Blog Archive

Tuesday, January 30, 2018

A Laissez-faire Attitude Toward the Residency Shortage

I want to discuss commonly held beliefs in Medicine which I believe help to create a laissez-faire approach to the solution of the Residency Shortage.  One belief deals with the assumption that highly ranked medical schools/residencies can “infuse” their graduates with a special knowledge not found elsewhere.  The other belief deals with the impression that foreign medical graduates are lesser doctors than US graduates.  International Medical Graduates (IMGs) are the group most affected by the residency shortage.  In 2017 69% of unmatched graduates were IMGs. I believe that these two assumptions promote the lackadaisical approach to a timely solution to the Residency Shortage.  If the unmatched doctors were Harvard graduates, the US would be in an uproar about the utter waste of human time, talent, money, and more doctors

 Consider this.  Assume that the US has a total of 1000 medical school openings each year, but that the schools receive a total of 5000 fully qualified applicants. 4000 applicants will be rejected.  Are we to assume that these 4000 applicants were not smart enough to gain acceptance into a US medical school?  No, there were only 1000 openings, and these positions were filled with the top candidates.  The 4000 disappointed applicants were not unqualified.  There just were not enough openings. In a similar example, the NRMP has 42,000 applicants for 32,000 residency positions each year.  10,000 graduates will not match, yet they met all of the requirements set forth by the NRMP (National Resident Matching Program).  They were fully qualified, but there were just not enough residency slots to meet the demand.

 Let us talk about highly ranked medical schools first.  According to Pauline W. Chen MD, “The notion that a medical school’s quality can be ranked and then passed on directly to their graduates has become an integral part of American culture…But most of these popular rankings reflect a school’s highly specialized research funding and capabilities, not the general quality of its medical school graduates.”(1) Dr. Fitzhugh Mullan was the lead author of a research study and paper conducted at George Washington University School of Medicine.  It included more than 60,000 graduates of America’s 141 medical schools from 1999 to 2001.  He said, “The absolute irreducible mission of medical schools is the education and graduation of doctors to care for the country as a whole.”(1) He continued with, ”The opportunity to learn from and be mentored by faculty members involved with the latest research can be stimulating for medical students, but the pressure to bring grant money into an institution can draw even the most enthusiastic educator away from students and back to the laboratory bench”(1)  According to Dr. Chen, “But educators like Dr. Mullan counter that traditional selection criteria based on cognitive exams and premedical course grades do not necessarily translate into clinical ability.”(1)   Dr. Mullan concludes with, “doctors who have done very well on everything from kindergarten to residency training in terms of getting into prestige places are assumed to have sharp intellects, but none of that correlates in any scientific way with their performance as physicians.”(1)  In essence, residency programs are selecting their residents based upon the same “cognitive exams” and highly ranked research hospital programs described by Dr. Mullan.  This is due to the inordinate number of applicants caused by the residency shortage, and the need to screen the number of applications which have to actually be “read”. 

Next let us consider the belief that IMGs are less qualified doctors, or they would have been accepted into a US medical school.  “During the 1950s, the need for a formal program of evaluation intensified due to explosive growth in the demand for health care services, an increase in economic opportunities for trained medical personnel, and a greater dependence on residents to provide medical care, which created a large number of available positions in U.S. GME (Graduate Medical Education) programs.” (2) The ECFMG (Educational Council for Foreign Medical Graduates) was created to monitor IMG credentials, and certify that IMGs have met medical education and examination requirements.  So when we as a Nation needed additional doctors and residents to provide medical care in the 1950s, we accepted IMGs into our residencies. But now that there is a residency shortage, not so much… “IMGs make up roughly 25% of physicians in training and practice in the United States.”(2)  Granted, they have not attended “highly ranked” medical schools according to “ American culture”.  BUT, they have passed all the criteria and requirements set forth by the NRMP for participation in the Match.  The IMGs have passed the same criterion tasks required of all residency programs, as their US counterparts, and passed the scrutiny of an almost 60 year old organization, the ECFMG.

In the US it is our own inflated self-regard which makes us ambivalent to the plight of the unmatched doctor.  The US is not the only producer of excellence in Medicine.  Let’s put aside our national biases towards medical education. Let’s save the fully qualified doctors who would like to complete the final step in their quest for licensure, especially in lieu of the projected doctor shortage over the next decade.

Tuesday, January 23, 2018

Put Up or Shut Up / Residency Shortage
A proposal to create a new medical license was made at the annual Florida Medical Association (FMA) meeting in August 2017.  In order to make a proposal at the FMA a strict procedure must be followed.  A delegate from a county medical association must obtain approval from their local medical society to bring a proposal to the state medical association.  Following strict written guidelines, the delegate is allowed 3.5 minutes to verbally present this proposal to the delegates.  The proposal presented at this year’s meeting had to do with the creation of a license called “Assistant Physician”, similar to the license passed in Missouri.  This license would allow graduate unmatched US doctors, who met all the requirements for application to the National Residency Matching Program (NRMP) for residency, to work under the supervision of a licensed physician.  This would permit meaningful work in Healthcare until the unmatched doctor could obtain a medical residency, in lieu of the current residency deficit.
This committee voted that the proposal “not be adopted”.  One of the objections discussed in a prior blog had to do with the belief that a residency shortage did not really exist.  I have since received written correspondence from the CEO of the NRMP stating that there have been 42,000 applications for 32,000 positions.  99% of the positions were filled, leaving 203 unfilled slots mostly in 1-year preliminary surgery, where “Many are dead-end positions that do not lead to further training”.  So there definitely is a residency shortage of about 10,000 slots per year.

The second objection raised against this proposal was from the medical student delegates.  They voted “no” because they felt money should be spent on Graduate Medical Education (GME) for creating more residency slots in Florida, and not money spent on creating a new license.  They felt the Assistant Physician license “would have legislative implications as the FMA’s job is to maintain that the physician stays as the leader of the health care team.  This could be a risk to the public if lesser trained providers are allowed to practice Medicine with MD/DO after their name.”(1)

The objection based upon how best to spend money to fix the residency shortage does not correlate with me.  Residency slots are subsidized by Medicare and Medicaid funding primarily.  States like Florida have created incentive money to hospitals for the creation of new residency slots.  The costs for enacting the AP license in Missouri were fairly minimal and involved primarily administrative costs, as delineated in their proposals.  Had these unmatched doctors been allowed to complete residencies, their applications would have been for traditional medical licenses, instead of the AP license.  So that expense would have occurred anyway.  The administrative costs associated with supervisory physicians would be additional, but fairly nominal in view of the benefits to the unmatched doctors and the underserved patients receiving care.  In summary, the worry about how to best spend money deals essentially with two different levels of government, the Federal level for Medicare/Medicaid, and the State level for licensure costs.  The two do not impact one another.  So money to create licenses would not reduce or impact the creation of new residency slots.

How will any of those medical student delegates feel if they happen to be some of the unfortunate doctors who do not match into a residency after graduation?  They might not be so cavalier with their objections.  What have these students and the FMA actually DONE to remediate this crisis of the residency shortage?  A doctor in my community said that the FMA was a “Go along to get along” organization.  He implied that nothing much gets done of significance.  For that matter, the AMA has not effectively dealt with this issue either, from my stand point.  So my answer is “Put up or shut up”.  If this situation had occurred to any of the FMA or AMA delegates, we would be hearing a different story!

(1)  FMA House of Delegates 2017; Consent Calendar Reference Committee III; Legislation; Aaron Sudbury, MD, Chair.

Tuesday, January 16, 2018

Challenge to YOU!  / Residency Shortage


The last 2 blogs explained the process of “peaceful activism” to bring the cause of the residency shortage to the forefront of the Nation’s attention.

As I have explained in my biography of the NoMatchMDs blog, I do not personally work in the field of Medicine.  Yet, I felt that the travesty of the residency shortage warranted my activism, in lieu of the 50 years I have observed Medical Education.  I cannot solve this problem on my own.

I continue to educate the readers of the blog about the intricacies of the residency shortage dilemma.  I have delineated the politics of Medicine which are preventing a timely solution to the shortage.  I have described how a huge majority of the public and medical professionals are unaware of the current scenario.

Perhaps you are interested in this blog because you or someone you know is personally affected by the residency shortage.  I would encourage you and your supporters to become involved in this cause.  If not YOU, then WHO?  Before I became aware of this crisis, I had never even read a blog.  I had never created a logo, a website, never had a Facebook page or used Twitter, never had spoken to a Congressman, never written to an elected official, or fought for any cause.  There comes a time when we each need to speak up and DO something!  I have had to get out of my own comfort zone to learn and use these new skills.  I will be part of a panel at a World Affairs Conference in St. Petersburg, Florida in February, speaking before several thousand people.  I have never done this before either…So I am challenging each of you to step up and help with this cause.  Go back and re-listen to the two previous blogs.  Form your own “protest” group and show up at a Match Day 2018 “reveal” party.  If mine is the only “voice” talking about the residency shortage, the solution will be long in coming…

Tuesday, December 26, 2017


Move Unmatched Dr. Grads to the “Top of the List” /
Residency Shortage

As I watched an episode of “Designated Survivor” a thought came to my head.  Move unmatched doctor graduates to the “Top of the List”.  “President Kirkman” was conducting a town hall meeting with constituents and was asked by a laid off factory worker what the “President” was going to do to help him.  The answer was “…I am going to create a public works program….and anyone in the last 4 years who has lost a job, their names are going to be put at the top of the list for these jobs”. 

 These unmatched doctors are the victims of a system which “shot itself in the foot”.  It allowed too many medical school grads, but reduced the number of residency slots needed to complete the last required step of training for a license.  I have read the sagas of unmatched doctors saying, “If only I had gotten a higher Step II score, maybe I would have matched”.  It is heartbreaking to hear the self recrimination of these unmatched doctors, when they are not the ones at fault.  And to add “insult to injury”, the match process continues to “selectively ignore” the same applicants’ repeated attempts to match, by using computer generated numeric cut points to “reduce” the deluge of applications each residency program is now receiving.

These unmatched doctor grads should be moved to the “top of the list” for residencies, to prevent their permanent loss to Medicine.  It seemed so “obvious in the “Designated Survivor” episode.  That’s what is FAIR.  How can we do that?  Here are some ideas I have brainstormed:

  • Utilize each and every accredited residency slot (some are left unfilled)
  • Create “emergency resident slots” to already accredited programs (@ least 1 slot for each existing program)
  • Create “Transitional Year Programs” with each medical school to place unmatched doctors
  • Move unmatched doctors to the “top of the list” in the next year’s match.  Each residency selects 1 unmatched doctor from the previous 5 years unmatched applicants
  • Place US citizens first, before any non-citizen applicants
  • Offer incentive money with state funds to private hospital corporations to add residencies, as in Florida with HCA Hospitals
  • Create positions at VA Hospitals for unmatched doctors to work under supervision of current VA staff doctors
  • Activate/Re-Activate a “House Physician” license (as in Florida) for unmatched doctors to work under supervision of hospital staff physicians
  • Expand House Physician license to County Health Clinics and VA system
  • Expand NRMP to 3rd tier match to “place” remaining unmatched doctors
  • Provide malpractice umbrella coverage to allow unmatched doctors to work under licensed physicians within their office
We have to quit “blaming” the unmatched doctors for their “failings”.  They have passed ALL the CRITERIA necessary to apply through the NRMP.  They deserve a Match!

Tuesday, December 19, 2017

A Win-Win for Doctors and Vets / #Save GME

Most of the solutions I have described to eliminate the Residency Shortage will take time to enact.  They involve legislative changes at both the National and State levels (I have already talked about how long and hard those changes can be).  I have also described what has been passed in several States.  What most concerns me are the unmatched doctor grads TODAY.  What can we do to “preserve” them before they are forced to leave Medicine permanently?

Perhaps you recall a “mini uproar” that came out in the Washington Post in May 2016.  The article titled, “VA:  Let nurses Treat Vets”, related how “The Department of Veterans Affairs would dramatically expand the authority of nurses to treat patients…”(1)  This plan was intended to reduce long waits for medical appointments and “to ensure the VA has the authority to address staffing shortages in the future”, according to VA Undersecretary for Health Dr. David Shulkin.

 I wrote to Dr. Shulkin at that time to propose a “win-win” for both doctors and vets.  I suggested hiring the unmatched doctor grads through the VA to see patients under the supervision of the current VA medical staff (much as with the supervision provided in a residency program).  The unmatched doctors would be given meaningful work as well as further medical experience and training.  The Vets would receive timely care with reduced appointment wait times due to the increased staffing.  The doctors would apply again for residency as the number of residency slots increased.  The supply of doctors would increase to alleviate doctor staffing shortages for the VA in the future as well.

Ironically, these doctors would be “distributed” all across the US, as are the Veteran Hospitals.  This would be a quick fix to two currently existing problems, the Residency Shortage and the long appointment wait times for Vets.

I received a response from Dr. Shulkin stating that the VA does NOT have its own residency programs (although residency programs actually DO staff VA hospitals).  I responded again to Dr. Shulkin that I was aware of that fact, but was instead suggesting a temporary use of these unmatched doctors until the deficit was eliminated.  Dr. Shulkin replied, “Oh, now I understand”, but nothing more was said.  I suppose this is where the politics come in to play.  I am assuming the “greater plan” was to reduce healthcare costs for Vets by allowing nurses to provide more cost effective care (I discussed the pros/cons of nurse vs. doctor provided care in a prior blog). 

So this is one proposal I am suggesting to “preserve” the unmatched doctors in a timely fashion before it is too late, and their educations would have been for naught.  The VA could more easily create a system much like Missouri did (Assistant Physician license), because the VA system is Federally operated.  It would require only “one” new license which would apply nationwide.  The usual hurdles of individual state licensure for these “unlicensed” doctors would not be an issue.  It would save the costly and tedious process of changing each state’s licensure laws to accommodate this National “emergency”.  These doctors could work to provide quality, yet supervised care to our veterans, while under the supervision of current VA doctors.


Tuesday, December 12, 2017

Know Better, Do Better / The Match
I am going to begin this blog by starting with the “bottom line”.  DO NOT match non-US citizens into residency slots until all US doctor graduates have matched into a residency.  It is as simple as that.  Get your own “house” in order first, then be generous with your excess.
 We DO have a responsibility as members of the human race to care for the well-being of others, namely, world-wide healthcare.  However, the licensing rules for the practice of Medicine in the US require the completion of a US RESIDENCY.  So first we owe the right to complete their training to our OWN graduated US DOCTORS, before offering residency slots to non-US citizens.  That is the way the “World” works.  Hurdles abound to protect the rights of the citizens of each country.  Their citizens’ right to work is met before hiring foreigners. 
Our country once welcomed non-citizen doctors to fill the gaps in our doctor shortages.  Since the Balanced Budget Act of 1997 ironically created an “imbalance” between the number of medical school graduates and residency slots, that situation has changed.  I would suggest an immediate freeze on matching non-citizens into our inadequate supply of residency slots, until this shortfall has been corrected.
Reporter Tony Dokoupil of CBS News presented a story about  foreign doctor graduates from President Trump’s 7 travel ban countries.  They were applying for residency slots in the US (1).  It turns out more than 1,000 doctors from these 7 countries ALONE were applying through the NRMP for the residency match on March 17, 2017 (does not include applicants from other foreign countries).  There are currently 15,000 doctor graduates from these SAME 7 countries ALREADY WORKING in US residencies today! 
Mr. Dokoupil interviewed the Dean of Southern Illinois University School of Medicine, Dr. Jerry Kruse, about these foreign applicants.  Dr. Kruse was anxious to help these doctors match, in spite of the travel ban, in hopes they would someday practice in the rural underserved areas of Southern Illinois.  Dr. Michael Gannon, president of the AMA, weighed in on this situation as well.  This is the misinformation that galls me!!!!  I “know” of 8,640 doctor graduates, 42% of which are US citizens, who would have loved to work in Southern Illinois.  They were the UNLUCKY doctor graduates who did NOT match into a residency on Match Day, March 18, 2016!!!  They cannot get a license without a US residency.
I am NOT saying “DO NOT MATCH FOREIGN MEDICAL GRADUATES”.  I am saying, “Match US citizen graduates from both US and Foreign Medical schools FIRST, and then match non-citizens second.  So now we KNOW BETTER, let’s do better…

Tuesday, December 5, 2017

Why Are We Not Upset? / DOC SHORTAGE

Initially upon learning about the “why’s” of the residency shortage, I thought the lack of action to correct this travesty was due to the lack of knowledge about its existence.  The doctors I contacted had heard a little about the residency shortage but just assumed the unmatched doctor grads were “weaker candidates” and would just have to reapply again next year.  As discussed in prior blogs, the residency shortage has NOTHING to do with applicant qualifications (since all have met the requirements for applying in the NRMP), and everything to do with the shortage and the compounding effects of re-applications.  Now we know the story.  Why are we not enraged??!!

Perhaps a feeling of powerlessness causes most of us to shrug our shoulders and feel grateful it does not affect us personally.  But what if this circumstance involved one of your children or a relative?  Knowing all the years of study, sacrifice, and money they had endured, only to be denied the right to complete the last requirement for practicing Medicine, might get your interest and action!

Just think of all the rural and underserved areas of our country which would be overjoyed to have one of these fully educated doctors work in their areas.  The healthcare professionals who serve for a week in a third world country know first hand the “preciousness” of a doctor.  Some friends of mine travel annually to Guatemala to perform orthopedic and gynecologic surgeries for the masses.  One team makes an initial visit prior to the team trip just to triage the patients on which they will operate.  That way, there will be no time wasted when they return during the actual team visit, and as many surgeries as possible will be performed.  How can we just “discard” our unmatched doctors with no regard for the “human condition”?  What would Guatemala not do for one of our “cast offs”??!!

Some might say, “Look at all of the lawyers who do not get jobs”.  Although this comparison is quite a “stretch”, at least the lawyers were allowed to complete all their requirements to practice Law.  They probably were aware before Law School that getting a job might be difficult.  I do not think most students beginning Medical School worry about not being able to “complete” the requirements to practice Medicine.  Usually, the hard part is getting “into” medical school.  If there was a “glut” of doctors in the US today, prospective students would enter medical school at their “own risk”, and not be “blindsided” in the end.

I believe the Medical community and all Healthcare Professional should actively promote a solution to this residency shortage.  The “Public” is clueless as to the traditions and requirements of Medicine.  Only those who have taken this path can fully appreciate the devastation that is occurring with the discard of thousands of fully educated doctors.  Yes, I know, you are all “very busy”, and do not have time to take on this cause.  But, you DO have your voices, your email contacts, your “followers”, your legislators, your colleagues, your Medical Societies, and ”theoretically” the AMA, to help promote this agenda FOR YOU.  So talk to them about it and demand a solution!