The use of geographic arbitrage to increase your chance of getting into medical schools

Leverage geographic arbitrage if, and only if, your motives are correct.

note – this is an excerpt from a Kindle Book titled “How to fail 13 classes and get into a top 10 medical school” set to be published in Q4 2020. If you would like to be notified when the book is available, please let us know in the contact section.

Living in a state that has a lower population density can be extremely beneficial for medical school applications. 

Only because she is modest and not because it is true, my little sister has been known to say that she only got into Harvard Medical School because she is from Wyoming. She got into Harvard Medical School because she is a uniquely perfect candidate that any institution would have been fortunate to have. Indeed, many schools threw full ride scholarships at her to have the privilege of her attending. 

Nonetheless, she raises a good point. State of residence can be included in a school’s diversity portfolio. And for good reason: as we learn and come to appreciate cultural competence and diversity, we know that people from different geographies have different ways of viewing the world. As such, we are empowered as individuals and our classes made richer by having classmates with life experiences that have given them exposure to folks from different geographies. 

Off the soapbox and on the pragmatic note – having a state residence from a state with a low population may potentially increase your chances of getting medical school interviews.

Hannah, being the perfect candidate that she was, didn’t need the help. I, being the unique candidate that I was, needed all the help I could get. Indeed, I can’t help but wonder how much being from WY helped me to get interviews with a few private schools in the midwest. 

While the above will remain speculation, I do know that out of the interviews that I received, 66% are directly associated with the fact that I was a Wyoming resident at the time of applying. This was evidenced by receiving interviews that were associated with the WICHE PSEP and WWAMI program. Both programs essentially serve the same purpose: some states, like WY, don’t have a medical school. As a result they partner with neighboring states who do and the state subsidizes tuition such that the student pays essentially what it would cost to be an in-state student at somewhere like the University of Utah. With this generous scholarship from the state, comes a 3 year commitment from the student to return to the state to practice. For the WICHE program, this can cut tuition by about half. For the WWAMI program, this reduces tuition to about 1/5th of what a student could expect to pay. 

Why WY?

Knowing the financial advantage available and believing that I might want to live and practice in WY when I grew up, below is the process of how I ended up as a WY resident. As mentioned in the intro section, I split my time between CO & WY growing up but always had a CO driver’s license. In 2017, my fiance at the time, wife now, started making plans on what we would do after she completed PA school in Portland OR. 

 

  • Would we:
    • Stay in Portland
      • + close to a new group of friends. Neat city. Near a group of my colleagues. 
      • – cost of living. PA job prospects. 
    • Move to San Francisco
      • + Where my company at the time was headquartered. Likely only chance to get to live there. 
      • – Cost of living. PA job prospects. No friends but close to colleagues. 
    • More to Denver, CO
      • + Close to a lot of old friends and family. My company had a satellite office there. 
      • – Cost of living wasn’t on par w/ Portland or SF but rising. PA job prospects. 
    • Move to Fort Collins, CO
      • + Where we grew up. Close to a lot of old friends and family. Easy commute to my company’s Denver, CO satellite office.
      • – Cost of living wasn’t on par w/ Portland or SF but rising. PA job prospects. 
    • Move to Cheyenne
      • + great PA job prospects for my wife. Cheaper cost of living (probably ⅓ of Portland or SF).
      • –  zero friends. Places don’t get any windier. I’d work remotely and occasionally have to commute 100 miles to Denver. 

 

Don’t let the +/- list fool you; moving to Cheyenne WY in 2018 made a lot of sense for us. 

  1. The cost of living is cheap
    1. We own and renovated a nice condo that would easily be 3 times as much if we had in just 40 miles south in CO. It’d be 5x as much in Portland or SF. We just bought a second townhouse and are comfortable with floating boat payments. One wouldn’t have been possible in any of the other locations. Owning two in WY, we are quite comfortable. 
  2. It let us kick the tires on the state
    1. If we were planning to practice here via the WWAMI or WICHE program, then we could really figure out if we wanted to live here. 
  3. It made me a stronger applicant
    1. As evidenced by those interviews for WICHE and WWAMI that I likely would not have gotten as a CO resident.
  4. My wife got a great dermatology PA job that would have been close to impossible in the bigger markets where they required applicants to have years of experience when applying. 

 

Geographical arbitrage can be an extremely powerful tactic.

 

Do this at your own peril 

If you think you are going to strategically become a resident of a state, take advantage of one of these scholarships then go live the good life in Florida instead of Cold Sneakers, MT, do not do it. 

  1. Admissions committees will sniff the insincerity out a mile away and take it to court if necessary.
  2. It is wrong. It’s harmful to the institution and the good people living in that state who need the care. 
    1. One day when we are all grown up and take the Hippocratic oath, we’ll swear to first do no harm. Just as the principles of this book need to be generalized and applied to specific situations, so does that oath. Taking resources away from a state to lower your tuition with zero intent of practicing there is harmful; don’t do it. 

 

Don’t make my mistake

In 2017, when we were living in Portland, I submitted an application to the UWSOM via the WWAMI program. My wife and I were pretty sure that we eventually wanted to live in WY. My personal statement, which as you know from Chapter 1 was poorly written, said something to that effect. I was still a CO resident at the time. I had zero evidence on my application that I wanted to work in WY. I didn’t have any volunteering experience in the state, a physical location or a driver’s license. As is detailed a bit more in chapter 9, they didn’t send me a secondary. This was peculiar for two reasons:

  1. They had sent me a secondary the previous year
  2. There was language on the website to make one think that they automatically sent secondaries to applicants who were in the same situation as me. 

Because of reason 1 and 2, I felt empowered to reach out to the admissions department and see why I didn’t receive a secondary. She reported that the executive committee from WY reviewed my file and deemed that I wasn’t fit for a secondary. 

 

The school graciously offered feedback at the end of the cycle. I took them up on it and had a meeting with a member of the admissions committee. They asked why I thought I didn’t received a secondary or subsequently interview invite:

I had two reasons

  1. My bad GPA
  2. The fact that I didn’t have anything from WY on my application

 

Much to my relief, she said:

  1. not to worry about my gpa. Yeah, you failed a bunch of classes but you told the story why and your MCAT demonstrates that you can perform in medical school. 
  2. You say that you want to live in WY, you are applying to a program that requires you to spend 3 years after residency working in the state and yet you have nothing from the state on your application. That is a big red flag

 

Issues like this have gone all the way to the courts. An applicant technically met the residency requirements for the state but the school turned her away. The student sued the school. 

State schools are investing hundreds of thousands of dollars and years into training physicians who will come back and practice in the state. 

In my case from 2017, it makes perfect sense that I did not get a secondary. My application seemed insincere and the admissions department sniffed that out a mile away. So if you leverage geographic arbitrage, do so sincerely and make sure you have the evidence to back it up. 

Flash forward to the application that I submitted in 2019 where I was eventually accepted. I had been a WY resident for almost 2 years, had some volunteer experience from the local VA and had bought a permanent residence here. From the executive committee’s perspective, my application must have seemed much more sincere. My actions matched my words.  

 

Actions <> words

Whether you say you want to practice family medicine but have only shadowed surgeons, say you want to live in WY when there is zero evidence from your application that you have even set foot in the state, executive committees will not and should not tolerate the insincerity. 

The lack of integrity in your application will cost you (I’ve seen this firsthand).

 

States to consider

This table can help you kick the tires on some states. https://www.aamc.org/system/files/2019-11/2019_FACTS_Table_A-20.pdf

 

I am quite partial to the region for a handful of regions but I’d direct your attention to the WWAMI states. 

WWAMI scholarship

  • Alaska – is cool enough that my wife and I went on our honeymoon there. 
  • Idaho – My grandma Carol’s grandfather apparently would say that “if you spent enough time in Idaho to wear out a pair of sneakers, you would never leave.” My wife had a rotation in Boise that I joined her for. After 6 weeks (not quite enough time to wear out my sneakers) I had a hard time leaving. Beautiful place and even better people. 
  • Montana – The Big Sky state easily gives WY and ID a run for their money as the prettiest country. The universities sprinkled throughout Missoula, Billings, Bozeman and other places in the state makes for a uniquely charming synergy: cowboy country that is vitalized by university settings and culture. 
  • Wyoming – If Cody WY is cool enough for the Kardashians, then perhaps it is worth checking out. 

 

WICHE PSEP scholarship 

  • WY – see above
  • MT – see above
  • New Mexico – strong emphasis on in state applicants who want to stay in the state to practice. 

 

As a guy from WY/CO, I am admittedly biased for this part of the country and not very knowledgeable about how this works in the midwest, east coast and in the south. However, the table above suggests that Delaware, Maine, New Hampshire, Rhode Island and Vermont don’t have many matriculants. Tufts offers a Maine tract for students interested in rural medicine. 

 

States to avoid?

Texas –  gets a good wrap because of the volume of school and reduced tuition for instate applicants. However, as you will see in the table above, there are a bunch of applicants and matriculants. There is a lot of chatter online that living in or moving to Texas can be a strategic decision for pre meds. 

California – is generally regarded as a tough state to be from. While there are a ton of school, there a ton of applicants plus more. Everyone wants to live in CA so the scholarships available to send folks back there are nonexistent in my research. 

Success leaves a trail. Ask a Texan or Californian about their states, not me. 

 

Have your big city and go fly fishing too?

There are physicians, among other professionals, who take advantage of geographical arbitrage as attendings. When my wife was in PA school in Portland from 2016-2017, I volunteered at a free clinic. Every two weeks, a renowned cardiologist would show up to the clinic to do some volunteering. Presumably, he needed something to fill the void with his two weeks of free time. 

Only because he walked in wearing a Boston Bruins hat one evening was I able to strike up a conversation with him and get the details. His situation was something like this:

Cardiology in Portland, like many specialties in many big cities was becoming a bit saturated. His lifestyle and compensation was suffering as a result. He loved living in Portland but didn’t love working there. He leveraged geographic arbitrage to have his cake and eat it too. 

For two weeks a month, he’d fly to rural Montana, do nothing but work and then return home to Portland to not work  for two weeks. His lifestyle and compensation benefited from this use of geographical arbitrage. When the fly fishing got good in the spring, he’d stay for four weeks at a time and shave two weeks off from the winter. 

 

A final invite and a final warning

As a premed, med student or resident, you aren’t going to do what the PDX cardiologist was doing but remember the golden rule of this book: take the principle and apply it to your own life. 

 

Rural communities and states with low population density have a disproportionately low amount of physicians. If you think you can take advantage of this fact just to get a scholarship then move to the Bay Area, think again. If you think that you might want to live in god’s country and provide care for the fine folks that live there, then you might consider making yourself a stronger applicant by leveraging geographic arbitrage.

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