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

http://nomatchmds.blogspot.com/

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

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Move Unmatched Dr. Grads to the “Top of the List” /

Residency Shortage

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

As I watched an episode of “Designated Survivor” a thought came to my head.  Move unmatched doctor graduates to the “Top of the List”.  “President Kirkman” was conducting a town hall meeting with constituents and was asked by a laid off factory worker what the “President” was going to do to help him.  The answer was “…I am going to create a public works program….and anyone in the last 4 years who has lost a job, their names are going to be put at the top of the list for these jobs”. 

 These unmatched doctors are the victims of a system which “shot itself in the foot”.  It allowed too many medical school grads, but reduced the number of residency slots needed to complete the last required step of training for a license.  I have read the sagas of unmatched doctors saying, “If only I had gotten a higher Step II score, maybe I would have matched”.  It is heartbreaking to hear the self recrimination of these unmatched doctors, when they are not the ones at fault.  And to add “insult to injury”, the match process continues to “selectively ignore” the same applicants’ repeated attempts to match, by using computer generated numeric cut points to “reduce” the deluge of applications each residency program is now receiving.

These unmatched doctor grads should be moved to the “top of the list” for residencies, to prevent their permanent loss to Medicine.  It seemed so “obvious in the “Designated Survivor” episode.  That’s what is FAIR.  How can we do that?  Here are some ideas I have brainstormed:

• Utilize each and every accredited residency slot (some are left unfilled)
• Create “emergency resident slots” to already accredited programs (@ least 1 slot for each existing program)
• Create “Transitional Year Programs” with each medical school to place unmatched doctors
• Move unmatched doctors to the “top of the list” in the next year’s match.  Each residency selects 1 unmatched doctor from the previous 5 years unmatched applicants
• Place US citizens first, before any non-citizen applicants
• Offer incentive money with state funds to private hospital corporations to add residencies, as in Florida with HCA Hospitals
• Create positions at VA Hospitals for unmatched doctors to work under supervision of current VA staff doctors
• Activate/Re-Activate a “House Physician” license (as in Florida) for unmatched doctors to work under supervision of hospital staff physicians
• Expand House Physician license to County Health Clinics and VA system
• Expand NRMP to 3^rd tier match to “place” remaining unmatched doctors
• Provide malpractice umbrella coverage to allow unmatched doctors to work under licensed physicians within their office

We have to quit “blaming” the unmatched doctors for their “failings”.  They have passed ALL the CRITERIA necessary to apply through the NRMP.  They deserve a Match!
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A Win-Win for Doctors and Vets / #Save GME

https://www.youtube.com/watch?v=VZvNDuP1xlY

Most of the solutions I have described to eliminate the Residency Shortage will take time to enact.  They involve legislative changes at both the National and State levels (I have already talked about how long and hard those changes can be).  I have also described what has been passed in several States.  What most concerns me are the unmatched doctor grads TODAY.  What can we do to “preserve” them before they are forced to leave Medicine permanently?

Perhaps you recall a “mini uproar” that came out in the Washington Post in May 2016.  The article titled, “VA:  Let nurses Treat Vets”, related how “The Department of Veterans Affairs would dramatically expand the authority of nurses to treat patients…”(1)  This plan was intended to reduce long waits for medical appointments and “to ensure the VA has the authority to address staffing shortages in the future”, according to VA Undersecretary for Health Dr. David Shulkin.

 I wrote to Dr. Shulkin at that time to propose a “win-win” for both doctors and vets.  I suggested hiring the unmatched doctor grads through the VA to see patients under the supervision of the current VA medical staff (much as with the supervision provided in a residency program).  The unmatched doctors would be given meaningful work as well as further medical experience and training.  The Vets would receive timely care with reduced appointment wait times due to the increased staffing.  The doctors would apply again for residency as the number of residency slots increased.  The supply of doctors would increase to alleviate doctor staffing shortages for the VA in the future as well.

Ironically, these doctors would be “distributed” all across the US, as are the Veteran Hospitals.  This would be a quick fix to two currently existing problems, the Residency Shortage and the long appointment wait times for Vets.

I received a response from Dr. Shulkin stating that the VA does NOT have its own residency programs (although residency programs actually DO staff VA hospitals).  I responded again to Dr. Shulkin that I was aware of that fact, but was instead suggesting a temporary use of these unmatched doctors until the deficit was eliminated.  Dr. Shulkin replied, “Oh, now I understand”, but nothing more was said.  I suppose this is where the politics come in to play.  I am assuming the “greater plan” was to reduce healthcare costs for Vets by allowing nurses to provide more cost effective care (I discussed the pros/cons of nurse vs. doctor provided care in a prior blog). 

So this is one proposal I am suggesting to “preserve” the unmatched doctors in a timely fashion before it is too late, and their educations would have been for naught.  The VA could more easily create a system much like Missouri did (Assistant Physician license), because the VA system is Federally operated.  It would require only “one” new license which would apply nationwide.  The usual hurdles of individual state licensure for these “unlicensed” doctors would not be an issue.  It would save the costly and tedious process of changing each state’s licensure laws to accommodate this National “emergency”.  These doctors could work to provide quality, yet supervised care to our veterans, while under the supervision of current VA doctors.

(1)

https://www.washingtonpost.com/news/powerpost/wp/2016/05/27/to-cut-wait-times-va-wants-nurses-to-act-like-doctors-doctors-say-veterans-will-be-harmed/?utm_term=.52493662cce7

http://nomatchmds.blogspot.com/

This Is a Shout Out! / #Save GME

https://www.youtube.com/watch?v=zCy3czECcgA 

I want to hear your stories…I want the Nation to really know and feel “your pain”. That is how we relate.  We imagine ourselves in someone else’s shoes, and then the problem seems real.

If you are willing to share your story, I will gladly protect your identity.  I realize how devastating this travesty has been.  I know how you must cringe every time a friend or relative asks you where you are in your training.  The answer for an unmatched doctor is “no where”.  That answer is a real conversation stopper in any social setting.  Do you quickly answer, “I did not match into a residency because there are currently too many med school grads for the number of available residencies”?  And those around you are thinking, “Yeh, right.  You must not have been a very good student.”  This situation has nothing to do with how good a student you were.  It has everything to do with a bureaucratic “slip up”.  The slip up occurred when the Federal Government decided to save money by reducing the number of residency slots, but forgot it still needed enough residency slots to accommodate the number of graduating med students.  This situation has NOTHING to do with how “smart” the unmatched doctors are.

Please tell us about your path to becoming a doctor, its challenges, sacrifices, and “costs”.  I will edit your story to fit into a blog (I have been told that blogs have to be short to keep the reader’s attention).  I will not reveal your identity, since I know how mortifying this tragedy has been.  My email is:  leslapol727@gmail.com
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