"Congress should update current Centers for Medicare & Medicaid Services (CMS) rules on federal matching for Medicaid GME, granting states greater freedom to strategically target the financing." The financing will just end up in someone else's pocket. When states can steal money, they do.
I agree that the US has less physicians and I agree that their proposed solution would work to quickly train/hire more physicians. However, the article failed to show a relationship between number of physicians and quality of health outcomes in countries that would prove that this is a problem worth solving.
There are also other confounders, for example, the mass entry of women into the medical education system at the same time: they tend to seek part-time employment arrangements, so it takes some 1.x 2020 doctors to replace each 1970 doctor. Women as physicians are wonderful, wouldn't have it any other way, the point is the confounder wasn't accounted for.
"Tend to seek" is too strong of wording, but "seek part time employment at a significantly higher rate" is on target.
E.g., the most recent source I can find is a 2019 survey:
> Women physicians were significantly more likely to report not working full-time than men physicians (40 of 177 [22.6%] vs 6 of 167 [3.6%]; odds ratio [OR], 7.83; 95% CI, 3.22-19.04)
That's because those data are already available elsewhere and also well known. In addition to lack of insurance, lack of access to primary care physicians means that the first time the medical systems sees a patient is in the ER. This is staggeringly inefficient. Add to this the fact that case managers are not physicians, and you wind up in a situation where there is often no one who actually has a general understanding of a patient's overall medical situation.
> the article failed to show a relationship between number of physicians and quality of health outcomes in countries that would prove that this is a problem worth solving.
Anecdotally it absolutely is. Finding an appointment for even the most basic level of care is impossible. If you’re sick, if the level of care you receive today or after a week or two is the same and the outcomes are the same, for me as a patient, it matters if I can suffer a few days less. I cannot count the number of times I’ve just had to “wait it out”. This is absolutely dangerous because sometimes, even the smallest of the things like “a sniffle” can become life threatening if not treated on time.
If you don't mind sharing, where are you living that finding a primary care appointment is impossible? During my recent battle with covid, I was able to get appointments with specialists in several fields in about 1 week or less, which I think was pretty reasonable. At the time I was living in Long Island, close to the Stony Brook University which I think makes the area a big hub for doctors.
I had a minor dislocation in my shoulder. It took me 1 month to finally see an orthopaedic doctor and a couple more weeks before I could meet a physical therapist. Guess what, my pain was nearly all gone by that point.
Only my primary care. It was a pretty major center in terms of associated doctors.
The idea that someone would have to keep calling different doctors offices to find one that would take me is just as absurd as needing to wait 1 month.
It really isn't, and Zocdoc solves this problem. Calling an office hardly takes 2 minutes; why wouldn't you shop around? By contrast your approach is "I've tried nothing and I'm all out of options".
Isn't the whole point of a primary care that a doctor chooses a 'limited' number of patients for whom they can make themselves available ?
I usually keep myself open to any doctor in my primary care location, outside the one person I see on a regular basis.
I don't see why you'd want to see a different doctor every time, if that means making sure insurances are sorted out, transferring all my media reports over to the new practice and building a new rapport with that doctor.
I went to urgent care when I had a bursitis and tendonitis two years ago. Two days later I was in with a PT. How you approach it will impact how quickly you can be seen.
I live in California. It took me 2 months of calling people to finally get someone who was accepting new patients to be my PCP within an hour commute(I had to pay for one medical membership). Getting ANY dermatologist appointment is 1 month out, getting a good dermatologist appointment was 3 months out (involved a lot of time calling them up again and again). My wife is undergoing mental health crisis, it took us two weeks of just basically calling everyone on the insurance phone book to finally get an appointment 1 week out. My PCP appointments usually take at least 1 week out at all times. When I needed a gastroenterologist for a “mystery pain” in the stomach, it took me 1 month of suffering before I could see them (if you’re dying call 911, else suffer), my CT scan appointment took a week and me constantly having to call them up to expedite it.
Basically the point being if you’re dying call 911 else wait at least a week to see someone. I as a person who has no medical degree should not be making that call. I should have access to someone who can make that call (without bankrupting myself). Even in third world countries you can see doctors the same day. It’s appalling you can’t in the greatest country in the world.
Baltimore MD, nobody I know has a PCP who they can actually see when they are sick -- like you can't get an appointment within 2 months. PCP's give you useless annual wellness checks, if you're actually sick or have another medical problem, you have to go to an Urgent Care where you see someone who is probably comptent to decide if you should go to an ER in order not to die, and that's about it.
We need a different kind of system for medical care. It has to be more like the dentist if we ever want to reduce costs on this side of the triangle. The MD should only see patients when absolutely necessary, the rest of the time a RN or CNA is completely fine. By having lower levels provide most of the care, we can change the economics and actually provide more care to people who don't get it now.
A lot of this is of our own making. Trying to get into a dermatologist for a skin condition is really hard. They are all booked up on cosmetic customers that pay more and increase profits. We want urgent cares on every corner because it is more convenient to our schedule than scheduling with our primary. All this duplication of facilities and staffing have consequences. Care from lower level staff is coming more and more rapidly, it is the only way to somewhat limit costs against the bloat on the other side. For that, we really need reference based pricing but don't forget that one person's waste is another person's salary.
> The MD should only see patients when absolutely necessary, the rest of the time a RN or CNA is completely fine
Today there are nurse practitioners with a four year undergrad in Nursing, 2-3 years of experience in hospital, and a 3 year full time masters degree (where fall and winter are spent in classroom and the summer term in the field). We are rapidly approaching the years of (relevant) schooling of an MD in family medicine...
This would be more believable position if nurse practitioners have ever been able to demonstrate equivalent medical knowledge to physicians, but when the best trained NPs were given the chance to take a watered down version of Step 3 which has a 97% MD pass rate with 1-3 weeks of casual studying, only 40% passed. The reality is an equivalent number of years does not equate the quality and rigor of the family medicine which is argueably one of the hardest specialties. This is notwithstanding the explosion of NP diploma mills with classes on lobbying and health care disparities who take any applicant with a pulse.
> but when the best trained NPs were given the chance to take a watered down version of Step 3 which has a 97% MD pass rate with 1-3 weeks of casual studying, only 40% passed.
Citation needed?
> This is notwithstanding the explosion of NP diploma mills
There's no standardization yet for NPs. I've seen short, one year programs as well as 3+ years ones. That's indeed an issue they must tackle.
I have not read the PDF report, but I agree with the title that the residency matching system in the US needs to be fixed.
My wife is a current resident in the US and she graduated from a medical school in SE Asia. She spent tens of thousands of dollars on exams, observerships (yeah, one has to pay to observe at the hospitals and there are only a handful of them that accept observers; there are a few clinics that take money for observerships), unpaid volunteering, unpaid research, and travels. All of that to make her resume stronger so that she can have a better chance at *residency lottery*. Worse, the residency spots are sometimes decided by internal contacts/introductions--just like a regular job. If one's year of graduation is higher than 5, it becomes much harder to get a residency match. Every year, we are leaving behind some perfectly qualified medical doctor candidates in the convoluted, costly and unnecessarily-restrictive system.
No wonder doctors in the US expect to make way above what doctors in other developed countries make because of the artificially tough road they have to traverse to become professional doctors in the US. This, in turn, affects (increases) the health care cost that we have to pay when we go see doctors.
In summary, it should not be that difficult to become a general (internal medicine) doctor in the US. Actually, I'd go as far as to say that it should not be that difficult to become a doctor of any specialty except a handful like (neuro/orthopedic/opthalmic/cardiac/general) surgeons. A lot of other developed countries (or countries like India, which produces very capable medical doctors) do away with residency bullshit. There must be something that the US can do to make hopeful residents' lives easier.
It also selects for being good at jumping through the arbitrary hoops of school / bureaucracy over intelligence. The results of this are apparent to anyone who has had to deal with the medical system in the US.
Maybe, but the smartest people I know all rabidly hate bureaucracy and credentialism. And if you're smart, why not go into finance / tech instead? No education requirements past college, and you can start earning good money immediately out of school. You even get a decent work life balance in the case of tech.
Because, as difficult to believe as it may be to some people, some people are not all about money since the beginning. Some remain idealistic well into their thirties and earn a medical degree.
Once you've got it though... that's when it starts to be difficult to stay idealistic and optimistic.
They probably should significantly be about the money considering they will likely be entering their 30s with a few hundred thousand dollars of debt.
Staring down the barrel of spending your 20s doing arduous, stressful work while your friends have fun, passing prime relationship building years, entering into final childbearing years...not much room for idealism once reality hits.
I know a few med people and a big one for them is risk aversion. Medicine never has a recession. There will never be a glut of doctors. You don’t need to job hunt every 2 years.
From the perspective of a US MD Medical Student. While the match system is certainly imperfect the numbers and points the report makes are either misleading or downright wrong.
First, the match rates they reference are pre-soap numbers. In reality, the majority (~99%) of US trained medical students do match somewhere.
Second, there are more positions (~38,000) than there are MD graduates (~32,000). Most of these positions are in primary care (Pediatrics, Internal Medicine, Family Medicine) (~17000).
Third, most of the unmatched physicians in this country are either US citizens who had to train internationally or foreign citizens who are attempting to gain US certifications.
From my perspective the issues with the match system are below:
1. Application Fever. The average applicant applies to 50-80 programs (depending on specialty) to guarantee matching.
2. Useful work hours. Many residents work 60-80 hours a week with much of this work being scut work rather than useful learning.
3. Low salary and benefits relative to training. Residency salaries are between 50k-70k annual which can be extremely difficult for families living in NYC or SF.
4. Inability to quit or switch programs. Many residents also don't have too much choice in residency location. In Washington State for example the residency positions available are extremely limited.
As a foreign medical grad, I agree 100%. Many people who are not med grads unfortunately do have completely skewed views of both our education and practice and are often thoroughly convinced to know everything about us. Strong opinions strongly held.
Many people who receive health care in the US have strong opinions that it is broken. That is, it is expensive compared to other industrialized countries. It requires sick people to own their health journey in a way other countries would find absurd. The experience of being at a doctor for anything but a basic malady is immensely frustrating.
So, there's a definite problem compared to other industrialized countries. And it seems like the supply is artificially constricted which exacerbates the problem.
From there, it's speculation. But which part of the above is missing evidence?
He said views are skewed, not lacking evidence. Your polemic perhaps demonstrates this. However, opinions that the system is broken may also be lacking evidence. US healthcare ranks highly for outcomes that typically frighten patients. US healthcare also ranks highly by satisfaction, though it also ranks highly for pessimistic outlook. These kinds of statistics may map to what the doctors in this thread are reporting.
> It does. The AMA decides how many residency spots there is.
Nope. This is a common misconception.
The AAMC (which is different from the AMA) determines the number of people who can graduate from medical school each year, but as pointed out in the original article, the bottleneck is in the number of residency slots. There are already more medical school graduates than there are slots to receive them; increasing the number of medical school graduates wouldn't result in more practicing physicians.
> Then who decides how many residency spots are available?
Well... Congress, essentially, by determining how much funding Medicare gets, a portion of which is allocated to funding residency programs.
Contrary to popular belief, residency programs are by and large not money-making operations (or even self-sustaining ones). If they were, hospitals would expand them! But because they lose money, the government has to subsidize them in order to encourage hospitals to run them at their current levels.
I've heard this simple explanation many times and it never makes sense. Review the EOB (Explanation of Benefits) after going to a hospital and getting examined by a resident, the bill is ~250$ for the 5min visit. Assume there is some work behind the scenes (writing scripts, reviewing charts) and one might think ~10min. That is effectively a million+ revenue center for the hospital for a resident making sub six figures, even considering 50% or more in charge-offs.
Why would the hospital restrict residency spots because of funding? Residents are wildly profitable, so that wouldnt make sense.
The explanation I'm told makes sense is this: US medical boards are unwilling to train more doctors because that would increase supply and reduce overall MD earnings. So they have a small number of openings each year, and blame the "shortage" on Congress.
> The explanation I'm told makes sense is this: US medical boards are unwilling to train more doctors because that would increase supply and reduce overall MD earnings. So they have a small number of openings each year,
That "explanation" might be plausible if "medical boards" were in control of the size of residency programs or hospitals' decisions to run them. Except, they're not.
> Why would the hospital restrict residency spots because of funding? Residents are wildly profitable, so that wouldnt make sense.
This is an example of a logical fallacy known as begging the question[0]. You are assuming that "residents are wildly profitable", and then trying to use that to disprove the statement that "residency programs are not profitable".
A better way to reason about this is by contradiction. Assume that hospitals are greedy and avaricious profit-seeking entities who will do anything that increases their bottom line. If residency programs were profitable, these greedy profit-seeking entities would open them (the hospitals that don't currently run programs) or expand them (the hospitals that do). Except, they choose not to. That provides a contradiction between the logical conclusion of the assumptions and actual reality.
It's much simpler to resolve that contradiction by rejecting the premise "residency programs are profitable" than by resorting to contorted explanations that hinge on objectively counterfactual assumptions (such as "medical boards control residency programs' decisions", which is objectively incorrect).
(Your explanation also falls flat when you realize that your logic actually provides US doctors and medical boards with a strong incentive to increase the number of medical school slots, because that would actually preserve earnings for domestic doctors. But that's a subtler point, and the topic at hand is residency programs.)
> If residency programs were profitable, these greedy profit-seeking entities would open them (the hospitals that don't currently run programs) or expand them (the hospitals that do). Except, they choose not to. That provides a contradiction between the logical conclusion of the assumptions and actual reality.
This seems to be the logical fallacy. Hospitals neither get to confer medical degrees nor award board certifications. They cannot just magically create residents out of thin air, they are restricted by supply. No amount of Matrix Architect speak makes them do so.
> This seems to be the logical fallacy. Hospitals neither get to confer medical degrees nor award board certifications. They cannot just magically create residents out of thin air, they are restricted by supply. No amount of Matrix Architect speak makes them do so.
You seem confused about the question at hand. As has been explained multiple times, including in the original article, there are more medical degrees granted every year than there are residency slots available at hospitals.
The whole question is why hospitals don't take advantage of the excess supply of of medical graduates by creating more residency positions.
Partly true. It's because my wife is an international medical graduate (IMG), so she had to do a lot more work than local (US) grads to show that she is qualified. Having said that, the local grads don't have it easier if you read the comments in this post. I have a few US friends who were pre-meds and are now professional doctors. I know that they had to put a lot of effort to signal to the programs (e.g., research publications, volunteering at big-name clinics/hospitals, etc.) that they are worthy of the residency training (at competitive programs of course).
While I agree with you in principle, I'd like to point out that it's a falasy to believe one specialty is more difficult than another (I'm and anesthesiologist).
What I meant was that for specialties that require more hands-on, emergency (life or death situation) practice such as cardiac/neuro/ortho surgeons (including anesthesiologists because they are part of the surgical teams), we should not allow anyone to easily get licenses (I will not be the judge of whether the current amount of training required for these specialists is enough or not to folks with better knowledge).
Most of all, I believe that we can train capable internal medicine/primary care doctors in just 5-6 years instead of 8+3 years that is required now.
'Hands-off' specialists (oncology, immunology etc.) need as much training and practice as a surgeon does. Internal medicine especially so, since they're the hospital's backbone. You break them, you break everyone else. The difference is in the education period: if you're in a 'hands-on' specialty, your level will be very dependent on the quality of your program. For more theoretical specialties, you are the main determinant of your final level. Anesthesiologist here, FWIW.
Regardless of the validity of the primary thesis (that there's a bottleneck in physician education, especially residency), I think the perspective in this is too narrow. There isn't just a bottleneck in physician education, there's a bottleneck in medical training in general, due to dated conceptions of professional identity and necessary training.
The entire system is broken in my opinion. Service provision should be more skills-focused, and less degree-focused, and deregulated to allow more competition in the types of services and professional identities that exist.
Currently in the US, access to care is too restricted or difficult. The response "let's open the floodgates to more physicians" is one response, but another response is "yes, do that, but let citizens receive care under different kinds of training models." Right now the assumption is RN -> LPN and MD->specialty->subspecialty, maybe with PA->specialty training, but there's many other forms of care from other types of providers that could exist. Pharmacists and psychologists are one example, where you might have specialized training -> broader training, or specialized training -> augmented skill set. There's also undoubtedly many other types of providers we can't even imagine now because the certification regulations are so strict; I also suspect a lot of care could be opened up to the general public on their own (many refills, for example, probably don't need repeat visits).
My sense is this is just the tip of the iceberg when it comes to medical certification overregulation.
The problem with direct specialty programs is the "you only have a hammer" problem. It moves the onus of diagnosis to the individual seeking care rather than the provider of care. This is likely somewhat the case already, but such approaches would start to formalize it.
There is a middle ground where we address the bottlenecks in the current medical professional pipeline by deregulating the number of licenses issued per year and sponsor the creation of new medical schools to educate more professionals at lower cost.
I agree with the "only have a hammer" problem but that already exists, and in a formal way vis-a-vis specialty boundaries. E.g., if you go see a neurologist, they're likely to see things through a neurology lens regardless of generalist training because of time in specialty and incentives. The legal consequences sort of keep it in check.
I also think to some extent it exists in the other direction as well, in terms of generalists not always recognizing when something needs to be referred to a more specialized setting.
It's largely addressed via training and consequences. And in any event, there's always the issue of "why not broaden training instead of assuming it always narrows?"
Training will only broaden when there is economic incentive for it - from a practical perspective a neurologist isn’t going to learn general practice after they make 500k per year as a neurologist in order to have an opportunity to make 150k per year.
This is problematic if we expect neurologists to be good well rounded doctors, but not if we just expect them to be good neurologists. I don’t expect my dentist to be able to deal with a heart murmur.
>The entire system is broken in my opinion. Service provision should be more skills-focused, and less degree-focused, and deregulated to allow more competition in the types of services and professional identities that exist.
In a country with a medical system that is already too profit-minded and with a population that is growingly anti-expert, this has the potential to go catastrophically wrong. We don't need to make it easier for people to sell horse paste and essential oils as miracle cures. So while reform may be needed, we would also need to be mindful that making it easier to provide medical services will also empower people with misaligned motives to take advantage of people.
What they should do is scrap the current system. Students should be able to enter med school straight out of HS. This is how it's done in Europe and their doctors are just as good as ours. The existing residency system should also be torn down. It is so exploitative that it had to be given a specific exemption from anti-trust laws to even be legal. Residents should instead be licensed as a junior level of doctor similar to a resident, but not locked into a single hospital. This way they can move around between hospitals which will have to compete over them on pay / benefits and work life balance. There should also be programs to allow lower level medical staff like nurses and physicians assistants to advance to doctor without having to lose 4 years income and spend a fortune on medical school.
> Students should be able to enter med school straight out of HS. This is how it's done in Europe
I had no idea about this, but it seems brilliant. Immediately immersing them in medicine instead of all the non-medical education you would be forced to complete(and pay for) in the US sounds like a win.
I don't know if I would go that far. University education usually involves a ton of general-education classes for the first two years: English, science, history, math, basic science, etc. High school quality is quite uneven in the US, so these classes are largely necessary, imho.
Also, that's not to mention the many "pre-med" classes that medical schools require for applicants. Are high school kids going to take the organic chemistry, biochem, etc. necessary for med school?
Topics build on each other. The average working engineer designing circuit boards isn’t calculating the nth derivative of a function on a daily basis.
That doesn’t mean that they didn’t need to understand calculus as a prerequisite to other classes where they did learn skills they use frequently.
MDs also aren’t technicians, they are a self regulating group of professionals with a high degree of legally protected autonomy and authority. Individually they make life or death decisions more frequently than anyone else. And as a group they make up regulatory bodies that impact everyone’s medical care. Like lawyers they have a very disproportionate impact on society. I think some amount of general education and general science background is appropriate.
1. Med school is a lot more expensive than undergraduate education.
2. Making a decent grade in those classes at an accredited school is a good filter.
3. MDs aren’t just technicians. They are leaders, managers, and ethicists. They have a higher level of legally protected autonomy than nearly any other profession. Given that, I think that 2 years of general education is appropriate. For the same reasons I think general education is appropriate for other professions with a high degree of autonomy, authority, and impact, e.g., civil engineers, lawyers, and teachers (all the teachers reading this are laughing at the autonomy part).
> Are high school kids going to take the organic chemistry, biochem, etc. necessary for med school?
Due to the competitiveness of getting a place on a medicine course, it's pretty much impossible to get into a medicine degree here in the UK without having taken Physics, Chemistry and Biology at A-level, and maybe maths too. So... yes.
Note also: medical degrees are longer than other degrees in Europe (5 years instead of the standard 3 here in the UK). But you go directly into a specialised medicine course. I think you can do a graduate medicine degree in 4 years if you have an undergraduate degree in a related field, but that's relatively uncommon.
It's not just any degree, though. In addition to that, there is a set of classes that you have to complete (each med school has their own requirements, but practically speaking, they're roughly the same: http://www.georgetowncollege.edu/four-year-plan-medical-scho...).
So, sure, you can enter med school with a BA in English, but you still have to have taken undergraduate level organic chemistry.
Practically speaking, that means at each school there's 1 or 2 majors that will hit the typical premed requirements in the course of completing the undergraduate degree and a handful of other majors where a minor or even less than that will allow you to complete the premed requirements.
But all that said, yeah, they engage in blatant credentialism because they use it as a way to filter students out, because there's a much smaller supply of available medical school positions than there is demand for medical school positions. It's so blatant that it's usually better to go to a school with grade inflation or a less rigorous school where you know you can max out the GPA, than to go to the toughest undergraduate school you can because admissions doesn't do a great job of leveling different schools, so a 4.0 from University of Grade Inflation can still beat out a 3.5 from a more-renowned university.
There’s no good reason for those prerequisites to be shoehorned into a random bachelor’s degree. Medical schools can add another year or eighteen months and teach their students those subjects themselves.
It's usually not a random degree. Usually it's like biology or molecular and cellular biology or maybe biochemistry or something like that, where the major itself is applicable to more than just medical school, it just happens to perfectly or nearly so overlap with medical school requirements.
An MD post-secondary degree is like 6 years, right? An undergrad and MD in the US is 8 years, so the difference isn't that much. That's basically just the general education requirements for an undergraduate degree, which as far as I can understand is just a general difference of the US vs european systems. US bachelors include a generality component absent in European degrees so the typical US undergrad takes a year or so longer than the typical European undergraduate degree.
From what I hear, Pre Med is the USA is a joke. All it really does is prepare you for the MCAT, and even does that poorly. So all undergrad just becomes a waiting room.
I went to high school with a ton of now doctors. My college degree is unrelated to programming, and I have built a career from the bottom up in web dev. I would say I’m fairly far along, have reached a senior IC level, and make good money.
My doctor friends are still not fully through training, and are just beginning to start their adult lives. It’s a disservice that some of my most intelligent friends had to waste 4 years on nothing and delay their professional and personal growth. No wonder less and less US citizens want to pursue medical careers.
Interest in becoming a physician has only increased in the last 10 years, especially over the last 3. Besides lots of nonphysician providers want the prestige of becoming an MD/DO without committing to it and the care they provide is suspect. I think there needs to be a certain amount of gate keeping (not to the point of salary inflation) to ensure those in this position of power to make healthcare decisions for patients, are willing to go through the hoops as opposed to looking for shortcuts.
I still use the knowledge I acquired as a pre-med in my practice and wouldn't trade that for the time saved. The bigger issue is the abusive indentured servitude and the limitless bureaucracy which deters good candidates away (rightly so)
This report highlights a big part of the problem in supplying physicians in the US. The issues with funding are captured well, as are the issues with the unmatched, that is medical school graduates who cannot secure a position and continue their training.
However, there are some important aspects of the modern residency system that are not captured well, that do contribute to the pipeline bottlenecks.
One major issue surrounds the UME - GME split, that is undergraduate medical education (that is medical students) vs. graduate medical education (that is residents). As a medical student now, one of the most striking comments is how our professors, especially those who are older, comment on how much they did during medical school. Right now, medical students learn under such close supervision most of the experience is shadowing-based, i.e. watching attending physicians, resident physicians, and midlevel providers. This means that on graduation as MDs, new interns have very limited experience in managing patients.
In turn, that makes intern year critical in training physicians. However, much of what is learned in intern year is often a retrenchment of what should have been covered in medical school by accreditation standards. The concerns about medical students graduating without a full set of the expected competencies have lead to the development of the Core Entrustable Professional Activities (EPAs), to create a framework by which students graduate with documented competency in each area.
Unfortunately, initial experiences with the EPAs have been mixed. This summer, an academic article reviewing schools experiences implementing the EPAs revealed that while most EPAs were being adopted well, some of the Core EPAs, specifically involving basic procedural competence (think drawing blood, starting IVs, basic bedside procedures), were considered more appropriate for GME [1], which adds to the GME curriculum in residency.
Given that the 4th year of medical school for most students consists of "elective time" and time off to interview for residency, shifting training from medical school to residency only adds to stress on the pipeline. For example, why should internal medicine residency be 3 years long? If graduates were documented as more competent on graduation, would a two year residency for primary care or prior to specialized subspecialty training be sufficient? In my experience working with residents at my medical school, 3rd year residents are in supervisory positions, dealing with less patient care than first and second year residents, the rest of their time seems to be consumed with applying for fellowship and studying for their Board certifications.
Of course, some of the dilution of undergraduate medical education comes as a result of defensive medicine, scope creep from midlevel providers, and excessive regulatory requirements. (Just look at all of the regulatory burden and turmoil around how attending physicians can attest medical student notes for CMS billing purposes. If anyone wants a migraine, I invite them to look into it.) Additionally, other causes of the dilution comes from the growth in US IMGs, mostly from the Caribbean medical schools. Those schools often pay to place students at US non-academic (often for-profit) hospitals that are less interested in the educational mission as they are in easy money from precepting students. In those cases, those students often have extremely circumscribed roles in the clinic, largely due to the institutional lack of emphasis and commitment to teaching [2].
Fixing the pipeline will require creating more residency positions, but it will also likely require changes all along the pipeline, such as making UME more meaningful and graduating MDs (or DOs) who are more ready for residency on Day 1, and then a serious look at residency length to ensure that GME experiences are meaningful and not simply "cheap labor [3]."
This loses sight of the lack of incentive missing from hospitals and even residency programs from funding their own positions. There’s literally no regulation preventing a program from funding their own without Medicare dollars. They just need ACGME to sign off on it.
Turns out if you hand out free money for minimum wage employees that rely on your training to not kill people, there’s very little incentive to pay out of pocket. Especially so when programs realize that their trainees will just work harder/longer for the same pay without much complaining.
I also think there’s a method to the madness of training program length and number of spots (namely, ensuring you have enough exposure to the common things/uncommon things you will encounter on your own to be competent), but I agree more scrutiny would weed out inefficiencies in the training process. But like, there’s an obvious reason neurosurgery residencies don’t take that many trainees every year, not just to create artificial scarcity.
On the financial side, we have to also look at opportunity cost and loan sizes. Why should I spend over 8 years post secondary and over $250k to become a doctor?
The match is insane because residents have zero negotiating power. They tried to sue over this but Congress decided that it should be illegal to sue over this
This is done by design. Constraining the supply while demand steadily increases is a recipe for increasing the salaries and the prestige of being a doctor.
What's the medical equivalent of 'code schools'? There isn't any because you can't practice medicine without a license in the United States.
The answer, as much as there is one, is PA schools. 2-2.5 year programs, overwhelmingly attended by women, after which you make solidly middle class money and do almost all the work people demand to see doctors for.
Physician salaries have been declining. The extra profit has been steadily taken by insurance companies, administration, pharma, and device manufacturers.
Residency acceptance is restricted by demand, not the other way around.
GP, or PCP, salaries are down. Pushing new entrants with huge loans into specializations, which pay better. So you have a huge demand at the basic level and a limited supply since fewer doctors want to do general practice. The market should take care of this, but you have the monopsony of insurers controlling reimbursement.
In Europe a doctor cannot be sued out of their livelihood, but US doctors are open to that after spending most of their youth (and into their 30s) training for the job with miserable work conditions and pay, and at exorbitant personal financial costs. The cost of the ability to sue doctors trickles everywhere through the training process, insurance, daily documentation, increased testing, and decreased training spots. In surgery for example, every resident has to hunt for opportunities to practice each procedure and fill their portfolio of required skills over time. If they don't the opportunities to do that after going into practice are far more limited. Existing doctors also need to maintain skill levels, or lose them - so the flow of cases in each discipline determines how many good practicing doctors you can have in that discipline. If you dilute the talent pool with the same number of annual cases available, you get many many more bad doctors. A Whipple surgery, for example is one of the longest and most complicated procedures in Surgery. Per studies, you don't want to be operated on by a Surgeon who has less than 15 Whipples per year under their belt. The hard part is not increasing the slots, but increasing the quality of training and existing talent pool when you have more people competing to learn from fewer procedures.
12 hrs is nothing. In many places the shifts are 24 hrs. In surgery residency, most only get to scrub in after they've done all of their admin work - so many deliberately push their hours to get more of what they need the most - OR time.
> Residents work 12+ hour days six to thirteen days in a row. Sometimes the days are longer.
... for absolutely no results.
Spend any time on a busy hospital ward, and you'll see overworked residents trying to one up one another in an attempt to impress whoever is in charge. "I've slept the least hours, therefore without me this floor would collapse". It's institutionalized hazing and cargo culting, nothing more.
A real innovation would be to open US funded and US led medical training centers in developing countries where you expand the healthcare options to the local population. That way more doctors can be trained by the high US standard of care, on more available cases, while more people get better care. If you want to be able to afford that financially, you need waivers on liability for the care provided. Smaller countries with high standards of care are already inverse examples of that - something along the lines of 80% of healthcare professionals trained in Bulgaria leave the country for better pay elsewhere.
the US can't fund their own healthcare i doubt they'll fund it elsewhere. and unfortunately there is rarely appetite for solving healthcare problems that are affecting mainly developing countries.
When the world, and especially the US, will finally realize that MD pay is the minor problem and that the insane amount of bureaucracy, administrative staff and legal experts that surround MDs are the real issue, we'll finally be able to improve things. Right now, admins and legal dictate how to do my job and order me around. That's the problem right there: corporate culture. Which should not be a thing in healthcare.
The system is working as intended, which is to restrict the supply of physicians and thereby increase their salaries.
The pipeline is also restricted upstream by the limited enrollments at med schools (drastically lower than the number of qualified pre-med students) and downstream by restrictions on what other medical professionals such as NPs and PAs can do.
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[ 2.9 ms ] story [ 71.7 ms ] threadDo you have a source for that?
E.g., the most recent source I can find is a 2019 survey:
> Women physicians were significantly more likely to report not working full-time than men physicians (40 of 177 [22.6%] vs 6 of 167 [3.6%]; odds ratio [OR], 7.83; 95% CI, 3.22-19.04)
https://jamanetwork.com/journals/jamanetworkopen/fullarticle...
Anecdotally it absolutely is. Finding an appointment for even the most basic level of care is impossible. If you’re sick, if the level of care you receive today or after a week or two is the same and the outcomes are the same, for me as a patient, it matters if I can suffer a few days less. I cannot count the number of times I’ve just had to “wait it out”. This is absolutely dangerous because sometimes, even the smallest of the things like “a sniffle” can become life threatening if not treated on time.
This is in Boston, one of the US medical meccas.
The idea that someone would have to keep calling different doctors offices to find one that would take me is just as absurd as needing to wait 1 month.
I usually keep myself open to any doctor in my primary care location, outside the one person I see on a regular basis.
I don't see why you'd want to see a different doctor every time, if that means making sure insurances are sorted out, transferring all my media reports over to the new practice and building a new rapport with that doctor.
Basically the point being if you’re dying call 911 else wait at least a week to see someone. I as a person who has no medical degree should not be making that call. I should have access to someone who can make that call (without bankrupting myself). Even in third world countries you can see doctors the same day. It’s appalling you can’t in the greatest country in the world.
A lot of this is of our own making. Trying to get into a dermatologist for a skin condition is really hard. They are all booked up on cosmetic customers that pay more and increase profits. We want urgent cares on every corner because it is more convenient to our schedule than scheduling with our primary. All this duplication of facilities and staffing have consequences. Care from lower level staff is coming more and more rapidly, it is the only way to somewhat limit costs against the bloat on the other side. For that, we really need reference based pricing but don't forget that one person's waste is another person's salary.
Today there are nurse practitioners with a four year undergrad in Nursing, 2-3 years of experience in hospital, and a 3 year full time masters degree (where fall and winter are spent in classroom and the summer term in the field). We are rapidly approaching the years of (relevant) schooling of an MD in family medicine...
Citation needed?
> This is notwithstanding the explosion of NP diploma mills
There's no standardization yet for NPs. I've seen short, one year programs as well as 3+ years ones. That's indeed an issue they must tackle.
My wife is a current resident in the US and she graduated from a medical school in SE Asia. She spent tens of thousands of dollars on exams, observerships (yeah, one has to pay to observe at the hospitals and there are only a handful of them that accept observers; there are a few clinics that take money for observerships), unpaid volunteering, unpaid research, and travels. All of that to make her resume stronger so that she can have a better chance at *residency lottery*. Worse, the residency spots are sometimes decided by internal contacts/introductions--just like a regular job. If one's year of graduation is higher than 5, it becomes much harder to get a residency match. Every year, we are leaving behind some perfectly qualified medical doctor candidates in the convoluted, costly and unnecessarily-restrictive system.
No wonder doctors in the US expect to make way above what doctors in other developed countries make because of the artificially tough road they have to traverse to become professional doctors in the US. This, in turn, affects (increases) the health care cost that we have to pay when we go see doctors.
In summary, it should not be that difficult to become a general (internal medicine) doctor in the US. Actually, I'd go as far as to say that it should not be that difficult to become a doctor of any specialty except a handful like (neuro/orthopedic/opthalmic/cardiac/general) surgeons. A lot of other developed countries (or countries like India, which produces very capable medical doctors) do away with residency bullshit. There must be something that the US can do to make hopeful residents' lives easier.
Once you've got it though... that's when it starts to be difficult to stay idealistic and optimistic.
Staring down the barrel of spending your 20s doing arduous, stressful work while your friends have fun, passing prime relationship building years, entering into final childbearing years...not much room for idealism once reality hits.
No formal ones. But you better keep up.
I know a few med people and a big one for them is risk aversion. Medicine never has a recession. There will never be a glut of doctors. You don’t need to job hunt every 2 years.
leetcode. gotta keep up even if you're 15 years deep in the tech industry
First, the match rates they reference are pre-soap numbers. In reality, the majority (~99%) of US trained medical students do match somewhere.
Second, there are more positions (~38,000) than there are MD graduates (~32,000). Most of these positions are in primary care (Pediatrics, Internal Medicine, Family Medicine) (~17000).
Third, most of the unmatched physicians in this country are either US citizens who had to train internationally or foreign citizens who are attempting to gain US certifications.
Lastly, NRMP is actually extremely transparent with match data; this reference backs up my claims: https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/...
From my perspective the issues with the match system are below: 1. Application Fever. The average applicant applies to 50-80 programs (depending on specialty) to guarantee matching. 2. Useful work hours. Many residents work 60-80 hours a week with much of this work being scut work rather than useful learning. 3. Low salary and benefits relative to training. Residency salaries are between 50k-70k annual which can be extremely difficult for families living in NYC or SF. 4. Inability to quit or switch programs. Many residents also don't have too much choice in residency location. In Washington State for example the residency positions available are extremely limited.
So, there's a definite problem compared to other industrialized countries. And it seems like the supply is artificially constricted which exacerbates the problem.
From there, it's speculation. But which part of the above is missing evidence?
https://en.m.wikipedia.org/wiki/List_of_countries_by_quality...
https://www.beckershospitalreview.com/hospital-management-ad...
Nope. This is a common misconception.
The AAMC (which is different from the AMA) determines the number of people who can graduate from medical school each year, but as pointed out in the original article, the bottleneck is in the number of residency slots. There are already more medical school graduates than there are slots to receive them; increasing the number of medical school graduates wouldn't result in more practicing physicians.
Well... Congress, essentially, by determining how much funding Medicare gets, a portion of which is allocated to funding residency programs.
Contrary to popular belief, residency programs are by and large not money-making operations (or even self-sustaining ones). If they were, hospitals would expand them! But because they lose money, the government has to subsidize them in order to encourage hospitals to run them at their current levels.
I have no doubts they are capable of losing money, on paper at least, especially when spending more means they can get a subsidy from the government.
Why would the hospital restrict residency spots because of funding? Residents are wildly profitable, so that wouldnt make sense.
The explanation I'm told makes sense is this: US medical boards are unwilling to train more doctors because that would increase supply and reduce overall MD earnings. So they have a small number of openings each year, and blame the "shortage" on Congress.
That "explanation" might be plausible if "medical boards" were in control of the size of residency programs or hospitals' decisions to run them. Except, they're not.
> Why would the hospital restrict residency spots because of funding? Residents are wildly profitable, so that wouldnt make sense.
This is an example of a logical fallacy known as begging the question[0]. You are assuming that "residents are wildly profitable", and then trying to use that to disprove the statement that "residency programs are not profitable".
A better way to reason about this is by contradiction. Assume that hospitals are greedy and avaricious profit-seeking entities who will do anything that increases their bottom line. If residency programs were profitable, these greedy profit-seeking entities would open them (the hospitals that don't currently run programs) or expand them (the hospitals that do). Except, they choose not to. That provides a contradiction between the logical conclusion of the assumptions and actual reality.
It's much simpler to resolve that contradiction by rejecting the premise "residency programs are profitable" than by resorting to contorted explanations that hinge on objectively counterfactual assumptions (such as "medical boards control residency programs' decisions", which is objectively incorrect).
(Your explanation also falls flat when you realize that your logic actually provides US doctors and medical boards with a strong incentive to increase the number of medical school slots, because that would actually preserve earnings for domestic doctors. But that's a subtler point, and the topic at hand is residency programs.)
[0] https://en.wikipedia.org/wiki/Begging_the_question
This seems to be the logical fallacy. Hospitals neither get to confer medical degrees nor award board certifications. They cannot just magically create residents out of thin air, they are restricted by supply. No amount of Matrix Architect speak makes them do so.
https://youtu.be/ZKpFFD7aX3c?t=81
You seem confused about the question at hand. As has been explained multiple times, including in the original article, there are more medical degrees granted every year than there are residency slots available at hospitals.
The whole question is why hospitals don't take advantage of the excess supply of of medical graduates by creating more residency positions.
Most of all, I believe that we can train capable internal medicine/primary care doctors in just 5-6 years instead of 8+3 years that is required now.
The entire system is broken in my opinion. Service provision should be more skills-focused, and less degree-focused, and deregulated to allow more competition in the types of services and professional identities that exist.
Currently in the US, access to care is too restricted or difficult. The response "let's open the floodgates to more physicians" is one response, but another response is "yes, do that, but let citizens receive care under different kinds of training models." Right now the assumption is RN -> LPN and MD->specialty->subspecialty, maybe with PA->specialty training, but there's many other forms of care from other types of providers that could exist. Pharmacists and psychologists are one example, where you might have specialized training -> broader training, or specialized training -> augmented skill set. There's also undoubtedly many other types of providers we can't even imagine now because the certification regulations are so strict; I also suspect a lot of care could be opened up to the general public on their own (many refills, for example, probably don't need repeat visits).
My sense is this is just the tip of the iceberg when it comes to medical certification overregulation.
There is a middle ground where we address the bottlenecks in the current medical professional pipeline by deregulating the number of licenses issued per year and sponsor the creation of new medical schools to educate more professionals at lower cost.
I also think to some extent it exists in the other direction as well, in terms of generalists not always recognizing when something needs to be referred to a more specialized setting.
It's largely addressed via training and consequences. And in any event, there's always the issue of "why not broaden training instead of assuming it always narrows?"
This is problematic if we expect neurologists to be good well rounded doctors, but not if we just expect them to be good neurologists. I don’t expect my dentist to be able to deal with a heart murmur.
In a country with a medical system that is already too profit-minded and with a population that is growingly anti-expert, this has the potential to go catastrophically wrong. We don't need to make it easier for people to sell horse paste and essential oils as miracle cures. So while reform may be needed, we would also need to be mindful that making it easier to provide medical services will also empower people with misaligned motives to take advantage of people.
I had no idea about this, but it seems brilliant. Immediately immersing them in medicine instead of all the non-medical education you would be forced to complete(and pay for) in the US sounds like a win.
Also, that's not to mention the many "pre-med" classes that medical schools require for applicants. Are high school kids going to take the organic chemistry, biochem, etc. necessary for med school?
That doesn’t mean that they didn’t need to understand calculus as a prerequisite to other classes where they did learn skills they use frequently.
MDs also aren’t technicians, they are a self regulating group of professionals with a high degree of legally protected autonomy and authority. Individually they make life or death decisions more frequently than anyone else. And as a group they make up regulatory bodies that impact everyone’s medical care. Like lawyers they have a very disproportionate impact on society. I think some amount of general education and general science background is appropriate.
Why can't med school teach all the classes needed for med school?
2. Making a decent grade in those classes at an accredited school is a good filter.
3. MDs aren’t just technicians. They are leaders, managers, and ethicists. They have a higher level of legally protected autonomy than nearly any other profession. Given that, I think that 2 years of general education is appropriate. For the same reasons I think general education is appropriate for other professions with a high degree of autonomy, authority, and impact, e.g., civil engineers, lawyers, and teachers (all the teachers reading this are laughing at the autonomy part).
Due to the competitiveness of getting a place on a medicine course, it's pretty much impossible to get into a medicine degree here in the UK without having taken Physics, Chemistry and Biology at A-level, and maybe maths too. So... yes.
Note also: medical degrees are longer than other degrees in Europe (5 years instead of the standard 3 here in the UK). But you go directly into a specialised medicine course. I think you can do a graduate medicine degree in 4 years if you have an undergraduate degree in a related field, but that's relatively uncommon.
So, sure, you can enter med school with a BA in English, but you still have to have taken undergraduate level organic chemistry.
Practically speaking, that means at each school there's 1 or 2 majors that will hit the typical premed requirements in the course of completing the undergraduate degree and a handful of other majors where a minor or even less than that will allow you to complete the premed requirements.
But all that said, yeah, they engage in blatant credentialism because they use it as a way to filter students out, because there's a much smaller supply of available medical school positions than there is demand for medical school positions. It's so blatant that it's usually better to go to a school with grade inflation or a less rigorous school where you know you can max out the GPA, than to go to the toughest undergraduate school you can because admissions doesn't do a great job of leveling different schools, so a 4.0 from University of Grade Inflation can still beat out a 3.5 from a more-renowned university.
This way is more revenue for BigEd though.
An MD post-secondary degree is like 6 years, right? An undergrad and MD in the US is 8 years, so the difference isn't that much. That's basically just the general education requirements for an undergraduate degree, which as far as I can understand is just a general difference of the US vs european systems. US bachelors include a generality component absent in European degrees so the typical US undergrad takes a year or so longer than the typical European undergraduate degree.
I went to high school with a ton of now doctors. My college degree is unrelated to programming, and I have built a career from the bottom up in web dev. I would say I’m fairly far along, have reached a senior IC level, and make good money.
My doctor friends are still not fully through training, and are just beginning to start their adult lives. It’s a disservice that some of my most intelligent friends had to waste 4 years on nothing and delay their professional and personal growth. No wonder less and less US citizens want to pursue medical careers.
And in the US there is no national high school curriculum, so an extra 2 years for general education isn't a bad idea.
However, there are some important aspects of the modern residency system that are not captured well, that do contribute to the pipeline bottlenecks.
One major issue surrounds the UME - GME split, that is undergraduate medical education (that is medical students) vs. graduate medical education (that is residents). As a medical student now, one of the most striking comments is how our professors, especially those who are older, comment on how much they did during medical school. Right now, medical students learn under such close supervision most of the experience is shadowing-based, i.e. watching attending physicians, resident physicians, and midlevel providers. This means that on graduation as MDs, new interns have very limited experience in managing patients.
In turn, that makes intern year critical in training physicians. However, much of what is learned in intern year is often a retrenchment of what should have been covered in medical school by accreditation standards. The concerns about medical students graduating without a full set of the expected competencies have lead to the development of the Core Entrustable Professional Activities (EPAs), to create a framework by which students graduate with documented competency in each area.
Unfortunately, initial experiences with the EPAs have been mixed. This summer, an academic article reviewing schools experiences implementing the EPAs revealed that while most EPAs were being adopted well, some of the Core EPAs, specifically involving basic procedural competence (think drawing blood, starting IVs, basic bedside procedures), were considered more appropriate for GME [1], which adds to the GME curriculum in residency.
Given that the 4th year of medical school for most students consists of "elective time" and time off to interview for residency, shifting training from medical school to residency only adds to stress on the pipeline. For example, why should internal medicine residency be 3 years long? If graduates were documented as more competent on graduation, would a two year residency for primary care or prior to specialized subspecialty training be sufficient? In my experience working with residents at my medical school, 3rd year residents are in supervisory positions, dealing with less patient care than first and second year residents, the rest of their time seems to be consumed with applying for fellowship and studying for their Board certifications.
Of course, some of the dilution of undergraduate medical education comes as a result of defensive medicine, scope creep from midlevel providers, and excessive regulatory requirements. (Just look at all of the regulatory burden and turmoil around how attending physicians can attest medical student notes for CMS billing purposes. If anyone wants a migraine, I invite them to look into it.) Additionally, other causes of the dilution comes from the growth in US IMGs, mostly from the Caribbean medical schools. Those schools often pay to place students at US non-academic (often for-profit) hospitals that are less interested in the educational mission as they are in easy money from precepting students. In those cases, those students often have extremely circumscribed roles in the clinic, largely due to the institutional lack of emphasis and commitment to teaching [2].
Fixing the pipeline will require creating more residency positions, but it will also likely require changes all along the pipeline, such as making UME more meaningful and graduating MDs (or DOs) who are more ready for residency on Day 1, and then a serious look at residency length to ensure that GME experiences are meaningful and not simply "cheap labor [3]."
[1] epmaybe ↗ This loses sight of the lack of incentive missing from hospitals and even residency programs from funding their own positions. There’s literally no regulation preventing a program from funding their own without Medicare dollars. They just need ACGME to sign off on it. giantg2 ↗ On the financial side, we have to also look at opportunity cost and loan sizes. Why should I spend over 8 years post secondary and over $250k to become a doctor?
Turns out if you hand out free money for minimum wage employees that rely on your training to not kill people, there’s very little incentive to pay out of pocket. Especially so when programs realize that their trainees will just work harder/longer for the same pay without much complaining.
I also think there’s a method to the madness of training program length and number of spots (namely, ensuring you have enough exposure to the common things/uncommon things you will encounter on your own to be competent), but I agree more scrutiny would weed out inefficiencies in the training process. But like, there’s an obvious reason neurosurgery residencies don’t take that many trainees every year, not just to create artificial scarcity.
https://en.m.wikipedia.org/wiki/Jung_v._Association_of_Ameri...
What's the medical equivalent of 'code schools'? There isn't any because you can't practice medicine without a license in the United States.
Residency acceptance is restricted by demand, not the other way around.
My partner is in their last year of residency.
Caribbean med school.
After ten hours you’re not learning. You’re existing and enduring.
Right now medical students are applying to 80+ residencies, and even at top schools some are failing to match.
The system is incredibly broken.
... for absolutely no results.
Spend any time on a busy hospital ward, and you'll see overworked residents trying to one up one another in an attempt to impress whoever is in charge. "I've slept the least hours, therefore without me this floor would collapse". It's institutionalized hazing and cargo culting, nothing more.
The pipeline is also restricted upstream by the limited enrollments at med schools (drastically lower than the number of qualified pre-med students) and downstream by restrictions on what other medical professionals such as NPs and PAs can do.
[+] https://en.wikipedia.org/wiki/ELAM_(Latin_American_School_of...
(giggle)