NOT TAKE ON MORE THAN A 2:1 DEBT:INCOME RATIO TO PAY FOR VET SCHOOL.

M&M Rounds: Multiple Withdrawals

During M&M rounds, we will examine some fictitious cases and evaluate the facts and consider some solutions to these problems.

Grace is a 23-year-old Caucasian female who presented for having three “Withdrawal” grades throughout her undergraduate career.  She applied to vet school last year and did not get in, and is concerned that these grades are part of the reason why.

Grace’s history is that she had a difficult undergraduate career.  She is a first-generation college student, and had a hard time adjusting to the study schedule required to do well in college level courses.  Grace is intelligent and hard-working, but her study skills were almost nonexistent when she started college.  Although she withdrew from courses as she did poorly in them, she retook those courses and did well, earning an “A” in one and a “B” in the other two.

The treatment for Grace is a little bit complicated.  A series of “W” grades may indicate that the student won’t be able to handle the rigor of the curriculum in vet school.  It suggests there may be a systematic problem with their learning abilities OR that they have a hard time balancing personal and academic responsibilities.  Students who have to work full time and/or take care of family members may have this sort of transcript.

Ultimately, Grace needs to demonstrate that she CAN handle the coursework of vet school and the rigorous demands it places on students.  The best way to do that is to continue her academic career, taking semesters with heavy course loads (16-18 credits/semester) in science-based courses.  A Master’s degree may fulfill that, as could finishing a second major.  

Grace will need to explain her “W” grades in the explanation statement area of the VMCAS, and assure evaluators that her study skills are now at the level they need to be for vet school.  I personally don’t believe adding a huge amount of veterinary experience will be helpful for Grace.  Grace’s problem isn’t lack of experience in veterinary medicine, it’s demonstrating that she CAN handle the course load in vet school, which is 18-22 credits of all science courses every semester.

I think there are two important lessons here.  One: you can’t change the past.  What’s happened has happened, and there’s no use in crying about it.  All you can do is press on and try to improve going forward.  Two: vet school is academically challenging.  You NEED to demonstrate you can handle those challenges.  If academics isn’t your thing, that’s fine.  There are MANY jobs relating to animals which do not require the academic rigor of vet school.  Do yourself a favor and find something that you would enjoy that plays to YOUR strengths.

M&M Rounds: You Got an F

During M&M rounds, we will examine some fictitious cases and evaluate the facts and consider some solutions to these problems.

Melissa is a 19-year-old Caucasian female presenting for receiving an “F” grade in Physics I.  She intends to go to veterinary school and is concerned that this mark on her transcript will prevent her from being accepted.

Melissa’s history is that she was in her second semester of college when she took Physics I.  She was also taking Chemistry II, Biology II, English Composition, and Eastern European History, for a total of 18 credits.  Melissa was a good student in high school, easily earning a 3.85 GPA, and took a couple of AP classes during her senior year.  Her first semester of college was relatively light, and she decided to increase her class load for the second semester, with a goal of applying to vet school after her second year of undergrad.

During her second semester, Melissa struggled with the course load, fulfilling responsibilities for a few clubs she was in, and spending time with her friends.  Before the second exam in Physics I, her high school boyfriend broke up with her and she got an “F” on the exam.  Before the final exam in Physics I, she was diagnosed with COVID and had to quarantine, which dramatically affected her happiness and motivation, and she got an “F” on the final.

The treatment is fairly straightforward: Melissa will have to retake Physics I.  Possibly during the summer, when she is not taking other courses, or during a semester when she has a relatively lighter load.  Having had the experience of a relationship ending and getting sick, next time she will be a little more resilient and be able to keep up her studies in spite of personal tragedy OR come up with mechanisms to manage the situation, e.g. talking to the professor, making use of university resources, seeking professional psychological help, or taking a medical withdrawal.

I see students on the APVMA Facebook group worry about this scenario a lot.  As an evaluator, I don’t think much of a single “F” on a transcript, as long as the rest of the coursework is laudatory.  I figure Something Happened to the student during that course (or semester).  Maybe they didn’t get along with the professor.  Maybe they slept through the final.  Who knows.  A single “F” isn’t a disaster by any means in my mind.

I think there are several lessons to be learned here.  One: Shit Happens.  You cannot control everything in the world, and sometimes things will happen to you that affect your life.  You get into a car accident.  Your parents die.  Life happens, and is unpredictable.  Two: A single “F” is not a problem.  Three: Just because you did well in high school doesn’t mean you’ll do well in college.  Four: When you have bad things happen, reach out for help.  You are never alone, there are people who can help.  Use that support.

M&M Rounds: You’re not an RFHB

During M&M rounds, we will examine some fictitious cases and evaluate the facts and consider some solutions to these problems.

Gary is a 21-year-old Caucasian male who presented for not being a reasonable freaking human being.  Lisa is a 26-year-old Asian-American female who presented for the same.  The symptoms for Gary include yelling at customer service people about things beyond their control, interrupting, and treating everyone as if they owe him something.  The symptoms for Lisa include freaking out about any little thing and dragging others into her drama, complaining constantly, and is only nice to people if she needs something from them.

Gary’s history is that he saw his father solve problems by getting angry and being rude to people.  His father would have road rage and constantly yell at other drivers.  When Gary got a “B” in high school chemistry, he cornered the teacher and badgered him until he was given an “A”.  Gary has not been very successful in relationships, leading him to be bitter towards the world.  Gary is now trying to get letters of recommendation for vet school, and isn’t being very successful.

Lisa’s history is that she saw her mother act very upset when anything went wrong and had a group of friends she would call to rant.  When she was young and cried, her parents gave her whatever she wanted.  As she grew up, she found she could smile and get her parents to get her another toy or a treat.  Lisa has had a series of boyfriends but has ultimately dumped them all.  Lisa has been on clinics during her fourth year of vet school and has gotten several comments from the faculty about her lack of professionalism.

As we can see, a series of life events and family situations have led to these personality flaws.  Unfortunately, such ingrained behaviors are very hard to change, and these individuals probably lack the self awareness and self-honesty necessary to identify the problem.  Nonetheless, if it is pointed out to them, or they reflect on why they have not been successful, they may find the motivation to become RFHBs.

The treatment is going to be a series of therapy sessions with competent psychologists who can help unpack what is going on with their upbringing and life approach.  Ultimately, this will be a long path for them.

Although these examples may be stereotypical, I see these students all the time.  Are you one of them?  “If you meet one a-hole a day, maybe they’re the a-hole.  If you meet five a-holes a day, maybe YOU’RE the a-hole.”  Being an RFHB is not a high standard, so check yourself to make sure you are meeting it.  If not, please find a competent psychologist to help you.

I think there are two lessons to be learned here.  One: you are a sum total of all the experiences you have had and decisions you have made.  Your family and upbringing have a tremendous impact on who you are.  Two: EVERYONE should pause and reflect on their approach to life and dealing with other humans.  Just because you are “successful” (as our society measures success, i.e. wealthy, etc.) doesn’t mean you are a “good” person.  There are plenty of narcissistic sociopaths out there running corporations (and countries).

M&M Rounds Series

One of my favorite blogs, the White Coat Investor, did Morbidity and Mortality rounds for one reader’s finances.  I think it’s a neat way to process information and present it to you in a format familiar to veterinary medicine.  For those who don’t know, in medicine we do M&M rounds when something goes wrong.  Usually, it involves presentation of the facts of the case, and then a discussion about what led to the adverse outcome.  The audience will usually contribute- sometimes helpfully, sometimes not.  

At the end of the day, hopefully everyone learns something and changes can be put into place to minimize the likelihood of the same adverse outcome happening again.  You can’t do much about things after they’ve happened- they are in the past and outside your circle of control.  BUT, you can learn from them and improve your decision-making next time you are faced with something similar.  Below are the Problems you might have encountered in veterinary medicine which we will go over in this series.

Were not raised to be an RFHB.

Received an F in an undergrad class.

Have multiple Withdrawal grades on transcript.

Matriculated at an expensive vet school.

Not matched for an internship.

Not matched for a residency.

Did not pursue an internship after graduation.

Did not get the right letters of recommendation.

Started a job that turned out to be a poor match.

Selecting a Residency

Selecting a residency program is an important decision.  You will be there for at least three years, and suffering through a bad fit for that long is not pleasant.  What you could tolerate for a year in an internship becomes intolerable over three years.  Moreover, the program has to prepare you to successfully to and pass your specialty board exam.  So how do you go about selecting the best residency program for you?

I believe there are some key variables you should consider when selecting a residency: boards pass rate, number of mentors, academic vs. private practice, and personal variables.

Boards Pass Rate

Arguably, the main purpose of a residency is to train you to be a specialist and prepare you to take the board exam.  Some specialty colleges also require credentials (e.g. case log, publication), which can be a hold-up for some people.  You should definitely know the credential acceptance rate and board pass rate for any residency to which you want to apply.  I know some programs which have terrible credentials acceptance rates because they don’t get their residents’ research projects completed in time.  Remember to compare the program’s board pass rate with the average.  In some specialties, the board pass rate may be 50%- if the program’s former residents have a first-time pass rate of 50%, I would call that pretty good.

Number of Mentors

I think one of the strengths of a residency is the number of perspectives you get during the residency.  There’s rarely one “right” way to do something in medicine, so learning a variety of different ways is helpful.  I think the best residents learn from all their mentors and take the rationales/explanations that work best for them.  In a program with two or- worse- only one mentor, you may not get a variety of perspectives and your clinical practice and education may be constrained as a result.  In the worst case scenario, if a program loses some or all of the mentors, you may not be able to complete the residency.  This is more likely with 1-2 mentors than 3-4.

Academia vs. Private Practice

I think you can get a great education in either setting, and I believe either setting can prepare you for the other (i.e. residency in private practice and then get a job in academia or visa versa).  One is not “better” than the other.  But there are important differences you need to consider.  In academia, you may get a graduate degree with your residency and, therefore, more formal classwork and training in research.  In academia, there are usually more specialties with which you can interact.  In private practice, the caseload is often higher and you get more hands-on experience.  In academia, you are expected to teach students and interns.  Consider what kind of environment you enjoy working in and which would be better for you.

Personal Variables

This includes a wide variety of considerations, like how much direction/direct mentoring do you want, if you are OK shoveling snow 7 months of the year, how expensive the town is, and what the personality of the mentors and other residents is.  The more you know about the program, the better decision you can make as to whether it would be a good fit for you or not.

I strongly suggest you do not take a “residency at any cost!” approach to selecting a program.  I really don’t think it is worth being miserable for three years of your life.  I think you should carefully consider the above variables before choosing where to apply or accept a position.  As always, be honest with yourself and try to reflect on what would make you happy.

Adverse Weather in Veterinary Academia

This may seem like an odd topic, but I realized the other day there is an unwritten rule we tend to abide by in veterinary academia (and probably most clinics) when faced with university closures during adverse weather.  This isn’t English or history- we have patients and clients we have to take care of, regardless of what the weather is doing.  So just because the university closes doesn’t mean you get the day/hours off.

I remember when I was working at a university in the south and there was a fairly serious snow storm.  I happened to be downtown and saw people skidding off the road, so decided not to get in my car.  Instead, I walked to the teaching hospital and slept in my office.  I went down to the ICU and helped out, because no one was going home OR coming in to the hospital in that weather.  So it was all hands on deck for anyone who could get there.

Recently, my current university closed due to tornadoes and was closed until 9am.  One of my residents told me that people were asking them what they should tell clients etc.  My advice at the time (which I still stand by) was, “If they look out the window and there’s a tornado, tell them not to come in.  If it looks all clear and the weather has passed, come on in.  We have to take care of these cases one way or the other!  Tell them to use common sense.”

Obviously, check with your own university’s regulations and don’t accept my guidance as gospel.  The typical unwritten rule for vetmed is that, if it is safe to come in and you are scheduled to come in, do so.  If it is not safe, do not do so.  Follow this regardless of official university closings.  If it’s a REAL weather mess (e.g. the hospital has become isolated and no one can get in or out), if it is safe for you to come in (i.e. you could walk there and avoid dangerous snowed-in roads), reach out to your supervisor to see if the hospital needs help even if you’re not scheduled to be there. 

When in doubt, communicate with your supervisor or supervising faculty to determine what to do.  Preclinical students follow the university-wide closures.  But those of us on clinics have Things To Do which don’t always care about the weather (i.e. living patients).  Just because the university is closed doesn’t mean you don’t have a job to do.

Interviews are More Likely to Harm Your Chances

Except for faculty/real world job positions- where the interview is THE way you get the job– I think the interview does not meaningfully distinguish candidates, except to weed them out.  I think it’s incredibly hard to positively distinguish yourself in the short time vet school, internship, and residency interviews give you (i.e. less than a couple of days).  It is exceptionally difficult to be a +1 in a short interview.  You are FAR more likely to fall flat on your face and provide the impression of being a -1.  How do you avoid having your application cut due to the interview?

Aim for Zero – This HAS to be step one because I cannot possibly emphasize this enough.  The interview is unlikely to help you stand out and is much more likely to sink your application, so you just need to NOT SUCK.  Don’t try to impress them.  Don’t be flashy and memorable.  You got the interview.  They basically WANT you.  So just aim for zero.

Watch Your Words – Be an RFHB.  Be respectful when talking about other people, particularly past mentors.  Don’t bad mouth anyone.  Remember, at this point they are looking for reasons NOT to accept you.  Don’t give them any reason because of a bad attitude.

Be Interested – Although I think it does help to smile and be positive, you at least need to be not disinterested.  It’s always demoralizing when I have an interview with someone who just doesn’t seem to want to be there.  You at least need to project the impression that you will show up and be engaged.  If you aren’t interested, why are you even applying?  Convey that interest during the interview.

Be Humble – Don’t brag or boast.  Don’t talk constantly.  Don’t dominate the conversation or the interview.  I HATE it when someone interrupts me, and from an interviewee (over whom, presumably, I have some measure of power) it shocks me into immediately marking them down.  If you think you’re the best thing since sliced bread, that comes across and is an immediate “no” for me and many others.  Unfortunately, if this is part of your personality, it will probably take years of therapy to remedy.  But if you do have control over it, be mindful to be humble throughout.

Just Be Cool – Be genuine.  Try to be the best version of yourself while still aiming for zero.  Try to relax.  The interviewees who impress me the most are quietly competent.  Do your best and focus on answering the question as asked, project who you are, and be professional.

In my opinion, the interview rarely distinguishes the top applicants from the middle applicants.  Although there are certainly rare gems (I would say 1-2 applicants/cycle) who impress me in a positive way, the vast majority of notes I make are about the applicants who impress me in a negative way.  Avoid getting yourself cut during the interview.  Aim for zero, be an RFHB, be humble, and you will do just fine.