Let’s talk about
the upcoming doctor shortage.Here are
some statistics and projections:
27.6%
of the current physician workforce are age 60+ years old and likely to
retire in the next 10 years (1)
32.6%
of practicing physicians are women
46.1%
of residents are women
“Historically
women have worked fewer hours than men-a trend that continues today” (2)
24% of
current US
physician workforce are IMG
(International Medical Graduates)
25.9%
of US “
resident” workforce are IMG
“By year
2025 the United States
will face a shortage of between 61,700-94,700 physicians”. (3)
“Thousands
of baby boomers are turning 65….seniors are the population with the
greatest healthcare needs”. (4)
“The
Association of American Medical Colleges (AAMC) projects there will be a
shortage of between 12,500-31,100 primary care physicians in the next 10
years…equally troubling is the shortage of between 28,200-63.700
specialists.”(4)
More
than 40,000 fully qualified doctors have not matched into a residency over
the last 5 years and cannot practice Medicine without residency training.
8,640
doctors did not match on March
17, 2016, what are they doing now?
“With
medical school and residency combined, it takes a minimum of seven years
to train a doctor.” (4)
What are we thinking?!!!In view of the upcoming doctor shortages over
the next decade, we are simply “discarding” our fully educated doctors!This just does not make sense!
The ACGME, via CEO
Thomas Nasca MD, does not support
the legislation enacted in Missouri.It deals with using unmatched doctors in
underserved rural areas, supervised by a licensed physician within a 50 mile
radius.The doctors could work and
reapply for a residency, while performing meaningful and necessary work until
the number of residencies catches up with the deficit.Dr. Nasca bases this belief on patient safety
and quality concerns.(1)He further
states that once an unmatched doctor has gone through 2 application cycles,
he/she will probably never get trained.They will remain untrained for the duration of their career.Dr. Nasca also infers that unmatched
international medical graduates are not as smart as US grads, or they would
have been accepted into a US
medical school.It sounds like Dr. Nasca
is not too worried about unmatched IMGs (International Medical Graduates)!
I can certainly see the points Dr. Nasca makes about patient safety and
quality.Yet, residency also deals with
training “new doctors” under a supervisory set of physicians, albeit closer in
proximity.
However, I have a different opinion about the qualifications of the
IMGs.Two of my own children have
graduated from medical schools, one a US
grad and one an IMG.As an educator and mother, I would categorize
the child who went to a US
medical school as “system smart”, and the one who went to an IMG
as “intellectually smart”.
The US
grad decided to go to medical school 2
years after graduating from college in “Broadcast Journalism”, with an “A”
average.The IMG
attended the same, very competitive university (97% of incoming freshman have
an academic scholarship), intending to go to medical school from the beginning, and majored in
“Cell Science/Microbiology”, obtaining a “B” average.The US
grad attended a local less competitive
university forpre-med classes
and got an “A” average.The IMG
grad took pre-med classes, along with a competitive pre-med science major,
while at the highly competitive university, getting a “B” average.
The US
grad was accepted “Early Decision” into a medical school with 1 application.The IMG
med student was only accepted into an international med school.Two graduates, fairly comparable
intellectually, one worked “smarter” in applying for medical school, while the
other majored in a subject intended to “help” in Medicine.It pays to know the system before you begin!
Yes, this story deals with only 2
medical students. There is a whole “continuum” of ability and IQ in MDs, some
are “book smart” and some are “system smart”.Probably all applicants wished to have gone to a US
medical school.They would not have had
to deal with this residency deficit, waited heavily against IMGs.In spite of all these points, all doctors
applying through NRMP have PASSED ALL THE REQUIREMENTS!Why shouldn’t they be allowed to complete
the last step of their training!
As CEO and spokesperson for the ACGME, I believe Dr. Nasca has a
responsibility to suggest a workable solution to this residency dilemma.Not only is a solution warranted, but
leadership in this role of CEO for such a vital organization in medical
education is warranted!If such
leadership had taken charge of this travesty, we would not be talking about
each state enacting its own legislation.We would not be dealing with the utter waste of human time, talent, and
money.The AMA has “adopted” a similar
stance, based on Dr. Nasca’s recommendation.So 2 of the most powerful agencies dealing with healthcare in the US
are leaving it up to others to fix this bureaucratic nightmare!
Here’s how medical school works…The first 2 years of medical
school cover the acquisition of medical knowledge.This occurs through lectures, reading, study,
and testing.The acquisition of this
knowledge occurs through individual interaction and involvement with the
subject matter.The last 2 years of
medical school include monthly clinical rotations at hospitals and clinics in
the subspecialty areas of Medicine.The
student treats patients under the supervision of residents, faculty, and
attending physicians.Supervised clinical
practice uses the knowledge acquired from the first 2 years of school on real
patients for the last 2 years.Here are
examples of how 3 real medical students approached
their learning.
“John” attended the University of Illinois Medical School in
the early 1970s, earning the honorary designation of “James Scholar”.This honor entitled him to the exclusive use
of a study carrel at the medical school, and the privilege of designing his own
course of study, as long as he passed all requirements and exams.John’s method of study involved reading each
medical text book cover to cover, not attending class, and graduating in 3
years.
“Mary” attended a US
medical school in the South.Her method
of study for the first 2 years was as follows.She listened to her online class lectures at an accelerated rate of
speed on her computer.She varied her
locations between her apartment, Starbucks, and Panera Bread Company.Her clinical rotations were taken at a
variety of hospitals and clinics in the greater metro area around her medical
school.
“Joe” attended An international medical school.He attended class lectures, read, studied,
and took exams.His clinical rotations
took place in the New York City metropolitan
area for the last 2 years of medical school.
These 3 students each had a different approach to the
didactic portion of their medical knowledge.The clinical rotations were a fairly uniform experience, all taken in
the US.They all graduated from accredited medical
schools with an MD degree.They all
passed USMLE parts I and II.They all
applied for residency through NRMP.Haven’t
they all fulfilled their side of the “Social Contract”?Don’t they all deserve the opportunity to
complete the final step in their training?
All US
citizens who have satisfied the requirements for an MD degree, and passed all
required exams (USMLE I AND II), have earned
the right to train and practice Medicine in the US.This is our “Social Contract”.Think of medical school as one big “lesson
plan”.As teachers know, each lesson
plan begins with the “Behavioral Objective” and ends with the “Criterion
Task”.If the goals and benchmarks
outlined in the Criterion Task have been met, the Behavioral Objective has been
met.US medical schools and government
legislatures have determined the criteria required to practice Medicine in the US.All medical school graduates who apply for
residency through the NRMP (National Resident Matching Program) have met these
criteria, both US medical school grads, as well as international medical school
grads. They have all passed the
CRITERION TASK!
Why aren’t we “upset”
if 25% of unmatched grads are from international medical schools,
especially since 42% of them in 2016 were US
citizens?Currently, 25% of physicians
practicing in the USare international medical school
graduates.(1) Considering the expected 90,000+ doctor shortage over the next
decade, that is quite a waste of fully educated doctors!
The ECFMG (Educational Council for Foreign Medical
Graduates) has been promoting excellence in international medical education for
60 years! (1) This organization has been evaluating the readiness of IMGs
(International Medical Graduates) to enter GME (Graduate Medical Education) programs
in the US.It has partnered with NBME (National Board of
Medical Examiners) to develop the clinical skills assessment for the USMLE (US
Medical Licensing Examination).To
become an accredited medical school with the SAME STANDARDS as a US
medical school, a foreign med school has passed rigorous standards and criteria.
“The ECFMG makes its
world-class experience with the primary-source verification of medical
education credentials available to the international medical regulatory
community.”(1)It is recognized world
wide.This is the organization
monitoring graduates of international medical schoolsThe IMGs applying through the NRMP have met
the “Criterion Task” for entry into US residencies!
According
to CME Report 3-A-16, from the Council on
Medical Education, the AMA recognizes the funding and distribution of residency
positions for GME (Graduate Medical Education) are “in crisis in the US
and that meaningful and comprehensive reforms are urgently needed”.This report focused only on US medical school seniors, and does not include International Medical Graduates (IMG).Currently, 25% of practicing physicians in
the US are
graduates of international medical schools.(1) Many of these are US citizens who attended
international medical schools.(2)Here
are some of the points made in this report and Resolution 308 (A-16):
“There
is a predicted physician shortage of between 46,100 and 90,400 physicians
by 2025” (AAMC, March 2015)
The overall match rate for US and IMG
medical students was 75.2%
The
majority of the 25% not
matching are International Medical Graduates(IMG)
There
has been continuous growth of US medical schools and increased enrollment
There
has been limited growth in
Graduate Medical Education (residency positions) due to caps in federal
funding (The Affordable Care Act)
The
AMA “will strenuously advocate for legislation” along with the AAMC
(Association of American Medical Colleges) to increase federal funding of
GME
Medical
school seniors’ “fear of being a loser” have caused residency applicants
to apply to an average of 47 programs to avoid not matching into a
residency (up 20% in the last 5 years)
This
has forced program directors to use USMLE scores and quantitative criteria
as a numeric “cutpoint” rather than perform an in-depth review of every
application
USMLEscores alone are NOT predictors of success in residencies
The
AMA is opposed to state
legislation for licensing “untrained” doctors on the basis of patient
safety and quality concerns
If the AMA says the number of GME positions is in “crisis”,
yet does not support state legislation for licensing unmatched doctors, how can
this catastrophic deficit in residency slots be rectified before these fully
educated and qualified doctors are forced to leave Medicine?More than 40,000 doctors have not matched
already in the last 5 years.
Why isn’t the plight of unmatched international medical
graduates as crucial as that of graduates of US medical schools, since 42% of IMG
in 2016 were also US citizens?
Are US medical schools better than IMGs?Are US graduates smarter than IMG
graduates?
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
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 enoughresidencyslots 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??
