Help Create the Tsunami of Outrage / Residency Shortage

https://www.youtube.com/watch?v=BOK9A7WdZvA

My last blog delineated the problems in bringing the Residency Shortage to the Nation’s attention.  No “one” person can solve this crisis, it involves too many variables:  ACGME accrediting, Medicare funding, and states legislation to “preserve” unmatched doctors.  My solution was to create a “Tsunami of Outrage” to bring the Residency Shortage to “the table”. 

This blog was first published on Jan. 31, 2017. To use “wave” terminology, it began with a “ripple” of readers.  In 5 months, the readership has increased to a small “wave”, reaching 232 readers during the first week of July.  Here are the statistics I am going to use to set a goal for dissemination and education about the Residency Shortage via the “NoMatchMDs” blog:

2017

• US Population – 321 million
• Total Professionally Active Physicians in US – 923,308
• US Congress – 535 Representatives and Senators
• Combination of  (MDs +  Congressmen = 923,843) -  about 1 million
• 200 million registered voters in US

Let’s visualize what it would take to reach a goal of 1 million readers of this blog, the total number of MDs and Legislators combined.  It is only through knowledge of the Residency Shortage that we can work toward a timely solution.  Here are my calculations.  If those 232 readers from the first week in July were to contact only 6 doctors or legislators EACH, and each of those contacts would make 6 contacts of their own, etc., etc.:

232 X 6 = 1,392

1,392 X 6 = 8,352

8,352 X 6 = 50,112

50,112 X 6 = 300,672

300,672 X 6 = 1,804,032

With only 5 cycles of contact, over 1.8 million people would have been reached with this information.  This is what it would take, 6 doctor/legislator contacts by each of 232 blog readers to theoretically contact “every” doctor and congressman in the US today…

This same story could extend to the education of the voting public.  If this process continued for 8 cycles, the total number contacted would rise to 390 million, almost twice the number of contacts than registered voters!

If you have followed this blog and find the cause of the Residency Shortage “compelling”, we cannot just let the message end with each one of us.  Knowledge without action is useless.  This “story” is too complex to explain it in “one sentence”.  The circumstances are many and varied.  Education of this travesty leading to a solution is the one and only goal of this blog.

At the end of each prior blog, I have asked the readers/listeners to contact the doctors and legislators in their local area to create action for the Residency Shortage.  Today, I am going to ask each of you to personally contact 6 doctors +/or legislators that you know.  Provide the link to this blog, “NoMatchMDs.blogspot”, and request that they in turn contact 6 more of their colleagues/legislators, etc., etc.  Tell them they can listen to this blog on their cell phones while commuting.  Just click on the YOUTUBE link with each blog.  Ask them to keep this “wave” going, with hopes that we will reach our goal of 1 million doctors + legislators.  Wouldn’t it be unbelievable if the cycle went 8 rounds and reached all 200 million registered voters??  It goes without saying that any “sharing” you may include in all your social media would be an added bonus.

So there we have it, a measurable goal.  Make 6 contacts each, ask your contacts to do the same and continue the cycle, and reach more than 1 million doctors and legislators in the US today.  Now that is a “TSUNAMI”!!

www.NoMatchMDs.blogspot.com

HCA Is at the Forefront of a Solution to the

Residency Shortage

https://www.youtube.com/watch?v=ocwML-EcVL0 

Hospital Corporation of America is leading the charge for a timely solution to the Residency Shortage nationwide.  “Nationally, HCA is one of the largest GME providers, with more than 203 programs….Currently 2,750 residents and fellows are participating and that number is expected to grow to 5,500 by 2020”.(1)  This would mean an additional 70 residency programs.  Perhaps other hospital corporations will follow HCA’s example.  The slow moving bureaucracies of Medicare Funding, the ACGME (Accreditation Council of Graduate Medical Education), and state licensure laws have precluded a timely solution in the public sector. 

Here is what is going on in Florida, where HCA says, “The physician shortage is especially critical in Florida”.  An IHS Global study found that Florida faces a shortage of about 7,000 physician specialists by 2025.  The Teaching Hospital Council and Safety Net Hospital Alliance report said, “We are not, to put it bluntly, training enough physicians….Without more physicians, Florida will have a tough time providing quality health care to our growing, aging and increasingly diverse population.”  You may recall from a prior blog that in 2015 Florida began a “GME Start-up Bonus Program” which funded $100,000 for each new residency “slot” in shortage specialties.  I would assume that HCA is taking advantage of these bonuses to help fund their new residency slots.  In Florida, HCA says,”Currently 336 residents …are training at one of our seven teaching hospitals, with plans to expand to more than 550 residents by the 2018-2019 academic year.”

The other 49 states seem to be approaching these Residency and Doctor Shortages in many different ways.  I see the private sector approach working very nicely in Florida, and would encourage other states to offer similar incentives to the hospital corporations operating in their states.  However, I would still mention that until the Residency Shortage is solved, each state give preference to its own citizen applicants for residency, as well as those unfortunate doctors who have not matched in prior years.  Upon completion of residency, many doctors opt to practice in the state of their training.  Why should a state offer incentives for new residency slots, only to have these trained doctors leave their state when finished? 

(1) HCA West Florida 2017 Community Report

www.NoMatchMDs.blogspot.com

The Human Side of the Residency Shortage/

A Personal Story

https://www.youtube.com/watch?v=WO0QvLjLy8I

Today I am going to share with you the “human” side of the Residency shortage.  It is the story of my husband’s personal journey to becoming a doctor.

I met my husband almost 50 years ago at the University of Illinois, Champaign.  When we first began to date my “husband” told me that he planned to go to medical school and would be studying very hard.  So I had been “warned”…He needed to get “A”s in his classes in order to get into medical school.  After we had been dating for awhile, I would sometimes try to “find” him between college classes to hang out.  I knew some of his favorite libraries to study, and I would try to seek him out.  Once he knew that I might look for him, he varied his study locations so he would not get tempted to quit studying if I found him.  He was truly the most dedicated student I had ever met!  I remember that during Spring final exams one semester, he studied so hard for his physics final that he scratched the corneas of his eyes.  His hard contact lenses did not move around enough to  get lubricated while he was studying.  So he was given a doctor’s note to skip the exam and told not to study any further.  During the summers he would work on his vocabulary in preparation for the MCAT exam.  He never stopped working toward the goal of acceptance into medical school.

 But, I really remember the day he received his acceptance into medical school.  It was his 21^st birthday.  His parents had called me from Chicago saying they had received his letter from the U of I Medical School and wanted to bring it to Champaign to see him open it.  They asked me not to say anything so it would be a surprise.  I held a little party at my college apartment and his parents were hiding in the bedroom.  Once the festivities began, they came out to the living room and presented their son with the letter.  We all watched him open it, and then I saw tears streaming down his cheeks….That was a momentous day in all of our lives!  It also meant another 4 years of exceedingly hard work, aiming toward the next goal, getting into a good residency program.

I would say that in the nearly 50 years my husband and I have known each other, Medicine has been at the epicenter of our lives.  It has dictated where we have lived, when, where, and how long we take vacations, etc.  My husband has always loved the Tradition of Medicine, it has a very rigid and rich protocol.  He loved the field of Medical Education and always wanted to become the director of a Residency Program, which he did.

My husband ended up taking 2 residencies and a fellowship:  Internal Medicine, Obstetrics and Gynecology, and a Gynecologic Oncology Fellowship.  That amounted to 8 years of training added to 8 years of college and medical school.

But why did I tell you this story?  I wanted you to know how traumatizing this Residency Shortage is on people just like my husband.  Just think of the devastation a fully qualified doctor graduate is feeling the day he/she finds out they did not match into a residency!  All that hard work and dedication, leading up to the last required step toward becoming a licensed physician, would have been for naught!

If you have listened to my prior blogs, you understand there is a good chance the unmatched doctors will never match into a residency in lieu of the current situation.  The extreme number of applications in today’s “Match” will favor the “cream of the crop” which has risen to the “top” numerically.  I cannot imagine the depths of despair these unmatched doctors are feeling.  I can NOT, I CAN not, I CAN NOT!

www.NoMatchMDs.BlogSpot.com

Why Isn’t the Medical Community Outraged About the Residency Shortage?

https://www.youtube.com/watch?v=_4uEAtnTJsw

Why isn’t the medical community outraged by this grave injustice, the Residency Shortage?  From what I have observed, doctors fall into 2 camps on this topic.  Physicians working in Academic Medicine at universities et al, would probably be aware of the current situation in residencies.  And those doctors in the private sector would generally not know about the shortage.  So this topic is “under the radar” for a huge percentage of practicing physicians, except for those who have completed residency in the recent past.  So why has Academic Medicine not lead the charge to correct this residency deficit, completing the last step of medical training?

There exists a tradition in Medicine that I have observed over the last 40 years.  I would compare it to a “fraternity of the Ivory Tower”.  Great reverence is shown to the leading gurus in the specialties of Medicine, the Professors.  These professors are the ones who write the textbooks used in the fields of Medicine, they are the ones conducting current research, and they are at the “cutting edge” of the most recent methods being used currently in the practice of Medicine today.  Here is how this “fraternity” operates.  The “Professor” functions in a role called, “The Attending Physician”.  Below the Attending comes the “Fellow”, a doctor specializing in the Attending’s field of Medicine.  Next, is the “Chief Resident”, followed by the third year resident (in a 4 year residency), second and first year residents, the Intern, and finally the “Medical Student”.  The lowest position in this hierarchy reports and is accountable to the person above.  During patient rounds in the hospital, questions are asked at the varying levels of difficulty and if the answer is “I don’t know”, you better find out that answer by the next day’s rounds or you will regret it!  Also, the residency schedule demands an extreme number of work hours per week.  In the last 15 years the maximum number of hours/week is 80 hours.  These hours are strictly regulated and are kept in detailed logs to prevent loss of accreditation  to a residency.  Take note, the LIMIT is 80 hours/week, twice a “normal” work week.  And unless you want disapproval from your peers who will have to take over your work load, don’t even think about taking a “sick day”!  There exists a definite work ethic and “sprit de corp” mentality that exists in this “combat like” training experience.  You better do your job or face disapproval by your peers.

Go back now to why Academic Medicine has not “lead the charge” to correct the Residency Shortage.  The traditions I described about the hierarchy of the medical education process translate into rewards and respect for excellence by your peers.  Those who excel are rewarded, and those who are lacking have to keep working.  Even though this crisis of the Residency Shortage is a result of Medicare Funding cuts by the Balanced Budget Act of 1997, the ramifications are not always clear cut.  The first instinct when a doctor does not match into a residency, is for those in Medicine to assume the doctor did not receive high scores in medical school, did not get good recommendations, or was a poor worker.  In essence, they got what they deserved.  They “just” have to re-apply next year, or have to go do some research, or work for free in an indigent care clinic to obtain some new recommendations.  This is how the “thinking” goes.  So no wonder Academic Medicine is not in an uproar!  Yet, even when they know it is a “numbers” problem, the lingering belief is that if an unmatched doctor had only been a “little bit better”, they would have matched.  It seems kind of crazy when we know there actually is a “shortage”.  But I think the traditions of Medicine’s hierarchy of learning come into play, even if only subconsciously.  So I have not observed a call to action for the Residency Shortage by the Academic Medicine community.

As CEO of ACGME (Accreditation Council for Graduate Medical Education), Thomas Nasca MD, inferred that IMGs (International Medical Graduate) were “lesser” doctor applicants.  If they were better students, they would have gotten into a US medical school.  So he does not appear to be worried about unmatched IMGs.  This feeling has influenced the stance of the AMA.  While the AMA has called for an increase in residency slots, their “position” talks mainly about US medical graduates who are less impacted by the Residency Shortage than IMGs.  In the 2017 Match, 69% of unmatched doctors were IMGs and 27.6% were US citizens.  The AMA still questions the Residency Shortage since most US grads have matched.  Perhaps, the AMA feels its responsibility is to graduates of US medical schools, although 25% of physicians practicing in the US today are IMGs.

Private practitioners I know lead exceedingly busy professional lives.  Even if they are aware of the Residency Shortage, they have little time and resources to create an outcry for a solution.  Although EVERYONE, doctor or non-doctor alike, is incredulous when they learn about the travesty of the Residency Shortage.  They view the inability to complete the last required step in training as a “blind-side”, an injustice, a travesty.

What about the unmatched doctors themselves?  They are “scattered” throughout the US.  There is no published list of unmatched applicants, to my knowledge.  Basically, the unmatched doctor is suffering their own personal devastation alone.  Other than, “someone who knows someone”, unmatched doctors are not broadcasting this news.  Ironically, they are actually still hoping they will match next time, and don’t want this “unsavory” quality disseminated.  I do not believe they realize how the deluge of applicants is affecting their chances for a subsequent match.  Not until they have re-applied 3-4 times will they start to “connect the dots”.  They are being selectively ignored by a system which cannot comfortably process the deluge of applicants, and one that does not want to select perceived “lesser candidates”.

These are the reasons I believe that have prevented the Residency Shortage from becoming a national uproar. By the time the “public” discovers this problem and the ensuing doctor shortage, it will already be too late for a timely solution.

http://ecfmg.org/about/history.html

http://www.nrmp.org/wp-content/uploads/2017/04/Main-Match-Results-and-Data-2017.pdf

www.NoMatchMDs.blogspot.com

Open Letter to the NRMP / #Residency Shortage

#The Match

https://www.youtube.com/watch?v=8RVTt8R4I1o

This letter is designed to bring the plight of the unmatched US doctor graduates to the Nation’s attention. These doctors did not obtain a medical residency due to the Residency Shortage which exists in the US, and as a result cannot practice Medicine in the US today.

The NRMP, National Residency Matching Program, which manages the medical residency selection process in the US, issued a statement which appears on an opening page of the NRMP website.  The statement was signed by Maria C. Savoia, MD, Chair and Mona M. Signer, President and CEO of the NRMP.  The Statement deals with the plight of foreign medical residency applicants from the 6 travel banned countries to the US Residency Match.  I have empathy for everyone who has invested time, energy, and money toward fulfilling their goal of becoming a physician, both citizen and non-citizen doctor graduates.  The graduates should all have the right to complete the necessary requirements.  To practice Medicine in the US requires completion of 1 post-graduate year of training at an accredited US residency.  As a Nation, we have a responsibility to address FIRST the tragedy of the Residency Shortage that has existed since the Balanced Budget Act of 1997 was passed, before dealing with placement of non-citizen applicants into US residencies.  “We” have a “Social Contract” to fulfill, the right to complete the necessary requirements for US licensure. Then we should worry about training the rest of the World….

As I read the statement, I felt an overwhelming sense of sadness and frustration that the NRMP has not issued a similar statement on behalf of the more than 50,000 unmatched doctor graduates (over the last 6 years alone).  They are unable to practice Medicine because they cannot complete the last required step of training, completion of a US residency.  42% of these graduates are US citizens.  These are the doctor applicants we should be worried about!

President Trump’s Executive Order suspends “entry into the US of certain individuals” (foreign residents of 6 travel-banned countries).  Here are the concerns expressed in the NRMP’s statement:

• “the upheaval it is causing is extensive”

Just think of the “upheaval” for a US doctor graduate who has fulfilled all requirements for residency according to the NRMP, and cannot complete the last required step to become a licensed physician in the US.

• “the affected applicants have worked hard for many years to achieve their goal of becoming a physician”

The unmatched US doctors have done the same hard work, passed the same exams,    and fulfilled the same requirements for application via the NRMP to achieve their goal of becoming a physician.

• “they should not be denied that opportunity because of a blanket policy”

The Balanced Budget Act of 1997, via Medicare funding, was a “blanket policy” that reduced medical residency funding, creating a deficit in residency slots compared to the number of medical school graduates.

• “US training programs should be able to select applicants based on their excellent character and qualifications without regard to nationality”

These same US programs should fulfill the “Social Contract” made with prospective US doctors when they were accepted into medical school, the opportunity to complete all requirements.  To practice Medicine in the US requires completion of a US residency.  US doctor graduates have “paid for” these residency slots via their tax dollars, which provides Medicare funding for residency slots.

• “The Executive Order disrupts that process very considerably”

What about the disruption that has occurred to unmatched US grads whose education is “worthless to Medicine” without a residency, whose school loans are now due, and who have no one to correct this injustice?

• “The NRMP will work with the administration and others in the graduate medical education community …being “fair” to both individuals and programs…”

I have not seen anything “fair” happen to unmatched US doctor graduates who have been “hung out to dry” on their own!  Please take a leadership role to correct this travesty in Medical Education as well.  Please issue a statement of concern to the same administration and medical educators on behalf of the unmatched doctor graduates in the US who could use a similar voice of support.  Surely, no “doctor graduate” should ever be wasted.

http://www.nrmp.org/wp-content/uploads/2017/02/NRMP-Statement-on-Immigration-Executive-Order.pdf

www.NoMatchMDs.blogspot.com

Is There “Really” A Doc Shortage?

https://www.youtube.com/watch?v=svuUeg7f56A&t=5s

Are we really going to have a doctor shortage over the next decade?  Or, could we provide more cost effective care through the utilization of NPs and PAs?  In that case, there might not really be a doctor shortage, as some believe.

I agree that greater use of NPs and PAs for follow-up and routine care would be more cost effective healthcare.  However, some patients only seek medical care on an as needed basis.  A new health problem might be their rare visit to see a doctor.  This might be a one-time chance to discover other untreated conditions, which might go “unexplored” by a PA or NP.  When I go to a doctor, I want to pay for that doctor’s “blink”, but I will discuss that idea a little later.

First, I want to discuss a theory from my teacher education days. The theory was called “Bloom’s Taxonomy” and dealt with the incremental levels of learning a student experiences with new subject matter.  To illustrate, remember when you were in high school and your teacher announced an upcoming test?  All the students would plead for a True/False exam.  I now know why.  True/False tests are at the lowest rung of learning.  The student has only to recognize the simplest level of knowledge about the material, whether the question was “True” or “False”.  The next levels up were “matching”, followed by “ fill in the blank”, and writing a complete sentence for the answers.  The highest levels on the learning curve were concept formation, synthesis, and prediction.  How does this idea relate to the projected shortage??

The amount of training required for a PA and a NP are 1-3 years post college graduation (the NP requiring a nursing degree).  The amount of education and training a doctor pursues is generally 7+ years after a college degree.  As I mentioned before, my 3 family members have trained for 7, 10, and 11 years post college. I would suggest that there is a significant difference in the knowledge level acquired in the training years between PAs/NPs and MDs.  The additional years spent in learning by an MD would allow for significant exposure to the learning levels of concept formation, synthesis, and prediction.  How can we equate 1-3 years of training with 7-10+ years of training?

Now back to the idea that when I go to the doctor I want to “pay” for that doctor’s “blink”.  In Malcolm Gladwell’s book, Blink, he defines his use of the word “blink” as “the power of thinking without thinking”(1 ).  When the years of study, experience, and familiarity come together an intuition exists much like the “adaptive unconscious”.  Mr. Gladwell describes this, “The adaptive unconscious is thought of, instead, as a kind of giant computer that quickly and quietly processes a lot of data…” (1) When I go to a doctor appointment, I want my doctor’s “computer brain” to bring forth the sum total of knowledge and experience acquired to date.

To answer the original question about whether there will be a doctor shortage in the next decade, I will say “Yes”.  NPs and PAs provide excellent, but DIFFERENT, levels of care than a doctor provides.  One degree does not replace the other.  I want MY doctors to have reached the upper echelons of “Bloom’s Taxonomy” in learning.  I want them to have had multiple exposures to a myriad of medical conditions, years of experience, and an “eye for the unseen”.

(1) http://www.course-notes.org/files/uploads/english/blink.pdf

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Ramifications of a Doctor Shortage

https://www.youtube.com/watch?v=zi2qSDB4t4o

Although some people question the legitimacy of an upcoming doctor shortage, the AAMC (American Association of Medical Colleges) does not.  The AAMC predicts a shortage of up to 105,000 doctors over the next decade.  Those who do not believe there will be a shortage propose that with more efficient healthcare management, the projected shortage would be alleviated.  I will discuss that issue in my next blog.  For today, assume there will be a doctor shortage.  What would the ramifications of that be like?

In the AAMC study of projected doctor shortages over the next decade, there is a predicted shortage of primary care doctors of up to 31,000 doctors.(1)  Ironically, because of the push for more primary care doctors, the surgical and specialty care areas of Medicine will suffer even more.  Specialty care would include Neurology, Gerontology, Urology, Psychiatry, Opthamology, and medical subspecialties.  These are all specialties well utilized by seniors. By 2030, the number of people in the US greater than 65 years old will be growing by 41%, while those less than 18 years old will be growing by 5%. (1)  When seniors will be receiving 2-3 times more healthcare, they will need the specialty areas of Medicine more than ever!  These are the specialties facing some of the greatest shortages. (1)  It takes 5-10 years to train a doctor.  If we are not proactive about our future healthcare needs today, we will all “be dead” by the time the shortfall of doctors can be replaced to meet the deficit.

The AAMC projection graphs show multiple scenarios about the potential numbers of doctors practicing over the next decade.  The graphs show how the numbers will differ depending upon current doctors retiring at age 65, plus or minus 2 years.  Here is what I am seeing in my corner of the US.  Doctors are retiring before age 65.  The requirement for electronic medical records, coupled with the advent of managed care, is causing some doctors to just quit early.  About 6 years ago, a number of doctors sold their practices to hospitals or managed care companies.  After the initial “sweetheart” income deals evaporated and the new projected lower salaries were announced, the doctors just quit practicing Medicine. They had non-compete clauses and had lost control over their own practice of Medicine.  1/3 of the currently practicing physicians in the US will be greater than 65 years old over the next decade.  So this story could repeat itself quite a bit over the next decade.

Due to the thoughtless discard of unmatched fully qualified doctors, we are “shooting ourselves in the foot”.  Our population is ageing and their healthcare needs are escalating.  Just when seniors need medical specialties the most, there will be a shortage.  What are we thinking?  I guess we are not thinking, or the Residency Shortage would have been solved yesterday!

(1)https://www.aamc.org/download/458082/data/2016_complexities_of_supply_and_demand_projections.pdf

http://nomatchmds.blogspot.com/