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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.