The solution to the National
residency shortage is not an easy one.It involves a combination of 3 separate factors:
Medicare
funding for increased residency slots (National issue)
reduce time
required to accredit a new residency program (2-3 years)-ACGME
new State legislation
necessary to “license” these new doctor grads until the deficit in
residencies is eliminated ( Statelevel).
The good news is that the first factor is
already being addressed. Senator Bill Nelson, FL, has resubmitted House Bill HR
2124 which, if passed by Congress, would increase the number of residency slots
by 15,000 over a 5 year period. However, the bill remains yet to be passed, and
it would take 5 years to fully implement.
We have right now more than 40,000 unmatched
doctors over the last 5 years alone.What will “carry” these doctors until the supply meets up with the
demand?
The licensing dilemma of
retaining these “untrained” doctors is what remains. These licenses are written
at the State level (The State of Florida
is projected to be 7000 doctors short by the year 2025).If legislation in each of the 50 states were
enacted to “carry” these doctors until the number of residencies has increased,
it would prevent the devastating loss of more than 8000 fully educated doctors
in the US this
year alone.
There currently exists in Florida
the “House Physician” license, Fl. Statutes 458.345, which allows an unlicensed
physician to be hired directly by a hospital and work under the supervision of
a licensed physician. Since the advent of Physicians Assistants, this license
has rarely been used. This idea could be expanded to work under an individual
doctor, much like the new Missouri
statute-House Bill 1842, under what is called the “Assistant Physician”
license. In Missouri these
doctors will work under the supervision of another licensed physician and then
re-apply for residencies in subsequent years.
Most important is to “preserve”
these unmatched doctors, until the supply equals the demand for
residencies.Medicare changes and ACGME
credentialing are slow moving bureaucracies.The States will have to move swiftly to enact legislation to enable
these unmatched doctors to obtain meaningful work, and also, to prevent their
loss to the Nation when we are going to need these doctors more than ever.
I have heard some pretty sad
stories from unmatched doctors.One
doctor wrote that he had applied 4 years in a row to the Match with no
success.He was planning to give up, but
somehow my website caught his interest.
Another med student was driving my son in an
UBER car in Chicago, and was
expressing fear of not matching.My son
warned him, “All I know is you better get a good score on your Step 2 Exam!”
One unmatched doctor is working
in an indigent care clinic in Jupiter, FL and desperate to complete his
training with a residency.Finally,
another unmatched doctor is working as a research coordinator, even after
completing an unpaid year in a research fellowship after medical school.
Some doctors who are forced to
start repayment of their school loans have no choice but to obtain some kind of
work.But for what else do they qualify?(I guess they qualify to be an UBER driver)
Just imagine the
desperation these graduate doctors are experiencing, and the sense of betrayal
in a system that has broken its “promise”.Dr. Keith Frederick, a legislator from Missouri,
has coined the term “Social
Contract” to describe what has happened in the US.
When a society establishes criteria to
obtain a professional license, the candidate can assume that when the
requirements are met, the license will be forthcoming.Our “society” has prevented the completion of
the criteria, and thus has broken the “Social Contract”.
Once a student has been accepted into medical school, the
time for elimination/screening is over.
The medical graduate
should be allowed to complete all the necessary steps to licensure.What if our country educated thousands of new
teachers but failed to provide enough opportunities to complete the final
requirement of student teaching?It just
would not make sense!
Here is a breakdown of the process involved in applying for
a Medical Residency:
Completion
of an extensive online application with NRMP beginning in September
$75
Registration fee
$ 30fee for each application
Average
of 47 applications submitted by each medical student (to “ insure “ a
match)
Total
spent by each applicant for NRMP application process:$ 75 +(47 X$ 30) = $1485
Total
number of applications submitted nationally (2016):47 X(35,476) = 1,667,372
Receive
interview requests and arrange travel( Air($500?) + Hotel/Food($200?) = $700? For each interview?)
Students
and programs submit certified rank lists to NRMP in February
Notification
of unmatched students and unfilled residency programs sent 4-5 days before
“Match Day”, mid-March
SOAP
( Supplemental Offer and Acceptance Program) for unmatched
students/programs occurs
“Match
Day “ in mid March, when residency
match results are posted (2)
The
process begins again next year (Note 3)
Some
doctors have to quit!Average debt $183,000 (Note 4)
Notes
My
experience shows that generally each residency has 1 administrative
assistant who manages the application process.Their duties include the usual
correspondence associated with an educational program.However, record keeping of program
statistics is a significant component to a residency program.Records of each residents’ test scores,
program requirements, medical rotations, evaluations, numbers of each type
of surgeries performed, and strict documentation of hours worked by each
resident for program accreditation , are all part of the ongoing
record-keeping for a solitary administrative assistant.
The
cycle repeats using the same numeric screening benchmarks, essentially
“skimming the cream” from all fully
qualified applicahttp://nomatchmds.blogspot.com/nts.The
“whey” pours over into next years’ applicants, compounding the numbers and
the problem
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”.
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”.
