The Angry Doctor / Residency Shortage

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

On Feb. 22^nd I participated in a panel discussion at the World affairs Conference held in St. Petersburg, FL.  My panel covered the topic of how to make our educational systems more relevant.  My topic for the panel was about the travesty occurring in medical education with the medical residency shortage.  I quoted the statistic of 50,000 doctors not matching over just the last 5 years, at the rate of 10,000/year according to the NRMP (National Residency Matching Program).  Afterwards, a retired doctor approached me about using that statistic of 50,000, stating that it was misleading since a large percent of those were foreign doctors.  He appeared visibly angry and walked away without listening to a further explanation.  At first I felt very badly, worrying that I had “lied” or used false information.  I continued to ponder this scenario for the rest of the day, but awakened the next day with a new incite.

I now realized why some physicians I have encountered have dismissed the existence of a residency shortage, because they believe it is mostly affecting foreign doctors.  They don’t care if a foreign doctor does not match, and probably, they prefer to keep foreign doctors from practicing in the US.  My husband has told me how some foreign doctors refer patients only to doctors of their own nationality, and, probably US doctors do the same.  Just like groups of any affiliation, we want to send business to our “fraternity” of peers.

My biggest revelation came when I realized that there is an “error” in the math when we are viewing these results.  The angry doctor wanted me to focus only on the 13,982 US doctors who did not match over the last 5 years, even though those US doctors are “competing” on a scale of 50,000 total unmatched doctors for the residency positions.  Until a preference is given to US doctors with residency programs, the benchmark of unmatched doctors has to be quoted at 50,000.  To keep our math accurate, we have to subtract the number of non-citizen applicants from the ENTIRE match, if we want to look at only the results of US doctors who do not match.  That is what I believe is complicating the thinking about the residency shortage.  The US doctors who are feeling “territorial” about their work turf do not want to help any foreign doctors get residencies and work in the US.  They are not going to get too worried when they hear about a 50,000 deficit in residency slots over the last 5 years when it includes unmatched non-citizen doctors.

Now let’s talk about the perspective of the actual residency programs.  Residency programs are trying to “hire” the best candidates for their residency programs.  They are looking for the highest credentials and achievements in their applicants.  Some foreign doctor applicants have already been practicing Medicine in their own countries before applying to a US residency.  There is no dictum for US residencies to give preference to US citizens.  However, since residency programs are funded through Medicare and other governmental sources with tax dollars, US citizens should be given first priority to these residency slots.  If residencies were required to select only US citizen applicants for residency slots, then I would willingly use the quote that 13,982 US doctors had not matched over a 5 year period.  We cannot dismiss the 13,982 unmatched US doctors, because the other 36,018 unmatched doctors who did not match were foreign doctors.

 Most importantly, the US doctors are totally dependent upon a US residency to obtain a medical license in the US (technically, 1 year of post-graduate training in a US residency is required for a license).  Foreign doctors are able to practice in their native countries without a US residency.  Over the last 5 years, 18,819 NON-CITIZEN doctors matched into US residency slots. (1) Had US doctors been given priority in the matches, that number would have easily taken care of the 13,982 unmatched US doctors.  Then according to the angry doctor, there would be no residency shortage.  To include only 13,982 unmatched US doctors as the statistic would diminish the enormity of the matching challenge that exists.

I am actually grateful to this angry doctor for making me aware of another misconception about the residency shortage.  These are the misconceptions which decrease the likelihood of a timely solution to the residency crisis.

Personally, I have no ill-will toward non-citizen doctors.  What I do hold “sacred” is the “social contract” which started the day any US citizen was accepted and began medical school, namely, the right to finish all requirements for licensure.  Any residency slots remaining AFTER this “contract” has been fulfilled would be generously offered to non-citizen applicants.

1.      http://www.nrmp.org/wp-content/uploads/2018/04/Main-Match-Result-and-Data-2018.pdf, Tbl 4, p15

www.NoMatchMDs.blogspot.com

Blog Plans Going Forward / Residency Shortage

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

   My goal for the past year has been to educate the public about all the nuances of the residency shortage.  The blogs covered topics on the process of medical education, how the residency shortage began, the ramifications of the shortage, the politics of the shortage, how the same applicants are being screened over repeatedly, the misconceptions about unmatched doctors, why some physicians are unaware or ambivalent about a situation affecting their own colleagues, and possible solutions to the residency shortage. 

   My goal going forward is to spend less time writing blogs, unless an important development occurs.  To avoid “insulting” subscribers with repeat blogs, I am planning to publish new posts only on Wednesdays.  I am going to recycle previously published posts on Tuesdays, as usual.  There are still millions of potential readers who have not read these blogs.  Instead, I will be spending my time contacting legislators and people of influence about the residency shortage.  Currently, Senator Chuck Schumer is promoting Senate Bill 1301, to increase the number of residency slots by 15,000 slots over a 5 year period.  This is at least the 11^th bill submitted to Congress for this purpose.  It needs momentum to get to a vote.

   Another worker has joined me in this cause.  She is currently developing a website to compile contacts who have been affected by the residency shortage.  Originally, she was going to create a private facebook group for this purpose.  However, with the goal of maintaining individual privacy of group members, and protection of private information, the decision was made to utilize the vehicle of a website.  It would require prior approval for membership.  When the website is operational, I will publish a blog with information for enrollment.  Please pass along this information to anyone you know who may benefit.

www.NoMatchMDs.blogspot.com

Residency Shortage = Doctor Shortage

  
https://www.youtube.com/watch?v=P3a03rDfyKg

Many people cannot relate to the current situation with the residency shortage.  My local congressman asked why the unmatched doctors could not just go and apply elsewhere for a job.  The rigid system in place for educating a doctor is very unforgiving.  Without a US residency, a doctor cannot obtain a medical license in the US, period.  One thing we can all relate to however, is the results of a doctor shortage.  That is when it will really mean something to which everyone can relate.

Updating a previous blog about the “Ramifications of a Doctor Shortage”, I wanted to talk more specifically about what this doctor shortage could entail.  The AAMC (Association of American Medical Colleges) now predicts that, “By 2030 the US population under age 18 is projected to grow by only 5%, while the population aged 65 and over is projected to grow by 55%.  Because seniors have a much higher per capita consumption of health care, the demand for physicians- especially specialty physicians- is projected to increase.”(1)  Additionally, on a scale of 1-5, the US currently has a per capita number of doctors of 2.6 compared to Austria at 5.0 (2)  Sweden, Switzerland, and Germany all have about 4 doctors per capita (2).  The US even falls behind the number of doctors per capita of a 3.4 average for other developed countries.  So the US already lags behind per capita in current number of physicians, and this scenario is predicted to get even worse up to the year 2030.  The US is predicted to have a 105,000 doctor shortage. 

Let’s talk about one of the most critical areas of the projected shortage.  “A shortfall of between 33,500 and 61,800 non-primary care physicians is projected by the AAMC (includes surgical and other specialists).”  Think about the average person’s use of doctors.  For females between 0-21, we would assume girls initially go to a primary care doctor and then change to an OB-GYN doctor in the teen years.  Perhaps they would go to the doctor once/year, and sometimes even less.  As I watched my own Mother as she aged she utilized the following physicians:  Primary Care, OB-GYN, orthopedist, Otolaryngologist, Cardiologist, Dermatologist, Audiologist, Ophthalmologist, Gastroenterologist, and Pulmonologist.  I am counting at least 10 specialists, and some on a frequent basis each year.  Going to a doctor has become part of the weekly ritual for many seniors.  Just imagine the difficulty that will be forthcoming in the next decade in receiving quality care from medical specialists.  Personally, I have called the office of a gastroenterologist each day for 3 days, have never talked to a human, left messages, and still have not received a call back.  The office message says to expect delays due to the high volume of calls (and I live in a city, not a rural area). 

 Now back to the current travesty of the residency shortage.  We can see how the non-medical person can relate to the upcoming doctor shortage.  But this doctor shortage directly correlates with the current medical residency shortage.  We as a Nation have been “discarding” fully educated and qualified doctors at the rate of 10,000 unmatched doctors per year.  The AAMC keeps writing about the need to increase the number of residency slots to prevent the loss of thousands of doctors, but to no avail.  No “one” person seems to be taking this impending crisis seriously.  It takes a minimum of 7, and up to 10 or more years, to educate and train a doctor, especially a surgeon or medical specialist.  By the time the doctor shortage is fully realized, the “solution” will take that amount of time and more to catch up with the deficit.  We need to act now to correct the residency shortage to prevent an impending doctor shortage in the future!

(1)   https://aamcblack.global.ssl.fastly.net/production/media/filer_public/73/32/7332e443-2302-4daa-a56e-6937a43646ea/2017_workforce_projections_key_findings.pdf

(2)   https://www.healthsystemtracker.org/dashboard/#access-affordability

www.NoMatchMDs.blogspot.com

The Difficulty of Re-Applying to a Residency

 
https://www.youtube.com/watch?v=B_-Pjs2fl0Q

As a fairly optimistic person, I would usually err on the side of optimism by encouraging a doctor who did not match into a residency the first time, to re-apply again next year.  However, with all that I have deduced over the last 2 years of research about the residency shortage, I would worry about setting up an unmatched doctor for failure.  Not matching the first time is devastating.  I actually fear the outcomes for these doctors with subsequent failures to match.  I have heard from several doctors who have failed to match after 3 or 4 re-applications.  One doctor actually sounded suicidal…This is what caused me to try to figure out what was happening and why.

I mentioned in my BIO that I have been on the sidelines of Medical Education for 50 years.  Based on my exposure to at least 7 different residency programs, there appears to be one Program Manager or Administrative Assistant assigned to the task of managing residency applications at each program.  With the current situation of the residency shortage, the fear of not matching has caused graduate doctors to apply to an average of 47 applications each.  The application process has been deluged with almost 2 million applications per year (42,000 applicants X 47 applications = 1.974 million applications).  Depending upon the specialty, that amounts to hundreds and thousands of applications to each residency program, and in turn, to 1 solitary program manager!  That is a lot of applications to read!  The applications are lengthy as well.  They include a personal statement and often 3 letters of recommendation, a dean’s letter, and other credentials.  As I have mentioned in a prior blog, several residencies in my area have received:

• 1,000 applications for 15 positions
• 900           “             “   20    “
• 1400         “             “   12    "

Based upon these numbers, I came to the conclusion that a computer-generated screening device had to be used to “whittle-down” the number of applications that actually had to be read.  I then realized that due to the “quantitative” screening (e.g. a STEP II score) performed by a computer, the same applicants would be repeatedly passed over, even though the applicants may have had additional years of training, research, etc. This is why my normally optimistic outlook was fearful of offering false hope to the doctors who had not matched the first time. 

Part of me worried that readers would say, “How do YOU know that is really happening?  You don’t work there…”  Another part of me realized no one would readily admit that this process was occurring.  They would want to say, “We read all applications we receive, and give fair consideration to each.”

So I contacted a residency Program Manager I know personally, and interviewed her about their application procedures as well as her other job responsibilities, knowing the full scope of her job would help to generalize the process somewhat to the other residencies across the US. She told me her program receives 500-600 applications, and that she reads each personal statement.  This is her first level of screening.  She admitted that if their numbers of applications were greater, she would resort to a screening of some kind.  She indicated that although there is an email network of program managers and that they communicate with one another, that probably no one would admit to using a computer screening to reduce the applications read for their programs.

The crush of applicants has deluged the programs with phone messages, emails, and cold- call visits.  It is useless to try to make contact with a residency to “state your case” or get a foot in the door.  The program manager said she answers as many emails and phone calls as she can, and lets the others go unanswered.  Any impromptu visits by applicants are not given an appointment.  So your hands are tied.  Your only chance is if your application made the “cut” in the computer screening of programs with huge numbers of applications.  This is why my normally optimistic self has become a realist…

 There are at least 13 other roles the program manager fulfills.  I will name just a few, which in themselves are quite detailed:

• keep track of 27 milestones accomplished for each resident (16 of them), twice/yr.
• organize a week-long orientation program for new residents
• maintain independent contractor contracts for each faculty member
• keep the “on call” schedules (365 days/year)
• process physician payments based on clinic, surgery, on-call, supervision, etc.
• maintain ACGME requirements and credentials
• reimburse and make travel arrangements for faculty
• set up online recommendations system for each monthly rotation for each resident
• read apps, set interviews, arrange visits, answer emails and phone messages
• etc., etc.

At this point you are probably thinking this is too much information.  I thought that providing this amount of detail would lend credibility to the plight of the unmatched doctor and their chances of successfully matching with successive re-applications.  I have tried to expose the “dirty little secrets” of what is going on during the residency shortage.  There are 42,000 applicants for 32,000 positions each year.  This has to be corrected!  It is complete insanity to discard fully educated and qualified doctors, especially in view of the projected doctor shortage!

 

www.NoMatchMDs.blogspot.com

 

A Laissez-faire Attitude Toward the Residency Shortage

 

 

https://www.youtube.com/watch?v=mBok9I3J_r0

I want to discuss commonly held beliefs in Medicine which I believe help to create a laissez-faire approach to the solution of the Residency Shortage.  One belief deals with the assumption that highly ranked medical schools/residencies can “infuse” their graduates with a special knowledge not found elsewhere.  The other belief deals with the impression that foreign medical graduates are lesser doctors than US graduates.  International Medical Graduates (IMGs) are the group most affected by the residency shortage.  In 2017 69% of unmatched graduates were IMGs. I believe that these two assumptions promote the lackadaisical approach to a timely solution to the Residency Shortage.  If the unmatched doctors were Harvard graduates, the US would be in an uproar about the utter waste of human time, talent, money, and more doctors

 Consider this.  Assume that the US has a total of 1000 medical school openings each year, but that the schools receive a total of 5000 fully qualified applicants. 4000 applicants will be rejected.  Are we to assume that these 4000 applicants were not smart enough to gain acceptance into a US medical school?  No, there were only 1000 openings, and these positions were filled with the top candidates.  The 4000 disappointed applicants were not unqualified.  There just were not enough openings. In a similar example, the NRMP has 42,000 applicants for 32,000 residency positions each year.  10,000 graduates will not match, yet they met all of the requirements set forth by the NRMP (National Resident Matching Program).  They were fully qualified, but there were just not enough residency slots to meet the demand.

 Let us talk about highly ranked medical schools first.  According to Pauline W. Chen MD, “The notion that a medical school’s quality can be ranked and then passed on directly to their graduates has become an integral part of American culture…But most of these popular rankings reflect a school’s highly specialized research funding and capabilities, not the general quality of its medical school graduates.”(1) Dr. Fitzhugh Mullan was the lead author of a research study and paper conducted at George Washington University School of Medicine.  It included more than 60,000 graduates of America’s 141 medical schools from 1999 to 2001.  He said, “The absolute irreducible mission of medical schools is the education and graduation of doctors to care for the country as a whole.”(1) He continued with, ”The opportunity to learn from and be mentored by faculty members involved with the latest research can be stimulating for medical students, but the pressure to bring grant money into an institution can draw even the most enthusiastic educator away from students and back to the laboratory bench”(1)  According to Dr. Chen, “But educators like Dr. Mullan counter that traditional selection criteria based on cognitive exams and premedical course grades do not necessarily translate into clinical ability.”(1)   Dr. Mullan concludes with, “doctors who have done very well on everything from kindergarten to residency training in terms of getting into prestige places are assumed to have sharp intellects, but none of that correlates in any scientific way with their performance as physicians.”(1)  In essence, residency programs are selecting their residents based upon the same “cognitive exams” and highly ranked research hospital programs described by Dr. Mullan.  This is due to the inordinate number of applicants caused by the residency shortage, and the need to screen the number of applications which have to actually be “read”. 

Next let us consider the belief that IMGs are less qualified doctors, or they would have been accepted into a US medical school.  “During the 1950s, the need for a formal program of evaluation intensified due to explosive growth in the demand for health care services, an increase in economic opportunities for trained medical personnel, and a greater dependence on residents to provide medical care, which created a large number of available positions in U.S. GME (Graduate Medical Education) programs.” (2) The ECFMG (Educational Council for Foreign Medical Graduates) was created to monitor IMG credentials, and certify that IMGs have met medical education and examination requirements.  So when we as a Nation needed additional doctors and residents to provide medical care in the 1950s, we accepted IMGs into our residencies. But now that there is a residency shortage, not so much… “IMGs make up roughly 25% of physicians in training and practice in the United States.”(2)  Granted, they have not attended “highly ranked” medical schools according to “ American culture”.  BUT, they have passed all the criteria and requirements set forth by the NRMP for participation in the Match.  The IMGs have passed the same criterion tasks required of all residency programs, as their US counterparts, and passed the scrutiny of an almost 60 year old organization, the ECFMG.

In the US it is our own inflated self-regard which makes us ambivalent to the plight of the unmatched doctor.  The US is not the only producer of excellence in Medicine.  Let’s put aside our national biases towards medical education. Let’s save the fully qualified doctors who would like to complete the final step in their quest for licensure, especially in lieu of the projected doctor shortage over the next decade.

(1)   https://mobile.nytimes.com/2010/06/17/health/17chen.html
 (2)   www.ecfmg.org/about/history.html

www.NoMatchMDs.blogspot.com

About The Residency Shortage

ABOUT

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

Imagine there is a projected teacher shortage of 90,000 teachers over the next decade.  Pretend that you wanted to be a teacher and attended a teacher’s college.  You have only 1 requirement left to fulfill, STUDENT TEACHING.  Assume that in spite of the projected teacher shortage, the Education Budget is cut nationally, which results in a limited supply of student teaching positions.  Without student teaching you can’t get your teaching credential.  Imagine that over the last 5 years alone, there were more than 40,000 students unable to find a student teaching assignment. They would have had to give up on a teaching career, find another job, and begin paying their student loans.  How could such a bureaucratic slip-up occur in view of the projected upcoming teacher shortage???

Well, this is exactly what is currently happening in Medical Education!  There is a projected shortage of 90,000 doctors over the next decade.  Over 40,000 doctors in the last 5 years ALONE have been UNABLE to match into a required residency.  They cannot complete the last step required for a Medical License!  They have to leave Medicine. After being accepted into Med School, 4 years of hard work, passing board exams, and graduating with an MD Degree, they now have to look for other work and begin repaying an average of $183,000 in student loans. 

 It is a classic case of bureaucracy, where the right hand does not know what the left hand is doing.  In 1997 the Federal Government’s “Balanced Budget Act” put a freeze on Medicare reimbursement for medical residency training slots.  Yet, with a projected doctor shortage of up to 90,000 physicians in the next decade, the number of medical schools was INCREASED.  What a surprise!  The number of medical schools increased at the same time as the number of required post-graduate training slots was REDUCED!  This catastrophe has left more than 40,000 graduate doctors, over the last 5 years alone, with no where to go!!

 This blog is designed to educate the public about this travesty.  It is a call to action to those who can help rectify this ongoing catastrophe.  The voices who can help include:  State and US Legislators, State and National Medical Societies, US and Foreign medical school deans, Residency Directors, Medical students, Physicians, Public Health Departments, and finally the MEDIA
http://nomatchmds.blogspot.com/

 

Video - Second-Half Summary/ Residency Shortage