Summary

Medical Residency Shortage = Doctor Shortage

https://www.youtube.com/watch?v=ff-3EGBabSY&t=2s

             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”.

http://www.nrmp.org/wp-content/uploads/2017/06/Main-Match-Program-Results-2013-2017.pdf

www.NoMatchMDs.blogspot.com

Residency Match: A Case of Supply/Demand

Residency Match:  A Case of Supply/Demand

https://www.youtube.com/watch?v=j0rtf4YQYds

 

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, http://www.nrmp.org/match-data/main-residency-match-data/http://www.nrmp.org/wp-content/uploads/2016/04/Main-Match-Results-and-Data-2016.pdf

What happens to unmatched doctor grads?

http://nomatchmds.blogspot.com/

Medical Residency Moratorium

https://www.youtube.com/watch?v=AWqulmvLbME 

   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 1^st 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 2^nd 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 1^st 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 1^st 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 1^st priority to US citizens during the medical residency shortage will ensure the preservation of ALL fully qualified doctors.

(1)    http://www.nrmp.org/wp-content/uploads/2018/03/Advance-Data-Tables-2018.pdf

(2)    https://www.aamc.org/advocacy/gme/71152/gme_gme0001.html

(3)    C:\Users\lesla\OneDrive\Documents\DGME PAYMENTS and How President Reagan....pdf

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Quantitative vs. Qualitative Residency Match / NRMP

Quantitative vs. Qualitative Residency Match/NRMP

https://www.youtube.com/watch?v=WUynulWye3E&t=33s

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.18^th 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!  Blake Memorial Hospital 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”.

* Pages7-12, http://www.nrmp.org/wp-content/uploads/2016/04/Main-Match-Results-and-Data-2016.pdf
http://nomatchmds.blogspot.com/

The Angry Doctor / Residency Shortage

https://www.youtube.com/watch?v=YHbOQeSHDOY

On Feb. 22^nd 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.

1.      http://www.nrmp.org/wp-content/uploads/2018/04/Main-Match-Result-and-Data-2018.pdf, Tbl 4, p15

www.NoMatchMDs.blogspot.com

Blog Plans Going Forward / Residency Shortage

https://www.youtube.com/watch?v=akzwcPmQKGQ

   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 11^th 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.

www.NoMatchMDs.blogspot.com

Residency Shortage = Doctor Shortage

  
https://www.youtube.com/watch?v=P3a03rDfyKg

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!

(1)   https://aamcblack.global.ssl.fastly.net/production/media/filer_public/73/32/7332e443-2302-4daa-a56e-6937a43646ea/2017_workforce_projections_key_findings.pdf

(2)   https://www.healthsystemtracker.org/dashboard/#access-affordability

www.NoMatchMDs.blogspot.com