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??
There was a great revelation that
occurred during the frustrating process of trying to contact my
legislators.After no responses to my
countless emails and phone calls, I realized that doctors who are members of the
State medical association have MEDICAL PRACTICES!I googled the names and addresses of members
of both the State and National Legislative Councils for the Florida Medical
Association.My husband and I sent
letters by US mail to each of these council members.Within days my husband received phone calls
from a number of these doctors.They
were very interested in the issue of “Residency Shortage”, and quite appalled
by the current travesty.
It turns out, most physicians and
healthcare professionals, do not really know the enormity of this
situation.The ramifications for
unmatched graduate doctors unable to complete their training are
appalling.The natural consequence of
“discarding” thousands of graduated and fully qualified doctors at a time when
there is an impending doctor shortage (up to 90,000 doctors over the next
decade) is complete insanity!
This is all going on ”under the radar”. These unmatched doctors are so
mortified and despondent, they’re not broadcasting this dire situation to
friends and family.It is very humbling,
because 20 years ago and before the Balanced Budget Act of 1997, all doctor
graduates matched into a residency.The
impression is that somehow they have failed, when it is the system which has
failed them.They are not stupid, there
is a SHORTAGE!
Have you ever wondered about the
procedure to create a new State law?If
you’re like me I thought, “Go to my local legislators”.That’s exactly what I tried to do.With all the hype of running for political
offices, I thought they would be ready and waiting for a meeting with one of
their constituents.Was I wrong!I have contacted no fewer than 30 public
officials and received exactly 2 responses (written by assistants).You probably won’t get an in person meeting
with your legislator, but you might get to speak with an assistant.And, you won’t get any audience at all if you
are not part of the legislator’s electoral district.
When I finally obtained an
appointment with my State Representative, I proceeded to tell the story of the
medical residency crisis.It turns out
that Medical Education has its own traditions, and you can’t just go “apply for
another job elsewhere”.So my
representative had no clue as to the components of medical training and the
process of communicating this dilemma was an uphill challenge.After countless letters, emails, and phone
calls to legislators, members of the State Board of Medicine, the State
Executive Director of Medicine, the State Surgeon General, and yes, even the
Governor of the State, I was nowhere on my quest to create a new State law for
physician licensure!
My next step was to contact the
Florida Medical Association (FMA) where the advice was ambiguous.It turns out that in the end, the real
process begins with your county branch of the State medical association.However, after numerous phone messages and
emails to the Executive Director of our county’s medical association, I could
not believe I was getting no answer!When I finally decided to go in person to the address of record, my GPS
lead me to a PO Box at the post office!What is with this world?!No one
answers anyone!It turns out, you will
only get a “response” if you are a member of the medical association.My husband had to make the call….
So after 4 futile months of
trying to get a starting point for the creation of a new State law, here is the
ANSWER:
Contact a Delegate from your county medical
association
Convince the Delegate of the merits of a new law
If they agree, begin the drafting of a proposal to
take to the annual meeting of the State medical association.
Present the proposal to the State association and
make amendments. If the association agrees…
The State association sends the proposal via their
legislative delegates to the Health Committee of the State Legislature for
drafting into a Bill
Continue the legislative process with the Bill to
pass a new law
So, you think you have the answer
now?Not so fast!You won’t believe the politics that get
involved.Politics?Yes, politics.Life is really a “turf”war!
