ACGME (Accreditation Council for Graduate Medical Education)/ IMG

ACGME (Accreditation Council for Graduate Medical Education)/ IMG

https://www.youtube.com/watch?v=hL3mwmLdMZE

     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 for pre-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!

(1) http://www.healthleadersmedia.com/quality/acgme-chief-sees-huge-risk-error-proposed-assistant-physician-licensure?page=0%2C2   

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A Tale of 3 Medical Students

A Tale of 3 Medical Students 

https://www.youtube.com/watch?v=6s1_3ZTanUg

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? 

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Our "Social Contract" / NRMP

Our “Social Contract”/ NRMP

https://www.youtube.com/watch?v=0TigWx26pCc

 

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 US are 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 schools  The IMGs applying through the NRMP have met the “Criterion Task” for entry into US residencies!

(1)http://ecfmg.org/about/history.html). 
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What is the American Medical Association Doing? AMA

What is the American Medical Association doing?

https://www.youtube.com/watch?v=06jOdVolNF0 

            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
• USMLE  scores 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?

 (1)   http://ecfmg.org/about/history.htmlhttp://ecfmg.org/about/history.html

 (2)   Report of the Council on Medical Education, CME Report 3-A-16

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Summary So Far/ Residency Shortage

Summary So Far/Residency Shortage

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

Here is a summary of the “Story” so far:

• 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

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Creative Solutions, State by State

Creative Solutions, State by State

https://www.youtube.com/watch?v=1m6LwTpJZnQ

            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 enough residency slots 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??

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Snail Mail Worked! / Doctor Shortage

Snail Mail Worked! / Doctor Shortage

 https://www.youtube.com/watch?v=sUyvlc3UOBI

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!

 Why hasn’t the AMA solved this crisis?
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