Blog Archive

Tuesday, July 25, 2017

A Tsunami of Outrage/ Residency Shortage

A Tsunami of Outrage/ Residency Shortage

Image result for tidal wave images free 

   Do you remember the outrage that ensued after the 2-3 hour wait times and missed flights that occurred at O’Hare Airport the weekend of May 14, 2016?  Frustrated passengers began tweeting #IHateThe Wait.  US Senator Mark Kirk, IL, called for TSA Administrator, Peter Neffenger, to fix this problem by Memorial Day or step down.  Even the White House weighed in on this travesty. (1)  By May 25th Mr. Neffenger told members of House Homeland Security Committee that the agency was taking measures to resolve this issue.  By May 24th an airline official said that O’Hare’s waits were down to 15 minutes.  That took 10 days to “fix”!

 This outrage is what has to happen to solve the current travesty of the residency shortage.  There are no “normal channels” to solve this crisis.  The Federal government is moving in typical fashion, slowly.  The first legislation introduced was “Resident Physician Shortage Reduction Act of 2011.  It was proposed again in 2013, and again by Senator Bill Nelson, FL, in 2015 (S1148) and by Representative Joseph Crowley (HR 2124) in the House.  Nothing has been passed or implemented at this point.

 This bill would increase the number of residency slots by 15,000 over a 5 year period.  We already have more that 40,000 unmatched graduates right now over the last 5 years alone!  The AMA and the ACGME have not proposed any solutions.  Only a few states have created legislation (generally applicable only to their own citizens). 

 The only glimmer of hope has been the budgetary allocations some states have made.  They have offered financial incentives to hospitals to increase residency slots or add new residencies.  This has had some success.

 Why are we not as outraged as the passengers at O”Hare Airport?  These unmatched doctors have spent more that 4 years of their lives and countless dollars trying to complete their medical training.  But they are deadlocked.  If I were they, I would gladly accept a 3 HOUR security delay in view of their own situations.

 We have to get the “word out”.  We have to tweet, blog, share on facebook, contact healthcare professionals and societies, contact legislators, and yes, even the White House!





Tuesday, July 18, 2017

The Human Side of the Residency Shortage/
A Personal Story

Today I am going to share with you the “human” side of the Residency shortage.  It is the story of my husband’s personal journey to becoming a doctor.

I met my husband almost 50 years ago at the University of Illinois, Champaign.  When we first began to date my “husband” told me that he planned to go to medical school and would be studying very hard.  So I had been “warned”…He needed to get “A”s in his classes in order to get into medical school.  After we had been dating for awhile, I would sometimes try to “find” him between college classes to hang out.  I knew some of his favorite libraries to study, and I would try to seek him out.  Once he knew that I might look for him, he varied his study locations so he would not get tempted to quit studying if I found him.  He was truly the most dedicated student I had ever met!  I remember that during Spring final exams one semester, he studied so hard for his physics final that he scratched the corneas of his eyes.  His hard contact lenses did not move around enough to  get lubricated while he was studying.  So he was given a doctor’s note to skip the exam and told not to study any further.  During the summers he would work on his vocabulary in preparation for the MCAT exam.  He never stopped working toward the goal of acceptance into medical school.

 But, I really remember the day he received his acceptance into medical school.  It was his 21st birthday.  His parents had called me from Chicago saying they had received his letter from the U of I Medical School and wanted to bring it to Champaign to see him open it.  They asked me not to say anything so it would be a surprise.  I held a little party at my college apartment and his parents were hiding in the bedroom.  Once the festivities began, they came out to the living room and presented their son with the letter.  We all watched him open it, and then I saw tears streaming down his cheeks….That was a momentous day in all of our lives!  It also meant another 4 years of exceedingly hard work, aiming toward the next goal, getting into a good residency program.

I would say that in the nearly 50 years my husband and I have known each other, Medicine has been at the epicenter of our lives.  It has dictated where we have lived, when, where, and how long we take vacations, etc.  My husband has always loved the Tradition of Medicine, it has a very rigid and rich protocol.  He loved the field of Medical Education and always wanted to become the director of a Residency Program, which he did.

My husband ended up taking 2 residencies and a fellowship:  Internal Medicine, Obstetrics and Gynecology, and a Gynecologic Oncology Fellowship.  That amounted to 8 years of training added to 8 years of college and medical school.

But why did I tell you this story?  I wanted you to know how traumatizing this Residency Shortage is on people just like my husband.  Just think of the devastation a fully qualified doctor graduate is feeling the day he/she finds out they did not match into a residency!  All that hard work and dedication, leading up to the last required step toward becoming a licensed physician, would have been for naught!

If you have listened to my prior blogs, you understand there is a good chance the unmatched doctors will never match into a residency in lieu of the current situation.  The extreme number of applications in today’s “Match” will favor the “cream of the crop” which has risen to the “top” numerically.  I cannot imagine the depths of despair these unmatched doctors are feeling.  I can NOT, I CAN not, I CAN NOT!

Tuesday, July 11, 2017

Why Isn’t the Medical Community Outraged About the Residency Shortage?

Why isn’t the medical community outraged by this grave injustice, the Residency Shortage?  From what I have observed, doctors fall into 2 camps on this topic.  Physicians working in Academic Medicine at universities et al, would probably be aware of the current situation in residencies.  And those doctors in the private sector would generally not know about the shortage.  So this topic is “under the radar” for a huge percentage of practicing physicians, except for those who have completed residency in the recent past.  So why has Academic Medicine not lead the charge to correct this residency deficit, completing the last step of medical training?

There exists a tradition in Medicine that I have observed over the last 40 years.  I would compare it to a “fraternity of the Ivory Tower”.  Great reverence is shown to the leading gurus in the specialties of Medicine, the Professors.  These professors are the ones who write the textbooks used in the fields of Medicine, they are the ones conducting current research, and they are at the “cutting edge” of the most recent methods being used currently in the practice of Medicine today.  Here is how this “fraternity” operates.  The “Professor” functions in a role called, “The Attending Physician”.  Below the Attending comes the “Fellow”, a doctor specializing in the Attending’s field of Medicine.  Next, is the “Chief Resident”, followed by the third year resident (in a 4 year residency), second and first year residents, the Intern, and finally the “Medical Student”.  The lowest position in this hierarchy reports and is accountable to the person above.  During patient rounds in the hospital, questions are asked at the varying levels of difficulty and if the answer is “I don’t know”, you better find out that answer by the next day’s rounds or you will regret it!  Also, the residency schedule demands an extreme number of work hours per week.  In the last 15 years the maximum number of hours/week is 80 hours.  These hours are strictly regulated and are kept in detailed logs to prevent loss of accreditation  to a residency.  Take note, the LIMIT is 80 hours/week, twice a “normal” work week.  And unless you want disapproval from your peers who will have to take over your work load, don’t even think about taking a “sick day”!  There exists a definite work ethic and “sprit de corp” mentality that exists in this “combat like” training experience.  You better do your job or face disapproval by your peers.

Go back now to why Academic Medicine has not “lead the charge” to correct the Residency Shortage.  The traditions I described about the hierarchy of the medical education process translate into rewards and respect for excellence by your peers.  Those who excel are rewarded, and those who are lacking have to keep working.  Even though this crisis of the Residency Shortage is a result of Medicare Funding cuts by the Balanced Budget Act of 1997, the ramifications are not always clear cut.  The first instinct when a doctor does not match into a residency, is for those in Medicine to assume the doctor did not receive high scores in medical school, did not get good recommendations, or was a poor worker.  In essence, they got what they deserved.  They “just” have to re-apply next year, or have to go do some research, or work for free in an indigent care clinic to obtain some new recommendations.  This is how the “thinking” goes.  So no wonder Academic Medicine is not in an uproar!  Yet, even when they know it is a “numbers” problem, the lingering belief is that if an unmatched doctor had only been a “little bit better”, they would have matched.  It seems kind of crazy when we know there actually is a “shortage”.  But I think the traditions of Medicine’s hierarchy of learning come into play, even if only subconsciously.  So I have not observed a call to action for the Residency Shortage by the Academic Medicine community.

As CEO of ACGME (Accreditation Council for Graduate Medical Education), Thomas Nasca MD, inferred that IMGs (International Medical Graduate) were “lesser” doctor applicants.  If they were better students, they would have gotten into a US medical school.  So he does not appear to be worried about unmatched IMGs.  This feeling has influenced the stance of the AMA.  While the AMA has called for an increase in residency slots, their “position” talks mainly about US medical graduates who are less impacted by the Residency Shortage than IMGs.  In the 2017 Match, 69% of unmatched doctors were IMGs and 27.6% were US citizens.  The AMA still questions the Residency Shortage since most US grads have matched.  Perhaps, the AMA feels its responsibility is to graduates of US medical schools, although 25% of physicians practicing in the US today are IMGs.

Private practitioners I know lead exceedingly busy professional lives.  Even if they are aware of the Residency Shortage, they have little time and resources to create an outcry for a solution.  Although EVERYONE, doctor or non-doctor alike, is incredulous when they learn about the travesty of the Residency Shortage.  They view the inability to complete the last required step in training as a “blind-side”, an injustice, a travesty.

What about the unmatched doctors themselves?  They are “scattered” throughout the US.  There is no published list of unmatched applicants, to my knowledge.  Basically, the unmatched doctor is suffering their own personal devastation alone.  Other than, “someone who knows someone”, unmatched doctors are not broadcasting this news.  Ironically, they are actually still hoping they will match next time, and don’t want this “unsavory” quality disseminated.  I do not believe they realize how the deluge of applicants is affecting their chances for a subsequent match.  Not until they have re-applied 3-4 times will they start to “connect the dots”.  They are being selectively ignored by a system which cannot comfortably process the deluge of applicants, and one that does not want to select perceived “lesser candidates”.

These are the reasons I believe that have prevented the Residency Shortage from becoming a national uproar. By the time the “public” discovers this problem and the ensuing doctor shortage, it will already be too late for a timely solution.

Tuesday, July 4, 2017

Open Letter to the NRMP / #Residency Shortage

#The Match

This letter is designed to bring the plight of the unmatched US doctor graduates to the Nation’s attention. These doctors did not obtain a medical residency due to the Residency Shortage which exists in the US, and as a result cannot practice Medicine in the US today.
The NRMP, National Residency Matching Program, which manages the medical residency selection process in the US, issued a statement which appears on an opening page of the NRMP website.  The statement was signed by Maria C. Savoia, MD, Chair and Mona M. Signer, President and CEO of the NRMP.  The Statement deals with the plight of foreign medical residency applicants from the 6 travel banned countries to the US Residency Match.  I have empathy for everyone who has invested time, energy, and money toward fulfilling their goal of becoming a physician, both citizen and non-citizen doctor graduates.  The graduates should all have the right to complete the necessary requirements.  To practice Medicine in the US requires completion of 1 post-graduate year of training at an accredited US residency.  As a Nation, we have a responsibility to address FIRST the tragedy of the Residency Shortage that has existed since the Balanced Budget Act of 1997 was passed, before dealing with placement of non-citizen applicants into US residencies.  “We” have a “Social Contract” to fulfill, the right to complete the necessary requirements for US licensure. Then we should worry about training the rest of the World….

As I read the statement, I felt an overwhelming sense of sadness and frustration that the NRMP has not issued a similar statement on behalf of the more than 50,000 unmatched doctor graduates (over the last 6 years alone).  They are unable to practice Medicine because they cannot complete the last required step of training, completion of a US residency.  42% of these graduates are US citizens.  These are the doctor applicants we should be worried about!

President Trump’s Executive Order suspends “entry into the US of certain individuals” (foreign residents of 6 travel-banned countries).  Here are the concerns expressed in the NRMP’s statement:
  • “the upheaval it is causing is extensive”
Just think of the “upheaval” for a US doctor graduate who has fulfilled all requirements for residency according to the NRMP, and cannot complete the last required step to become a licensed physician in the US.
  • “the affected applicants have worked hard for many years to achieve their goal of becoming a physician”
The unmatched US doctors have done the same hard work, passed the same exams,    and fulfilled the same requirements for application via the NRMP to achieve their goal of becoming a physician.

  • “they should not be denied that opportunity because of a blanket policy”
The Balanced Budget Act of 1997, via Medicare funding, was a “blanket policy” that reduced medical residency funding, creating a deficit in residency slots compared to the number of medical school graduates.

  • US training programs should be able to select applicants based on their excellent character and qualifications without regard to nationality”
These same US programs should fulfill the “Social Contract” made with prospective US doctors when they were accepted into medical school, the opportunity to complete all requirements.  To practice Medicine in the US requires completion of a US residency.  US doctor graduates have “paid for” these residency slots via their tax dollars, which provides Medicare funding for residency slots.

  • “The Executive Order disrupts that process very considerably”
What about the disruption that has occurred to unmatched US grads whose education is “worthless to Medicine” without a residency, whose school loans are now due, and who have no one to correct this injustice?

  • “The NRMP will work with the administration and others in the graduate medical education community …being “fair” to both individuals and programs…”
I have not seen anything “fair” happen to unmatched US doctor graduates who have been “hung out to dry” on their own!  Please take a leadership role to correct this travesty in Medical Education as well.  Please issue a statement of concern to the same administration and medical educators on behalf of the unmatched doctor graduates in the US who could use a similar voice of support.  Surely, no “doctor graduate” should ever be wasted.

Tuesday, June 27, 2017

Summary So Far/ Residency Shortage

Summary So Far/Residency Shortage

Here is a summary of the “Story” so far:

  • The goal of this blog is to tell the compounding story of the Medical Residency Shortage-how it began and what has resulted
  • In 1997 the Balanced Budget  Act effectively cut the number of residency slots available by reducing the reimbursement allocated to hospitals involved with resident education for patient care
  • The fear of not matching into a residency and being considered “a loser”, has caused the average number of applicants/medical school graduate to increase to 47 applications each
  • The deluge of applications has triggered the use of “quantitative” screening for resident applicants to reduce the number of applications needing “detailed review”
  • Unmatched applicants are in “limbo”.  They can’t complete the last requirement of their training.  They cannot practice Medicine and they can’t demonstrate qualifications due to lack of malpractice coverage
  • Application process repeats yearly, compounding the problem, more time and more money wasted with each application cycle, and some doctors have to give up and quit Medicine
  • Some very sad stories of repeated failure to match.  The time for “weeding out” should have occurred before beginning medical school
  • The solution to this travesty is very complex:  Federal, state, and ACGME
  • We need to “preserve” unmatched doctors until they match

Tuesday, June 20, 2017

Creative Solutions, State by State

Creative Solutions, State by State


            State by State licensing to retain these “untrained” doctors is quite a challenge.  It requires the interest and enthusiasm of state medical societies to bring proposed legislation to their state legislatures. They have to proceed through the lengthy legislative process to enact changes to their existing licensing statutes. Imagine this process for each of the 50 states!

 What are the numbers we are talking about for unmatched doctor grads? (LINK)

  • More than 8,640 unmatched doctors on March 18, 2016
  • More than 40,000 unmatched doctors over the last 5 years
Unmatched doctor grads ESTIMATE by State for 2016 ?

  • California:  1,037 unmatched doctors (based on % of National Population)
  • Florida:  536                             
  • New York:  527                     
  • Texas:  734                             
These unmatched doctor graduates are fully qualified and have met all the requirements set by the National Resident Matching Program (NRMP) to participate in the national “Match”.  They have obtained their MD degrees and passed all required exams, such as USMLE parts Step I and Step II.  There are just not enough residency slots available to meet the increased demand. In order to “preserve” these unmatched doctors until the supply of residency slots increases, each State would have to pass new legislation.  Medical licensure is legislated state by state.  This legislation would allow these grads to work “under supervision” in “qualified settings” (Essentially, residency allows work “under supervision” in a qualified program).  If given the opportunity for meaningful work (and service to the community!), these unmatched grads could re-apply for residency as the numbers of residency slots increase.  The result:  preservation of fully qualified doctors while addressing the impending doctor shortage in the next decade.

 Three states have passed this legislation so far, Arkansas, Kansas, and Missouri.  “Arkansas Graduate Registered Physician Act” applies to an “individual who is a resident of Arkansas…”  Kansas passed a special license which applies to graduates of the University of Kansas School of Medicine.  Missouri passed legislation for “Assistant Physician” which is open to US residents.  State by state legislation could generate its own set of problems while trying to ameliorate this crisis situation.  Arkansas and Kansas have “prevented” a huge influx of desperate unmatched doctors flocking into their states by gearing legislation for their own state residents/graduates.  Missouri could be the “recipient” of this influx.  Just think of all the time, effort, and money which this state by state legislation would entail!

 Why haven’t the AMA and ACGME (Accreditation Council for Graduate Medical Education) acted to correct this travesty on a National level??


Tuesday, June 13, 2017

OH! So We Just Need a New Law? / Doc Shortage

OH!  So We Just Need a New Law?/ Doc Shortage

Have you ever wondered about the procedure to create a new State law?  If you’re like me I thought, “Go to my local legislators”.  That’s exactly what I tried to do.  With all the hype of running for political offices, I thought they would be ready and waiting for a meeting with one of their constituents.  Was I wrong!  I have contacted no fewer than 30 public officials and received exactly 2 responses (written by assistants).  You probably won’t get an in person meeting with your legislator, but you might get to speak with an assistant.  And, you won’t get any audience at all if you are not part of the legislator’s electoral district.

 When I finally obtained an appointment with my State Representative, I proceeded to tell the story of the medical residency crisis.  It turns out that Medical Education has its own traditions, and you can’t just go “apply for another job elsewhere”.  So my representative had no clue as to the components of medical training and the process of communicating this dilemma was an uphill challenge.  After countless letters, emails, and phone calls to legislators, members of the State Board of Medicine, the State Executive Director of Medicine, the State Surgeon General, and yes, even the Governor of the State, I was nowhere on my quest to create a new State law for physician licensure!

 My next step was to contact the Florida Medical Association (FMA) where the advice was ambiguous.  It turns out that in the end, the real process begins with your county branch of the State medical association.  However, after numerous phone messages and emails to the Executive Director of our county’s medical association, I could not believe I was getting no answer!  When I finally decided to go in person to the address of record, my GPS lead me to a PO Box at the post office!  What is with this world?!  No one answers anyone!  It turns out, you will only get a “response” if you are a member of the medical association.  My husband had to make the call….

 So after 4 futile months of trying to get a starting point for the creation of a new State law, here is the ANSWER:

  • Contact a Delegate from your county medical association
  • Convince the Delegate of the merits of a new law
  • If they agree, begin the drafting of a proposal to take to the annual meeting of the State medical association.
  • Present the proposal to the State association and make amendments. If the association agrees…
  • The State association sends the proposal via their legislative delegates to the Health Committee of the State Legislature for drafting into a Bill
  • Continue the legislative process with the Bill to pass a new law
So, you think you have the answer now?  Not so fast!  You won’t believe the politics that get involved.  Politics?  Yes, politics.  Life is really a “turf”war!