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Wednesday, July 18, 2018


Medical Residency Shortage = Doctor Shortage

             Pretend there is a projected teacher shortage of 105,000 teachers over the next decade.  Pretend that you wanted to be a teacher and attended a teacher’s college.  You have only 1 requirement left to fulfill, student teaching.  Assume that in spite of the projected teacher shortage, the Education Budget is cut nationally, which results in a limited supply of student teaching positions.  Without student teaching you can’t get your teaching credential.  Imagine that over the last 5 years alone, there were more than 50,000 students unable to find a student teaching assignment. They would have had to give up on a teaching career, find another job, and begin paying their student loans.  How could such a bureaucratic slip-up occur in view of the projected upcoming teacher shortage???

            Well, this is exactly what is currently happening in Medical Education!  There is a projected shortage of 105,000 doctors over the next decade.  Over 50,000 doctors in the last 5 years alone have been unable to match into a required residency.  They cannot complete the last step required for a medical license in the US!  They have to leave Medicine. After being accepted into medical school, 4 years of hard work, passing board exams, and graduating with an MD Degree, they now have to look for other work and begin repaying an average of $183,000 in student loans. 

             Here’s what happened.  In 1997 the Balanced Budget Act capped the amounts paid in reimbursement for residency slots to hospitals with residency programs.  However, with the projected doctor shortage the number of medical schools was increased.  The number of residency “slots” went down, while the number of graduated doctors went up.  As a result, the number of residency applicants soared.  For fear of being a “loser”, each doctor graduate applies to an average of 47 residencies each.  Some programs have received 1,400 applications for 12 residency positions, 1,000 applications for 15 positions, etc.  In order for residency programs to reduce the number of applications for closer scrutiny, a computer screening tends to favor top-scoring applicants, year after year, selectively “ignoring” other fully credentialed candidates.  Many of these doctor grads have earned extra degrees or done research to enhance their credentials and re-applied in subsequent years, only compounding the already dire circumstances.  Many have had to give up and been forced to look for other jobs and begin re-paying huge student loans.  Some doctors have re-applied for residency for 4 years in a row with no success.  The screening process keeps “skimming the cream off the top” of applicants, selectively ignoring the same candidates repeatedly.  They do this because they can.  The demand greatly exceeds the supply of residencies.

If the solution to increase the number of residencies is so obvious, why has this deficit in residencies not been corrected?  Misconceptions about the residency shortage, as well as political agendas about reducing future healthcare costs, have precluded a unified front on this issue.

 At the recent Florida Medical Association meeting in August, a proposal was made to create a new license. It would allow unmatched doctors to work in a capacity similar to a physician assistant until the number of residency slots increased.  This proposal was voted down by the delegates for several reasons.  Politically, some healthcare professionals want to use nurse practitioners and physician assistants in roles currently performed only by doctors.  Hence, they do not believe there will be a doctor shortage in the next decade, and are not worried about the unmatched doctors.

Some delegates do not believe that a residency shortage really exists, and that the applicants were too picky in their specialty choices or locations.  According to the CEO of the National Resident Matching Program (NRMP), Mona Signer, there have been 42,000 applicants for 32,000 positions.  She said that 99% of the positions were filled with only 203 unfilled slots, mostly in Preliminary Surgery. Ms. Signer said of the unfilled slots “many were dead- end positions that do not lead to further training”.  So there is annual deficit of 10,000 residency slots.

 In 2017 69% of unmatched doctors were graduates of foreign medical schools, even though 27.6% of the unmatched grads are US citizens.  The impression has been that if these foreign graduates had been smarter, they would have been admitted to US medical schools. However all residency applicants through the NRMP must pass the same exams and fulfill the same requirements for participation.  As an educator, that means they all passed the same “criterion task”. 

None of these political agendas or misconceptions really matter.  These doctors have a right to complete the last step of their training.  They have fulfilled their side of the contract.

How can we fix the residency shortage for the long term?  I see it as three-fold. Medicare should expand the increase in residency slots.  Legislation was proposed to the US Congress at least 11 times since 2009 to increase the number of residency slots by 15,000 over a 5 year period. None have yet to pass.  At the rate of 10,000 unmatched graduates per year, we would still “lose” 35,000 doctors over the next 5 years, even if the Residency Shortage Reduction Bill were to pass in 2018.  Secondly, the credentialing process needs to accelerate.  It now takes 2-3 years to accredit a new residency program. Finally, each State should pass legislation for a new license to “carry” these doctors in relevant jobs until they match into a residency.   Our Nation has broken its “Social Contract” with these unmatched doctors who are here now.  We need to fix it before they are forced economically to leave Medicine permanently.

What do we need to do in the short term?

 US citizens should be given first priority to US residencies until the deficit is eliminated.  Doctors who are non-citizens are not required to complete training in the US in order to practice in their own countries.  Also, as taxpayers, US citizens should be able to benefit from the Medicare and Medicaid dollars they have paid to support US residencies.  In order to live and work in the US, doctors who are US citizens must complete a minimum of 1 year post-graduate training in a US residency.

To prevent a permanent loss to healthcare, the unmatched doctors should be moved to the top of the list for residencies.  We need to be “fair” to the doctors who have been waiting for years to complete their training, and not just “fair” to the highest scoring applicants.  Any elimination of doctors should have occurred before they went to medical school, and not blind-sided after graduation.

Other measures which could be taken include emergency licensing to allow unmatched doctors to work, just like physician assistants can work right after graduation.  Also, each medical school could create “Transitional Residency Slots” to place their unmatched doctors until more residency slots become available, as with one medical school already.  Another suggestion has been to allow the unmatched doctors to work at VA facilities which are sorely in need of more healthcare providers.  They could work under the supervision of current VA doctors, much like residency.

           Most importantly, we as a Nation need to apologize with “action” to correct this deficit!  Unmatched doctors have suffered a humiliation, frustration, and economic loss through no fault of their own.  We need to fulfill our “Social Contract”.

Tuesday, July 17, 2018

Residency Match: A Case of Supply/Demand

Residency Match:  A Case of Supply/Demand


During the 1990’s at Bayfront Medical Center in St. Petersburg, FL, the OB/GYN Residency would interview about 50 candidates for 4 residency slots.  The program would often reach their 32nd rank to fill its spots, and sometimes would have to “scramble” by phone to fill all their positions.  This occurred when the number of residency slots exceeded the number of applicants (1).  Now that program ranks 50 candidates and fills their slots by their 10th rank.  Medical students afraid of not matching are applying to an average of 47 residency programs each.  You can see why the numbers of applications have sky-rocketed.

 The difficulty for lesser candidates is how to “breach” the hurdle of their “lower” quantitative scores (even though they are fully qualified DOCTORS).  They are no longer medical students and not yet residents. They have no “umbrella” of supervision and malpractice coverage with which to demonstrate positive attributes to a residency program through an Observership. 

 Most residency programs have started using voicemail, rather than answering thousands of phone requests. Desperate candidates are trying to get an appointment to meet in person and state their case. The residency phones go directly to voice mail. Their email requests are dealt with by generating an automatic response that says they are “filled”.  I was told that an unmatched doctor graduate was escorted out of the residency office by SECURITY at a Miami hospital, when he tried to request an audience in person!  He was told, “You should not have come here.  You should have phoned or sent an email!”

  No doctor who has achieved the right to attend and graduate from medical school should be “eliminated” before having the right to complete the last step of training.  None of these unmatched doctors can work without at least 1 year of post-graduate training (unlike a Physician Assistant who can work immediately after graduation).  Clearly, the number of residency slots needs to increase, YESTERDAY!

(1)   page 6,

What happens to unmatched doctor grads?