Cosigner Needed to Become a Cardiothoracic Surgeon

It was the spring of my residency application cycle, when I came across this looming threat on the AAMC website: 

“If your account has an unpaid balance, the AAMC will revoke your access to MyERAS. In addition, ERAS will contact your Designated Dean's Office as well as ERAS business partners, including EFDO and ECFMG, to prohibit your access to ERAS until the debt is paid in full. “

My mind anxiously began to go through the familiar motions of budgeting. How many meals would I have to skip? Would I need to find a second job? What did I need to do to have a chance at achieving my dream of becoming a cardiothoracic surgeon? 

I had done as much as I could do until now, and my dream felt nearly within reach. I did well in school and was elected into AOA. I was in leadership roles, helped create foundations, and published research.

However, the road to becoming a cardiothoracic surgeon in the United States was also much more expensive than I had anticipated. It would cost me $1,578 just to submit my application.

I grew up below the poverty line and was in and out of foster care throughout high school. I experienced bouts of homelessness leading up to college and worked as a waitress to make ends meet. Needless to say, familial financial support had never been an option for me. During medical school, I took out the maximum allotted amount of student loans for my living expenses which comes to about $25,000 a year. The residency application alone would cost me over 5% of my annual income. I had supplemented my income with tutoring but was still short and would not receive another financial aid disbursement to cover the remaining costs until two weeks after the submission date. I was panicking. 

I emailed one of my deans to ask if they had emergency funds to help students in situations like mine. She told me there were no grants, scholarships, or additional loans for residency applications and I was encouraged to either take out a personal loan or put the total on a credit card. While this might seem like a simple solution, many personal loans or credit cards require a good credit history—which can be challenging for someone from a low socioeconomic background—or a co-signer (also challenging for someone from a low socioeconomic background). 

I looked into getting a personal loan, but since I was technically unemployed the interest rate would have been over 11%. As I ran out of options, and was in need of any and all advice, I shared my situation on Twitter. To my surprise, I received an outpouring of similar stories. 

People in similar positions as mine had taken on jobs delivering food, or driving for Uber during medical school. Many had taken on thousands of dollars in additional debt. 

Many of them had applied for residency when interviews were in person; for some, the interview cycle had cost them more than $10,000. Fortunately, the president of the American Medical Women’s Association (AMWA) saw my post and created an emergency grant for medical students in situations like mine and I was able to afford my application. 

In looking back, the cost of submitting the application is just one of many ways in which applying to a competitive residency can create immense financial burdens and bottlenecks. . 

The greater disparity  exists in the preparation leading up to the application. Integrated cardiothoracic surgery residency positions are the most competitive of all specialities with a 2023 match rate of 36% (NRMP). 

The advice that I received during my first few years of medical school was that networking was invaluable  and to do this, I would need to complete away rotations and attend conferences. 

With only 49 available positions in the country, every little bit counts. Away rotations can be invaluable for people who don’t have a CT department, CT fellowship, or an I6 program at their institution. Away rotations and conferences have become especially important in the era of virtual interviews. In 2020, 95% of program directors surveyed felt that interactions with faculty were one of the top ten most important factors used in determining which applicants to interview and rank (NRMP). While the virtual interviews do allow for some interaction with the applicants and program faculty, 75% of program directors for surgical residencies felt that the virtual interviews made it difficult to identify personality fit and 60% felt like they could not fully evaluate the applicants commitment to the specialty (Asaad 2022). 

To combat these barriers, many applicants end up doing two or more away rotations. In addition, applicants are also encouraged to attend annual conferences to network with program faculty at locations where they did not complete away rotations. There are discounted prices for student registration, but depending on the location, the costs of flights and hotels can create a price tag of up to $2,000. 

For the CT applicant, the costs go even further than networking and traveling rotations. The average scores for an I6 applicant for the USMLE board exams are about 10-15 points higher than the national average. The USMLE preparatory courses, which are all but required to not only have a competitive score but to pass, run between $600-$800 per resource. Additionally, 99% of CT applicants also dual apply to general surgery due to the high probability of going unmatched into an I6 residency. 

I completed three rotations in cardiothoracic surgery across the country. The application fees for the programs I applied to rotate at ranged from $50-$350 per program. Some programs broke down the estimated cost to attend an away rotation including transportation and lodging which came to about $5,000 per rotation. I was fortunate enough to receive a scholarship that funded one of my rotations and scraped together enough money for the other two by borrowing from friends, tutoring, and selling random items in my apartment I could afford to part with. I would go long stretches skipping meals since hospital food was often out of my budget. After 12-14 hours on a shift, if I was lucky, I could lessen my hunger pangs with the peanut butter and graham crackers that were stocked in nutrition rooms. I stayed with a friend for one of my rotations and while sleeping on a couch was not ideal, it opened the door to allow me to rotate at the institution I later matched into for residency. 

-The application fees for the programs I applied to rotate at ranged from $50-$350 per program. Some programs broke down the estimated cost to attend an away rotation including transportation and lodging which came to about $5,000 per rotation.

The field of cardiothoracic surgery has made leaps and bounds to diversify the workforce, but the cost of entry is still inaccessible for most who do not have familial financial support. For those of us who take on additional work to afford our goal, we have less time for family, exercise, studying, and overall well-being. This can have a deleterious effect on our test scores and performance on rotations—leading to less competitive applications. 

It’s a vicious cycle with no end in sight yet. 

References:

Asaad M, Elmorsi R, Ferry AM, Rajesh A, Maricevich RS. The experience of virtual interviews in resident selection: A survey of program directors in surgery. J Surg Res 2022;270:208-213.

Dr. Naima Alver is a first year integrated cardiothoracic surgery resident at the University of Washington.

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The opinions expressed in the article is not affiliated with any institution, company or product. The article should not be interpreted as medical advice.