The only way the residency shortage will resolve in a timely
fashion depends on YOU!I mean this
literally.There is a no “One” person
who can effect this change before countless fully qualified doctors are “lost”.It will take a groundswell of voices to bring
this travesty to the forefront of our Nation.We need YOUR VOICE.
The solution to the residency shortage will not be
linear.As you have read, some states
are creating legislation to “preserve” their unmatched doctors until the number
of residency slots catch up.Some states
are increasing their budgets to teaching hospitals to underwrite the addition
of residency slots and the beginning of new residency programs.Some states are allowing other health care
professionals to perform services once performed only by doctors.Some states are still “wallowing” in
bureaucratic doldrums.The solutions are
a “little bit of this and a little bit of that”.
In the meantime,
thousands of unmatched doctors are dealing individually with an unimaginable
“betrayal” and all that it encompasses (school loans, no career path, and
despondency).They “did” what we told
them to do, and we “broke the contract”.Ultimately, “we” will pay the price for this travesty.Right when the baby boomers tap into
healthcare the most, there will be a doctor shortage.Forget about “preventative care”.We will be lucky to get “reactive care” for
our healthcare challenges.
When the Balanced Budget Act of 1997 reduced the
reimbursement for residencies, yet increased the number of medical schools, the
resulting impact has been devastating.“We” knew this Act was not perfect at the outset, and changes would have
to be made.Little did we know the
“individual” repercussions that would ensue.
These unmatched doctors have worked so hard, for so many
years, and at such great expense, not to be able to complete the final step in
their training.The “right hand” of
Congress definitely did not know what the “left hand” was doing.We have got to make this RIGHT!
Only your voices and those of your contacts can effect the
“tsunami” needed to bring this solution to the forefront.Please write, tweet, share, and “demand” a
solution now!
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 25th
Mr. Neffenger told members of House Homeland Security Committee that the agency
was taking measures to resolve this issue.By May 24th 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”HareAirport?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!
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.
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!
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!
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 forpre-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!
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?
