August 3, 2017,
someone was listening….Julio Ochoa, editor for Health News Florida,
broadcast a story about the residency shortage in Florida
on NPR Radio, WUSF.He started the story
by talking with Dr. Michael Smith, a 2014 graduate from a Caribbean
medical school, who has applied 3 years in a row for a residency in
Medicine.Each year Dr. Smith applied to
hundreds of residencies at a cost of $5,000 per year with no luck.He will re-apply for a 4th time in
2018.Dr. Smith has accrued a medical
school debt of about $350,000 to date, with the inability to work as a licensed
physician to begin repayment.To work in
the US as a
licensed physician requires a minimum 1 year post graduate training in a US
residency.In reality, the “real
minimum” number of residency years is 3 years, for the ability to become board
certified.Doctors are really considered
“employable” when they are board certified.
Mr. Ochoa broadcast this story one day before the beginning
of the Florida Medical Association annual meeting.The timing could not have been better!Apparently, most of the meeting’s attendees
did not hear this story.A proposal to
create the new license described in Mr. Ochoa’s story to preserve the unmatched
doctors, failed to gain support from the membership.They voted “no” on the proposal.The objections raised dealt with the belief
that a residency shortage does not really exist, that the doctor graduates were
too selective in their choice for residency specialties and that is why they
did not match, and that emphasis should be placed on increasing medical
education (number of residency slots) and not on creating “short-term”
licensing.Each of these objections
provides fodder for upcoming blogs.The
current situation of the residency shortage continues to wallow in the doldrums
due to these very misconceptions.
By the way, that “someone” who was listening to Mr. Ochoa’s
broadcast, offered Dr. Smith an immediate spot in a “Transitional Residency
Program”.Hopefully, this is “the foot
in the door” that Dr. Smith has long awaited!Congratulations Dr. Smith on your willingness to speak out about this
travesty of the residency shortage.It
was never YOUR fault.It was our Nation
that broke its “Social Contract”!
Please listen to Mr. Ochoa’s story for yourself.Here is the link where you will find it:
After the last presidential election, a group of
congressional staffers outlined successful strategies for making contact with
members of Congress.This information
came about as a result of the outcome of the presidential election, as a way to
keep congressional representatives aware of the feelings of their
constituents.This group of staffers has
adopted the name, “Indivisible”, to represent this cause, and to encourage
similar groups to form across the country.It is an insider’s guide to make contact with your legislators.
I want to utilize these “insider tactics” to bring the
Residency Shortage to the Nation’s attention.I am going to suggest that those who would like to find a timely end to
the residency shortage, adopt a similar strategy.Contact your own members of Congress using
the Indivisible strategies.It is only
through action that we can hope to eliminate the travesty of the residency
shortage.As I have said, there is no ONE
person who has the power to correct this situation. (That is, unless there is a
presidential order…) I will describe some of the key points derived from the
“Indivisible Guide” to create action, and then propose a more detailed plan to
implement these ideas on the upcoming Match Day, March 16, 2018.
To begin, members of Congress are concerned with
“reelection, reelection, reelection. So they want their constituents to think
well of them, and they want good, local press”.(1) The guide describes four
local advocacy tactics:
·town hall meetings
·other
local public events ·district
office visits ·coordinated calls
For the residency shortage, all four tactics
could be utilized to make contact with legislators.But for Match Day 2018 on March 16th,
I am going to focus on “local public events”, i.e. Match Day results gatherings
across the US.In my area, that
translates to the University of South Florida(USF) Match results party.It was held last year at Ulele Restaurant in
Tampa, Florida.These events occur
across the US on Match Day, when doctor graduates get the results of their
residency match.It is quite a
celebration when each graduate finds out where they will be living and working
for the next few years in their residency.The idea is to utilize media attention which will be present to
highlight this joyful event, but also to bring attention to the plight of the
unmatched doctors.There is no ill will
or rancor involved, just an opportunity to provide another side to this story.
A small group of people to “attend” and distribute
information at a Match Day results event is all it would take.There are about 180 DO and MD medical schools
in the US.Just imagine if the residency shortage story
line was generated and picked up by the Media at each one of these
locations!Email your contacts and post
a message on your Facebook page to generate a grass roots group to attend the
Match Day party near your local medical school.Record everything at those events and share these clips on Social Media,
as well as with local and national media.Optimize your visibility by staying together as a group, wear similar
clothing or message shirts, and carry signs.Identify and try to speak with reporters on the scene.
One key item described in the Indivisible Guide is that
Members of Congress, and probably the Media as well, WANT “concrete asks that
entail a verifiable action- vote for a bill, make a public statement, etc.Perhaps one example of a “concrete ask” could
be “Create an emergency placement for unmatched doctors while increasing the
number of residency slots”.You could
tailor your “concrete ask” to something pertinent to your State like, “Grant
immediate Physician Assistant licensure to unmatched doctors until the residency
deficit is eliminated”, or ”Add 2 additional residency slots/year to every
existing residency until the deficit is eliminated”.
At the onset of the NoMatchMDs.blog I stated that my goal
was to educate the public about the residency shortage.With this knowledge a solution to this
travesty could be found.As I have read,
a good salesman is really an educator who provides information, which leads the
customer to want what the salesman is selling.Then when we know better, we do better.This has been my continual focus, to educate the public.That is why I am proposing “we” use every
tool at our disposal to get this message out, even if it means “peaceful
activism”.
To help with this instruction I have created a website, a
blog, a Facebook page, and a twitter account.I have also created a brochure, a poster, stickers, and business
cards.I am happy to make all of these
WORD documents available for your use and reproduction in your own area.You can distribute the brochures at your
Match Day event, use the poster as a sign, wear the stickers, and hand out the
business cards.All you need is a small
group of supporters to join with you on March 16, Match day 2018.Please let us all know of your plans, to give
inspiration to others who are waivering.You can write a “comment” to my blog and I can share it with other
readers.The Guide also stresses the
need for a “group”, rather than 1 or 2 people.So get your friends and colleagues to join you in this important cause.
In the next blog I will be more specific about my plans to
“demonstrate” for a solution to the residency shortage on Match Day 2018, March
16th.Please let me know of
your plans, so I can encourage others to follow your example.
I will re-publish this blog several times leading up to
Match Day, hoping to enlist more “activists” to our cause.I have already had offers from my own family
members to fly to Tampa for Match
day 2018, to help form a group at USF Match Day.
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”!!
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?
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 21st 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!
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 accreditationto 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.
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.
