Veterinary internships in the USA

Introduction

To say the popularity of veterinary internships is growing would be an understatement. In 1988 there were 175 internship positions, encompassing all species and specialties, and in 2021 there were 1,639. But when someone is considering applying for a post, one question stands out; is it the right choice for me? Talking about internships is a complex task; my career pathway leading to my current position as a board-certified emergency and critical care small animal specialist involved my completing a rotating small animal internship and a residency after obtaining my DVM degree, and I am a strong believer in internships. As an intern mentor, and having previously served as an intern director, I believe I have seen both the pros and cons of what they can offer. Apart from anything else, and as well as being of enormous benefit clinically, an internship will teach you how to work with people you don’t like, how to resolve indecision, and how to manage patients whose owners will not refer. You will build confidence and learn efficiency, discover how to find answers to difficult or seemingly impossible questions, and learn how to evaluate scientific literature. Your ability to communicate quickly and effectively will grow, and you will – hopefully – make some life-long friends (Figure 1). However, this article is intended to help veterinarians and veterinary students who are considering internship as the next step on their professional ladder to make a truly informed decision, and although it is from a North American point of view, much of the information will be relevant to those elsewhere.

What is an internship?

The governing body in the USA, the American Association of Veterinary Medical Colleges (AAVMC), defines a veterinary internship as a one-year service education program undertaken immediately or soon after graduation from a DVM or similarly equivalent program, with the purpose of providing veterinarians with mentored training in a clinical setting 1. Rotating internships allow the veterinarian to move between offered specialties within a practice or set of practices, while a specialty internship is completed in a specific concentrated area that is recognized by the American Board of Veterinary Specialties (or equivalent outside the USA) 1.

Originally, many of the internship programs were offered through veterinary schools, with the express goal of preparing veterinarians for ongoing specialty training through fellowships or residencies. Over time, more and more private practices started to offer such programs (Figure 2). During this period of program growth, complaints that the quality of internships declined, with less mentorship and education, and a shift of interns functioning as low-paid labor. Corporate expansion into the veterinary field, and the desire to recruit and retain specialist talent, likely contributed to the types and numbers of programs offered, including the introduction of specialty internships, which have increased from 241 positions in 2014 to 610 positions in 2021, a 2.5-fold increase 1.

How popular are internships?

As of 2021, there are now more positions than applicants for small animal rotating internships; in 2020 there were a record 312 unfilled positions on “match day” for internship programs 1. This does raise the question as to what needs to change – most notably in private practices, where the “match rate” (defined as the likelihood of an applicant successfully matching to a program) for a rotating small animal medicine and surgery internship fell from 82.5% in 2014 to 61.7% in 2021, whilst academic match rates remained above 90% during the same period 1. There is no easy answer; a common suggestion is to improve the work-life balance during the internship, but many would argue that this is just not a realistic goal for an intern year. I would suggest improving salaries and benefits, emphasizing mentoring and mental health solutions, removing non-competes from internship contracts, and advocating for loan forgiveness or deferral during an intern year to make these programs more appealing. One alternative is the idea of “bootcamp” programs – which offer focused training within a shorter timeline to help the clinician onto a lucrative career path 2.

What are the costs?

Over the past 10 years the American Veterinary Medical Association (AVMA) has released economic data about the financial cost of an internship, and their most recent position statement is for applicants to choose programs that demonstrate a clear path for career advancement 3,4,5. So while this article is not intended to focus on the debt problem for young veterinarians, it is important to consider the impact of debt and how that contributes towards a decision about completing an internship. An AVMA survey of 3,243 students graduating in the year 2020 from 30 US veterinary training programs revealed a median debt of around $160K (Figure 3) 6, and it should be noted that 480 of the 2,859 respondents who gave information about their debt reported they had no educational debt, which will skew the figures somewhat. (In addition, AVMA accredited schools outside the US, including Ross and St. George in the Caribbean, are excluded from this data, and their students carry higher debt loads; a 2018 survey showed their graduates to have a median debt of around $295K 7.) There is also evidence showing that debt levels will vary depending on an individual’s race and gender 8.

If you are in the fortunate minority of graduates who lack significant educational debt, this may allow more financial breathing room after completion of an internship. However, for the majority of graduates, it is vital to calculate the financial impact of an intern year. This should include calculations of accrued interest on student loans, and how this may increase either your monthly repayments or your repayment timeline. It should also consider lost income from a year without a professional-level salary. In 2021 the mean salary in private practice was $92,704, whilst an intern’s mean salary was $36,433 6. The debt-to-income ratio (DIR) at graduation is rising in the veterinary field (Figure 4), and is higher for women when compared to men 9. Such considerations are even more important for applicants who plan to move on to a residency, as these financial inequities will be magnified over an additional 3-4 years of training. There is a real concern for the future of internship and specialty medicine that it will be restricted to the 15-20% of graduates that leave with no or low debt burdens following their training.

Finally, it is important to also recognize the human cost internship programs can have on our personal lives; whether that be delaying marriage, having children, or caring for aging parents, a year spent working 50-80 hours a week is not conducive to a good work-life balance 10.

What are the employment prospects?

From an employer’s perspective, veterinarians who have completed a rotating internship are preferred over their counterparts that have not completed one, and it can be argued that in some cases an internship is almost mandatory (Figure 5). The corporate internship programs can have additional benefits for both intern and company. Many corporates that offer internships also use their graduates as a pool of skilled veterinarians to place within their organization, and interns with favorable reviews may be prioritized for residency or specialty internship posts, either within the corporate organization or in a sponsored residency at a veterinary school. Such sponsored residencies should be considered carefully, as they will be associated with a required period of service to the corporate sponsor, typically between 3 and 5 years, and the site or geographic location of practice following this type of training may or may not be negotiable. Such details should be agreed in writing before any commitment is made, including information about non-compete clauses.

The adage that “one year of internship provides the equivalent of five years of clinical experience” has to be balanced against the quality of the internship – something which holds true for both the intern and the employer. While the AVMA and AAVMC provide guidelines for internships, there is no one body that monitors programs to ensure they are compliant with the plans laid out in the description 1.

Remember too that veterinary medicine is now so complex that there is no way to learn everything required for licensure and practice during your veterinary school career, but neither is there a guarantee that you will see every possible condition as an intern. Additionally, the level of experience gained from an internship can vary depending on the program selected.

Application process and timeline

Let’s delve into the process and timeline involved for the application. Firstly, most (but not all) US internships are listed in the Veterinary Internship and Residency Matching Program (VIRMP), often called “the match” – see www.virmp.org. Internships and residencies (e.g., many zoo, laboratory medicine, and exotics programs) can also be listed elsewhere (referred to as “outside the match”) and as they work to their own timeline and have varying application requirements, there is no standard guide for how to apply to them. However, you should approach these programs no differently than those available through VIRMP, and there should be no perceived or real difference in quality between programs inside and outside the match.

The VIRMP application process opens up in the fall of the year before the program starts – so for 2024 applicants, the period for internship application starts in October of 2023 when programs list their information, with applicants able to enter their information starting in November, and runs through February of 2024 should the schedule remain similar to the 2023 cycle. The VIRMP homepage has a schedule of important dates for both institutions and applicants. Information on the programs start to be entered on the website about a month before applicants can enroll in the match, so there will be a 2–4-week period to look through the programs to make sure you want to apply through VIRMP. There is also a withdrawal period for applicants and programs should something change that prevents you (or them) from being committed to the match process.

What needs to go into your application? There are the basics, like your contact information, your veterinary college, your clinical area of interest, and your work eligibility in the US or Canada. Transcripts must be submitted electronically from your school, and the process should be started early to avoid delays. Next are things that take more work to compile, including your personal statement, your curriculum vitae (CV), and letters of reference.

A recent review of the internship and residency match process asked the institutions how they use various factors to evaluate program applicants 11. Seven factors were considered, including overall GPA (grade point average), grades within a specialty area, the interview, the personal statement, class rank and the CV. Although class rank or grades may intuitively seem to be the most important, program directors actually value letters of reference above all other factors, with the interview, CV and cover letter considered more important than the GPA and class ranking. Use this information accordingly, and spend time on these parts of your application, asking mentors for their input.

A minimum of three and a maximum of four letters of recommendation are permitted, and quality matters more than quantity. Choosing who to write your letters should be done with care; at the very least, a referee should be willing to produce a favorable letter and know you well enough to write something meaningful. There is a standardized form (SLOR) for them to complete, which will include questions about how long they have known you, your knowledge base, and your ability to work in the clinic or team setting, as well as a short (400 words) paragraph to embellish on the standard questionnaire.

There are two common mistakes applicants must avoid. The first is approaching someone late in the application process, who then declines, leaving you to engage with someone who doesn’t know you as well or may write less favorably. The second is to ask someone in a prominent position who does not know you very well, which may result in a low quality or generic letter. By all means ask veterinarians with whom you have spent summers, done research, or worked with before veterinary school, but be sure to also include those working with you during your clinic rotations. It is helpful to ask a potential referee from your clinical year at the start of a rotation; this allows them to note things important to your letter of recommendation that are beyond the standard academic evaluation. Schedule specific rotations early on in your clinical year if they are essential to your planned career path for this very reason. Be ready to provide your letter-writer with your CV and personal statement, and if applying after a period of time away from the establishment, update them on how you have spent your time since graduation. Finally, it is worth noting that it can take time to compose a letter, so do not panic; you will be notified when the SLORs have been submitted.

Once the application paperwork is completed, the next step is to sort through the available programs with a critical eye 12. There are some simple first filters to apply: type of species treated and the type of program (rotating internship, specialty internship, residency). But before going much further, I recommend you draw up “must-have” and “ideally-has” lists. These may change as you go through the match process, but the must-have list will allow you to make a broad pool of programs to consider, whilst the ideally-has list will help you rank them. You may find out that your must-have list is unrealistic, and it can also normalize your expectations for an internship year. My recommended short list of must-haves for a program are:

• a responsive and involved internship director(s),
• supportive local, and if applicable, regional hospital management,
• structured mentorship,
• specialty services that support the internship.

Another key factor is the standard of the hospital’s support staff, as it is hard to perform as an intern without good support from the technicians, assistants, financial office and front desk staff. Perhaps self-evidently, the benefits and salary of the position should also be part of your must-have list.

After this it is time for some detective work. This can be approached using a typical SOAP (subjective, objective, assessment, plan) protocol, as outlined in Figure 6. Start with a chosen program description, which has obviously been written as a promotion, and then critically review the practice website and their social media. Ask to speak with current interns and program graduates, as they will have different points of view on the program, and can advise on the balance of learning and labor, supervised shifts with mentoring vs. unaccompanied or minimally supervised periods. Some of this data is now available through VIRMP, which now has exit surveys of graduating interns from their programs. If you are interested in pursuing specialty training, review how many graduates of the intern program matched into a residency and make sure there are established specialists in your area of interest employed at the practice. Look for alumni of your school who may have completed a program of interest and ask for their opinion. This is your opportunity to check the promised program against the actual delivery.

Figure 6. The internship program SOAP.

Many internship programs have moved away from unsupervised or unaccompanied clinical time for interns over the past 5-10 years, and liability concerns have accelerated this trend. Whilst sole charge can be daunting and may increase the chance of errors, remember that if you choose private practice after an intern year, the employer’s expectation is that no handholding will be needed. Some programs may include overnight solo shifts for interns in the second half of their training, which may be seen as a negative, but it can make you a better clinician. If shifts are always supervised, ask how the program phases out the safety net of staff doctor supervision and promotes independent decision-making, which is vital for your development.

A program director may reach out to you to schedule an interview after reviewing your application, and you can do the same if you have seen a promising program description. Keep in mind that directors are busy and must balance their clinical duties with their program selection duties, so once a date and time is set, avoid rescheduling unless a true emergency arises. These interviews often last about 30 minutes, and increasingly take place on-line rather than face-to-face, but whatever the format you should be professional in your dress and presentation. Be prepared with a list of two or three questions to ask the director at the end; a lack of any questions is a red flag, but so are endless queries that cause the interview to run over time.

You may also be able to schedule a visit to the practice for a day, depending on your clinical rotations and travel budget. If this is impossible, I generally do not hold this against rotating intern applicants; visits are much more important for specialty internship and residency applicants. Many hospitals also had externship programs pre-COVID, and these will hopefully resume, as they can be a strategic way to introduce yourself to a program, but they do take some advance planning. Ensure you have open rotations during peak periods for extern visits (August through December), arrive on time, treat all the staff well, wear a nametag, and leave your mobile phone alone. If unsure about the dress code, ask if professional dress or scrubs are recommended for the visit, and for specialty internship and residency visits, show up in professional dress and bring scrubs in case they are needed.

Once you have done your research, make your assessments for each individual program, starting with the must-haves. Eliminate those programs that lack your must-haves and then rank the remaining programs from first choice to last. It is critically important to exclude all programs you do not want from your list, as you run the risk of being matched to your last choice that you retained “just in case” –even though you knew it didn’t meet your must-have list.

Getting a placement

You will have some time to wait after you rank your programs and complete your application submission, but “Match Monday” is the day when the results of the pairing of applicants and programs are released. When logging on to your VIRMP account you will either learn that you have your program for the next year, or that you didn’t match. If matched, you will likely hear from the intern director shortly, sometimes by phone or text, more often by email. If you failed to match, you might be relieved and choose not to go further; rest assured, this is okay, and you will still find a job. Do not feel pressured to look for programs that are still available just because other unmatched classmates are doing so. However, if you are disappointed, remember that opportunities still abound for your internship plans. Go back to your must-have and ideally-has lists and start seeing what available programs fit; this is called “the scramble”. There will be a list of unmatched applicants for programs to look at, and a list of unmatched programs for applicants to review. It is also worthwhile doing a quick scan of this list to make sure the programs you ranked are not showing, as mistakes do happen. Check for emails from the VIRMP frequently, as there are likely to be many directors asking you to interview or discuss their program. The key here is to not feel pressured into making an immediate decision; although time is limited, perform another SOAP, and trust gut instinct if you get bad vibes about a program. In the past few years, it has been an applicant’s market, with more program vacancies than unmatched applicants to fill the posts.

Conclusion

This article attempts to offer unbiased information about veterinary internships and perhaps enables hopeful applicants to have a useful road map. There are many problems with current veterinary internships, yet quality programs with genuine goals do exist. An internship will teach you many things, and not just clinical matters, but essential skills that every veterinarian should know, and as the face of veterinary practice changes, the skills gained can be very much to your advantage in an increasingly challenging profession. No matter your path, remember that you are worth the investments you have made in yourself, and the veterinary community is happy to have you.