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
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 enoughresidencyslots 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??
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!
Have you ever wondered about the
procedure to create a new State law?If
you’re like me I thought, “Go to my local legislators”.That’s exactly what I tried to do.With all the hype of running for political
offices, I thought they would be ready and waiting for a meeting with one of
their constituents.Was I wrong!I have contacted no fewer than 30 public
officials and received exactly 2 responses (written by assistants).You probably won’t get an in person meeting
with your legislator, but you might get to speak with an assistant.And, you won’t get any audience at all if you
are not part of the legislator’s electoral district.
When I finally obtained an
appointment with my State Representative, I proceeded to tell the story of the
medical residency crisis.It turns out
that Medical Education has its own traditions, and you can’t just go “apply for
another job elsewhere”.So my
representative had no clue as to the components of medical training and the
process of communicating this dilemma was an uphill challenge.After countless letters, emails, and phone
calls to legislators, members of the State Board of Medicine, the State
Executive Director of Medicine, the State Surgeon General, and yes, even the
Governor of the State, I was nowhere on my quest to create a new State law for
physician licensure!
My next step was to contact the
Florida Medical Association (FMA) where the advice was ambiguous.It turns out that in the end, the real
process begins with your county branch of the State medical association.However, after numerous phone messages and
emails to the Executive Director of our county’s medical association, I could
not believe I was getting no answer!When I finally decided to go in person to the address of record, my GPS
lead me to a PO Box at the post office!What is with this world?!No one
answers anyone!It turns out, you will
only get a “response” if you are a member of the medical association.My husband had to make the call….
So after 4 futile months of
trying to get a starting point for the creation of a new State law, here is the
ANSWER:
Contact a Delegate from your county medical
association
Convince the Delegate of the merits of a new law
If they agree, begin the drafting of a proposal to
take to the annual meeting of the State medical association.
Present the proposal to the State association and
make amendments. If the association agrees…
The State association sends the proposal via their
legislative delegates to the Health Committee of the State Legislature for
drafting into a Bill
Continue the legislative process with the Bill to
pass a new law
So, you think you have the answer
now?Not so fast!You won’t believe the politics that get
involved.Politics?Yes, politics.Life is really a “turf”war!
The solution to the National
residency shortage is not an easy one.It involves a combination of 3 separate factors:
Medicare
funding for increased residency slots (National issue)
reduce time
required to accredit a new residency program (2-3 years)-ACGME
new State legislation
necessary to “license” these new doctor grads until the deficit in
residencies is eliminated ( Statelevel).
The good news is that the first factor is
already being addressed. Senator Bill Nelson, FL, has resubmitted House Bill HR
2124 which, if passed by Congress, would increase the number of residency slots
by 15,000 over a 5 year period. However, the bill remains yet to be passed, and
it would take 5 years to fully implement.
We have right now more than 40,000 unmatched
doctors over the last 5 years alone.What will “carry” these doctors until the supply meets up with the
demand?
The licensing dilemma of
retaining these “untrained” doctors is what remains. These licenses are written
at the State level (The State of Florida
is projected to be 7000 doctors short by the year 2025).If legislation in each of the 50 states were
enacted to “carry” these doctors until the number of residencies has increased,
it would prevent the devastating loss of more than 8000 fully educated doctors
in the US this
year alone.
There currently exists in Florida
the “House Physician” license, Fl. Statutes 458.345, which allows an unlicensed
physician to be hired directly by a hospital and work under the supervision of
a licensed physician. Since the advent of Physicians Assistants, this license
has rarely been used. This idea could be expanded to work under an individual
doctor, much like the new Missouri
statute-House Bill 1842, under what is called the “Assistant Physician”
license. In Missouri these
doctors will work under the supervision of another licensed physician and then
re-apply for residencies in subsequent years.
Most important is to “preserve”
these unmatched doctors, until the supply equals the demand for
residencies.Medicare changes and ACGME
credentialing are slow moving bureaucracies.The States will have to move swiftly to enact legislation to enable
these unmatched doctors to obtain meaningful work, and also, to prevent their
loss to the Nation when we are going to need these doctors more than ever.
I have heard some pretty sad
stories from unmatched doctors.One
doctor wrote that he had applied 4 years in a row to the Match with no
success.He was planning to give up, but
somehow my website caught his interest.
Another med student was driving my son in an
UBER car in Chicago, and was
expressing fear of not matching.My son
warned him, “All I know is you better get a good score on your Step 2 Exam!”
One unmatched doctor is working
in an indigent care clinic in Jupiter, FL and desperate to complete his
training with a residency.Finally,
another unmatched doctor is working as a research coordinator, even after
completing an unpaid year in a research fellowship after medical school.
Some doctors who are forced to
start repayment of their school loans have no choice but to obtain some kind of
work.But for what else do they qualify?(I guess they qualify to be an UBER driver)
Just imagine the
desperation these graduate doctors are experiencing, and the sense of betrayal
in a system that has broken its “promise”.Dr. Keith Frederick, a legislator from Missouri,
has coined the term “Social
Contract” to describe what has happened in the US.
When a society establishes criteria to
obtain a professional license, the candidate can assume that when the
requirements are met, the license will be forthcoming.Our “society” has prevented the completion of
the criteria, and thus has broken the “Social Contract”.
Once a student has been accepted into medical school, the
time for elimination/screening is over.
The medical graduate
should be allowed to complete all the necessary steps to licensure.What if our country educated thousands of new
teachers but failed to provide enough opportunities to complete the final
requirement of student teaching?It just
would not make sense!
Here is a breakdown of the process involved in applying for
a Medical Residency:
Completion
of an extensive online application with NRMP beginning in September
$75
Registration fee
$ 30fee for each application
Average
of 47 applications submitted by each medical student (to “ insure “ a
match)
Total
spent by each applicant for NRMP application process:$ 75 +(47 X$ 30) = $1485
Total
number of applications submitted nationally (2016):47 X(35,476) = 1,667,372
Receive
interview requests and arrange travel( Air($500?) + Hotel/Food($200?) = $700? For each interview?)
Students
and programs submit certified rank lists to NRMP in February
Notification
of unmatched students and unfilled residency programs sent 4-5 days before
“Match Day”, mid-March
SOAP
( Supplemental Offer and Acceptance Program) for unmatched
students/programs occurs
“Match
Day “ in mid March, when residency
match results are posted (2)
The
process begins again next year (Note 3)
Some
doctors have to quit!Average debt $183,000 (Note 4)
Notes
My
experience shows that generally each residency has 1 administrative
assistant who manages the application process.Their duties include the usual
correspondence associated with an educational program.However, record keeping of program
statistics is a significant component to a residency program.Records of each residents’ test scores,
program requirements, medical rotations, evaluations, numbers of each type
of surgeries performed, and strict documentation of hours worked by each
resident for program accreditation , are all part of the ongoing
record-keeping for a solitary administrative assistant.
The
cycle repeats using the same numeric screening benchmarks, essentially
“skimming the cream” from all fully
qualified applicahttp://nomatchmds.blogspot.com/nts.The
“whey” pours over into next years’ applicants, compounding the numbers and
the problem
