10 ms·

Repairing the U.S. Medical Residency Pipeline

73 points by gok 5y ago

djoldman 5y ago
PDF: https://www.niskanencenter.org/wp-content/uploads/2021/09/Unmatched-Repairing-the-US-Residency-Pipeline.pdf https://www.niskanencenter.org/wp-content/uploads/2021/09/Un...
downrightmike 5y ago
"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.
jimbob45 5y ago
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.
- killjoywashere 5y ago
  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.
  - soldehierro 5y ago
    > they tend to seek part-time employment arrangements Do you have a source for that?
    - mlyle 5y ago
      "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) https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2740777 https://jamanetwork.com/journals/jamanetworkopen/fullarticle...
- hyperion2010 5y ago
  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.
- darth_avocado 5y ago
  > 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.
  - Invictus0 5y ago
    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.
    - screye 5y ago
      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. This is in Boston, one of the US medical meccas.
      - Invictus0 5y ago
        How many doctors offices did you reach out to? Did you try to find one on zocdoc?
        screye 5y ago
        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.
- snarf21 5y ago
  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.
  - 908B64B197 5y ago
    > 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...
    - nacho2100 5y ago
      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.
      - 5y ago
programmertote 5y ago
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.
- fallingknife 5y ago
  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.
  - MattGaiser 5y ago
    That probably correlates with intelligence. It is a waste of intelligence, but it certainly requires it.
    - 5y ago
derbOac 5y ago
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.
- lumost 5y ago
  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.
  - derbOac 5y ago
    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?"
fallingknife 5y ago
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.
- clipradiowallet 5y ago
  > 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.
  - bradleyjg 5y ago
    Any job or grad program that requires a college degree but will accept any and all majors is engaging in pure credentialism.
    - mr_overalls 5y ago
      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?
      - 5y ago
acerjio 5y ago
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]." [1] https://journals.lww.com/academicmedicine/Fulltext/2021/07001/Revisiting_the_Core_Entrustable_Professional.4.aspx https://journals.lww.com/academicmedicine/Fulltext/2021/0700... [2] One of my preceptors who graduated from a Caribbean school flatly said that medical school was just for observation, and that she didn't actually do anything until residency. While she became an excellent physician, this attitude did not correspond to the educational expectations of our institution, nor do I think reflects the expectations of most of the US system. [3] PGY (post graduate year) salaries are very, very low on an hourly basis. PGY-1 salaries are anywhere from $58k/year to $65k/year for FY22. However, as residents like to point out, when you calculate their salary across the hours they work, the rate is usually less than federal minimum wage.
rcpt 5y ago
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 https://en.m.wikipedia.org/wiki/Jung_v._Association_of_American_Medical_Colleges https://en.m.wikipedia.org/wiki/Jung_v._Association_of_Ameri...
- yhoneycomb 5y ago
  They literally made an anti-trust exemption just for the match system.
  - rcpt 5y ago
    Kind of figures given that residency is funded by Medicare and anything that smells like increasing that money is a political explosion.
GiorgioG 5y ago
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.
- tbihl 5y ago
  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.
- mushbino 5y ago
  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. My partner is in their last year of residency.
  - yardie 5y ago
    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.
- rscho 5y ago
  > What's the medical equivalent of 'code schools'? Caribbean med school.
dzink 5y ago
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.
- jounker 5y ago
  Residents work 12+ hour days six to thirteen days in a row. Sometimes the days are longer. 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.
  - dzink 5y ago
    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.
    - rcpt 5y ago
      My wife is a family medicine resident and explained to me that she has a 28 hour shift next month
rscho 5y ago
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.
musicale 5y ago
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.
LargoLasskhyfv 5y ago
Meanwhile in Cuba... [+] https://en.wikipedia.org/wiki/ELAM_(Latin_American_School_of_Medicine)_Cuba https://en.wikipedia.org/wiki/ELAM_(Latin_American_School_of... (giggle)

73 points by gok 5y ago

PDF: https://www.niskanencenter.org/wp-content/uploads/2021/09/Unmatched-Repairing-the-US-Residency-Pipeline.pdf https://www.niskanencenter.org/wp-content/uploads/2021/09/Un...

downrightmike 5y ago

"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.

jimbob45 5y ago

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.

killjoywashere 5y ago
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.
- soldehierro 5y ago
  > they tend to seek part-time employment arrangements Do you have a source for that?
  - mlyle 5y ago
    "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) https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2740777 https://jamanetwork.com/journals/jamanetworkopen/fullarticle...
hyperion2010 5y ago
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.
darth_avocado 5y ago
> 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.
- Invictus0 5y ago
  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.
  - screye 5y ago
    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. This is in Boston, one of the US medical meccas.
    - Invictus0 5y ago
      How many doctors offices did you reach out to? Did you try to find one on zocdoc?
      - screye 5y ago
        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.
snarf21 5y ago
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.
- 908B64B197 5y ago
  > 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...
  - nacho2100 5y ago
    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.
    - 5y ago

programmertote 5y ago

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.

fallingknife 5y ago
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.
- MattGaiser 5y ago
  That probably correlates with intelligence. It is a waste of intelligence, but it certainly requires it.
  - 5y ago

derbOac 5y ago

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.

lumost 5y ago
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.
- derbOac 5y ago
  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?"

fallingknife 5y ago

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.

clipradiowallet 5y ago
> 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.
- bradleyjg 5y ago
  Any job or grad program that requires a college degree but will accept any and all majors is engaging in pure credentialism.
  - mr_overalls 5y ago
    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?
    - 5y ago

acerjio 5y ago

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]." [1] https://journals.lww.com/academicmedicine/Fulltext/2021/07001/Revisiting_the_Core_Entrustable_Professional.4.aspx https://journals.lww.com/academicmedicine/Fulltext/2021/0700... [2] One of my preceptors who graduated from a Caribbean school flatly said that medical school was just for observation, and that she didn't actually do anything until residency. While she became an excellent physician, this attitude did not correspond to the educational expectations of our institution, nor do I think reflects the expectations of most of the US system. [3] PGY (post graduate year) salaries are very, very low on an hourly basis. PGY-1 salaries are anywhere from $58k/year to $65k/year for FY22. However, as residents like to point out, when you calculate their salary across the hours they work, the rate is usually less than federal minimum wage.

rcpt 5y ago

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 https://en.m.wikipedia.org/wiki/Jung_v._Association_of_American_Medical_Colleges https://en.m.wikipedia.org/wiki/Jung_v._Association_of_Ameri...

yhoneycomb 5y ago
They literally made an anti-trust exemption just for the match system.
- rcpt 5y ago
  Kind of figures given that residency is funded by Medicare and anything that smells like increasing that money is a political explosion.

GiorgioG 5y ago

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.

tbihl 5y ago
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.
mushbino 5y ago
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. My partner is in their last year of residency.
- yardie 5y ago
  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.
rscho 5y ago
> What's the medical equivalent of 'code schools'? Caribbean med school.

dzink 5y ago

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.

jounker 5y ago
Residents work 12+ hour days six to thirteen days in a row. Sometimes the days are longer. 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.
- dzink 5y ago
  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.
  - rcpt 5y ago
    My wife is a family medicine resident and explained to me that she has a 28 hour shift next month

rscho 5y ago

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.

musicale 5y ago

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.

LargoLasskhyfv 5y ago

Meanwhile in Cuba... [+] https://en.wikipedia.org/wiki/ELAM_(Latin_American_School_of_Medicine)_Cuba https://en.wikipedia.org/wiki/ELAM_(Latin_American_School_of... (giggle)