M.D., but not a doctor
She was due back at her $11-per-hour job as a medical scribe — a note-taking shadow of the doctor that she could have been. But Bubenik needed a few minutes to compose herself after an outright rejection from the director of internal medicine for a chance to apply to his residency program.
At least he was honest, she says. It was for the same reasons Bubenik had heard hundreds of times — the program was "highly competitive" and she "wasn't the right fit."
Bubenik graduated from Oregon Health & Science University School of Medicine in 2013, but despite years of desperate searches and all-or-nothing gambles, she has not been able to land a residency, making her degree worthless.
Well, actually, less than worthless. It's put her about $350,000 in the hole and shattered her already-bad credit scores. The 40-year-old mother of two recently moved her family in with her adult daughter in Happy Valley — homeless and out of options.
"Sara's story feels unique and feels particularly unfortunate," says Dr. Leah Werner, a former classmate currently practicing in Portland. "She was somebody who — if given the right support and given the right resources from the (OHSU) School of Medicine — would have succeeded."
A spokeswoman for the OHSU School of Medicine says the university is barred by federal privacy laws from talking about a specific student. However, she offered a statement from Senior Associate Dean Dr. George Mejicano saying the university has a higher-than-average residency placement rate and works hard to support its students (see sidebar, below).
Several of Bubenik's classmates agree she could do the work well, but point to different broken links in a system that has allowed a capable, state-funded medical school graduate to be blocked from pursuing a career in medicine.
Meanwhile, Bubenik, her husband and toddler are scraping by. She works 14-hour shifts while he takes care of the baby and looks for work, hoping to parlay a Master of Business Administration degree earned while he lived in The Netherlands. They are keeping their fingers crossed that their terrible credit won't bar them from a rental opening July 15.
The (Mis) Match
Though there is a physician shortage — the Association of American Medical Colleges estimates a shortage of up to 90,000 doctors nationally by 2025 — there are more than 1,000 medical school graduates who do not get into a residency every year through the National Residency Match Program (NRMP).
The nonprofit was established in 1952 to address the problem of matching medical degree holders with residency programs that wanted them.
Mona Signer, NRMP executive director and CEO, says the idea was to cut down on "exploding offers" that a med school student had to accept within 24 hours.
"This is just a more orderly process," Signer says.
Orderly, perhaps, but also secretive and expensive. Bubenik says she sold her car to afford the application fees to 20 programs and travel expenses to the ones that wanted to interview her — to no avail.
Signer says medical degree holders might not match because of academic trouble, or they apply to programs outside of their reach.
"Those who don't match, it's not because there's a shortage of positions," Signer says, adding that M.D.s can apply to positions in pharmaceutical companies or do research, in lieu of the clinical practice that requires a residency certification.
"I think that's a fairy tale that people tell themselves," Bubenik counters, saying she's submitted hundreds of applications and every position she's seen requires a residency or years of experience. "If I could find something like that, I would take it."
Doesn't fit mold
Bubenik does look terrible on paper. A diagnosis of a learning disability came after she had taken two extra years in medical school and failed the first step of the United States Medical Licensing Exam.
She has since passed all three steps of the exam — including the one designed for post-residency students — and graduated from Kansas State University's Master of Public Health program, a two-year degree she added to try to make herself more competitive.
Bubenik still was not matched during this spring's NRMP Match, and the farther away from her graduation date she gets, the even-less attractive a candidate she will be.
She wonders, too, if she simply doesn't fit the culture of medicine — she's not sporty, and comes from a lower socioeconomic background than many of her peers.
"I just never realized how important networking is," she says. "Being a single mom, I wouldn't hang out with everybody. I would go home and study."
Bubenik started her career in medicine as a licensed practical nurse (LPN) — a formerly pregnant teenager who dreamed of a better life for herself and her daughter. After getting into medical school by the skin of her teeth, she joined the military to help with living expenses and tuition payments. But the government eventually said her credit scores — the ones she had told the recruiter about when she joined — were too low to get the security clearance needed for a doctor and kicked her out with a $180,000 tax lien. The tax lien was assessed to repay two years of monthly stipends for living expenses, medical school tuition payments and military training.
Despite having two graduate degrees in the field, Bubenik is now considered unqualified or overqualified to be an LPN or any other level of health care job, such as a nurse or a physician assistant. Her medical scribe job is entry-level.
Dr. Walter Crittenden, staff anesthesiologist at Providence Portland Medical Center and a classmate of Bubenik's, lays the blame for this at the feet of Oregon Health & Science University.
"I think it comes down to: OHSU graduated her and gave her a degree; therefore they believe she met all the requirements" to become a doctor, Crittenden says. "She's done everything that she's supposed to do and it hasn't worked. So, what? She's just out of luck? Her alma mater should have some sort of fail-safe."
Crittenden believes OHSU should offer an internship or gap-year program for students who don't match into a full residency.
" 'Pay us back all the money, but your degree is worthless?' That doesn't seem right," he says.
Who is high risk?
Dr. Lisa Dodson, a former faculty member at OHSU and currently working as the dean of a medical college in Wisconsin, lays the blame for this problem at the feet of the NRMP. She says that the system is incredibly stressful, leading students to apply to dozens of programs in the hopes of getting a residency. This overburdens administrators of residency programs who then create arbitrary cut-off requirements to get through all the applications, she says.
"It creates a lot of burden on students in general and particularly any kind of students with blemishes on their records," says Dodson, who was Bubenik's academic adviser toward the end of her medical school career. "It's really gotten out of hand."
She adds that residency programs seem to falsely associate a lack of trouble on medical school exams with a low-risk candidate, even though doctors with stellar academic track records can still have other issues with clinical practice.
Dodson says she found Bubenik's biggest problem to be that she was too self-sufficient — she didn't ask for help before it was too late.
"I don't think she's going to be a high risk. I actually think she's going to be a great doctor," Dodson says, adding that the only solution she can see at this point for Bubenik is to go back in time. "I don't know what the answer is. If I knew, I would have helped her fix it by now."
Efforts in other states
In Missouri, Kansas or Arkansas, Bubenik might have a chance. In those states, laws are in place to allow non-residency M.D.s to work under a doctor's supervision, continuing to get medical experience and industry contacts while they try to get into a residency program.
Missouri State Rep. Dr. Keith Frederick (R-Rolla) designed an assistant physician program for M.D.s who could apply to work in a similar capacity to nurse practitioners in underserved areas of the state. But, despite passing easily in the Legislature in 2014, the program still hasn't gotten off the ground.
"We are hearing, definitely, from people all over the country," says his legislative assistant Joyce Bush. "People are calling and emailing him all the time" about the program.
Kansas' and Arkansas' programs are for in-state graduates only. And according to press reports, none of them have people practicing under them yet — faced with opposition from powerful lobbying groups like the Association of American Medical Colleges, which worry about allowing a loophole in physician training.
"Twenty-five years ago, you could graduate from medical school and go and hang up a shingle ... that is no longer true because medicine has gotten so complicated and so specialized," Dodson says. "It's a huge bind for a lot of students."
Bubenik's OHSU School of Medicine class president, Jessica Carlson — on her road trip to her post-residency career as a general surgeon in Gold Beach on the southern Oregon coast — says without someone willing to take a risk, Bubenik is at the end of the road to a career as a doctor.
"She's in a horrible situation," Carlson says. "I've tried to help her as best I can and I'm just out of ideas. She just needs that one person, or that one hospital, to take a chance on her."
Dr. George Mejicano, OHSU senior associate dean, says the university is operating under a congressional cap on the number of residency programs for which it can be reimbursed. Despite that, OHSU has joined other teaching hospitals in using institutional funds to expand its residency programs. But the supply is not keeping pace with demand, Mejicano says, because medical schools everywhere are expanding their classes to prepare for the physician shortage.
Mejicano says in the past five years, OHSU has had a 98 percent match rate for graduates seeking residencies, compared to a 96.6 percent rate nationwide.
"The OHSU School of Medicine offers support and assistance to all medical students in order to help them navigate their medical school experience and residency match program preparedness," Mejicano said in a statement. "Students may take advantage of mentorship from OHSU faculty members and advising about careers in medicine and the intricacies of applying for residency. Students are allowed to participate in rotations across the country and are given elective opportunities so that they can determine which specialty best fits their interests and talent."
NOTE: This story has been updated from its original version to correct the spelling of the names of Mona Signer and Leah Werner.