March 16,2018
Tampa, Florida.As described in prior
blogs, a demonstration of peaceful activism took place in front of the USF
Match Day celebration.The goals were to
bring the travesty of the medical residency shortage to the Nation’s attention
and to gain media coverage for finding a solution to this grave injustice.While several television stations sent camera
crews to the celebration, no reporters were evident.The camera crews did not film the
demonstration, only the ceremonial events.That was a disappointment.However, our team of activists put forth a colorful, organized, and
informative display, which was live-streamed on facebook and social media.Hopefully, with all the “shares” on facebook
many more citizens learned about the residency shortage that day.The elimination of the residency deficit
continues to be an uphill challenge.It
will only be solved when enough people become aware of it, enraged by the
injustice of it, and connect the resulting doctor shortage to it.I would encourage each of you to do your part
in disseminating this important issue.
Our
debriefing after the demonstration gave us the following things to consider for
the future.Contact the medical school
in advance to ask them to join forces to address the residency shortage.Be sure to have signs of “Congratulations”
for the matched doctors.This
demonstration was not intended to detract from the great celebration that day,
but to bring attention to the unlucky doctors who had not matched and were not
there celebrating.Continue to make
contact with legislators, medical school deans, and persons of influence who
can implement the necessary changes to eliminate the residency shortage.
www.NoMatchMDs.blogspot.com
Tuesday, March 5, 2019
Answers from the NRMP / Does a Residency
Shortage Really Exist?
At the annual Florida Medical Association meeting in August
of 2017, a proposal was made by a delegate to create a new “Assistant
Physician” license for the State of Florida,
like the one passed in Missouri.This would enable unmatched doctors to
actually work in Medicine until the number of residency slots increased.They could eventually obtain a residency
leading to licensure while maintaining and improving their medical skills.This proposal was voted down by the
members.One reason given repeatedly was
that a residency shortage does not really exist.How can this be, given the match results of a
9,000+ slot annual deficit?
Once and for all I want to answer the question “Does a
residency shortage actually exist or not?”To me, the answer is obvious, “yes”, because each year 8,000-9,000
doctors do not match into a residency.Why then is there such disagreement on the answer to this question?
In order to get a legitimate answer to this question, Mona Signer,
the CEO of the National Residency Matching Program (NRMP) was contacted.Let me begin with some of the numbers that
Ms. Signer provided:
“The
NRMP Main Residency Match encompasses 42,000 applicants and 32,000
positions”
“more
than 99% of the positions are filled”
“Post-SOAP
(Supplemental Offer and Acceptance Program) only 203 positions remain
unfilled, and many were in preliminary surgery”
When
asked why the preliminary surgery positions go unfilled:“Many are dead-end positions that do not
lead to further training.”
So according to a legitimate
source, the CEO of the NRMP, about 10,000 applicants to the Residency Match per
do not match into a residency slot.So
yes, a residency shortage actually exists!
Not so fast my friend! Here are the issues which distort the factual
answer to whether a residency shortage really exists.Some people say that a residency shortage
does not exist because there is not and WILL NOT be a doctor shortage in the
next decade.If there is not an impending
doctor shortage, why worry about 10,000 unmatched doctors each year?Other people contend that the majority of
unmatched doctors are graduates of International Medical Schools (IMGs).So why worry about them?Here are some statistics which deal with
these issues:
·The American Association of Medical Colleges
(AAMC) projects a doctor shortage of
up to 105,000 doctors over the next decade
·In the 2017 Match, 45% of unmatched doctors were
IMGs
·27.6% of unmatched doctors in 2017 are US
citizens
·14,000+ US
citizens, IMGs, did not match over the last 5 years
To me the factual answer to whether a residency shortage
really exists does not depend upon whether you believe in the use of less
costly healthcare providers for the future of Healthcare in the US.
It does not matter where a doctor went
to medical school, as long as they have met all the criteria for application
through the NRMP.It DOES matter to me
if the applicants are US citizens.These
are the doctors who are required to complete a US
residency to practice in the US.They are the citizens whose tax dollars are
funding US residencies through Medicare and Medicaid.They are the students who followed the
“rules” of the Social Contract to practice Medicine in the US
and are entitled to complete the last requirement.
The social and
political aspects of Medicine in the US
have nothing to do with whether a residency shortage exists.IT DOES!
Some times the only way to get peoples’ attention is to go
after their money…Yes, YOUR money.Just
imagine if all of the Nation’s student loan debt went into default.In 2017 the total US
student loan debt reached $1.45 Trillion.That total exceeds total US
credit debt by $425 Billion.Just
imagine if all 50,000 unmatched doctor graduates over the last 5 years declared
bankruptcy and their student loans went into default.The average medical school debt is $183,000,
but some of the unmatched doctors I have heard from have debts of $350,000,
$400,000, and more.That is a lot of
student debt coming out of our tax dollars in the event of default.
Because our Nation has broken its “Social Contract” with unmatched
doctor graduates, they cannot obtain the work necessary to repay millions of
dollars in student loans.They cannot
obtain a license to practice Medicine in the US
without a required US
medical residency.This residency
shortage began when the Balanced Budget Act of 1997 capped the number of funded
residency slots.Now the number of fully
qualified medical graduates exceeds the number of residency slots
available.Without a residency these
unmatched doctors cannot practice Medicine.
Currently, I am asking a lawyer in my city to consider the
feasibility of a class action lawsuit against the Federal Government on behalf
of the unmatched doctor graduates.Although I am not a lawyer, here is how my thinking goes.
The US
division of Medical Education has created a list of requirements for medical
licensure in the US.At the same time, another division of the US
government, Health/Medicare, has cut the spending necessary to complete the
final step required to obtain a medical license, namely, completion of a US
medical residency.Two US
departments are working in opposition to one another.This is to the detriment of its citizens, who
have followed a prescribed regimen of study, only to reach a dead end when it
comes to completing the last requirement for licensure.Would this be considered “Bait and
Switch”?You get the idea…
Recently, an L.A. Times editorial talked about predatory
loans.It defined “predatory lending” as
loans “with no way to repay their original loans other than to obtain further
ones”.The Consumer Financial Protection
Bureau will require payday and auto title lenders “to do the sort of thing
banks and credit unions already do:Before extending a loan, they’ll have to determine whether the borrower
can repay it”.The last sentence of the
editorial says, “the issue here isn’t access to credit.It’s protection from predatory lending”.
If a medical graduate cannot repay student debt because of a
government whose right hand does not know what the left hand is doing, I would
accuse the US Government of “predatory lending”!
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…
Assuming that over the last 5 years alone over 50,000
doctors have not matched into a residency, why are we not hearing more about
the Residency Shortage?Why are we not
outraged?Surely, the 50,000 unmatched
doctors should be incredulous about their futures, despondent, mortified,
frustrated, and ultimately furious with a system which has betrayed them! Why
are we not hearing from them or about them?My answers include:the unmatched
doctor is embarrassed by “their own” failure to match- a “dirty little secret”,
the lack of a support group or committee to join, the isolation each unmatched
doctor experiences while their peers are rejoicing in a “match”, and the other
unmatched doctors are “scattered” across the US.
There is a sense of futility unmatched doctors have when they try to figure out
a plan, a solution, or “someone” to contact to correct this injustice.Think about it.Who would you contact under the
circumstances:your legislator, your
dean, the Federal Government?There is
no “one person” who can right this wrong.
Recently, my son met a new doctor graduate at a happy hour
he was hosting in his Chicago
condo.The doctor had failed to match
into a residency this past March and was very sad and reluctant to discuss
it.My son told her about my blog and
website, and encouraged her to look at them.The topic was so painful that she just wanted to drop the subject.My heart cringed ONCE AGAIN when I heard this
sad story.My first thought was, if only
she would listen to my blogs she would realize the fault for not matching was
not hers, but a system which had failed her.That also, the sheer numbers of applicants and the use of computerized
screening had probably eliminated her application from consideration, that any
redeeming parts of her application had probably gone UN-READ, and that
unfortunately that scenario was bound to repeat itself in subsequent match
attempts.I hoped that with this
knowledge her sadness and embarrassment would change to one of anger and
determination to let her voice be heard on this travesty.
Leading up to the next residency Match Day 2018 I am
going to be focusing on getting those 50,000 unmatched doctors to unify and
speak out.No one will care about the
solution to the Residency Shortage as much or as fervently as those affected by
it.Ironically, in the next decade we
will all be affected by it to some degree with the impending doctor
shortage.Yet, until the unsuspecting
public is directly impacted by this shortage, there will be little public
outcry.That is why the unmatched
doctors, their friends, family and colleagues need to get over their
“uncomfortable” dirty little secrets, and convert their embarrassment to
action!Let’s get the word out there
regarding the residency shortage and our Nation’s failure to uphold its side of
our “Social Contract
The last blog gave an overview of the Indivisible Guide for
public action.I described how it could
be utilized to bring the residency shortage to the Nation’s attention.To many of you the idea of demonstrating or
picketing might seem ludicrous.Granted
I would have felt the same way before I became aware of the residency
shortage.Yet, the direness of the
circumstances of unmatched doctors calls for drastic measures.
Normally, I am very much an optimist.However, in this particular situation I have
realized the futility of successive re-applications for residency slots.I have “laid out” the reasons for this
futility in many of my prior blogs.The
Nation is short 10,000 residency slots each year.The demand for a residency given the current
supply creates such a skewed application process.The system will repeatedly favor the highest
scoring candidates.The result is that
many fully qualified doctors graduates have to give up on a career in Medicine.
So here are the specifics of what I plan to arrange for
“peaceful activism” in Tampa on Friday, March 16, 2018, Resident
Match Day.I hope you will take these
ideas and plans and use them at a Match Day celebration where you live.You have 180 medical schools from which to
choose…
Explore
city permits for protests in my area (none needed if on public sidewalks
and not obstructing traffic)
Contact
family, friends and supporters to form a group of activists to “picket” at
the USF Match Day party in Tampa, FL
on March 16, 2018
Prepare
public relation materials to hand out:brochures and business cards (download these at my website:www.NoMatchMD.com)
Order
25 t-shirts with the NoMatchMD logo on them (doctors wear white coats)
Create
protest posters to carry at the demonstration –
-“What About the Docs Who Don’t
Match?”
-“Doctor Blindside”
-“Save Our Doctors!”
-“Discarded Doctors!”
-“Residency Shortage = Doctor
Shortage”
-“Create More Residency Slots”
·Reach out to media contacts, especially those
who have written about the residency shortage.Send them protest specifics and include reference links to this issue
and a quote to use for a story.
I am going to make PR materials available for you to download
on my website, www.NoMatchMD.com (logo, brochure, business card, poster and
sticker template).Please use them to
make your participation more probable.
I hope this will help you too, to get out of your comfort
zone and help in the quest to correct the residency shortage.
August 3, 2017,
someone was listening….Julio Ochoa, editor for Health News Florida,
broadcast a story about the residency shortage in Florida
on NPR Radio, WUSF.He started the story
by talking with Dr. Michael Smith, a 2014 graduate from a Caribbean
medical school, who has applied 3 years in a row for a residency in
Medicine.Each year Dr. Smith applied to
hundreds of residencies at a cost of $5,000 per year with no luck.He will re-apply for a 4th time in
2018.Dr. Smith has accrued a medical
school debt of about $350,000 to date, with the inability to work as a licensed
physician to begin repayment.To work in
the US as a
licensed physician requires a minimum 1 year post graduate training in a US
residency.In reality, the “real
minimum” number of residency years is 3 years, for the ability to become board
certified.Doctors are really considered
“employable” when they are board certified.
Mr. Ochoa broadcast this story one day before the beginning
of the Florida Medical Association annual meeting.The timing could not have been better!Apparently, most of the meeting’s attendees
did not hear this story.A proposal to
create the new license described in Mr. Ochoa’s story to preserve the unmatched
doctors, failed to gain support from the membership.They voted “no” on the proposal.The objections raised dealt with the belief
that a residency shortage does not really exist, that the doctor graduates were
too selective in their choice for residency specialties and that is why they
did not match, and that emphasis should be placed on increasing medical
education (number of residency slots) and not on creating “short-term”
licensing.Each of these objections
provides fodder for upcoming blogs.The
current situation of the residency shortage continues to wallow in the doldrums
due to these very misconceptions.
By the way, that “someone” who was listening to Mr. Ochoa’s
broadcast, offered Dr. Smith an immediate spot in a “Transitional Residency
Program”.Hopefully, this is “the foot
in the door” that Dr. Smith has long awaited!Congratulations Dr. Smith on your willingness to speak out about this
travesty of the residency shortage.It
was never YOUR fault.It was our Nation
that broke its “Social Contract”!
Please listen to Mr. Ochoa’s story for yourself.Here is the link where you will find it:
After the last presidential election, a group of
congressional staffers outlined successful strategies for making contact with
members of Congress.This information
came about as a result of the outcome of the presidential election, as a way to
keep congressional representatives aware of the feelings of their
constituents.This group of staffers has
adopted the name, “Indivisible”, to represent this cause, and to encourage
similar groups to form across the country.It is an insider’s guide to make contact with your legislators.
I want to utilize these “insider tactics” to bring the
Residency Shortage to the Nation’s attention.I am going to suggest that those who would like to find a timely end to
the residency shortage, adopt a similar strategy.Contact your own members of Congress using
the Indivisible strategies.It is only
through action that we can hope to eliminate the travesty of the residency
shortage.As I have said, there is no ONE
person who has the power to correct this situation. (That is, unless there is a
presidential order…) I will describe some of the key points derived from the
“Indivisible Guide” to create action, and then propose a more detailed plan to
implement these ideas on the upcoming Match Day, March 16, 2018.
To begin, members of Congress are concerned with
“reelection, reelection, reelection. So they want their constituents to think
well of them, and they want good, local press”.(1) The guide describes four
local advocacy tactics:
·town hall meetings
·other
local public events ·district
office visits ·coordinated calls
For the residency shortage, all four tactics
could be utilized to make contact with legislators.But for Match Day 2018 on March 16th,
I am going to focus on “local public events”, i.e. Match Day results gatherings
across the US.In my area, that
translates to the University of South Florida(USF) Match results party.It was held last year at Ulele Restaurant in
Tampa, Florida.These events occur
across the US on Match Day, when doctor graduates get the results of their
residency match.It is quite a
celebration when each graduate finds out where they will be living and working
for the next few years in their residency.The idea is to utilize media attention which will be present to
highlight this joyful event, but also to bring attention to the plight of the
unmatched doctors.There is no ill will
or rancor involved, just an opportunity to provide another side to this story.
A small group of people to “attend” and distribute
information at a Match Day results event is all it would take.There are about 180 DO and MD medical schools
in the US.Just imagine if the residency shortage story
line was generated and picked up by the Media at each one of these
locations!Email your contacts and post
a message on your Facebook page to generate a grass roots group to attend the
Match Day party near your local medical school.Record everything at those events and share these clips on Social Media,
as well as with local and national media.Optimize your visibility by staying together as a group, wear similar
clothing or message shirts, and carry signs.Identify and try to speak with reporters on the scene.
One key item described in the Indivisible Guide is that
Members of Congress, and probably the Media as well, WANT “concrete asks that
entail a verifiable action- vote for a bill, make a public statement, etc.Perhaps one example of a “concrete ask” could
be “Create an emergency placement for unmatched doctors while increasing the
number of residency slots”.You could
tailor your “concrete ask” to something pertinent to your State like, “Grant
immediate Physician Assistant licensure to unmatched doctors until the residency
deficit is eliminated”, or ”Add 2 additional residency slots/year to every
existing residency until the deficit is eliminated”.
At the onset of the NoMatchMDs.blog I stated that my goal
was to educate the public about the residency shortage.With this knowledge a solution to this
travesty could be found.As I have read,
a good salesman is really an educator who provides information, which leads the
customer to want what the salesman is selling.Then when we know better, we do better.This has been my continual focus, to educate the public.That is why I am proposing “we” use every
tool at our disposal to get this message out, even if it means “peaceful
activism”.
To help with this instruction I have created a website, a
blog, a Facebook page, and a twitter account.I have also created a brochure, a poster, stickers, and business
cards.I am happy to make all of these
WORD documents available for your use and reproduction in your own area.You can distribute the brochures at your
Match Day event, use the poster as a sign, wear the stickers, and hand out the
business cards.All you need is a small
group of supporters to join with you on March 16, Match day 2018.Please let us all know of your plans, to give
inspiration to others who are waivering.You can write a “comment” to my blog and I can share it with other
readers.The Guide also stresses the
need for a “group”, rather than 1 or 2 people.So get your friends and colleagues to join you in this important cause.
In the next blog I will be more specific about my plans to
“demonstrate” for a solution to the residency shortage on Match Day 2018, March
16th.Please let me know of
your plans, so I can encourage others to follow your example.
I will re-publish this blog several times leading up to
Match Day, hoping to enlist more “activists” to our cause.I have already had offers from my own family
members to fly to Tampa for Match
day 2018, to help form a group at USF Match Day.
Hospital Corporation of America
is leading the charge for a timely solution to the Residency Shortage
nationwide.“Nationally, HCA
is one of the largest GME providers, with more than 203 programs….Currently
2,750 residents and fellows are participating and that number is expected to
grow to 5,500 by 2020”.(1)This would
mean an additional 70 residency programs.Perhaps other hospital corporations will follow HCA’s
example.The slow moving bureaucracies
of Medicare Funding, the ACGME (Accreditation Council of Graduate Medical
Education), and state licensure laws have precluded a timely solution in the
public sector.
Here is what is going on in Florida,
where HCA says, “The physician shortage is
especially critical in Florida”.An IHS Global study found that Florida
faces a shortage of about 7,000 physician specialists by 2025.The Teaching Hospital Council and Safety Net
Hospital Alliance report said, “We are not, to put it bluntly, training enough
physicians….Without more physicians, Florida
will have a tough time providing quality health care to our growing, aging and
increasingly diverse population.”You
may recall from a prior blog that in 2015 Florida
began a “GME Start-up Bonus Program” which funded $100,000 for each new
residency “slot” in shortage specialties.I would assume that HCA is taking
advantage of these bonuses to help fund their new residency slots.In Florida,
HCA says,”Currently 336 residents …are
training at one of our seven teaching hospitals, with plans to expand to more
than 550 residents by the 2018-2019 academic year.”
The other 49 states seem to be approaching these Residency
and Doctor Shortages in many different ways.I see the private sector approach working very nicely in Florida,
and would encourage other states to offer similar incentives to the hospital
corporations operating in their states.However, I would still mention that until the Residency Shortage is
solved, each state give preference to its own citizen applicants for residency,
as well as those unfortunate doctors who have not matched in prior years.Upon completion of residency, many doctors
opt to practice in the state of their training.Why should a state offer incentives for new residency slots, only to
have these trained doctors leave their state when finished?
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!
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 accreditationto 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.
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.
Are we really going to have a doctor shortage over the next
decade?Or, could we provide more cost
effective care through the utilization of NPs and PAs?In that case, there might not really be a
doctor shortage, as some believe.
I agree that greater use of NPs and PAs for follow-up and
routine care would be more cost effective healthcare.However, some patients only seek medical care
on an as needed basis.A new health
problem might be their rare visit to see a doctor.This might be a one-time chance to discover
other untreated conditions, which might go “unexplored” by a PA or NP.When I go to a doctor, I want to pay for that
doctor’s “blink”, but I will discuss that idea a little later.
First, I want to discuss a theory from my teacher education
days. The theory was called “Bloom’s Taxonomy” and dealt with the incremental
levels of learning a student experiences with new subject matter.To illustrate, remember when you were in high
school and your teacher announced an upcoming test?All the students would plead for a True/False
exam.I now know why.True/False tests are at the lowest rung of
learning.The student has only to
recognize the simplest level of knowledge about the material, whether the
question was “True” or “False”.The next
levels up were “matching”, followed by “ fill in the blank”, and writing a
complete sentence for the answers.The
highest levels on the learning curve were concept formation, synthesis, and
prediction.How does this idea relate to
the projected shortage??
The amount of training required for a PA and a NP are 1-3
years post college graduation (the NP requiring a nursing degree).The amount of education and training a doctor
pursues is generally 7+ years after a college degree.As I mentioned before, my 3 family members
have trained for 7, 10, and 11 years post college. I would suggest that there
is a significant difference in the knowledge level acquired in the training
years between PAs/NPs and MDs.The
additional years spent in learning by an MD would allow for significant
exposure to the learning levels of concept formation, synthesis, and
prediction.How can we equate 1-3 years
of training with 7-10+ years of training?
Now back to the idea that when I go to the doctor I want to
“pay” for that doctor’s “blink”.In Malcolm
Gladwell’s book, Blink, he defines his use of the word “blink” as “the
power of thinking without thinking”(1 ).When the years of study, experience, and familiarity come together an
intuition exists much like the “adaptive unconscious”.Mr. Gladwell describes this, “The adaptive
unconscious is thought of, instead, as a kind of giant computer that quickly
and quietly processes a lot of data…” (1) When I go to a doctor appointment, I
want my doctor’s “computer brain” to bring forth the sum total of knowledge and
experience acquired to date.
To answer the original question about whether there will be
a doctor shortage in the next decade, I will say “Yes”.NPs and PAs provide excellent, but DIFFERENT,
levels of care than a doctor provides.One degree does not replace the other.I want MY doctors to have reached the upper echelons of “Bloom’s
Taxonomy” in learning.I want them to
have had multiple exposures to a myriad of medical conditions, years of experience,
and an “eye for the unseen”.
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 LawSchool
that getting a job might be difficult.I
do not think most students beginning MedicalSchool 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!
