Match Results Shows The Heat Is Up

[dragonfly99]

I was taking more about residency, not fellowship.
I've nothing against foreign citizens and agree that many of the ones who come here for residency are very bright...they have to be to do so well on exams which for many of them are not even being given in their native language, etc.

However, the residency admissions process is a zero sum game in the sense that there are only "x" spots in things like IM residency, and if there are more qualified US citizens training in med school (as opposed to the dearth of med students we had to fill up these residencies in years past) perhaps we don't need to go trolling abroad so often to fill up our residencies. I think US schools ramping up admissions somewhat was a good thing, as it really didn't make much sense to have a system where qualified US citizens were denied med school admissions every year due to the small number of spots available in US schools, and then we'd just bring in a bunch of folks from other countries to fill up our internship and residency positions. It's just not a very sensible system to not train enough doctors for your country, but rely in importing them. I can't think of many other countries that would do that...it just doesn't make a lot of sense.

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[Coastie]

Sorry about the miscalculation, from researching this a big more I find that in 2005 about 8 Billion was spent for graduate medical education subsidies by the Federal Government. While 8 Billion is alot, the military budget is many times this, and the Iraq war is about 10 billion or so a month (or was), . . .

I wonder if there is more to the addition of more allopathic and DO seats than just trying to catch up with FMG and IMG growth. If 200 residency seats are added each year over the next ten years this would roughly keep up with allopathic growth, maybe 3,000 allopathic seats would be added . . . but DO schools are really ramping up seats, so much that a lot of new DO schools would have to open AND existing schools would have to add a lot of seats. I guess I am wondering why?

I have heard that D.O. residencies often go unfilled, maybe this is a buffer that can soak up some of these extra DO students coming out of the pipeline. . . Maybe DO schools are planning on creating some new residency programs . . .

And Obama's bailouts and personal/corporate welfare has been many trillions since January. What's your point? We need military funding, we need war funding....

Just calling you out for some lame stats thrown into an otherwise good post. I think we should increase residency funding. I believe we should also have a US citizen match followed by non-citizen match. I think the DO and MD spots should be put into one match. If they aren't, the AOA is playing a dangerous game of being left completely out one of these days..Finally, I think the new proliferation of sub-par medical schools (mostly DO so far, but MDs are there too, with more around the corner) should STOP. For-profit medical schools should be SHUT DOWN. Milking these poor kids out of tons of $$ to go to "medical school" in a strip-mall with poor clinical rotations and residency spots more likely to be in community FP programs at best is disingenuous..

 

[BobA]

You may want this to be true but there are currently no rules stating this. For example there are multiple FMGs with MBBS degrees in the UAMS Radiology Residency Program and an FMG from the Phillipines in the Duke Derm Residency program and from Brazil in the Henry Ford Derm Residency Program ( http://www.uams.edu/radiology/education/residency/diagnostic/current_faces.asp http://www.henryfordhealth.org/body_program.cfm?id=49994 http://dukederm.duke.edu/modules/curpastresidents/index.php?id=1 ). Do you really think there were no qualified AMGs that applied for those spots and did not match into rads or derm? However the situation does not compare to the IT field where there are firms which teach companies how to not hire Amercans (see: http://www.youtube.com/watch?v=TCbFEgFajGU http://www.youtube.com/watch?v=Fx--jNQYNgA&feature=related )

Doesn't the exception prove the rule?

 

[exPCM]

Doesn't the exception prove the rule?

And the point was that there are no firm rules that USMGs must be given preference in selection for residency spots over FMGs.

SO WHAT IS YOUR POINT?

 

[McGillGrad]

As a Canadian, I am biased, but the match should attract the best candidate. Of course, they should speak fluent English (fluent does not mean sans accent, btw) and with a firm understanding of American culture.

Anything less creates a medical system that resembles the US auto industry. Lower quality and less efficiency.

 

[BobA]

By that argument we should just scrap AMGs and bring in the best and brightest of China and India for all our residencies. Considering how huge their populations are, you could almost certainly fill all our residencies with people who perform better on exams and at the job than lazy, stupid, Americans, no?

Yeah, all the US allopathic's are lazy and stupid. That's how they got into and completed a US allopathic medical school.

 

[McGillGrad]

And the point was that there are no firm rules that USMGs must be given preference in selection for residency spots over FMGs.

SO WHAT IS YOUR POINT?

The point is clear to anyone who understands that idiom. Obviously, you lack that ability.

 

[BobA]

And the point was that there are no firm rules that USMGs must be given preference in selection for residency spots over FMGs.

SO WHAT IS YOUR POINT?

I'm sorry. I missed your point. I thought you were on one of those FMG's can match into anything rants. My bad.

 

[McGillGrad]

Yeah, all the US allopathic's lazy and stupid. That's how they got into and completed a US allopathic medical school.

He's actually making a very weak point. He means to say that if only the best should get the spot, then the Americans would lose by sheer numerical inferiority.

What he forgets is that language and culture trump raw stats most of the time for good reason.

 

[exPCM]

The point is clear to anyone who understands that idiom. Obviously, you lack that ability.

I understand idioms quite well. I just don't understand idiots.

 

[McGillGrad]

I understand idioms quite well. I just don't understand idiots.

How do you survive without talking to yourself? Considering that you wouldn't understand what you're saying....see how I spelled that out for you

 

[exPCM]

I'm sorry. I missed your point. I thought you were on one of those FMG's can match into anything rants. My bad.

BobA, no problem. Good luck in your medical career!

 

[Coastie]

The point is clear to anyone who understands that idiom. Obviously, you lack that ability.

Why are you antagonizing American attendings for no good reason? As a self-described non-American who attends a non-big 3 (SGU, Ross, AUC) caribbean school, I'd stay away from ad hominems towards American attendings and work towards asking advice on how best to make a career in medicine!

 

[McGillGrad]

Oh jeez, massa! I should know mah place massah! Please forgive dis uppity negro, massah!

Get a life. If you really believe that an AMG attending is better than you because of their position, you are one sad sack of a human being.

Why are you antagonizing American attendings for no good reason? As a self-described non-American who attends a non-big 3 (SGU, Ross, AUC) caribbean school, I'd stay away from ad hominems towards American attendings and work towards asking advice on how best to make a career in medicine!

 

[Tigerz_Fan]

Oh jeez, massa! I should know mah place massah! Please forgive dis uppity negro, massah!

McGill,

That gave me a good laugh! Thanks, I needed that!

 

[caliprincess]

Oh jeez, massa! I should know mah place massah! Please forgive dis uppity negro, massah!

Wow....there are no words! lol!

 

[cali-ob]

Oh jeez, massa! I should know mah place massah! Please forgive dis uppity negro, massah!

McGill,

That gave me a good laugh! Thanks, I needed that!

really? Did it give you a good laugh? Cause I found it quite stupid and offensive. No place for racial undertones in this convo IMO.

 

[NotAProgDirector]

To try to get back on track here:

1. Residency slots are not funded by Congress, at least not directly. Residency slots are funded by medicare. Medicare is an entitlement program -- it is not part of the official budget that congress passes each year. Medicare collects it's own taxes (via paycheck deductions) and then pays for healthcare, GME, and some other stuff. This is good in many ways -- GME funding is not subject to the whim of each congress and it's budget, funding is stable, etc. Congress did cap the number of spots as mentioned above, and could remove that cap, but probably won't for an important reason -- Medicare is going bankrupt. Up till now, medicare has been a "free ride" for the government. It collected it's own taxes and fees, and paid it's own costs, without Congress needing to fund it. In fact, it was making so much money a few years ago there was a suggestion that the gov't should "borrow" some of the money in the Medicare Trust Fund for it's own use. Now, Medicare is going bankrupt. When that happens, there is the serious chance that GME funding will be cut severely. If, as a congressperson, you have to vote for less GME funding or less healthacre for seniors, which would you choose? Seniors have a much bigger lobby, they will win every time.

2. Although I have nothing against IMG's at all, the US is likely going to need to limit the number of IMG's getting residency spots and prioritize spots to US grads. The system is coming to the breaking point. However, I don't think we'll get to a two stage match -- 1) PD's will hate it, 2) It would delay IMG appointments even later which would cause more visa problems, and 3) it would not affect programs who take candidates outside the match, and because of #2 might actually encourage programs to take more residents outside the match. So, unless the match becomes "all in" = everyone must use it, then I don't see this as a solution.

There is a very simple solution. Sometime in the near future, there will be a poor US grad match. Multiple schools will see a spike in unmatched candidates, while spots are filled by IMG's. A catalyst event will occur -- a senator's/congressperson's/big wig's child will not match. Someone will bring the issue to congress's attention.

Congress will look at the situation. They will pressure the NRMP to change their match system, but that will take way too long and has all of the problems mentioned above.

So Congress will change what they have control of -- the H visa. The H visa is designed to bring international citizens with advanced / professional training into the US to fill a job that otherwise would not be filled by a US citizen. Congress will see that there are plenty of unmatched US citizens willing to take those spots occupied by H visa IMG's.

If Congress disallows / limits H visas for medical residents, much of the problem will go away. Although some IMG's will come on J visas, many will not. Congress could limit J visas also.

Notably, this change would not affect US citizens attending carib or other international schools.

This actually raises an interesting question for those US citizens who are unmatched. If a program matched an IMG and is getting them an H visa, theoretically this should only be allowed if there is not a US citizen who is equally qualified for the position. If you were willing to work at the job, theoretically you could petition the program (? or USCIS). I have no idea if the employer is required to hire you under such circumstances -- or whether you would just torpedo the visa app, upset the PD, and still end up short a job. Probably the latter.

 

[BobA]

To try to get back on track here:

1. Residency slots are not funded by Congress, at least not directly. Residency slots are funded by medicare. Medicare is an entitlement program -- it is not part of the official budget that congress passes each year. Medicare collects it's own taxes (via paycheck deductions) and then pays for healthcare, GME, and some other stuff. This is good in many ways -- GME funding is not subject to the whim of each congress and it's budget, funding is stable, etc. Congress did cap the number of spots as mentioned above, and could remove that cap, but probably won't for an important reason -- Medicare is going bankrupt. Up till now, medicare has been a "free ride" for the government. It collected it's own taxes and fees, and paid it's own costs, without Congress needing to fund it. In fact, it was making so much money a few years ago there was a suggestion that the gov't should "borrow" some of the money in the Medicare Trust Fund for it's own use. Now, Medicare is going bankrupt. When that happens, there is the serious chance that GME funding will be cut severely. If, as a congressperson, you have to vote for less GME funding or less healthacre for seniors, which would you choose? Seniors have a much bigger lobby, they will win every time.

2. Although I have nothing against IMG's at all, the US is likely going to need to limit the number of IMG's getting residency spots and prioritize spots to US grads. The system is coming to the breaking point. However, I don't think we'll get to a two stage match -- 1) PD's will hate it, 2) It would delay IMG appointments even later which would cause more visa problems, and 3) it would not affect programs who take candidates outside the match, and because of #2 might actually encourage programs to take more residents outside the match. So, unless the match becomes "all in" = everyone must use it, then I don't see this as a solution.

There is a very simple solution. Sometime in the near future, there will be a poor US grad match. Multiple schools will see a spike in unmatched candidates, while spots are filled by IMG's. A catalyst event will occur -- a senator's/congressperson's/big wig's child will not match. Someone will bring the issue to congress's attention.

Congress will look at the situation. They will pressure the NRMP to change their match system, but that will take way too long and has all of the problems mentioned above.

So Congress will change what they have control of -- the H visa. The H visa is designed to bring international citizens with advanced / professional training into the US to fill a job that otherwise would not be filled by a US citizen. Congress will see that there are plenty of unmatched US citizens willing to take those spots occupied by H visa IMG's.

If Congress disallows / limits H visas for medical residents, much of the problem will go away. Although some IMG's will come on J visas, many will not. Congress could limit J visas also.

Notably, this change would not affect US citizens attending carib or other international schools.

This actually raises an interesting question for those US citizens who are unmatched. If a program matched an IMG and is getting them an H visa, theoretically this should only be allowed if there is not a US citizen who is equally qualified for the position. If you were willing to work at the job, theoretically you could petition the program (? or USCIS). I have no idea if the employer is required to hire you under such circumstances -- or whether you would just torpedo the visa app, upset the PD, and still end up short a job. Probably the latter.

Very informative and insightful post, aPD!

 

[exPCM]

aPD, thanks for your post.
I completely agree that the chance of the government lifting the cap and funding more residency spots is essentially zero.

Good point on the H1B visa. I wonder if an unmatched unemployed US grad may actually try to petition thinking that they have nothing to lose. I sure would not look down on someone who did this. Desperate people sometimes take desperate measures.

I agree that we will see a poor US grad match soon particularly when you look at the rapid growth in med school enrollments with almost static residency spots.

The DOs have one refuge in that the osteopathic match is not open to non-DOs, although I believe there are more DO grads each year than positions available in the osteopathic match.

 

[Medstudentquest]

To try to get back on track here:

1. Residency slots are not funded by Congress, at least not directly. Residency slots are funded by medicare. Medicare is an entitlement program -- it is not part of the official budget that congress passes each year. Medicare collects it's own taxes (via paycheck deductions) and then pays for healthcare, GME, and some other stuff. This is good in many ways -- GME funding is not subject to the whim of each congress and it's budget, funding is stable, etc. Congress did cap the number of spots as mentioned above, and could remove that cap, but probably won't for an important reason -- Medicare is going bankrupt. Up till now, medicare has been a "free ride" for the government. It collected it's own taxes and fees, and paid it's own costs, without Congress needing to fund it. In fact, it was making so much money a few years ago there was a suggestion that the gov't should "borrow" some of the money in the Medicare Trust Fund for it's own use. Now, Medicare is going bankrupt. When that happens, there is the serious chance that GME funding will be cut severely. If, as a congressperson, you have to vote for less GME funding or less healthacre for seniors, which would you choose? Seniors have a much bigger lobby, they will win every time.

2. Although I have nothing against IMG's at all, the US is likely going to need to limit the number of IMG's getting residency spots and prioritize spots to US grads. The system is coming to the breaking point. However, I don't think we'll get to a two stage match -- 1) PD's will hate it, 2) It would delay IMG appointments even later which would cause more visa problems, and 3) it would not affect programs who take candidates outside the match, and because of #2 might actually encourage programs to take more residents outside the match. So, unless the match becomes "all in" = everyone must use it, then I don't see this as a solution.

There is a very simple solution. Sometime in the near future, there will be a poor US grad match. Multiple schools will see a spike in unmatched candidates, while spots are filled by IMG's. A catalyst event will occur -- a senator's/congressperson's/big wig's child will not match. Someone will bring the issue to congress's attention.

Congress will look at the situation. They will pressure the NRMP to change their match system, but that will take way too long and has all of the problems mentioned above.

So Congress will change what they have control of -- the H visa. The H visa is designed to bring international citizens with advanced / professional training into the US to fill a job that otherwise would not be filled by a US citizen. Congress will see that there are plenty of unmatched US citizens willing to take those spots occupied by H visa IMG's.

If Congress disallows / limits H visas for medical residents, much of the problem will go away. Although some IMG's will come on J visas, many will not. Congress could limit J visas also.

Notably, this change would not affect US citizens attending carib or other international schools.

This actually raises an interesting question for those US citizens who are unmatched. If a program matched an IMG and is getting them an H visa, theoretically this should only be allowed if there is not a US citizen who is equally qualified for the position. If you were willing to work at the job, theoretically you could petition the program (? or USCIS). I have no idea if the employer is required to hire you under such circumstances -- or whether you would just torpedo the visa app, upset the PD, and still end up short a job. Probably the latter.

Great post!

 

[medsRus]

This actually raises an interesting question for those US citizens who are unmatched. If a program matched an IMG and is getting them an H visa, theoretically this should only be allowed if there is not a US citizen who is equally qualified for the position. If you were willing to work at the job, theoretically you could petition the program (? or USCIS). I have no idea if the employer is required to hire you under such circumstances -- or whether you would just torpedo the visa app, upset the PD, and still end up short a job. Probably the latter.

Really interesting post. Any legal points of view on its precedence or feasibility?

 

[GeraldMonroe]

Question : does anyone know how many total medical students are going to be in the class of 2013? I would very much like to know how many total medical students (MD + DO) will be trying to match in 2013 versus this last match.

 

[exPCM]

Question : does anyone know how many total medical students are going to be in the class of 2013? I would very much like to know how many total medical students (MD + DO) will be trying to match in 2013 versus this last match.

I will take a stab at this. I am not going to include IMG/FMG nummbers because I have not seen any data on what will be happening with IMG/FMG med school enrollments between now and 2013 and I don't think I can make informed estimates on IMG/FMG numbers.

Class of 2009
Enrollment from the AACOM survey: 3908 DO
Enrollment from the AAMC survey graph: ~16800 MD
US DOs in NRMP match 2009: 2875
US MD seniors in NRMP match 2009: 16008
US MD prior year grads in NRMP match 2009: 1222
PGY-1 spots in NRMP match: 22427

Note: There were much smaller numbers of applicants in the San Francisco Match. Otolaryngology joined the NRMP Match in 2006, Neurology joined in 2007, and Neurological Surgery joined in 2009. Many Anesthesiology and Emergency Medicine programs have converted their positions from Advanced (PGY-2) to Categorical (PGY-1) over the last few years, affecting the trends in those specialties.
see: http://www.nrmp.org/data/advancedatatables2009.pdf

Class of 2013
Enrollment from the AACOM survey : 5096 DO
Enrollment from the AAMC survey graph:~18100 US MD
US DOs in NRMP match: estimate 3748
US MD seniors in NRMP match: estimate 17300
US MD prior yr grads in NRMP match: estimate 1500 (somewhat of a guess, as more and more US seniors do not match I think this number will increase some each year)
PGY-1 spots in NRMP match: estimate 22650 (minimal change -I do not see any more new specialties entering the match and the conversion in EM and anesthesiology is pretty much completed. If you look at Table 3 of the 2009 NRMP data tables you can see that the growth from 21454 PGY-1 spots in the match in 2005 to 22427 in 2009 is almost entirely due to otolaryngology, neurology and neurosurgery entering the match and the changes/conversions in anesthesiology and emergency medicine)

 

[GeraldMonroe]

Thanks. So, 7-8% more competitors. That isn't "good", but it isn't unbeatable. So if a residency had 100 spots, and an 88% match rate, then it would have an 81% match rate in 2013. (there's a specific residency I'm interested in with an 88% match rate)

I guess I should study hard and hope I'm not in that last 7%. But an 80% chance is high enough that it's plausible to make it happen.

This is really lame that nothing is being done to alleviate the projected physician shortage.

You've got one set of numbers, exPCM, that says there isn't one. However, how do you compensate for :

1. Population growth since the 1980s when the number of med school sets were fixed
2. Baby boomers
3. doctors retiring earlier than projected
4. Women doctors statistically working 20% fewer hours than men (it's great that more women are doctors, but this does need to be taken into account for future planning)
5. The complexity of medical care has increased. Nearly every procedure today has a large number of additional, more complex steps to follow to prevent rare adverse events. Doctors routinely order and analyze the results of far more laboratory testing than they used to
6. It's possible to a patient with a complex set of conditions to be kept alive, creating work for dozens of specialists in order to maintain the patient. Previously, the patient would have died before they got to the point of needing a squad of physicians to keep them alive a short while longer.

All that sounds like it would create a shortage, which is why the recommendation to increase seats was supposedly made.

If there is not going to be a shortage due to the baby boomers decaying and the demographics of the physician workforce changing to include people who work fewer hours, then there must be a surplus of doctors right now. That is, if the current ratio of doctors is more than enough, such that the increased future demand will not put a strain on them, then there must be extra doctors today.

If there were currently a surplus of doctors
- current attendings would routinely work light workweeks
- there would be unemployed fully qualified physicians with a clean license
- physicians would be undercutting each other and compensation would be driven down by competition for patients
- it would be possible to get an appointment immediately to see many types of doctor

I'm interested to see how you respond to this, exPCM. Truth is, anyone can lie with statistics, and maybe there's some saying there is/will be a surplus, and other statistics saying there is/will be a shortage. However, common sense seems to overwhelmingly support only one possibility...

 

[GeraldMonroe]

Why is everyone so certain that the number of residency spots funded by medicare is going to stay fixed? I know politicians are stupid, but right now the party in power wants to lower the costs for medicare. The democrats also have a vested interest in providing "free" health insurance for a large demographic group of people who usually vote democrat...

Anyways, it's a common, publicly held belief that the the AMA creates an artificial monopoly on physician training in order to drive up prices. Every last politician on capital hill who is considering health care reform has to know this. Thus, one of the logical first steps towards reform would be to increase GME funding in order to create more physicians. Even if that meant importing thousands of FMGs to fill the excess open spots.

I'm not saying that this is the best idea, I just don't see why Congress would not have this as an early step for healthcare reform.

 

[exPCM]

Thanks. So, 7-8% more competitors. That isn't "good", but it isn't unbeatable. So if a residency had 100 spots, and an 88% match rate, then it would have an 81% match rate in 2013. (there's a specific residency I'm interested in with an 88% match rate)

I guess I should study hard and hope I'm not in that last 7%. But an 80% chance is high enough that it's plausible to make it happen.

This is really lame that nothing is being done to alleviate the projected physician shortage.

You've got one set of numbers, exPCM, that says there isn't one. However, how do you compensate for :

1. Population growth since the 1980s when the number of med school sets were fixed
2. Baby boomers
3. doctors retiring earlier than projected
4. Women doctors statistically working 20% fewer hours than men (it's great that more women are doctors, but this does need to be taken into account for future planning)

All that sounds like it would create a shortage, which is why the recommendation to increase seats was supposedly made.

If there is not going to be a shortage due to the baby boomers decaying and the demographics of the physician workforce changing to include people who work fewer hours, then there must be a surplus of doctors right now. That is, if the current ratio of doctors is more than enough, such that the increased future demand will not put a strain on them, then there must be extra doctors today.

If there were currently a surplus of doctors
- current attendings would routinely work light workweeks
- there would be unemployed fully qualified physicians with a clean license
- physicians would be undercutting each other and compensation would be driven down by competition for patients
- it would be possible to get an appointment immediately to see many types of doctor

I'm interested to see how you respond to this, exPCM. Truth is, anyone can lie with statistics, and maybe there's some saying there is/will be a surplus, and other statistics saying there is/will be a shortage. However, common sense seems to overwhelmingly support only one possibility...

I do not really know for sure if we are going to a physician shortage or a surplus in the future as these predictions have many variables to account for. Many physicians are now postponing retirement as their 401ks have been hammered. Midlevels are replacing physicians in many places. DNPs will be entering practice in the next few years. The elderly population is growing as the baby boomers retire. There may in fact be an overall shortage or an overall surplus in the future but if you research this issue you will find that 10 years ago the IOM was predicting a surplus ( http://www.nihp.org/Issue Briefs/Workforce Newsletter.htm ) and now we have the AAMC projecting shortages http://www.aamc.org/workforce/recentworkforcestudies2008.pdf
I am not certain who is right on the surplus/shortage.

What I am certain of is that without an increase in residency spots there will basically be no increase in the supply of physicians. I am also a firm believer that the med schools are using these shortage projections as a justification for ramping up enrollments and not admitting that a big factor in the enrollment increases is the goal of bringing in more tuition money to help improve med schools finances.

 

[Law2Doc]

Why is everyone so certain that the number of residency spots funded by medicare is going to stay fixed? I know politicians are stupid, but right now the party in power wants to lower the costs for medicare. The democrats also have a vested interest in providing "free" health insurance for a large demographic group of people who usually vote democrat...

Anyways, it's a common, publicly held belief that the the AMA creates an artificial monopoly on physician training in order to drive up prices. Every last politician on capital hill who is considering health care reform has to know this. Thus, one of the logical first steps towards reform would be to increase GME funding in order to create more physicians. Even if that meant importing thousands of FMGs.

I'm not saying that this is the best idea, I just don't see why Congress would not have this as an early step for healthcare reform.

Training residents costs a ton of money. Politicians don't usually have to go further than this point -- they would have to earmark a lot of money to provide for more doctors -- not a very salable position in an era where healthcare costs are already deemed too high. And adding new residencies doesn't generate new doctors to the locations that need them necessarily. And it's a slow process -- you really have to start this before you have a shortage because by the time someone emerges from residency it's at least 3+ years after whenever you created a new residency slot. While there is currently a shortage of residents in some regions and specialties, this is largely driven by the aging baby boomer generation. The generation immediately behind that one is substantially smaller, so once the baby boomers die off, the demand for healthcare drops off precipitously. (Anyone who works in college admissions can tell you that the number of college age kids is starting to drop off over the last few years.) So it's a lot of older people, living longer that is the drag on healthcare currently, but it's a problem with an end in sight -- it would be short sighted to address this shortage only to have doctors emerge from residency just as the demand was starting to tail down.
But you also have to take into account that med schools are increasing and residencies are not by design. The AAMC published a number of statements, in 2005, indicating that US schools should fill US healthcare needs, and that it would be preferable if all US doctors attended schools with LCME oversight, to ensure a certain standard of quality. Since then med schools have been encouraged by the AAMC to dramatically increase enrollment, but no increase was seen in residencies. So it seems pretty clear that the AAMC is moving toward its goal, in theory forcing non-US trained folks out of the game by having them compete for fewer and fewer slots each year. Eventually the offshore locations will go bankrupt after a few years of students graduating and not being able to find slots. That, I believe, is the master plan here.

 

[exPCM]

Why is everyone so certain that the number of residency spots funded by medicare is going to stay fixed? I know politicians are stupid, but right now the party in power wants to lower the costs for medicare. The democrats also have a vested interest in providing "free" health insurance for a large demographic group of people who usually vote democrat...

Anyways, it's a common, publicly held belief that the the AMA creates an artificial monopoly on physician training in order to drive up prices. Every last politician on capital hill who is considering health care reform has to know this. Thus, one of the logical first steps towards reform would be to increase GME funding in order to create more physicians. Even if that meant importing thousands of FMGs to fill the excess open spots.

I'm not saying that this is the best idea, I just don't see why Congress would not have this as an early step for healthcare reform.

Aprogdirector has already answered why GME funding will not increase.
This idea that the AMA is "driving up prices" is a myth. Physician reimbursements have not even kept up with inflation over the last 20 years and these reimbursements are set by Medicare and other insurers and not by the AMA or physicians. Big reimbursement cuts are in the works for 2010. The only thing that has kept physician incomes from dropping over the last 20 years is that physicians are working harder and seeing more patients to compensate for declining reimbursements. For example catarct surgery reimbursement has gone from $2800 to $600 since 1987 - How does this indicate that the AMA is "driving up prices"?

 

[GeraldMonroe]

While there is currently a shortage of residents in some regions and specialties, this is largely driven by the aging baby boomer generation. The generation immediately behind that one is substantially smaller, so once the baby boomers die off, the demand for healthcare drops off precipitously.

How long will this take to happen? My back of the envelope math says 34 years from today. If that were true, I would be probably be less than 10 years from retirement by the time the baby boomers were mostly dead and no longer requiring resources.

Also, I hate to over-complicate this discussion, but what about medical care increasing in complexity? Biotech products like ribozymes and gene therapy are inherently a lot more complex than pharmaceuticals. If the stem cell and regenerative research ever produces useful results, then it will be possible to do various complex auto-tissue transplants.

Further, every complex medical treatment that works creates even more work for future physicians. Even patient who survives a disease has to be treated for the next disease they get, and so on and so forth. Also, many diseases aren't cured, they are managed, and when a patient is being managed for one disease and then develops a new one, their care becomes more and more complex.

 

[GeraldMonroe]

I just thought of something new to add to the discussion.

There's big talk about midlevels (PAs and NPs) coming to take the jobs away from physicians. No need for PCP physicians, midlevels will do all the work. Everyone on these forums gripes about how midlevels have a pathetic amount of education relative to physicians. They predict that patient care will suffer, and physicians will have to work for peanuts in order to even have a job.

Think about this logically

There's one of two possibilities

a. Maybe being a Primary care physician isn't that hard. Maybe, with the help of computer databases, a midlevel could do the job of a PCP just as well, and patients and society both benefit. I don't believe this either, but if it were possible to do the job up to standards with less training, then it's tough luck for doctors. No one deserves to have their job protected just for the sake of creating a job. Otherwise we'd still have railroad brakemen.

b. Midlevels will do a poor job, and will mismanage the patients they see quite badly. Patients will have all sorts of diseases misdiagnosed, and will get sicker and sicker. Chronically ill patients won't be managed correctly, and will get progressively more ill.
Think about this from a Machiavellian perspective. Most of the time, a midlevel probably won't screw up so badly as to actually kill a patient, which is bad for everyone. No, they'll let the patient get sicker and sicker until they have to be treated by a specialist physician. Hooray! More work for doctors of every specialty, since usually sicker patients require a dangerous intervention or procedure in order to treat them. For instance, heart disease can be managed with drugs, but if it gets bad enough, it has to be corrected surgically. Cancer is easy to excise when it's small, but if it gets large, the patient will need an elaborate course of chemo and radiation stretched out over years until the patient inevitably succumbs.

Terrible for patients, of course. I'm never letting any of my family see a midlevel for anything more serious than a cold. But it doesn't seem likely that they will be stealing the jobs of most doctors...

End note disclaimer : I do acknowledge that "midlevels gone wild" is a bad thing. I'm just suggesting that it won't necessarily have the detrimental effect on employment for those of us who don't take the easy way out, and do 10 years of post-college education.

 

[GeraldMonroe]

Aprogdirector has already answered why GME funding will not increase.
This idea that the AMA is "driving up prices" is a myth. Physician reimbursements have not even kept up with inflation over the last 15 years and these reimbursements are set by Medicare and other insurers and not by the AMA or physicians. Big reimbursement cuts are in the works for 2010. The only thing that has kept physician incomes from dropping over the last 15 years is that physicians are working harder and seeing more patients to compensate for declining reimbursements.

My response to this is simple. Every attending physician I've ever seen or heard about is busy with patients. Most of them are frankly swamped. I suspect you are as well. The insurance industry has a near monopoly on pricing, which means that the industry can distort prices as it sees fit.

Are you saying that the reason for the price decline is because of a surplus of physicians? I say the price decline is mostly caused by the monopoly power of medicare. Also, the procedures with the biggest declines are ones that probably have become much more common than they were before.

Doctors are refusing to see these medicare patients for the reason you are displaying in that chart. An economist would tell you that this shortage of supply generally indicates a price ceiling that is below the market price. If there were a current surplus of physicians, doctors would not be refusing to see medicare patients.

 

[Tigerz_Fan]

Oh jeez, massa! I should know mah place massah! Please forgive dis uppity negro, massah!


really? Did it give you a good laugh? Cause I found it quite stupid and offensive. No place for racial undertones in this convo IMO.

It was a comment that caught me off guard in the middle of such a serious conversation. It made me laugh because it caught me off guard, not because of the implications. If that offends you, then I apologize.

 

[exPCM]

My response to this is simple. Every attending physician I've ever seen or heard about is busy with patients. Most of them are frankly swamped. I suspect you are as well. The insurance industry has a near monopoly on pricing, which means that the industry can distort prices as it sees fit.

Are you saying that the reason for the price decline is because of a surplus of physicians? I say the price decline is solely and completely caused by the monopoly power of medicare.

Doctors are refusing to see these medicare patients for the reason you are displaying in that chart. An economist would tell you that this shortage of supply generally indicates a price ceiling that is below the market price. If there were a current surplus of physicians, doctors would not be refusing to see medicare patients.

Your simple response is flawed. Many doctors I know have threatened to stop seeing Medicare patients but very few have actually done this. The reimbursements have also been cut by Cigna, Aetna, United, Blue Cross, etc. so there is no way to avoid cuts unless you do not take any insurance. How many ophthalomologists or radiation oncologists or orthopedic surgeons do not take Medicare? How often is cataract surgery, cancer treatment, and joint replacement performed on the over 65 versus the under 65 population?
There are very few "concierge" physicians who are able to get by without taking any insurance plans. Many docs rightly feel that if they don't take insurance they will lose most of their patients to their competitiors that do take insurance.

 

[Tigerz_Fan]

aPD has an excellent post, as always...

I can understand everyone's point of view in this thread. But, let's remove the visa issue for the moment:

If we do a separate match for AMG vs FMG, what will we do with our US citizens who train elsewhere?

What I mean by that, even US-citizen Carib students are certified by ECFMG which makes them a FMG regardless of citizenship status. Even though all clinicals are in the US. Also, many US citizens train abroad without US clinical experience.

So do we have a separate match for all of FMG vs AMG? Or will we consider our US citizens who had to leave for their training? And if we separate it out like that, then will be separate the US citizens who did clinicals in the US vs those who didn't?

I'm not sure what the right answer is, and there is a strong possibility that there really is no correct way to fix the situation.

 

[psychforme]

What I mean by that, even US-citizen Carib students are certified by ECFMG which makes them a FMG regardless of citizenship status. Even though all clinicals are in the US. Also, many US citizens train abroad without US clinical experience.

Honestly, why care about the leftovers who couldn't get into a real medical school? Let them practice in the caribbean.

 

[Tigerz_Fan]

Honestly, why care about the leftovers who couldn't get into a real medical school? Let them practice in the caribbean.

The "psychopathology" is evident now:

http://forums.studentdoctor.net/showthread.php?t=533643

Anyway, interested to see what others have to say....

 

[DarthNeurology]

To try to get back on track here:

Although I have nothing against IMG's at all, the US is likely going to need to limit the number of IMG's getting residency spots and prioritize spots to US grads. The system is coming to the breaking point. However, I don't think we'll get to a two stage match -- 1) PD's will hate it, 2) It would delay IMG appointments even later which would cause more visa problems, and 3) it would not affect programs who take candidates outside the match, and because of #2 might actually encourage programs to take more residents outside the match. So, unless the match becomes "all in" = everyone must use it, then I don't see this as a solution.

I think there was almost a poor "US grad match" as about 1,700 US seniors and past graduates of US schools went unmatched this round. I think that if the son or daughter of a "big whig" doens't match, they will be focused on applying more broadly in the next match, and won't try to limit H visas as this would take too long. I seriously doubt that the Obama administration would want to limit H visas to decrease competition for US grads, partly as Obama is part Kenyan and appears to be pro-immigrant.

While US medical schools may believe that the students they are producing are a "better product", there are literally thousands of IMGs/FMGs that have a better application, higher board scores and clinical evals, than perhaps the bottom 10 to 25% of US schools.

Also, many residency PDs are foreign grads themselves, and if not, then have taken foreign grads into their programs for years. One such community IM program I have seen takes almost ALL, i.e. 95% of their residents from India, and many of their attendings are foreign trained, there is no incentive for the PD to favor US grads over IMGs/FMGs. A person at a US school would have to call them and say "Uh, a lot of our students didn't match last year, how do you think they are stacking up when they apply to your program?" Also, many US grads wouldn't apply to many of the places that FMGs/IMGs train, which is why many don't participate in the match, as they are run-down compared to academic medical centers affiliated with US schools, and they are in poor locations. Would a US student want to go to residency in Harlem or the Bronx?? Such locations have many FMGs/IMGs . . .

The only way to "force" residency programs to take US grads is to make a law, like restricting the H visa, which will not be passed under the current administration. At any rate "forcing" residency programs to take US students won't be possible as PDs feel they have the right to decide who is best for their program, the best that would happen is that some residency programs over the next 10 years might have a higher and higher percentage of US grads, but certainly not enough to accomodate the huge increases in the AMG population.

Nobody has to do anything. Sure US medical school administrators might say that we "have to do something" to give US med school students jobs. But nobody cares besides the AMGs left out and the US med schools, and considering how heterogeneous the residency programs are in the US, the problem won't get "fixed". There will always be FMGs/IMGs by the thousands applying to and matching in residency, totally displacing them would take decades and a change in culture. Maybe 100% acacemic centers can be made to take all US students no matter how bad they are, but many community programs won't. There will always be places that US grads don't want to go for residency training . . .

The biggest problem is that the residency positions that will be "fought over" are in primary care fields like IM, Peds, Family . . . the percentage of US students wanting these fields will have to change, and more US students aiming for pretigious IM residencies will have to settle for IM in podunk country. The strain in terms of enough derm, etc . . . residencies is being felt. Even amoung residencies like surgery, IMGs/FMGs are filling these by the boat load, as there are many FMG run surgery programs. So the "poor match" for US grads has already happened for hundreds of US med students who wanted surgery or radiology, couldn't get it, while many US IMGs and FMGs did . . . there wasn't an outcry when this happened and it will happen for IM and Peds too.

While many law school grads can't find a job after graduation, or can't find the right or good job, if the same thing happens to a small but significant percentage of US students, say 10% don't match each year, there won't be any tears shed by many outside of US medical schools and this won't be seen as a "problem" by Congress or anyone outside of medicine and will just be considered a reality and a consequence of US schools ramping up enrollment numbers to make money a sort of "administrators at US schools got what they deserved" as this is trying to form a monopoly on residency positions in the US, which has had a long history of being a meritocracy as FMGs/IMGs do get orthopaedic surgery positions even . . . The price of getting significant monopoloy on all the residency positions in the US for AMGs will be that maybe 10% of US med schools classes don't match. Remember that thousands of perhaps qualified IMGs/FMGs don't match while the best of them do, there is a HUGE pool of FMG/IMGs to compete against.

In the end if there is "poor US grad match" in the future it is the fault of the US med schools that ramped up enrollment in the name of greed and wanted to create a monopoly on residency positions, and they are the ones to blame. It will be impossible for US grads to simply displace FMGs/IMGs at many program as there is no incentive for PDs to do this, many of whom are FMGs/IMGs.

 

[McGillGrad]

The "psychopathology" is evident now:

http://forums.studentdoctor.net/showthread.php?t=533643

Anyway, interested to see what others have to say....

Results from that gosh darn search function always pops up at the most random times, eh.

 

[dilated]

The only way to "force" residency programs to take US grads is to make a law, like restricting the H visa, which will not be passed under the current administration. At any rate "forcing" residency programs to take US students won't be possible as PDs feel they have the right to decide who is best for their program, the best that would happen is that some residency programs over the next 10 years might have a higher and higher percentage of US grads, but certainly not enough to accomodate the huge increases in the AMG population.

Actually, all that would have to happen is for CMS to declare that Medicare graduate education payment will only pay salaries for US citizen residents. Or that it will only pay for non-US citizens if a suitable US citizen cannot be found (EXACTLY like an H1B visa already is). Overnight the number of IMGs accepted would drop by 95%.

 

[McGillGrad]

If you look at France's system, it is much more fair and effective than the American system.

Anyone can take the medical school entrance exam, but only the top 10% (or so) can move forward. There are no prerequisites besides the entrance exam and that allows for flexibility in the numbers of doctors to train without a huge lag (such as is seen with the increase in spots in US med schools).

I am pretty certain you have to be a Frnch citizen, though. And the average pay for a French physician is 60,000 Euro. Then again, you only work 32 hours a week. Give and take, I guess.

 

[McGillGrad]

Actually, all that would have to happen is for CMS to declare that Medicare graduate education payment will only pay salaries for US citizen residents. Or that it will only pay for non-US citizens if a suitable US citizen cannot be found (EXACTLY like an H1B visa already is). Overnight the number of IMGs accepted would drop by 95%.

That is true, but so would the quality of medicine in the US.

 

[racerx]

I find it interesting that U.S. tax dollars, in the form of medicare money, are being used to fund training of physicians who often go back to their home countries to practice. Shouldn't taxes be used first to help the people from which they're collected?

Call me a xenophobe if you will, but I think we need to ensure U.S. tax dollars are going toward helping U.S. citizen's first.

 

[Hernandez]

That is true, but so would the quality of medicine in the US.

You think that 1000-2000 less FMGs per year in residencies would affect the quality of medicine in the US in any measureable way? I've seen juast as many FMGs which were lousy clinicians I wouldn't want my family to see as those who were probably better than I am.

 

[Taurus]

So Congress will change what they have control of -- the H visa. The H visa is designed to bring international citizens with advanced / professional training into the US to fill a job that otherwise would not be filled by a US citizen. Congress will see that there are plenty of unmatched US citizens willing to take those spots occupied by H visa IMG's.

If Congress disallows / limits H visas for medical residents, much of the problem will go away. Although some IMG's will come on J visas, many will not. Congress could limit J visas also.

Interesting idea. You already see that with the govt severely limiting banks that take bailout money from hiring foreigners. This certainly would be a quick and cheap solution, although it probably would be just a stopgap measure. You still need to lift that cap eventually.

 

[Pascal8]

Oh jeez, massa! I should know mah place massah! Please forgive dis uppity negro, massah!

WHy isn't McGillGrad banned as yet ? He is a KNOWN TROLL . He is banned at valuemd.com for trolling and multiple accounts .

sdn - flush the turd .

 

[Pascal8]

That is true, but so would the quality of medicine in the US.

oh shut up - stay and spew your " america hatred " in canada or france - don't bring your crap here .

 

[Law2Doc]

...
If we do a separate match for AMG vs FMG, what will we do with our US citizens who train elsewhere?

What I mean by that, even US-citizen Carib students are certified by ECFMG which makes them a FMG regardless of citizenship status. Even though all clinicals are in the US. Also, many US citizens train abroad without US clinical experience.

So do we have a separate match for all of FMG vs AMG? Or will we consider our US citizens who had to leave for their training? And if we separate it out like that, then will be separate the US citizens who did clinicals in the US vs those who didn't?

I'm not sure what the right answer is, and there is a strong possibility that there really is no correct way to fix the situation.

The issue isn't so much about IMG/FMG/US. If you read the 2005 AAMC press releases, it's about US medical education generating enough bodies to satisfy US demand. So the goal is to have US schools increase to the point that they graduate the same number of seniors as slots. By increasing the rolls of US students, you decrease the pool of individuals going offshore; those that do will have an awful time trying to get back.

Meaning if you get to the point where you have to do multiple matches and the like, you will break it down by US schooled vs not US schooled. FMG=IMG in this scheme-- If it's not under LCME control, it's not going to get an equal bite at the apple. If this trend continues and the AAMC dream becomes a reality, look for offshore schools catering to USFMGs to go out of business rapidly.

 

[exPCM]

I think there was almost a poor "US grad match" as about 1,700 US seniors and past graduates of US schools went unmatched this round. I think that if the son or daughter of a "big whig" doens't match, they will be focused on applying more broadly in the next match, and won't try to limit H visas as this would take too long. I seriously doubt that the Obama administration would want to limit H visas to decrease competition for US grads, partly as Obama is part Kenyan and appears to be pro-immigrant.

The Obama administration has already passed a law limiting H1B visas for the banks that have been bailed out as part of President Obama's stimulus package. Just happened with a quick stroke of the President's pen.
BofA Rescinds Job Offers to Foreign MBA Grads: Report
Bank of America is starting to withdraw offers to some MBA students that graduate from US business schools this year, the Financial Times reported Monday.

The $787 billion stimulus package makes it more difficult for financial institutions like Bank of America that receive money from the government's Troubled Asset Relief Program, or TARP, to apply for H-1B visas for highly-skilled immigrants if they have recently laid off US workers, the paper said.

If a bank receives TARP money it must jump through more hoops to hire a foreign worker under the program, including making attempts to hire US workers first. The number of H-1B visas allowed is currently capped at 65,000.

Bank of America was "allowed to have the employees—the problem was Bank of America did not recruit American workers first and/or were going to replace American workers with those MBAs," Ron Hira, assistant professor of public policy at Rochester Institute of Technology, told CNBC.

"And we know Bank of America has policy in place to replace American workers with H-1Bs," Hira said, adding that the highly-skilled visa program is basically just a "cheap labor" program for companies.

see: http://www.cnbc.com/id/29592885
P.S. Are there not any qualified American MBA students looking for a job and graduating from business schools this year who are capable of doing those jobs at Bank of America?

 

[Pascal8]

Its a simple solution .Restrict H1 visas for medical residency which is a training position .

Train US CITIZENS ( AMGS and ECFMG certified US citizens from offshore shcools) first and foremost . ANy shortage of spots that remains can be offered to H1 visa requiring foreign doctors .

Simple as that .

Plan B :

Offer more residency spots