During the 1990’s at BayfrontMedicalCenter
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!
Here is an
idea that would allow ALL qualified doctor applicants the ability to obtain a
license to practice Medicine.Currently,
the medical residency shortage has prevented as many as 10,000 doctors per year
from completing one of the last required steps for licensure in the US.This idea could be accomplished at no
additional cost and without the passage of a new Bill or Amendment.
Applicants to
medical residencies in the US fall into 2 major categories, US citizens or
non-US citizens.Over the last 5 years,
18,819 NON-US citizen graduates matched into a 1st year US residency
program.At the same time, 13,982 US
citizen graduates DID NOT match into a US residency (1).Without at least one year of post-graduate training
in an accredited US residency program, no doctor can obtain a US medical
license.Without a US residency, the
UN-matched US citizen doctor graduates cannot even practice in their own
country.However, non-US citizen doctor
graduates CAN practice in their country of origin without a US residency.
Here is the
idea.Give first priority to US doctor
applicants for US residency programs, and 2nd priority to non-US
citizens, until the residency shortage is eliminated.All applicants would have the ability to work
as citizens of their respective countries.
How could
this be accomplished without costs or legislation?The costs of Graduate Medical Education are
paid through (2):
·Medicare
·Medicaid
·Veteran Affairs and Defense
·State and local governments
·Faculty practice plans
The only non-government source of revenue in this list
is the Faculty practice plans.Congress
could place “conditions” for the receipt of federal money to residency programs
by requiring 1st priority be given to US citizen doctor applicants
for US residency programs.President
Ronald Reagan used a similar strategy to strengthen drunk driving laws
nationwide.He convinced Congress to
place “conditions” for the receipt of federal money for highway construction in
each state.Congress required states
pass more stringent drunk driving laws in order to receive federal money.US tax dollars fund most of these federal
departments, and tax-paying US citizens should be given 1st priority
to receive the benefits they have “paid for”.
While non-US
doctors have provided valuable services to our country, these doctors also have
the opportunity to practice Medicine in their own countries, while US doctors
cannot.Giving 1st priority
to US citizens during the medical residency shortage will ensure the
preservation of ALL fully qualified doctors.
The problem is NOT just that
there are not enough residency positions currently available in the US
today.The travesty is that many of
those unmatched doctors will not match in the next few years either, and will
have to quit Medicine!Yes Quit!Just think about the utter waste of time,
talent, money, and DOCTORS.
Over 8,640 doctor graduates
nationally did not match into a residency on Mar.18th of this year.*
One might think that they can just re-apply next year and all will be
well.Unfortunately, a majority of these
doctors will probably never match before their credentials have to be renewed,
and their training will be for naught.
These doctors will
not match in succeeding years due to the compounding affect of prior years’
candidates re-applying the next year, but more importantly due to the unique
situation of having their application being “selectively ignored”.
The number of applications received by each residency has
increased exponentially.Brandon
Regional Hospital Internal Medicine Residency Program received over 900
applications for 20 positions before the residency had even begun!BlakeMemorialHospital
in Bradenton received more than
1000 applications for 15 positions and it just began this July! All Children’s Hospital in St.
Petersburg received 1,400 applicants for 12 slots.
No administrative assistant has the time to
read through 1,000 applications looking for “redeeming qualities” of lower
scoring but fully qualified candidates.The programs will have to rely upon a computer screening using common
benchmarks, like Step 2 scores, to reduce the number of applications they
review.So the top ranked candidates
will be selected quantitatively versus qualitatively, and the lower scoring
candidates will continue to be “selectively ignored” repeatedly and fall into a
“limbo”.
On Feb. 22nd I participated in a panel
discussion at the World affairs Conference held in St. Petersburg, FL.My panel covered the topic of how to make our
educational systems more relevant.My
topic for the panel was about the travesty occurring in medical education with
the medical residency shortage.I quoted
the statistic of 50,000 doctors not matching over just the last 5 years, at the
rate of 10,000/year according to the NRMP (National Residency Matching
Program).Afterwards, a retired doctor
approached me about using that statistic of 50,000, stating that it was
misleading since a large percent of those were foreign doctors.He appeared visibly angry and walked away
without listening to a further explanation.At first I felt very badly, worrying that I had “lied” or used false
information.I continued to ponder this
scenario for the rest of the day, but awakened the next day with a new incite.
I now realized why some physicians I have encountered
have dismissed the existence of a residency shortage, because they believe it
is mostly affecting foreign doctors.They don’t care if a foreign doctor does not match, and probably, they
prefer to keep foreign doctors from practicing in the US.My husband has told me how some foreign
doctors refer patients only to doctors of their own nationality, and, probably
US doctors do the same.Just like groups
of any affiliation, we want to send business to our “fraternity” of peers.
My biggest revelation came when I realized that there
is an “error” in the math when we are viewing these results.The angry doctor wanted me to focus only on
the 13,982 US doctors who did not match over the last 5 years, even though
those US doctors are “competing” on a scale of 50,000 total unmatched doctors
for the residency positions.Until a
preference is given to US doctors with residency programs, the benchmark of
unmatched doctors has to be quoted at 50,000.To keep our math accurate, we have to subtract the number of non-citizen
applicants from the ENTIRE match, if we want to look at only the results of US
doctors who do not match.That is what I
believe is complicating the thinking about the residency shortage.The US doctors who are feeling “territorial”
about their work turf do not want to help any foreign doctors get residencies
and work in the US.They are not going
to get too worried when they hear about a 50,000 deficit in residency slots
over the last 5 years when it includes unmatched non-citizen doctors.
Now let’s talk about the perspective of the actual
residency programs.Residency programs
are trying to “hire” the best candidates for their residency programs.They are looking for the highest credentials
and achievements in their applicants.Some foreign doctor applicants have already been practicing Medicine in
their own countries before applying to a US residency.There is no dictum for US residencies to give
preference to US citizens.However, since
residency programs are funded through Medicare and other governmental sources
with tax dollars, US citizens should be given first priority to these residency
slots.If residencies were required to
select only US citizen applicants for residency slots, then I would willingly
use the quote that 13,982 US doctors had not matched over a 5 year period.We cannot dismiss the 13,982 unmatched US
doctors, because the other 36,018 unmatched doctors who did not match were
foreign doctors.
Most importantly, the US doctors are totally dependent
upon a US residency to obtain a medical license in the US (technically, 1 year
of post-graduate training in a US residency is required for a license).Foreign doctors are able to practice in their
native countries without a US residency.Over the last 5 years, 18,819 NON-CITIZEN doctors matched into US
residency slots. (1) Had US doctors been given priority in the matches, that
number would have easily taken care of the 13,982 unmatched US doctors.Then according to the angry doctor, there
would be no residency shortage.To
include only 13,982 unmatched US doctors as the statistic would diminish the
enormity of the matching challenge that exists.
I am actually grateful to this angry doctor for making
me aware of another misconception about the residency shortage.These are the misconceptions which decrease
the likelihood of a timely solution to the residency crisis.
Personally, I have no ill-will toward non-citizen
doctors.What I do hold “sacred” is the
“social contract” which started the day any US citizen was accepted and began
medical school, namely, the right to finish all requirements for
licensure.Any residency slots remaining
AFTER this “contract” has been fulfilled would be generously offered to
non-citizen applicants.
My goal for
the past year has been to educate the public about all the nuances of the
residency shortage.The blogs covered
topics on the process of medical education, how the residency shortage began,
the ramifications of the shortage, the politics of the shortage, how the same
applicants are being screened over repeatedly, the misconceptions about
unmatched doctors, why some physicians are unaware or ambivalent about a
situation affecting their own colleagues, and possible solutions to the
residency shortage.
My goal going
forward is to spend less time writing blogs, unless an important development
occurs.To avoid “insulting” subscribers
with repeat blogs, I am planning to publish new posts only on Wednesdays.I am going to recycle previously published
posts on Tuesdays, as usual.There are
still millions of potential readers who have not read these blogs.Instead, I will be spending my time
contacting legislators and people of influence about the residency
shortage.Currently, Senator Chuck Schumer
is promoting Senate Bill 1301, to increase the number of residency slots by
15,000 slots over a 5 year period.This
is at least the 11th bill submitted to Congress for this
purpose.It needs momentum to get to a
vote.
Another
worker has joined me in this cause.She
is currently developing a website to compile contacts who have been affected by
the residency shortage.Originally, she
was going to create a private facebook group for this purpose.However, with the goal of maintaining
individual privacy of group members, and protection of private information, the
decision was made to utilize the vehicle of a website.It would require prior approval for
membership.When the website is
operational, I will publish a blog with information for enrollment.Please pass along this information to anyone
you know who may benefit.
Many people cannot relate to the current situation with the
residency shortage.My local congressman
asked why the unmatched doctors could not just go and apply elsewhere for a
job.The rigid system in place for educating
a doctor is very unforgiving.Without a US
residency, a doctor cannot obtain a medical license in the US,
period.One thing we can all relate to
however, is the results of a doctor shortage.That is when it will really mean something to which everyone can relate.
Updating a previous blog about the “Ramifications of a
Doctor Shortage”, I wanted to talk more specifically about what this doctor
shortage could entail.The AAMC
(Association of American Medical Colleges) now predicts that, “By 2030 the US
population under age 18 is projected to grow by only 5%, while the population
aged 65 and over is projected to grow by 55%.Because seniors have a much higher per capita consumption of health
care, the demand for physicians- especially specialty physicians- is projected
to increase.”(1)Additionally, on a
scale of 1-5, the US
currently has a per capita number of doctors of 2.6 compared to Austria
at 5.0 (2)Sweden,
Switzerland,
and Germany all
have about 4 doctors per capita (2).The
US even falls behind
the number of doctors per capita of a 3.4 average for other developed
countries.So the US
already lags behind per capita in current number of physicians, and this
scenario is predicted to get even worse up to the year 2030.The US
is predicted to have a 105,000 doctor shortage.
Let’s talk about one of the most critical areas of the
projected shortage.“A shortfall of
between 33,500 and 61,800 non-primary care physicians is projected by the AAMC (includes
surgical and other specialists).”Think
about the average person’s use of doctors.For females between 0-21, we would assume girls initially go to a
primary care doctor and then change to an OB-GYN doctor in the teen years.Perhaps they would go to the doctor
once/year, and sometimes even less.As I
watched my own Mother as she aged she utilized the following physicians:Primary Care, OB-GYN, orthopedist,
Otolaryngologist, Cardiologist, Dermatologist, Audiologist, Ophthalmologist,
Gastroenterologist, and Pulmonologist.I
am counting at least 10 specialists, and some on a frequent basis each
year.Going to a doctor has become part
of the weekly ritual for many seniors.Just imagine the difficulty that will be forthcoming in the next decade
in receiving quality care from medical specialists.Personally, I have called the office of a
gastroenterologist each day for 3 days, have never talked to a human, left
messages, and still have not received a call back.The office message says to expect delays due
to the high volume of calls (and I live in a city, not a rural area).
Now back to the current travesty of the residency
shortage.We can see how the non-medical
person can relate to the upcoming doctor shortage.But this doctor shortage directly correlates
with the current medical residency shortage.We as a Nation have been “discarding” fully educated and qualified
doctors at the rate of 10,000 unmatched doctors per year.The AAMC keeps writing about the need to
increase the number of residency slots to prevent the loss of thousands of doctors,
but to no avail.No “one” person seems
to be taking this impending crisis seriously.It takes a minimum of 7, and up to 10 or more years, to educate and
train a doctor, especially a surgeon or medical specialist.By the time the doctor shortage is fully
realized, the “solution” will take that amount of time and more to catch up
with the deficit.We need to act now to
correct the residency shortage to prevent an impending doctor shortage in the
future!
As a fairly optimistic person, I would usually err on the
side of optimism by encouraging a doctor who did not match into a residency the
first time, to re-apply again next year.However, with all that I have deduced over the last 2 years of research
about the residency shortage, I would worry about setting up an unmatched
doctor for failure.Not matching the
first time is devastating.I actually
fear the outcomes for these doctors with subsequent failures to match.I have heard from several doctors who have
failed to match after 3 or 4 re-applications.One doctor actually sounded suicidal…This is what caused me to try to
figure out what was happening and why.
I mentioned in my BIO
that I have been on the sidelines of Medical Education for 50 years.Based on my exposure to at least 7 different
residency programs, there appears to be one Program Manager or Administrative
Assistant assigned to the task of managing residency applications at each
program.With the current situation of
the residency shortage, the fear of not matching has caused graduate doctors to
apply to an average of 47 applications each.The application process has been deluged with almost 2 million applications
per year (42,000 applicants X 47 applications = 1.974 million
applications).Depending upon the
specialty, that amounts to hundreds and thousands of applications to each residency
program, and in turn, to 1 solitary program manager!That is a lot of applications to read!The applications are lengthy as well.They include a personal statement and often 3
letters of recommendation, a dean’s letter, and other credentials.As I have mentioned in a prior blog, several
residencies in my area have received:
1,000
applications for 15 positions
900““20“
1400““12
"
Based upon these numbers, I came to the conclusion that a
computer-generated screening device had to be used to “whittle-down” the number
of applications that actually had to be read.I then realized that due to the “quantitative” screening (e.g. a STEP II
score) performed by a computer, the same applicants would be repeatedly passed
over, even though the applicants may have had additional years of training,
research, etc. This is why my normally optimistic outlook was fearful of
offering false hope to the doctors who had not matched the first time.
Part of me worried that readers would say, “How do YOU know
that is really happening?You don’t work
there…”Another part of me realized no
one would readily admit that this process was occurring.They would want to say, “We read all
applications we receive, and give fair consideration to each.”
So I contacted a residency Program Manager I know
personally, and interviewed her about their application procedures as well as
her other job responsibilities, knowing the full scope of her job would help to
generalize the process somewhat to the other residencies across the US.
She told me her program receives 500-600 applications, and that she reads each
personal statement.This is her first
level of screening.She admitted that if
their numbers of applications were greater, she would resort to a screening of
some kind.She indicated that although
there is an email network of program managers and that they communicate with
one another, that probably no one would admit to using a computer screening to
reduce the applications read for their programs.
The crush of applicants has deluged the programs with phone
messages, emails, and cold- call visits.It is useless to try to make contact with a residency to “state your
case” or get a foot in the door.The
program manager said she answers as many emails and phone calls as she can, and
lets the others go unanswered.Any
impromptu visits by applicants are not given an appointment.So your hands are tied.Your only chance is if your application made
the “cut” in the computer screening of programs with huge numbers of
applications.This is why my normally
optimistic self has become a realist…
There are at least 13 other roles the program manager
fulfills.I will name just a few, which
in themselves are quite detailed:
keep
track of 27 milestones accomplished for each resident (16 of them),
twice/yr.
organize
a week-long orientation program for new residents
maintain
independent contractor contracts for each faculty member
keep
the “on call” schedules (365 days/year)
process
physician payments based on clinic, surgery, on-call, supervision, etc.
maintain
ACGME requirements and credentials
reimburse
and make travel arrangements for faculty
set up
online recommendations system for each monthly rotation for each resident
read
apps, set interviews, arrange visits, answer emails and phone messages
etc.,
etc.
At this point you are probably thinking this is too much
information.I thought that providing
this amount of detail would lend credibility to the plight of the unmatched
doctor and their chances of successfully matching with successive
re-applications.I have tried to expose
the “dirty little secrets” of what is going on during the residency
shortage.There are 42,000 applicants
for 32,000 positions each year.This has
to be corrected!It is complete insanity
to discard fully educated and qualified doctors, especially in view of the
projected doctor shortage!
