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Thanks Shibil Thayath for the question,Why did Swami Vivekananda think Kerala is a lunatic house/mental asylum?Well, its indeed true that Swami Vivekananda said this in a public address at Madras in 1897 which was actually using a paragraph which he once wrote to his follower- Pandit Shankarlal, a poor brahmin who often used to host Swamiji while during his Khetri visit.The following was the paragraph which he spoke in 1897 public address at Madras and which he wrote in 1892 letterWas there ever a sillier thing before in the world than what I saw in Malabar country? The poor Pariah is not allowed to pass through the same street as the high-caste man, but if he changes his name to a hodge-podge English name, it is all right; or to a Mohammedan name, it is all right. What inference would you draw except that these Malabaris are all lunatics, their homes so many lunatic asylums, and that they are to be treated with derision by every race in India until they mend their manners and know better. Shame upon them that such wicked and diabolical customs are allowed; their own children are allowed to die of starvation, but as soon as they take up some other religion they are well fed. There ought to be no more fight between the castes.IILetters to Panditji MaharajAnd what he said based on his experience was indeed trueKerala’s caste system was the most unique of all kinds in India prevailing that era. Casteism existed across India and it was a huge concern. But Kerala’s caste system was very unique. The biggest factor, it wasn’t based on standard Indian caste system with its own unique caste hierarchies and different from rest of India.I have explained the caste system of Kerala in detail in the below post and please read the same to understand more betterArun Mohan (അരുൺ മോഹൻ)'s answer to I'm learning about Indian castes etc., I would to like know the ranking of these groups - Nairs, Nambudiri, Iyer (Tamil), Iyengar.?In Kerala, majority of today’s Hindu community (in that era, it wasn’t as recognized as only upper castes were officially seen as Hindus) as lower castes and untouchables.The degree of untouchability was the most interesting. It do even even between members of so-called upper castes. Every has to maintain a distance from other castes in the hierarchy as per certain rules and its the most strictest of all in India that time. Its called Tintal, which means habitation rules, all in reference to a Nampoothiri (Brahmin) perspective.A Nair (upper caste) can definitely be in closer contact with a Nampoothiri or even approach near to him, but must not physically touch a Nampoothiri and need to maintain a space of 8 feetAn Ambalavasi can in closer contact with a Nampoothiri and can touch him (if outside the temple), but when speaking or interacting, must maintain 3 feet.A Nair and Ambalavasi can touch each other, but need to maintain 3–8 feet depending upon the levels within these communitiesAn Ezhava (lower class) has to maintain 36 feet from a Nampoothiri and 28 feet from a Nair or 33 feet from an Ambalavasi. They must not come in straight frontline of a Nampoothiri’s vision, but on his sides only.A Pulya (lowest class) has to maintain 96 feet from a Nampoothiri, 88 feet from a Nair and 93 feet from an Ambavasi. They must not be in any approach side of a Nampoothiri and Ambalavasi, can be in approach a Nair- but only on his side at appropriate feetThe rules are more complex that this. For example, a Pulya or Ezhava can’t walk any road with 100 and 50 Meters from a temple wall respectively. They can work in the fields of upper castes, but to walk back to home, they cannot use the same path as a Nampoothiri/Nair used.The rules of settlement are too complex. Lower castes cannot own land and has to live as tenants (I have explained those concepts in detailed in this link), but their rights of tenancy are determined by caste rules.The most interesting part of all these, these laws are not bound for a Native Christian or Muslim (that time they are addressed as Mohammedan) or Jews. Jews and Native Christians by virtue of Copper Plate grants issued by Chera Emperor were traditionally in ranks of a Prince and thereby in same level of Nair nobles and aristocrats. They enjoy all social benefits as fit for Noblity in whole. Muslims or Mappillas were seen as extension of Nair community, so again, they too enjoy same social status as that of Nairs.A Muslim can visit a Nair house and live there (vice versa) which otherwise not allowed between two Hindu castes. A Nampoothiri lady cannot visit a Nair house nor Nair be allowed to enter a Nampoothiri Illam. Thats the state even in upper caste Hindu communities, so no need to mention lower castes.Native Christians (Nasranis) and Jews maintained all typical Hindu upper caste sensibilities, including extreme contempt to lower castes and believed in same Nampoothiri like pollution rules. So that means, a lower caste has to follow same rules towards a Christian/Jews as they have to follow with a Nampoothiri when comes to space or distance.Nasranis, Jews, Mappillas all enjoyed same social advantages as Nairs or nobility as they all were landed community while majority of Hindus of today weren’t. My detailed answer on Christian social status is given in below answerArun Mohan (അരുൺ മോഹൻ)'s answer to How did Christian missionaries attain higher conversion rates in coastal Tamil Nadu and Kerala?Now the interesting part.In olden days, temples were strictly meant for Hindus (Hindu in that era’s sense was only upper castes). Lower castes weren’t seen as Hindus and they had their own places of worship. Now in Kerala revenue concept, lands around the temple belong to Devaswom/Brahmaswoms (Brahmaswoms abolished in Travancore/Cochin by early 1800s). So all land around the temple belongs to Devaswoms. So what it means was, land itself is as sacred as temple and all temple caste pollution rules apply. This also means lower castes who weren’t seen as Hindus can’t use that land.But the hypocrisy is that, the fields which also part of Devaswom has to be ploughed and worked by these lower castes where these laws don’t apply, but apply for non-field/farm land.So they can’t walk around the temple and its roads. But a Christian/Jew/Muslim can because they were equal to Nairs and hence caste laws apply.So while an Ezhava who may believe in Shiva/Vishnu can’t walk even near the temple road, a Christian who don’t believe in Shiva can walk. That was height of hypocrisy. Another act of hypocrisy was, while all the caste laws apply in daylight, once the night falls, Nampoothiri/Nair overlords used to kidnap or forcibly drag lower castes ladies to their rooms for sex. At that time, these caste laws of distance and pollution don’t apply.But things weren’t in a conflict point untill start of 1800s. In 1817, Her Highness Queen Gouri Lakshmi Bai of Travancore issued a proclamation of universal education to all citizens irrespective of caste, creed, religion etc. This was further strengthen during the reign of illustrious Swathi Thirunal Maharaja later who even introduced the concept of free English education for all and introduced western subjects including politics and history in school education.This gave opportunities atleast to backward communities (non-depressed) to seek modern educationNow they got educated, but no economic opportunities as that area (socio-economic affairs) were very much old styled and as per rules. So even a highly educated Ezhava, have no other opportunity other than his traditional job of climbing coconut and tap its liqour or cut the coconuts.And this is the standard reply which the famous medical professional-Dr. Palpu got. Dr. Palppu who was a top ranker in his school education in Travancore was denied a Medical admission in Travancore’s Royal Medical College citing his caste as Ezhava. He had to go to Madras to get his Medical admission and later went to London for his higher studies and even got trained in Virology, thus becoming the first Indian to be trained in the-then emerging new age concept. He was about to be appointed in Travancore’s Royal Medical services, only to be opposed by orthodox and higher castes professionals citing his caste and denied a job. And he had to migrated to Mysore Kingdom where he joined as Royal Doctor and eventually became Royal Chief Medical Officer of Mysore Kingdom (3rd highest post in Mysore after British Resident, Diwan). And he also became the first Indian to be a member at prestigious British Royal Medical Council of Virology.Dr. Padmanabha Palpu- the first virologist and celebrated medical professional from Kerala who is also famous as social reformerDr. Palpu was extremely bittered at the way he was treated in his home country. He loved use his expertise for Travancore, but sidelined due to his caste. So he was an active participant in all social movements, notably the famous Malayalee Memorial of 1891 to ensure Malayalees get employment in State Service instead of Tamil Brahmins and used his higher offices to highlight the injustices faced by Ezhavas in Travancore thro’ writings in many English publications and social campaigns etc.And Swami Vivekananda happened to read many of these English write-ups of Dr Palppu (how he was even denied to use the word Padmanabha as his official name citing as irreverence to Imperial Deity of Travancore). In 1891, Vivekananda visited Bangalore where Dr. Palpu was the City’s Chief Municipal Surgeon then. As Vivekananda visited Bangalore as official guest of Mysore Maharaja, the state doctor was assigned for his medical attention and Dr. Palpu got acquittances with Vivekananda. And they became good friends. Its thro’ Dr. Palpu, Vivekananda came to know the horrors of Kerala caste system. And Vivekananda’s spiritual concepts and his radical thoughts inspired Dr. Palpu.'Dr Palpu was inspired by Swami Vivekananda'From Bangalore, he visited Malabar district of British Madras Presidency and reached the banks of River Nila (today’s Bharathapuzha) at Shornour where he has to cross into Kochi Kingdom. The Royal Customs Officer of Kochi Kingdom asked to prove his caste identity which was the first rude shock as only upper castes could use the Cochin State Bridge at Shornour to cross into Kingdom. Though Vivekananda was born in a Bengali Upper caste family, its equivalence in Malayalee caste system was hard to prove and none of the officers understood what Datta caste (Karyastha in North India) actually means in Malayalee terms. So he was denied to use the State Bridge and had to depend ferry to cross into Kingdom. He faced similar denial to use a Horse cart which was only reserved for upper castes and had to depend bullock cart to reach Kodungalloor. One of the princes of Kodungalloor- Goda Varma Thampuran who was a scholar in Sanskrit and Puranas invited Vivekananda for a debate on this after hearing a famous Pandit from North came. But that debate ended no where as it slipped into caste discrimination topic which Thampuran refused to discuss, rather wanted to discuss on puranas.For 3 days, Vivekananda stayed in Kodungalloor as Thampuran’s guest, yet denied entry into the famous Kodungalloor temple as none of the priests and officials of temple able to understand the caste equivalence of Vivekananda’s in Malayalee terms and hence not allowed. This kept on continuing in majority of temples he went in Kerala.He reached Ernakulam (modern Kochi city) in Dec 1892 where he met Chattambi Swamikkal who was a famous spiritual guru/philosopher of Kerala (later a key personality in Kerala renaissance). Both of them admired each other and understood their key philopshies and need of change etc. Chattambi Swamikkal advised many newer concepts of yoga and spiritualism and asked him to find a secluded post to practices it and feel enlightenment.And Vivekananda went from Ernakulam to Kollam where he became a friend of Travancore Princess’s tutor who worked in Bengal. Thro’ this tutor, he was introduced to Travancore’s famous King- H.H Sree Moolam Thirunal Maharaja who was highly modern in social life, but orthodox when coming to religion and concepts. The Maharaja who used to sit close to Vivekananda for talking in evenings or enjoy close walks in the Palace gardens etc, becomes ultra orthodox in morning hours by strictly maintaining distance rules for avoiding caste pollution (including shunning seeing a sansyasi in morning hours which is still a bad omen in Kerala beliefs) as he has to visit Sree Padmanabha temple. This duality and orthodox mentality of even a highly modern/liberal king was quite surprising for Swamiji. Swamiji was also denied even entry into Trivandrum Fort (East Fort) citing him as lower caste which also made him offended because generally sansyasis donot have caste in any part of India.He decided to visit Kanyakumari which was the tip of India (then part of Travancore). At Kanyakumari, he was planning to mediate in the beach area, when suddenly he saw a rock, quite few kms away into Sea. He was denied access to that rock, citing its the meditating spot of Goddess Kumari (Maha-Maya- the Great Virgin who sworn to isolate herself in meditation after Lord Shiva refused to marry) and no one else allowed to visit that spot to avoid goddess being disturbed.Vivekananda was amused at this superstitious belief and he said, if Goddess is meditating, I too will join with her in that which offended many caste Hindus who dismissed him as a Lunatic. He sought help of everyone in the beach to take him to that rock, including fishermen, but none agreed fearing the wrath of Goddess as well as upper castes. Finally he swam across the 1.5 Kms in open sea channel and reached the rock, where he meditated 3 full day and night practicing the technique which Chattambi Swamikkal advised and felt much enlightened. He felt his first enlightenment there at the tip of this great civilization with never ending oceans beyond.Painting of Enlightenment of Swami Vivekananad at the Rock in KanyakumariThe Kanyakumari Vivekananada Rock Memorial as of today with the Devi temple in middleThe news of Vivekananda breaking a local custom (entering a prohibited area) offended many caste hindus and he has faced lot of abuses in his return later (much like how reformists faces in Sabarimala today)All these negative experiences which he faced in Kerala actually validated the horrors of Kerala caste system which Dr. Palpu narrated to him and indeed it was the key reason he mentioned Malabaris as lunatics.There is another reason for him to believe so.In Kerala/Malabar (as said in that time), Sansyasis are not revered community. Even today, there is a general contempt towards the concept of Sansyasam in general, especially early Sansyasam (taking renunciation in their youth etc). So generally people don’t revere or encourage them in a big way, unless in a philosophical debate or similar.On the contrary, a Christian Priest has a huge reverence in Kerala society even today. He would be addressed as Father and seen in a fatherly role.This wasn’t the trend in other parts of India then and even today. So while Vivekananda as a Sansyasi faced lot of contempt in Kerala, he observed how even upper Hindu castes do revere Christian priests. He has made a mentioning of this in his article.He also noticed one unique thing. While a good percentage of women of supposed to be lower castes (goldsmith community) spoke Sanskrit fluently and able to recite many scriptures during his Kodungallor days, he noticed majority of Nampoothiris (brahmins) can’t speak Sanskrit, but quote themselves as authority of Purnas and scriptures. So he has said, despite of having higher ability of learning a language that majority of lower castes were denied across India, many Malabaris unable to move out of the cage into which they being imprisoned in name of rituals and customs.These concepts and experiences also fuel in his belief that its a lunatic asylum of casteismIs it good or bad.I believe, that remarks had played a key positive role in Kerala renaissance.The people of Kerala, who could take in Vivekananda’s caustic criticism with an open mind and in the right spirit, made use of the ‘lunatic asylum’ observation as an opportunity and inspiration for introspection and self-evaluation. The 'self-treatment’ by making use of Vivekananda’s description of Kerala continues even today. Thats why, almost all Kerala renaissance movements often consider Vivekananda’s famous words as their tipping point of rise of Navodanam (renaissance/enlightenment) and he been seen as a symbol of renaissance in Kerala.Even Sree Narayana Guru and his organization- SNDP often considers Vivekananda’s open criticism as the key tool that stimulated educated Malayalee mindset to revolt against the rampant casteism.Thats why SNDP’s first official magazine edited none other than by Kerala’s most celebrated poet- Kumaran Asan named it as Vivekodayam which has dual meaning. Its symbolic meaning- Wakening the inner wisdom (Vivek- Wisdom and Udayam- rise) and other meaning was a tribute to Swami Vivekananda who played the role of being a stimulus to almost all renaissance movement.Almost all social groups in Kerala renaissance, be it Nairs, be it Nampoothiris, be it Ezhavas, be it Pulyas, be it Christians etc often quotes Vivekananda’s classic words as a reminder how primitive we were in past and how far we need to move to reach shores of civilization and humanity.I see no shame in that, rather more happy and proud that a Bengali man, who has no connect with Kerala and no personal requirement for reforming Kerala society, played such a critical role in puncturing our idiotic and worst caste inflated balloon and helping us to move forward in social reformation and cleaning untouchabilityIf Kerala has less red in this map, its those words that helped clear our shit that once glow us in deep red.That classic words often reminds us that we were lunatics once and acts as moral reminder not be return back to that shithole againAnd interesting fact for Right wingersIn Kerala, almost all parties, be it Congress, be it Communists, be it IUML or Kerala Congress, all sees Swami Vivekanandan as one of the most influential reformer than gave Vivekam (wisdom) to usOne of Kerala’s famous communist leader and teacher- R Sugathan (the first Communist Member in Travancore Cochin Legislature in 1952 and later again in 1954) has made a detailed write up about Vivekanandan in Kerala Kaumadi Newspaper on 22nd Jan 1963. The most relevant portion whose English Translation isAnd due to this reason, Kerala communists (as Kerala Communism itself is a byproduct of Hindu renaissance movement) often see Vivekananda as a symbol of enlightenment, a man who provided the right medicine against Kerala’s primitiveness and man behind Kerala’s Renaissance movement.Swami Vivekananda’s imagery used in CPM’s state congress meetings in KeralaKerala govt officially celebrated 125th year of Swamiji’s visit to Kerala that sparked Renaissance in Kerala as Vivekanandasparshanam (the touch of Vivekananda) in presence of multi-religious leaders and key politicians of all parties in 2017As a Malayalee, I shall always be indebted to Swamiji for his inspiring words which we always help us to introspect!!!Further readinghttps://www.esamskriti.com/essays/pdf/20%20Vivekananda%20n%20Social%20Movements%20in%20Kerala%20PB%20January%20February%201989-compressed.pdf125 years after Swami Vivekananda called Kerala 'lunatic asylum'Vivekanada's Lunatic Kerala

Q. Are there graduates of medical schools (MDs and comparable) who are unable to get into a residency program? If so, what happens to them?A. A few articles of interest:Understand Your Odds of Getting into ResidencyShortage of residency slots may have chilling effect on next generation of physiciansOptions Exist for Med Students Without Residency Matches (usnews.com)Medical Students Match Day (statnews.com)Unmatched Graduate: “Med Schools to Blame”Foreign medical graduates get a raw deal. Here's why.Understand Your Odds of Getting into ResidencyMARCH 08, 2017 Heidi Moawad, MDIn recent years, we have all been hearing more and more in the medical community about doctors who are not able to successfully get into a residency training program in the United States. Physicians in this predicament are in a difficult jam, unable to proceed with a career they have spent so much time and money working toward, while at the same time, unable to get work in most other desirable professions, which also require years of specialized education and internships.Many aspiring physicians wonder about the numbers behind this bleak situation and what it means for them. If you have been unable to match so far – or if you are apprehensive that you may have a low chance of matching – the statistics behind this problem can help you gain some insight into your chances of getting into an accredited residency program.MATCH PROGRAM FACTSThe National Residency Matching Program (NRMP) itself, which is the organization that matches physician applicants to U.S. residency training programs, provides a uniform process for all applicants, with consistent application deadlines and scheduled announcements of match results.According to the most recent NRMP results from 2016, there were more than 35,000 applicants for approximately 27,000 PGY1 positions. The gap between applicants and positions is the reason that there are so many medical school graduates who are not able to work as doctors. Of these applicants, about 20,000 are graduates of U.S. medical schools, and the remainder of physician applicants are International Medical School graduates.While there are certainly a substantial number of physicians who do not match in a residency spot, there were more available positions for PGY1 spots this past year than ever before. But, the number of applicants for the 2016 match reached an all-time high. The number of U.S. allopathic medical school and osteopathic medical school applicants was only about 20,000, which is substantially fewer than the number of residency positions available. And, it turns out that most (more than 95 percent) U.S. graduates did match in a residency program.However, there are hundreds of U.S. medical school graduates who do not match each year. U.S. medical students who were not recent graduates had a significantly lower match rate than recent graduates, for various reasons. And American students who graduated from international medical schools did not fare as well as American students who graduated from U.S. medical schools, with a slightly higher match rate than non-U.S. citizen International Medical School graduates, which was little more than 50 percent in 2016.LARGER NUMBER OF APPLICANTSThere has been a larger number of applicants than ever before because most of the applicant groups are growing. There are slightly more U.S. allopathic medical school graduates, more U.S. citizen International Medical School graduates and more Osteopathic medical school graduates, which adds up to more applicants. And, there are more non-U.S. International Medical School graduates applying for residency spots as well. Despite all of the negativity about the medical field, there are still huge numbers of people who want to work as physicians, particularly in the United States, where most doctors perceive the system to be relatively fair, uncorrupt and of high quality.Interestingly, there are also many non-U.S. International Medical School graduates who do not even apply for the match because they have not passed USMLE tests, have scored low on the examinations or have other concerns that make it impractical to apply. And a large number of non-U.S. International Medical School graduates apply for residency, but receive no interviews, and thus do not have the option to proceed with ranking programs in the match.DO YOU HAVE TO MATCH TO WORK AS A DOCTOR?While you can take USMLE parts 1 and 2, and there are special circumstances that allow for you to take USMLE part 3, each state has its own requirements for medical licensing. At least one to two years of residency or internship training is typically required in order to obtain a medical license. If you want to work as a clinical physician, it is best to try to get a position through the match, or shortly after the match during the so-called scrambling period if you do not match. In fact, there are even instances in which physicians become ill or leave training programs, opening unexpected slots that need to be urgently filled at any time during the year.Physicians who want non-clinical work can succeed without residency training, but residency training even helps open the non-clinical route to better options. Therefore it is worthwhile to continue in the process, even accepting a position in a less desirable specialty, whether your aspiration is patient care or non-clinical work.There are options for doctors who do not have residency training, however. To get the most updated information, visit Careers for Physicians Without Residency, which is regularly updated with more opportunities.Shortage of residency slots may have chilling effect on next generation of physiciansBY BRUCE KOEPPEN, M.D. — 01/22/16 11:00 AM ESTMost people are aware of America's looming physician shortage, but the shortage of residency slots for medical school graduates has received less attention.In order to practice medicine in this country, graduates of allopathic (MD) and osteopathic (DO) medical schools must complete a residency training program. In recent years the number of MD and DO graduates has increased by more than 23 percent in an effort by schools to address the country's growing physician shortage, which the American Association of Medical Colleges estimates will approach 90,000 too few physicians by 2025.While the number of medical school graduates is increasing, the number of residency training positions has not kept pace. If this imbalance is not addressed, the number of American MD and DO graduates will exceed the number of first-year residency positions, which by some estimates could occur as soon as 2017. When this happens, young physicians-who dedicated years to the pursuit of a medical education and incurred significant debt doing so-will not be able to practice medicine, and the physician shortage will persist.Part of the problem stems from the funding mechanism for Graduate Medical Education (GME). Medicare covers the majority of the cost teaching hospitals spend on training medical residents, but the Balanced Budget Act of 1997 capped the number of residency slots the federal government would fund. The shortfall-what is not covered by the Federal government-is paid for by the hospitals where residents train. While it is possible to increase the number of residents they train, to do so, hospitals must fund the entire cost of those training positions.Though patient care has shifted its emphasis to wellness and prevention, the current reimbursement system has not yet caught up. It is still based on the number of procedures performed, incentivizing hospitals to fund additional residencies in revenue-producing specialties instead of primary care.Adding to the problem, are for-profit schools that pay hospitals for medical student residency training spots-an incentive for some cash-strapped hospitals-something that is a growing concern among medical school deans. Residency slots that are taken by trainees from non-accredited schools reduce the number of slots available to trainees from accredited allopathic and osteopathic schools.Some of these non-accredited for-profit schools train as many as 1000 students a year without clinical facilities or full time faculty. According to a 2013 Bloomberg Markets investigation, many students who attend these schools incur tremendous debt and fail to complete the programs; many of those who complete the programs are unable to find a residency.The shortage of residency slots is also affecting graduates of accredited programs. Last year, more than 500 graduates from US allopathic medical schools were unable to obtain a residency training position. As more students graduate from medical school in the coming years, this number will only increase.We need to find ways to address the shortfall. There are several solutions being considered.The Foreign Medical School Accountability Fairness Act, a bi-partisan bill from the House and the Senate that would protect taxpayers and students, eliminates an exemption that entitles certain foreign medical schools to US Department of Education Title IV funding without meeting minimum requirements. The bill would ensure that 60 percent of enrollees in medical schools outside the US and Canada must be non-US citizens or permanent residents and have at least a 75 percent pass rate on the US Medical Licensing Exam.Other pending legislation includes the Training Tomorrow's Doctors Today Act, which would add 15,000 new residency training positions over the next five years; and the Resident Physicians Shortage Reduction Act of 2015, which aims to protect against the rapid shortfall of primary care physicians.The Affordable Care Act's $230 million Teaching Health Center Graduate Medical Education Program is designed to train primary care physicians mostly in non-hospital settings, which is exactly where the majority of primary medicine is practiced. Moreover, many of these new training programs serve underserved communities. These residency programs do not rely on Medicare funding, but must be self-supporting by 2017.These efforts all have merit, but the wheels are turning slowly and the clock is ticking. Training physicians doesn't happen overnight. Our lawmakers need to move quickly for the sake of patients and the physicians who have invested so much time and effort into learning how to care for them.Koeppen is founding dean of the Frank H. Netter School of Medicine at Quinnipiac University.Options Exist for Med Students Without Residency Matches (usnews.com)Few days are as important as Match Day for a medical school student.Dozens of videos on YouTube show students crying tears of joy and hugging classmates as they finally learn, this year on March 15, where they will spend the next three to seven years doing their residency. This day marks the unofficial end of medical school and the beginning of a career as a doctor.[Learn about recent changes in the matching process for residents.]On the Monday of Match Week, students learn if they were matched with a residency program. This year there were approximately 40,000 registrants. Unmatched students – this month, 963 registrants were unmatched, according to the National Resident Matching Program – are automatically entered into the Supplemental Offer and Acceptance Program, a one-week process that allows them to apply for unfilled residency positions.Residency offers through SOAP "continue through Friday of Match Week, and that process has been very efficient," says Hal Jenson, president-designate of the National Resident Matching Program.Before SOAP was created, students went through a similar process called "the scramble." But even with coordinated, last-minute efforts to place students, some still find themselves without a residency.After not matching in anesthesiology in 2010 and then failing to find a residency program through the scramble, one aspiring physician spent a year teaching anatomy, physiology and microbiology at a technical school until the next match."I still wanted to do anesthesiology, but I left it open to other fields as well. It sort of becomes a you-take-what-you-get type of deal," says the now second-year resident, who asked not to be identified. He settled for internal medicine."Initially you are disheartened, but what can you do about it? Either you sulk, or you fix it and figure out another situation," he says.[Find out how medical residency work hours can vary.]Experts say there are typically two reasons students don't match. They apply for highly competitive residencies, such as dermatology or radiology, even though their medical school performance makes them unlikely candidates for those slots, or they place too few schools on their ranking list, which they give to the National Resident Matching Program.While unmatched students can take alternative routes to residency, many in the medical field agree it's best to avoid the situation outright. One way is to rank several residency programs at which a student has interviewed."I tell medical students they should always put at least five places," says Stephen Klasko, dean of the University of South Florida Health's Morsani College of Medicine. He encourages students, particularly those who didn't initially match, to expand the number of hospitals they are willing to go within their chosen specialty, or consider choosing a different specialty.Lynn Buckvar-Keltz, associate dean for student affairs at the NYU School of Medicine, says grades and exam scores matter when applying for residency, but those aren't the only factors."Being an engaged, enthusiastic member of the clinical teams during the clinical clerkship is an important part of the student's medical school experience and therefore their residency application as well."[Follow a day in the life of a medical intern.]If an aspiring physician is unmatched, there are a few options.Students can contact their medical school and ask for a transitional slot, which mimics the fourth year of school, or seek a research fellowship."If they do a transitional year or a research fellowship, they can then become more competitive in one of those specialties or they can decide to match in family medicine or general internal medicine where it's easier to get a slot," says Klasko.Obtaining another degree could also increase a student's chances of matching in the next cycle, Klasko says."Now all of a sudden I'm a pretty cool candidate," he says. "It doesn't look like I'm somebody who failed. I'm somebody who decided to get a master's in public health or an MBA. Now I'm a differentiated candidate."Searching for a medical school? Get our complete rankings of Best Medical Schools.Corrected 4/10/13: A previous version of this article misstated the name of the National Resident Matching Program.Tags: doctors, education, graduate schools, medical school, studentsDelece Smith-Barrow is an education reporter at U.S. News, covering college admissions; she previously wrote about graduate schools.POLITICSMedical Students Match Day (statnews.com)Looming question for medical students: Will they be shut out of advanced training? By MELISSA BAILEY MARCH 17, 2016Dr. Heidi Schmidt looks on while a nurse takes the vitals of a patient in a medical clinic at the St. Vincent de Paul food pantry in Indianapolis.They’re about to graduate from medical school with an MD to their names, but hundreds of students across the US learned this week that they haven’t advanced to the next step of training — and will not be allowed to practice medicine.Most medical students found out Friday where they’re headed for their residency, where they’ll work alongside licensed doctors, gradually gaining more responsibility. But each year, a sizable group learns shortly before the official “Match Day” that they’ve been shut out of this training.This year, for instance, more than 29,000 applicants got placed in a first-year residency through the main matching process. But 8,640 did not — a number that includes international applicants and aspiring physicians who graduated from medical schools in recent years, as well as current fourth-year students.That mismatch has prompted a policy debate: Should the rural and urban clinics that struggle to find doctors be allowed to scoop up unmatched graduates so their talents don’t go to waste? Or would it be dangerous to put them in front of patients without a traditional residency, which typically lasts at least three years?Missouri, Kansas, and Arkansas have passed laws to allow unmatched graduates to work in medically underserved areas without doing a residency.Otherwise, “a lot end up wasting all of their education, because there is no place for them in the health care delivery system without having a residency,” said Dr. Edmond Cabbabe, a plastic surgeon in St. Louis who conceived of the Missouri law.Passed in 2014, but not yet implemented, the law will create an “assistant physician” license for these newly minted doctors, who will work with a collaborating physician. That physician will have to directly supervise the new doctors for at least a month before they can see patients on their own. One impetus for the law: Nearly all of Missouri’s 101 rural counties face a shortage of primary care providers.Arkansas this year approved new rules allowing recent medical school graduates with ties to the state to work as a “graduate registered physician” before residency. Kansas, too, created a special license; it’s restricted to graduates of the University of Kansas School of Medicine who strike out in the match process, and it allows them to work, under supervision, for just two years. At that point, they’re expected to move on to a residency.Related Story:Medical students demand an end to pricey exam testing patient care skillsWhile supporters hail such laws as a groundbreaking solution, the medical establishment has frowned on them.The Association of American Medical Colleges “is concerned by efforts that would bypass the experiences necessary for physicians to provide safe and effective patient care independently,” said Tannaz Rasouli, AAMC’s senior director of government relations.The American Medical Association also came out against such programs. Instead, it has called on government, insurance payers, and foundations to pitch in money to create more residency spots.So far, no one is practicing medicine under any of those new regulations.But they could help MDs like Dr. Heidi Schmidt, a Juilliard-trained opera singer and entrepreneur who graduated from American University of the Caribbean School of Medicine on the island of St. Maarten. She received honors in clinical coursework, but struggled with standardized tests and had to make multiple attempts to pass two national board exams.Residency programs often see multiple board exam attempts and degrees from foreign medical schools as red flags when evaluating candidates.Schmidt, who also has master’s degrees in public health, music, and pharmaceutical science, has the title “doctor,” but her options are limited. Without at least one year of postgraduate residency, she can’t practice medicine in the United States. To work as a nurse or a physician assistant, she’d have to go back to school and get a different degree.To stay in medicine, she volunteers in Indianapolis at Gennesaret Free Clinics for the homeless and working poor. She sees patients, but she said a licensed physician must sign off on all her work. Schmidt said she can’t get paid until she becomes a licensed physician. And she longs to treat patients on her own.“My dream has always been to be a physician for the poor,” she said.Dr. Heidi Schmidt at the St. Vincent de Paul food pantry in Indianapolis, Ind. After not being matched with a residency, Schmidt’s plans of becoming a licensed doctor are on hold, so she volunteers at a medical clinic there.LUCAS CARTER FOR STATSeniors in traditional (non-osteopathic) US medical schools have better odds than those from foreign schools: Their match rate has hovered around 94 percent. But that still means 1,130 didn’t get a residency in the main match this year.That news can be a shock. As a senior at the University of Virginia medical school last year, Dr. Daniel Harris applied to 67 general surgery residencies and landed eight interviews at residency programs. On the Monday before Match Day, he got an email letting him know that none had accepted him.Harris said he was in disbelief, but he didn’t have time to process that feeling. He had just two hours to decide which programs he would apply to through the Supplemental Offer and Acceptance Program, or SOAP, which helps unmatched applicants find open spots.Harris picked 20 programs and hit “submit.”“I maybe started crying at that point,” he said. “There was nothing more I could do.”Harris got lucky: He was one of 599 US medical school seniors who scooped up unfilled spots through SOAP last year. Other types of applicants — for instance, those from foreign schools — grabbed another 400-plus spots.That still left hundreds of seniors at US medical schools, and thousands from international schools, halted in their quest to practice medicine in the United States.Were they weeded out for good reason? That’s open for debate. Surely, some were ill-prepared. Others may have been unlucky or just played their cards wrong when picking which residencies to apply for.The most common reason for not matching is poor scores on national board exams, according to a 2005 survey by the AAMC. Other reasons include: applying to a specialty that’s too competitive for the applicant’s academic standing; poor interviewing or interpersonal skills; and having to take a board exam multiple times to pass.Some people in this situation, like Dr. Nick Milligan, decide not to pursue a medical license. Milligan graduated from St. George’s University School of Medicine, on the Caribbean island of Grenada, in 2014. He said he was disappointed not to match with a residency, but he ended up happily employed at Coachella Valley Volunteers in Medicine in California, where he has used his medical training to build a diabetes education program.Medical school grads face a staggering $183,000 in debt, on median, but they can seek relief, as Milligan does, from federal programs that limit monthly loan payments to 10 percent of income.Most graduates of US medical schools don’t give up on becoming a licensed doctor if they don’t match, said Geoffrey Young, AAMC’s senior director for student affairs and programs. They often spend a year doing research, or complete a fifth year of medical school, then apply to the match the following year.Related Story:An urgent call for diversity in medicine, ‘the profession I love’More than 99 percent of US medical school graduates do end up practicing medicine within six years of graduation, Young and coauthors found in a study published in JAMA.The new state laws might offer some of the unmatched students another route to a medical career.Missouri is expected to open enrollment for its assistant physician license this fall. Because it has the least restrictive rules, it may face a flood of applicants from around the country.Schmidt could be one of them.If Missouri opens the door for her to treat patients, she said, “I’d pack up and move in a second.”Update: The story has been updated to include statistics about the matching program for this year.Unmatched Graduate: “Med Schools to Blame”by SkepticalScalpel | Oct 17, 2016 | 30 commentsSkeptial Scalpel (click to view)The following was submitted as a series of comments on my Physician’s Weekly post about Missouri’s new law allowing medical school graduates who did not match into residency positions to work under supervision. The comments have been edited for length and clarity:I am a 38-year-old US medical graduate who has attempted to match 3 times with no success. I decided not to throw the money away again this cycle. I have half a million dollars in educational loans. I would exchange my situation with any non-US-IMG because they probably don’t have massive loans. I have seen kids coming fresh from India with no loans who match in their first attempts because they score high enough on USMLE to separate themselves from people like me.Based on USMLE scores, the matching system is fair to a lot of us. What fails US grads is the educational loan structure that allows us to borrow without any accountability of medical schools that are benefiting most. If medical schools are going to produce doctors who cannot match after genuine attempts, the schools should be blamed. They have standards that require students to pass each course in order to graduate. If they believe a student is not good enough to become a doctor, they shouldn’t graduate the student. Students would benefit more if the medical schools could determine which med students won’t be good doctors earlier on and dismiss them. Then the students will not pile up so much debt.Some graduates find that their training is not good enough to become a physician. It’s a scam. Why do medical schools get a free ride on this? Everyone who has completed medical school successfully with passing scores on USMLE Step 1 and 2 should be allowed to use that acquired knowledge. Why not let those who have demonstrated they can work under supervision get job?What fails US grads is the educational loan structure that allows us to borrow without any accountability of medical schools that are benefiting most.When I try to get a nonclinical job, they read my resume and tell me I am overqualified for the position. I have tried to hide my MD degree and use only my Bachelor of Science degree (biology) in order to get a job. But they tell me I don’t have experience, and the big gap between my undergrad education and my current situation cannot be explained. Some employers have asked me if I spent the time in jail.I applied to PA schools last year and had no success. Some of my rejection letters said as a medical doctor, I am not a good fit for PA career. Some PA programs wanted me to go back to college again to take pre-med courses.Besides medicine I have no other skills I can use to make a living. I am broke. I refuse to become homeless. Last month I applied and qualified for food stamps. Next week I am starting a $10.15/hour job as a UPS package handler while I am looking for other better opportunities.Each year about 5% of US graduates do not match to a residency and have nowhere to go. There are many reasons we did not match—most commonly because of academics. If I were a program director, I would interview the best applicants and rank them accordingly. I just believe unmatched doctors must be given other opportunities to make use of their acquired knowledge instead wasting it in a warehouse or a grocery store.If fresh college grads with 2 years in PA school can become providers under a licensed physician why can’t someone who made it through med school in 4 years function at the same level? Having an MD degree without a residency is like having a felony record. No one will give you a job. Having an MD degree without a residency dooms you to struggle in life. I wish I didn’t have the heavy weight of the MD degree on my back.I hope marginal pre-med students will read my story and make a rational decision before applying to medical school. Med schools want to fill their classes because they know the more students they have, the more money they will make. As they collect your tuition, they will tell you they are nonprofit institutions.No med schools will tell pre-med students the drawbacks such as the scarcity of postgraduate training as med school class sizes increased 30% since 2000. Most schools only publish lists of students who matched successfully and fail to mention those who don’t match. Pre-med students should be told what happens to all graduates of each med school.My story may not be relevant to pre-meds who have demonstrated great potential in medicine (GPA, MCAT, and motivation). The problem is some med schools can’t fill their classes with 100% smart kids. What they do instead is lower their standards to get more students to fill the class. Why? Because they want to make money and are not held accountable.If they can’t recruit students who can become licensed physicians in the US, the classes should be left unfilled. What is point of educating someone and giving him a piece of paper that can’t be used? These institutions should be held accountable for tuition and fees if a medical graduate attempts to match to complete his training but failed. This will force them to dismiss academically or professionally unfit students from medical schools before they accrue massive loans.I don’t see how the schools could ever be forced to do what the writer wants.Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last six years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 2,500,000 page views, and he has over 15,500 followers on Twitter.Foreign medical graduates get a raw deal. Here's why.ERIC BEAM, MD | EDUCATION | MAY 23, 2016On my recent tour of residency programs, I had the pleasure of meeting many foreign medical graduates (a.k.a. FMGs; not to be confused with international medical graduates, who are U.S. citizens who go abroad for medical school).Almost uniformly, they struck me as confident, mature and articulate. Many were older than me, some by as much as 10 or 15 years. Most had extensive research experience, and a few had even completed residency already in another country and were here to take a shot at becoming a U.S.-licensed physician, which would require them to do it all over again. To an outsider, they would appear as competitive candidates for programs that aspire to produce first-class doctors. But I did not envy their plight. In our conversations, one thing became clear: Whereas I was hoping to match into one of my top-choice programs, they were hoping to match, period. And, in 2016, only 50 percent did.FMGs get a raw deal. With the exception of Canada, we don’t recognize international medical training as meeting our quality standards; thus, doctors licensed to practice in their home countries must start at square one if they want to work here. Before they even apply to residency, FMGs need a stamp of approval from the Educational Commission for Foreign Medical Graduates (ECFMG). Only about half succeed in getting certified.One major hurdle, apart from the written exams, is the USMLE Step 2 Clinical Skills test, which requires a high-stakes demonstration of English proficiency and a costly trip to one of the five U.S. cities where it’s offered. (Interestingly, from 1998 to 2004 this test was called the Clinical Skills Assessment, and only FMGs were required to take it.) It’s virtually impossible for a FMG to start residency directly after finishing medical school. They’re often encouraged to do a few years of research to pad their résumé, or to do a rotation or two at a U.S. hospital. This adds up to a lot of time, money and effort spent on an endeavor that is far from a sure thing.All of this is not to say that we shouldn’t have a rigorous screening process for who we allow to train and practice here. We should, and we do. But we must acknowledge that the deck is stacked firmly against FMGs. Imagine you’re a program director comparing two applicants side-by-side, one a U.S. medical graduate and the other a FMG. If, on paper, the two appear to have equivalent qualifications, there’s a good chance the FMG worked harder and sacrificed more to get there. That is an achievement worthy of recognition.But these days it’s become something of a badge of honor for residency programs to exclude FMGs from their rosters, and historically they have served as “fillers” for residency spots that remain vacant after U.S. students have matched. In 1995, the Council on Graduate Medical Education, an advisory body tasked with making recommendations to the Department of Health and Human Services, singled out FMGs in their annual report and proposed cutting federal funding for their training by 75 percent in an effort to reverse course on an impending “physician surplus” (oh, the irony). They walked back this recommendation in a subsequent report due to anticipated “legal complexities,” but even their less controversial plan carried the same aim: to severely restrict FMGs from entering the physician workforce.I have heard two arguments for keeping FMGs out. The first is that their training is substandard. While I’m sure this applies to some cases, it is certainly not a universal truth. Is it really so hard to believe that a student whose education happens outside of a glittering first-world multi-million-dollar medical complex could learn the same principles of biomedical sciences as a student in this country? Is that student not examined as rigorously, mentored as thoughtfully, challenged as intensively, as one of ours?The second argument against FMGs is the so-called “brain drain” theory; that taking FMGs will siphon much-needed talent from poorer countries where doctors are scarce. I take particular issue with this one. All people, no matter their provenance, should be allowed to use their gifts to better their own lives, especially if that means escaping poverty or conflict.And let’s be honest: When a program director rejects a FMG, is he really thinking about the physician supply in Pakistan? What if we applied the same logic within our borders? If a medical student in physician-poor Arkansas graduates at the top of her class, with all the attendant publications and honors to her name, and wants to train at Massachusetts General Hospital, we don’t say, “No, you have to stay, Arkansas needs you.” We let her go as far as her talent and ambition will take her. Will Arkansas suffer? Minimally, perhaps, but they’ll be OK.The U.S. prides itself on having the best doctors in the world, so why not bolster our ranks by welcoming some of the best students the world has to offer? It’s curious that diversity is championed in medical school and residency admissions, just not this kind of diversity. Our knee-jerk aversion to FMGs seems to be the last true sanctioned form of admissions discrimination. First, we must ask ourselves if we want our admissions process to be truly merit-based. If the answer is yes, then it’s time to start recognizing merit even when it comes from outside our borders.Eric Beam is an internal medicine resident who blogs at the Long White Coat.Image credit: Shutterstock.com

Let's go down the list of what makes a nation as, well, a nation:languagecurrencyanthemhistoryculturenormsstandardslawsHow to determine what the language should be? Do we go by most popular which is English, or most spoken which will be either Mandarin/Chinese or Hindi?(I am NOT learning Hindi, by the way; I know another 5 languages but this one gives me the most trouble).What do we do with currency? Do we even keep it? And who is to decide?(Whatever the decision is, there will be a black market for the currency anyway, it's the way economics, criminals, and human nature go around the rules).An anthem - this is even tougher than the language, since an anthem can be translated into any language; but do we have a nation which was formerly a colony of another nation singing triumphantly over their independence or do we keep the pompous anthems composed during the period of that colonialism?(And how to decide on this?)History.Ugh. What do we keep? What do we delete? How to even compile it - since victors write the history, how do we reconcile the glorious view that Russia's leaders have for themselves against the lackluster (and almost paranoid) behavior that other nations observe coming from Russia?What do we do with the Native Americans: US history treats them in one way, and the world (outside US) treats them in a completely different way.And how to make nations which have centuries-old conflicts to put their kids into schools where kids will sit next to one another? Will the historically-based hatred be permitted or not and what are the implications of stating "My nation/history/geography is better than yours"?(Right now we have borders separating those countries and without borders we need to self-police - who will set rules on that?)Culture.If historically mandated outfits (let's pick a Burqas) are present, how do we regulate it? Do we allow them in the name of preservation of cultural identities? Do we ban them in the name of a homogenized nation?And who will decide whether to go burqa-less or compromise on headscarves for everyone? Which tradition takes precedence? How do we evaluate it?In terms of living standards, when people from developing nations are allowed to roam freely among the members of the first world, and these persons decide to settle in another area (let's say the settlers came to NYC) - their living standards will be vastly different from the native inhabitants of that geographical area.So, let's say the newcomers go without medical care (since it's not a must in the area where they are originally from), and these residents allow their personal hygiene to be below that common sense (for the first world) threshold - do we track them and teach them new standards or do we let them be?Do we tell them that they are tracked and monitored or do we just snoop quietly?And finally, the laws.Where do we begin?Labor-wise, from the worker-centric protectionism of Europe to "at will" standards of US, to very few female workforce participants in Middle East, to overtime and overworking mandates to the Far East - how do we reconcile it all?For other laws (governing contracts and even criminal laws) - they are based on precedents, and some countries have longer lists while others are pretty much one-liners. The latter, I am referring to the contract which I had been privy to - between my then-employer and a new client; the contract was drafted by both parties: US side came up with a voluminous document preparing for every conceivable eventuality, and Japanese client basically came up with a letter stating that both parties are entering into the relationship and will work out their differences as they come up. A huge difference in mentality.To combat these, we can certainly allow exceptions. But how to we uphold them? Is it based on the birth? What if the child chooses not to use the exemption? Can anyone claim this exemption since we'll be one big happy family now - so can I claim something that's applicable to residents of sub-Saharan Africa and can they claim something that's applicable to residents of US?Or do we keep track of the origins of each nation and have a registry of their residents? Or do we abandon it all and mandate one set of rules for all? And what do we do with grandparents and great-grand-parents who are old-school and refuse to participate in our one-nation program?(And if those grandparents have access to their own kids, they can teach the new generation about the old ways - or do we deny them that access? Do we separate families or do we permit everything?)As I see it, it will be a complete and total mess.(And I am not co-mingling with the nation which oppressed my ancestors - well, more than one nation, actually - so what do we do with me? I am not that old and I have a young child, so breaking up my family just won't work...unless I claim one of those cultural exemptions...)