A Tsunami of Outrage/ Residency Shortage

A Tsunami of Outrage/ Residency Shortage
https://www.youtube.com/watch?v=wvXBq9P_hjw

 

   Do you remember the outrage that ensued after the 2-3 hour wait times and missed flights that occurred at O’Hare Airport the weekend of May 14, 2016?  Frustrated passengers began tweeting #IHateThe Wait.  US Senator Mark Kirk, IL, called for TSA Administrator, Peter Neffenger, to fix this problem by Memorial Day or step down.  Even the White House weighed in on this travesty. (1)  By May 25^th Mr. Neffenger told members of House Homeland Security Committee that the agency was taking measures to resolve this issue.  By May 24^th an airline official said that O’Hare’s waits were down to 15 minutes.  That took 10 days to “fix”!

 This outrage is what has to happen to solve the current travesty of the residency shortage.  There are no “normal channels” to solve this crisis.  The Federal government is moving in typical fashion, slowly.  The first legislation introduced was “Resident Physician Shortage Reduction Act of 2011.  It was proposed again in 2013, and again by Senator Bill Nelson, FL, in 2015 (S1148) and by Representative Joseph Crowley (HR 2124) in the House.  Nothing has been passed or implemented at this point.

 This bill would increase the number of residency slots by 15,000 over a 5 year period.  We already have more that 40,000 unmatched graduates right now over the last 5 years alone!  The AMA and the ACGME have not proposed any solutions.  Only a few states have created legislation (generally applicable only to their own citizens). 

 The only glimmer of hope has been the budgetary allocations some states have made.  They have offered financial incentives to hospitals to increase residency slots or add new residencies.  This has had some success.

 Why are we not as outraged as the passengers at O”Hare Airport?  These unmatched doctors have spent more that 4 years of their lives and countless dollars trying to complete their medical training.  But they are deadlocked.  If I were they, I would gladly accept a 3 HOUR security delay in view of their own situations.

 We have to get the “word out”.  We have to tweet, blog, share on facebook, contact healthcare professionals and societies, contact legislators, and yes, even the White House!

(1)http://www.zerohedge.com/news/2016-05-18

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Solve DOC Schortage State by State

Solve DOC Shortage State by State

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

Until the residency deficit has been resolved, I suggest that each state “preserve” its own doctors.  Currently, the “best numerical candidates” prevail in the residency match (see previous blogs).  That would have to change. 

The tradition of Medical Education is to “reward” the “best” students.  The students with the best GPA, the best test scores, get into the most competitive schools and residencies.  It’s hard to change that mindset.  Every institution wants to attract “the best”.  Any graduate doctor who has passed the requirements of “The Match” already is “the best”.

 I recall the tuition for medical school in South Carolina 5-10 years ago.  Tuition for in-state residents was approximately $50,000/year, and out-of-state $80,000/year.  I remember thinking that if accepted to a South Carolina medical school, a student could get their education, but South Carolina would not be underwriting any part of that cost.  South Carolina would not share in the expense of a doctor’s education, only to have the graduate leave upon graduation.

 Here are the dollars that Florida has allocated to increase the numbers of residencies in the state:

• 2013, $80 Million for recurring State and Federal funding for Graduate Medical Education (residencies)
• 2015, additional $100 Million appropriated by Florida Legislators for “Graduate Medical Education Startup Bonus Program”
• Program “Gives hospitals a one-time $100,000 Bonus for every new residency slot in shortage specialties” (1)
• The first year 66 new residency positions in seven shortage specialties qualified for the bonus” (1)
• Florida faces a shortage of 7,000 physician specialists by 2025

As described in a prior blog, Arkansas and Kansas are garnering doctors for their own states.  Their residency solutions apply only to their citizens.  Until the residency deficit is eliminated, I believe that Florida should do the same.  Florida tax dollars are providing the monetary incentives to increase the number of residencies in Florida.  So Florida residents and its unmatched doctors should benefit.  Residency selection in Florida residencies should be skewed toward residents of Florida, not using the traditional numerical ”cutpoints”.  Florida is addressing the residency shortage by allocating tax dollars to increase the number of residencies.  The State of Florida and its doctor grads should benefit from these tax dollars.  These are the doctors who plan to live, work, and stay in Florida.

(1)http://wusfnews.wusf.usf.edu/post/florida-increases-medical-residency-slots-still-faces-doctor-shortages#stream/0

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Slam Dunk? / Politics / Residency

Slam Dunk?/ Politics/Residency
https://www.youtube.com/watch?v=DZt3xeV_n00&t=2s

   Too many medical students, yet not enough residency slots.  Impending doctor shortage, yet “discarding” fully educated doctor grads.  Why isn’t the solution to this dilemma a “slam dunk”?  Because nothing is ever that simple.  There are the “politics” involved that complicate the solution to this deficit. 

                                                            (Bloom's Taxonomy) 

    Is there really going to be a physician shortage, or are the VA, The Affordable Care Act, and some states planning to utilize less expensive physician assistants and nurse practitioners to administer healthcare?   Josanne Page of the Cleveland Clinic said, “P.A.s generally make about half a physician salary or less, depending on specialty (an ER doctor makes an average $270,000, an emergency-room P.A. $112,000).” (1)

 “ And several states, such as Arizona, Maine, Maryland, Nevada, Vermont, and Washington have liberalized laws to enable nurse practitioners and PAs to perform some treatment normally done by doctors.” (2)  The Affordable Care Act has allowed millions more insured patients, with a shortfall of sufficient doctors to treat them.  Compared to other countries, the US has 2.5 practicing physicians per 1,000 people vs. 3.2 physicians per 1,000 for an average of 34 other countries. (3)

 Is a PA or NP qualified to see patients as effectively as a doctor?  A PA curriculum typically requires 1 year of classroom learning and 1 year clinical work.  A NP requires a 1-3 year program post graduate after obtaining a nursing degree.  Doctor training requires a minimum of 7 years after college.  The 3 doctors in my family had 7 years, 10 years, and 11 years of post college training.  The further depths of knowledge and medical experience afford a doctor a level of synthesis not attainable with lesser years of study. 

 A dermatologist I know recommended that a patient obtain a consult regarding a skin ailment, sometimes associated with pancreatic cancer( The patient returned to thank the doctor for the early diagnosis of pancreatic cancer which might have been missed under normal circumstances.)  Would a PA have known that correlation? 

  An OB/GYN doctor told a patient to obtain further diagnostics for continued lactation after cessation of breast feeding.  There is an association with pituitary tumors with uncharacteristic lactation.  The patient did end up having a pituitary tumor.  Would this have been noticed by a PA?  Often, a doctor never enters the room when a PA is seeing a patient.

     Ironically, PAs who by “definition” are “supervised” by a doctor, are allowed to work immediately after graduation.  A doctor with 4 years of medical school cannot work at all, until obtaining a license upon completion of a residency.  They can’t even work as a PA due to the stringent PA licensure rules!

(1) http://www.nytimes.com/2014/08/03/education/edlife/the-physician-assistant-will-see-you.html?_r=0

(2) http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/08/11/to-address-doctor-shortages-some-states-focus-on-residencies

(3)http://www.epi.umn.edu/mch/wp-content/uploads/2013/09/ACA-Overview.pdf

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Doctor Shortage / Waste

Doctor Shortage/Waste

https://www.youtube.com/watch?v=DZt3xeV_n00&t=2s

 

   Let’s talk about the upcoming doctor shortage.  Here are some statistics and projections:

• 27.6% of the current physician workforce are age 60+ years old and likely to retire in the next 10 years (1)
• 32.6% of practicing physicians are women
• 46.1% of residents are women
• “Historically women have worked fewer hours than men-a trend that continues today” (2)
• 24% of current US physician workforce are IMG (International Medical Graduates)
• 25.9% of US “ resident” workforce are IMG
• “By year 2025 the United States will face a shortage of between 61,700-94,700 physicians”. (3)
• “Thousands of baby boomers are turning 65….seniors are the population with the greatest healthcare needs”. (4)
• “The Association of American Medical Colleges (AAMC) projects there will be a shortage of between 12,500-31,100 primary care physicians in the next 10 years…equally troubling is the shortage of between 28,200-63.700 specialists.”(4)
• More than 40,000 fully qualified doctors have not matched into a residency over the last 5 years and cannot practice Medicine without residency training.
• 8,640 doctors did not match on March 17, 2016, what are they doing now?
• “With medical school and residency combined, it takes a minimum of seven years to train a doctor.” (4)

What are we thinking?!!!  In view of the upcoming doctor shortages over the next decade, we are simply “discarding” our fully educated doctors!  This just does not make sense!

(1)   page 12

https://www.aamc.org/download/452922/data/thenationsphysicianworkforceandfuturechallenges.pdf

(2)   page 13

https://www.aamc.org/download/452922/data/thenationsphysicianworkforceandfuturechallenges.pdf

(3)

https://news.aamc.org/for-the-media/article/gme-funding-doctor-shortage/

(4 )page 1

https://www.aamc.org/download/386378/data/07252014.pdf

(3)   page 2

https://www.aamc.org/download/386378/data/07252014.pdf

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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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