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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What is the American Medical Association Doing? AMA

What is the American Medical Association doing?

https://www.youtube.com/watch?v=06jOdVolNF0 

            According to CME Report 3-A-16, from the Council on Medical Education, the AMA recognizes the funding and distribution of residency positions for GME (Graduate Medical Education) are “in crisis in the US and that meaningful and comprehensive reforms are urgently needed”.  This report focused only on US medical school seniors, and does not include International Medical Graduates (IMG).  Currently, 25% of practicing physicians in the US are graduates of international medical schools.(1)  Many of these are US citizens who attended international medical schools.(2)  Here are some of the points made in this report and Resolution 308 (A-16):

• “There is a predicted physician shortage of between 46,100 and 90,400 physicians by 2025” (AAMC, March 2015)
• The overall match rate for US and IMG medical students was 75.2%
• The majority of the 25% not matching are International Medical Graduates(IMG)
• There has been continuous growth of US medical schools and increased enrollment
• There has been limited growth in Graduate Medical Education (residency positions) due to caps in federal funding (The Affordable Care Act)
• The AMA “will strenuously advocate for legislation” along with the AAMC (Association of American Medical Colleges) to increase federal funding of GME
• Medical school seniors’ “fear of being a loser” have caused residency applicants to apply to an average of 47 programs to avoid not matching into a residency (up 20% in the last 5 years)
• This has forced program directors to use USMLE scores and quantitative criteria as a numeric “cutpoint” rather than perform an in-depth review of every application
• USMLE  scores alone are NOT predictors of success in residencies
• The AMA is opposed to state legislation for licensing “untrained” doctors on the basis of patient safety and quality concerns

If the AMA says the number of GME positions is in “crisis”, yet does not support state legislation for licensing unmatched doctors, how can this catastrophic deficit in residency slots be rectified before these fully educated and qualified doctors are forced to leave Medicine?  More than 40,000 doctors have not matched already in the last 5 years.

 Why isn’t the plight of unmatched international medical graduates as crucial as that of graduates of US medical schools, since 42% of IMG in 2016 were also US citizens?

 Are US medical schools better than IMGs?  Are US graduates smarter than IMG graduates?

 (1)   http://ecfmg.org/about/history.htmlhttp://ecfmg.org/about/history.html

 (2)   Report of the Council on Medical Education, CME Report 3-A-16

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Summary So Far/ Residency Shortage

Summary So Far/Residency Shortage

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

Here is a summary of the “Story” so far:

• 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

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