The underemployment story is the big one here. My story is a slightly more extreme example, but similar. I graduated from an Irish medical school 3 years ago. I had great, but not amazing grades, but securing a residency has proved very difficult. Many interviews but no position. I'm fortunate to have secured a physician assistant job in the interim, but I'm earning significantly less than I otherwise would be. As a kicker, I want to be a rural family doc, a position in high demand, but given the difficulty of securing a residency I can't fulfill that role.