The coming residency bloodbath

[exPCM]

From AMA news November 11:
American allopathic medical schools enrolled 18,390 first-year students for 2009, a 2% increase from last year and a new high, according to the Assn. of American Medical Colleges.

Four new medical schools accounted for half of the 2009 increase: FIU Herbert Wertheim College of Medicine in Miami; University of Central Florida College of Medicine in Orlando; The Commonwealth Medical College in Scranton, Pa.; and Texas Tech University Health Sciences Center Paul L. Foster School of Medicine in El Paso.

Of the other 127 AAMC-member schools, 57 increased the size of their first-year classes by more than 10%, according to the AAMC. The number of enrollees has grown steadily since 1999, when there were 16,221 first-year students.

Applicants to osteopathic medical schools also increased this year. Nearly 13,000 applicants competed for 5,100 available slots, according to the American Assn. of Colleges of Osteopathic Medicine. The increase of nearly 9% from the previous year set a record for the third straight year
http://www.ama-assn.org/amednews/2009/11/09/prse1111.htm

According to the AMA news, medical schools are markedly increasing their enrollments such that there will 19909 allopathic and 5227 osteopathic students admitted in 2012.
This is a total of 25136 US medical school spots per year.
http://www.ama-assn.org/amednews/200...3/prsb0623.htm

The number of Medicare funded resident spots was capped in 1997 and there are ~24000 first year residency spots.
http://www.ama-assn.org/amednews/2009/11/09/prse1111.htm
Also courtesy of aprogdirector is the following table:
--------------------------------------------------------------------------------

Code:
Year Total Filled Unfilled USMG Unmatched
2009 22427 21340 1087 1072
2008 22240 20940 1300 883
2007 21845 20514 1331 1005
2006 21659 20072 1587 949
2005 21454 19760 1694 921
Following the trend, there will be more unmatched USMG's than all available scramble spots next year
Note: 1st year spots in the NRMP have increased somewhat because specialities like urology and neurology used to not be in the NRMP (they had other matches outside the NRMP) but have joined in recent years.

---

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[docB]

Will they up the cap on funded residency spots? There's been a lot of chest thumping about the doctor shortage in Washington but that usually dies down when it comes time to pony up the dough.

 

[lipomas]

And all of them want to be radiologists, dermatologists, or gastroenterologists (unless they do ER).

 

[RegularNihilist]

Great news for those already attendings. You get ppl working their bums off to earn a residency spot, and the bottle neck prevents the market from flooding with doctors. At least something working your way under the threat of obamacare and reduced wages. Everything is cynical and egotistical in this world. So, be happy, every once in a while, when there is good news, and a-hole politics playing in favor of your own interests. Don't worry about the loons touting that the entire licensure and regulations system should be broken, it won't happen anyway. Relax.

 

[agranulocytosis]

I hope not many more will want to match gen surg.

 

[Law2Doc]

I hope not many more will want to match gen surg.

Fields rise and fall in popularity, but there's no real reason to think that each specialty won't see a proportional increase.

 

[Taurus]

Here's an update on increasing residency slots.

Bill Complicates Drive to Add Primary-Care Doctors

By JANET ADAMY

A handful of Democratic senators are pushing to change pending health-care legislation so that it would help increase the country's stock of primary-care doctors, heeding warnings that the bill may exacerbate the difficulty some Americans already have in finding a doctor.

More than 30 million Americans would get health insurance under the health-care overhaul that passed through the House and a similar bill moving forward in the Senate. If that does indeed happen, many previously uninsured people who haven't had a regular doctor before will need a primary-care physician. Demand would also likely increase for nurse practitioners and general surgeons.

But pressure to keep down the legislation's cost led Democrats to exclude one way of alleviating the projected shortage. Medical colleges, backed by some Democrats, want funding for 15,000 more slots for graduate medical residencies in primary care and general surgery. The government currently pays part of the cost for such residencies through Medicare.

Senate Majority Leader Harry Reid co-sponsored a separate bill to do just that this spring. But when doctors pressed him to include the measure in the broader health-care overhaul he crafted, the Nevada Democrat balked because the estimated $10 billion to $15 billion cost over a decade would inflate the bill's overall price too much.

Now, some Democrats are preparing to press for a more limited expansion of residency slots once the Senate begins hashing out the bill on the floor next week. Sen. Charles Schumer of New York plans to introduce an amendment that would add about 2,000 residency spots to the current 100,000. The amendment would give first priority to primary-care doctors and general surgeons.

The scaled-back effort underscores the pressures facing Senate Democrats as they embark on altering a 2,074-page bill that will touch almost every American and remake an industry that accounts for nearly one-sixth of the nation's economy. President Barack Obama has set the cost ceiling for the bill at $900 billion over a decade. That means even widely supported provisions are getting left out because they add to its estimated $848 billion current tab.

"Ideally, we should have the 15,000 that we asked for," Mr. Schumer said of the proposed expansion of residency positions. "But we're all trying to keep the costs of the bill down."

Even without an insurance expansion, the American Medical Association estimates the country will be short 85,000 doctors in primary care, cardiology, oncology and general surgery by 2020.

The shortage is especially acute in certain rural areas. Doctors say the relatively lower prestige and pay in primary care tends to drive medical students into more-lucrative specialties.

Both the House and Senate bills contain provisions to address the issue. The Senate bill increases funding for the National Health Service Corps, which helps repay student loans for doctors, nurse practitioners and dentists who work in underserved parts of the country. Primary-care doctors who participate can get up to $50,000 of loans repaid. The bill also reallocates some unused residency slots toward higher-need areas.

Atul Grover, chief advocacy officer for the Association of American Medical Colleges, said such changes are significant but don't go far enough. Government funding for medical-residency slots hasn't increased since 1997 because of a budget-control bill that froze funding for the spots.

"We're not going to have enough doctors, even if you don't consider expanding insurance coverage to millions of people," Dr. Grover said. "It's just a question of time before it leads to longer waits for all of us to get in to see the doctor."

In Massachusetts, which required people to carry health insurance starting in 2006, wait times to see certain doctors are rising and community hospitals have more acute shortages of family and internal-medicine doctors, according to a study by the Massachusetts Medical Society. Forty percent of family-medicine physicians no longer accepted new patients as of this year, up from 30% in 2007, the study found.

Still, Partners HealthCare, the state's largest health system, said it had generally absorbed the influx of patients. Partners HealthCare got a private sponsor to help fund its own doctor loan-forgiveness programs, and offered reimbursement of up to $75,000 in debt per student.

"I don't think you'd find a lot of horror stories about long waits or people having a bad experience," said chief operating officer Tom Glynn.

Nancy Nielsen, immediate past president of the American Medical Association, predicted a similar outcome nationally if the bills pass. "I think we can indeed anticipate a surge, and then it will settle out," she said, as the initial need for care peters out.

At the University of Arkansas for Medical Sciences, which runs medical training and care facilities throughout the state, Chancellor Dan Rahn isn't so sure. He is pushing for more spots to train doctors in internal medicine, family practice, gynecology and pediatrics, particularly in rural areas. He said psychiatrists from Little Rock must drive 190 miles to care for patients in the northwest part of the state because the university doesn't have funding to train residents there.

He has a potentially powerful ally in his plight: Sen. Blanche Lincoln, a moderate Democrat whom Mr. Reid is heavily courting to support the bill. Dr. Rahn plans to press his case in a meeting with her next week.​

 

[exPCM]

Here's an update on increasing residency slots.

Bill Complicates Drive to Add Primary-Care Doctors

By JANET ADAMY

A handful of Democratic senators are pushing to change pending health-care legislation so that it would help increase the country's stock of primary-care doctors, heeding warnings that the bill may exacerbate the difficulty some Americans already have in finding a doctor.

More than 30 million Americans would get health insurance under the health-care overhaul that passed through the House and a similar bill moving forward in the Senate. If that does indeed happen, many previously uninsured people who haven't had a regular doctor before will need a primary-care physician. Demand would also likely increase for nurse practitioners and general surgeons.

But pressure to keep down the legislation's cost led Democrats to exclude one way of alleviating the projected shortage. Medical colleges, backed by some Democrats, want funding for 15,000 more slots for graduate medical residencies in primary care and general surgery. The government currently pays part of the cost for such residencies through Medicare.

Senate Majority Leader Harry Reid co-sponsored a separate bill to do just that this spring. But when doctors pressed him to include the measure in the broader health-care overhaul he crafted, the Nevada Democrat balked because the estimated $10 billion to $15 billion cost over a decade would inflate the bill's overall price too much.

Now, some Democrats are preparing to press for a more limited expansion of residency slots once the Senate begins hashing out the bill on the floor next week. Sen. Charles Schumer of New York plans to introduce an amendment that would add about 2,000 residency spots to the current 100,000. The amendment would give first priority to primary-care doctors and general surgeons.

The scaled-back effort underscores the pressures facing Senate Democrats as they embark on altering a 2,074-page bill that will touch almost every American and remake an industry that accounts for nearly one-sixth of the nation's economy. President Barack Obama has set the cost ceiling for the bill at $900 billion over a decade. That means even widely supported provisions are getting left out because they add to its estimated $848 billion current tab.

"Ideally, we should have the 15,000 that we asked for," Mr. Schumer said of the proposed expansion of residency positions. "But we're all trying to keep the costs of the bill down."

Even without an insurance expansion, the American Medical Association estimates the country will be short 85,000 doctors in primary care, cardiology, oncology and general surgery by 2020.

The shortage is especially acute in certain rural areas. Doctors say the relatively lower prestige and pay in primary care tends to drive medical students into more-lucrative specialties.

Both the House and Senate bills contain provisions to address the issue. The Senate bill increases funding for the National Health Service Corps, which helps repay student loans for doctors, nurse practitioners and dentists who work in underserved parts of the country. Primary-care doctors who participate can get up to $50,000 of loans repaid. The bill also reallocates some unused residency slots toward higher-need areas.

Atul Grover, chief advocacy officer for the Association of American Medical Colleges, said such changes are significant but don't go far enough. Government funding for medical-residency slots hasn't increased since 1997 because of a budget-control bill that froze funding for the spots.

"We're not going to have enough doctors, even if you don't consider expanding insurance coverage to millions of people," Dr. Grover said. "It's just a question of time before it leads to longer waits for all of us to get in to see the doctor."

In Massachusetts, which required people to carry health insurance starting in 2006, wait times to see certain doctors are rising and community hospitals have more acute shortages of family and internal-medicine doctors, according to a study by the Massachusetts Medical Society. Forty percent of family-medicine physicians no longer accepted new patients as of this year, up from 30% in 2007, the study found.

Still, Partners HealthCare, the state's largest health system, said it had generally absorbed the influx of patients. Partners HealthCare got a private sponsor to help fund its own doctor loan-forgiveness programs, and offered reimbursement of up to $75,000 in debt per student.

"I don't think you'd find a lot of horror stories about long waits or people having a bad experience," said chief operating officer Tom Glynn.

Nancy Nielsen, immediate past president of the American Medical Association, predicted a similar outcome nationally if the bills pass. "I think we can indeed anticipate a surge, and then it will settle out," she said, as the initial need for care peters out.

At the University of Arkansas for Medical Sciences, which runs medical training and care facilities throughout the state, Chancellor Dan Rahn isn't so sure. He is pushing for more spots to train doctors in internal medicine, family practice, gynecology and pediatrics, particularly in rural areas. He said psychiatrists from Little Rock must drive 190 miles to care for patients in the northwest part of the state because the university doesn't have funding to train residents there.

He has a potentially powerful ally in his plight: Sen. Blanche Lincoln, a moderate Democrat whom Mr. Reid is heavily courting to support the bill. Dr. Rahn plans to press his case in a meeting with her next week.​

Let's see - med school enrollments are going up parabolically and this bill increases residency spots by 2000 which is only a 2% increase. If all 2000 spots went to primary care it would provide for an additional 667 first year spots, 667 second year spots, and 667 third year spots. Of course they are saying general surgery is to be included. If half the slots went to general surgery then 1000 slots would provide for 200 PGY1, 200 PGY2, 200 PGY3, 200 PGY4, and 200 PGY5 surgery slots and only 333 per each year (PGY1,2,3) for the primary care slots.
So you would see only 533-667 total new PGY1 slots in the match IF it passed. This will not prevent the bloodbath even if passed.
If passed the legislators could then claim to have fixed the problem and they would not have to entertain further pleas to raise the cap because they could say "we already fixed the problem".
So the bill to increase by 15000 slots is dead as Senator Reid balked at the cost and now this measure for 2000 slots is in the running. The 15000 slots would have made a difference, this is window dressing.

 

[J1515]

Creating more spots isn't going to make people want to go into primary care any more.

 

[Miami_med]

It is amusing to see the acknowledgement that shortages in primary care and general surgery are due to low pay followed by a statement that really does nothing to address the really obvious problem that they've just acknowledged.

 

[spectrin]

when do you think this bottle neck effect will take place..someone from my school's administration said 2012-2013

 

[Labslave]

Hopefully the impact of this will be lessened slightly for AMGs by fewer FMGs being accepted for residency (no offense to any FMGs reading this).

 

[Saga1]

I personally feel that there will be an increase because of many factors such as the AMA saying that there will be no more GME funding to allied health programs, there will be more direct medicare payments to residency programs and the health care bill initiatives.

 

[3dtp]

I personally feel that there will be an increase because of many factors such as the AMA saying that there will be no more GME funding to allied health programs, there will be more direct medicare payments to residency programs and the health care bill initiatives. There's a lot of pressure from many organizations (and now the media) to increase doctor supply. Senator Reid was one of the guys who came up w/ the 15000 slot increase and he's the Democrat leader.
Anyways if there isn't a slot increase most AMGs don't have to worry. I have heard that PDs usually look at AMGs first, then US-DOs and then FMGs. So if you're an AMG you're still good.

The AMA is increasingly a toothless wonder and political pawn that does not represent us. And the country is broke. There's not a lot more money here, there or anywhere. If there are N residency positions and N+Y AMGs, then Y AMGs will be stuck. Perhaps we can resurrect the GP for Obamacare.

 

[exPCM]

The AMA is increasingly a toothless wonder and political pawn that does not represent us. And the country is broke. There's not a lot more money here, there or anywhere. If there are N residency positions and N+Y AMGs, then Y AMGs will be stuck. Perhaps we can resurrect the GP for Obamacare.

Agree with this 100%.

One thing I have seen people post is that for residency selection
US MD> US DO>IMG in terms of order of preference/selection.
I think that this is not uniformly true. I have seen several residency programs that had IMG program directors who would tend to actually give higher preference to IMGs.
There is no law or rule that states that AMGs must get preference for US residency slots. I predict it may become a hot button issue when we start seeing significant numbers of US MDs and US DOs not selected for residency positions (therefore unemployed) while some number of IMGs are continuing to be selected.

 

[ANCAdoc]

There is no law or rule that states that AMGs must get preference for US residency slots. I predict it may become a hot button issue when we start seeing significant numbers of US MDs and US DOs not selected for residency positions (therefore unemployed) while some number of IMGs are continuing to be selected.

I agree this is going to become an issue. Tough debate, but in the end I believe our gov't has an interest stake in US grads being able to complete their training. After all, public education is still subsidized by state gov't.

I'm not so sure FMGs will feel the squeeze as much as we think.

 

[Saga1]

What do you guys think?

 

[exPCM]

I remember reading an artcle in an AHME newsletter about how in a few years American grads will be getting fewer residencies as well because many AMGs apply to primary care residencies as a backup and every year more and more primary care programs sign pre matches w/ IMGs so these AMGs will be straight outta luck. The situation will however still not be as dire for them as it will be for DOs or IMGs. The news letter called for an increase in slots as well.

What do you guys think?

The cap was put in place in 1997 partly due to the fact that growth in new slots and the money to fund them was spiraling upward.
The AAMC and various bodies have tried to get the cap lifted since 1997 without success. Back in 1997 we were in the Internet boom which was followed by the real estate boom.
Now the country is broke and running huge deficits. There is no pot of money to significantly expand GME which is why Harry Reid and most others in Congress stopped the 15000 slot bill.
The biggest advocate of the 15000 slot bill was Senator Schumer who is from New York where they have huge numbers of residents and many hospitals which depend upon and want to increase their supply of cheap resident labor.
Here is a good overview on GME in NY:http://docs.google.com/viewer?a=v&q...2IUo8x&sig=AHIEtbQJ20Zr2WShy3zt1GmKnctaXKpfHA
I think it is very safe to predict that there will not be a significant funding increase implemented to increase residency slots for the forseeable future as US government borrowing is basically maxed out.
The physician shortage is just hype anyway. The main areas of shortage are areas where physicians can't make a living (low socioeconomic, high Medicaid coverage areas). Producing more physicians does not solve the problem that physicians can't make a living in these areas. Anyhow midlevels are being looked at as cheaper alterantives to docs anyway (e.g. Minute Clinics).

In India they have increased med school enrollment enormously allegedly because of the need to fill a shortage of docs in the rural areas. Well they still have a shortage in the rural areas as docs can't make a decent living in the rural areas there. So where are all these new docs from the Indian med schools going - they are going to cities in India or they are going overseas.
http://www.egworkshop2007.net/sessi.... 42 - Mahal - Medical Education in India.pdf

 

[McGillGrad]

...

 

[3dtp]

...

 

[McGillGrad]

Who was it who said:

http://forums.studentdoctor.net/showthread.php?t=331320

Oh wait, it was you. I know it's out of character, but please try to be civil.

...

 

[latinman]

People never change

I am assuming that ur talking about yourself. Don't pay too much attention about what Attendings do or don't do with their free time. If I were you, I would worry about making sure you land a spot in the specialty of ur choice. Once u finish training, and become Board Certified then u will become a God.

At that point, you can then decide how to spend ur free time.

 

[smq123]

All right, enough with the back-and-forthing. Can we keep it on topic, please?

 

[Giemsa]

Just from the Canadian perspective:

The Canadian system operates very close to a 1:1 Canadian med student : residency position.

The match is like musical chairs when there is just enough chairs for everybody: you all get a seat, just not where you might have wanted it.

Without saying whether that's the right way or wrong way to approach residency training, I think that could be where the US is heading, too. By increasing the number of med school seats to match the number of residency spots, it would force the residencies to fill. This is the current approach here.

 

[exPCM]

Just from the Canadian perspective:

The Canadian system operates very close to a 1:1 Canadian med student : residency position.

The match is like musical chairs when there is just enough chairs for everybody: you all get a seat, just not where you might have wanted it.

Without saying whether that's the right way or wrong way to approach residency training, I think that could be where the US is heading, too. By increasing the number of med school seats to match the number of residency spots, it would force the residencies to fill. This is the current approach here.

Giemsa,
Thanks for the Canadian perspective. I think we are heading in the direction of Canada on this issue.
McGillgrad,
I sense you are upset. It is all not doom and gloom if you are an administrator at a medical school - all the tuition hikes and class size expansions are keeping the money rolling in and from another thread on this board it appears that there is a never ending supply of people willing to go 300K or more in debt to become physicians.
If you want to look at something that people should be getting upset about here is a good example. This is from the Tufts School of Medicine website:

http://www.tufts.edu/med/docs/about/offices/finaid/CostsMD.pdf
The prices that schools are charging have become obscene IMO. In the 3rd and 4th years the cost of attendance at Tufts is >80K per year. I actually would not be surprised to see a 100K yearly cost of attendance (COA) at some schools within 5-7 years and I believe that there will be plenty willing to pay even at 6 figure COA rates.
P.S. Having free time does not equate with being a poor physician. I can tell you that the best physicians are often the fastest and most efficient. It is certainly true in pathology. This is also often true in other specialties.
In surgery there is a saying (admittedly debatable): "There are good fast surgeons and bad fast surgeons but there is no such thing as good slow surgeon".

 

[McGillGrad]

What you say is right, but posting on this topic incessantly makes it seem like this is a bad thing.

How is it bad to have enough slots for the best and the brightest? How is it detrimental to have lower salaries that attract more passionate physicians, instead of financial opportunists? Why shouldn't the current system implode under it's own weight in order to force a system whereby patients become more responsible for their health and insurance corporations cede discretionary power back to physicians? Will it harm us in the short-run? Yes, it will. Will it get worse before it gets better? It probably will, but it cannot continue this way.

Giemsa,
Thanks for the Canadian perspective. I think we are heading in the direction of Canada on this issue.
McGillgrad,
I sense you can't handle the truth. It is all not doom and gloom if you are an administrator at a medical school - all the tuition hikes and class size expansions are keeping the money rolling in and from another thread on this board it appears that there is a neverending supply of people willing to go 300K or more in debt to become physicians.
I can tell you that the best physicians are often the fastest and most efficient. I can make a diagnosis on a good portion of my daily cases in less than 30 seconds. Another pathologist may spend a lot more time but that does not equate with being better. This is also true in other specialties.
In surgery there is a saying: "There are great fast surgeons and bad fast surgeons but there is no such thing as great slow surgeon".

 

[exPCM]

What you say is right, but posting on this topic incessantly makes it seem like this is a bad thing.

How is it bad to have enough slots for the best and the brightest? How is it detrimental to have lower salaries that attract more passionate physicians, instead of financial opportunists? Why shouldn't the current system implode under it's own weight in order to force a system whereby patients become more responsible for their health and insurance corporations cede discretionary power back to physicians? Will it harm us in the short-run? Yes, it will. Will it get worse before it gets better? It probably will, but it cannot continue this way.

I see you are passionate on some of these issues. However, I don't make the rules and I am not rooting against you. I wish you well in your career.
I am posting some information that I feel that applicants do not always get from their school administrators and faculty.

 

[McGillGrad]

I see you are passionate on some of these issues. However, I don't make the rules and I am not rooting against you. I wish you well in your career.
I am posting some information that I feel that applicants do not always get from their school administrators and faculty.

I reread my post and left out one important thing. I meant to say best and brightest of LCME schools. If there are extra places for USIMGs or IMGs, then fine, but most spots should be filled with qualified US grads because they will best represent US regulated medical education.

If an IMG/USIMG can prove to be worthy, then there will be places for them because America has always rewarded those who excel in their fields. Medicine is hardly a place for mediocrity.

 

[Coastie]

Medicine is hardly a place for mediocrity.

Agreed, which is why carib med schools are near the end of their lifespan, imho. Carib grads will be squeezed out in the coming blood bath, and it won't be pretty.

I think non-matched MD/DO grads should be able to work as mid-levels with mid-level pay (80-130k), building their resume', and reapplying to residency when they choose.

This would increase the level of mid-level care. Of course, PA/APRN groups would be upset. I hope the increase in available mid-level care would squeeze out APRNs, and stabilize the mid-level "shortage".

 

[Saga1]

Agreed, which is why carib med schools are near the end of their lifespan, imho. Carib grads will be squeezed out in the coming blood bath, and it won't be pretty.

I think non-matched MD/DO grads should be able to work as mid-levels with mid-level pay (80-130k), building their resume', and reapplying to residency when they choose.

This would increase the level of mid-level care. Of course, PA/APRN groups would be upset. I hope the increase in available mid-level care would squeeze out APRNs, and stabilize the mid-level "shortage".

Only the good carib grads make it to residency

 

[Saga1]

I think the idea of following the Canadian example would be good for the US. Enough spots to cloesly match the number of AMG graduates. Have one match with all AMG's in it with no prematching allowed. What remains could be dispensed to FMG/IMG. Hopefully, this would stop/significantly decrease the ridiculous Caribbean education system that has developed.

There are problems with this scenario for several reasons

 

[StevenRF]

The prices that schools are charging have become obscene IMO. In the 3rd and 4th years the cost of attendance at Tufts is >80K per year. I actually would not be surprised to see a 100K yearly cost of attendance (COA) at some schools within 5-7 years and I believe that there will be plenty willing to pay even at 6 figure COA rates.

http://med.stanford.edu/md/financial_aid/files/2009-10 SOM Budget_revised_102809.pdf

95k for a four quarter year. When tuition at schools starts to break the 100k mental barrier, maybe med school will make the news. It's sad they can even charge tuition during third and fourth year. 400k could buy you a nice 3bedroom house, all the furnishings, and two cars for the garage in some places in this country. Its pretty ridiculous.

 

[Saga1]

While I do see some validity in your points, I few things seem off. The number of people completing residency will stay consistent despite the increased number of graduates and and decreased FMG/IMG's taken so I don't see long wait times like Canada happening because the supply of physicians will continue. The problem in our country isn't so much a lack of physicians but a maldistribution of physicians with saturation in big cities.

I disagree, as the population increases and the supply stays constant wait times will continue to increase. I don't see a real redistribution happening either as most physicians would rather live in big cities making more money than live in the rural areas. There is a reason why the J visa can be waived if IMGs decide to stay in rural areas.

As to Canada being more friendly to FMG/IMG's; taking US grads back to canada isn't the issue. What to look at is the number of foreign trained grads taken into Canadian residencies; while there has been some increase with respect to this it is no where near the level of the US.

There has been an increase in Canadian born/raised IMGs matching. It is easier for a Canadian who has gone to an international school to match back in Canada compared to an IMG from India or Egypt for 2 reasons: a) common culture b) a young IMG is a lot better investment than an older one. Nonetheless the US is still a better option for all IMGs.

As for my opinion on the Caribbean vs. FMG issue. I personally would like all Caribbean schools banned, including the Big 4. The are simply pandering for the most part to a group of students who couldn't cut it with their GPA's, MCAT's, etc. and who chose the easy way out by leaving the country for a 2nd class education. While many cite excellent board scores by these grads, I question the validity of these scores when i see cases of students studying for 2-6 months gor these tests when most of my colleagues studied 3-4 weeks. I would rather the US fill its spots with FMG's (Asia, etc.) who were born in other countries and probably had to be in the top percent of the population to get into a med school in their home country and want to immigrate for a better life for themselves and their families than the typical Caribbean grad.

Caribbean is not the easy way out.

 

[Saga1]

The population may be aging, but significantly increasing I don't think so. Further, increasing the number of residency spots won't change people's desire to live in bigger cities. So increasing the spots will just worsen the saturation and is unlikely to cause a significant benefit to underserved areas. The best way to spread doctors out to underserved areas is to add further monetary incentives..

Would adding more incentives be more costly?

Whether you like it or not, the Caribbean is the easy way out. Am I supposed to sympathize with the fact that they have to live on a foreign island, have poorer rotations, or score higher than AMG MD/DO to get a residency? The reason it is the easy way out is that the requirements to get into an American MD school are higher and considered to be the primary form of medical education in this country. Instead of working to increase GPA (difficult and time consuming), improving their MCAT scores (difficult and time consuming) or expanding their extracurriculars the leave. That is taking the easy way out.

I never asked for your sympathy, I am just logically looking at whether it is the 'easier' route. It might be much easier to get into a caribbean medical school than an LCME school, but it is much easier to get a residency as an AMG compared to a FMG/IMG. Only 50% of carib grads get a residency.

 

[Saga1]

I agree with you when it says it's harder to get a residency, and it should be. But when you look at the quality of the education and the average stats of a matriculant it is easier in a Caribbean med school so I still consider it the easy way out because instead of going to the first tier of medical education in the US (i.e a US MD/DO school), Caribbean students are willing to lower their standards to go to whatever med school is out there.

As for other US nationals going to med schools In Australia, Ireland, Poland, etc they have to be weighed on a case by case basis. Some of these international schools are excellent and deserve to be considered as such. But many are simply money factories that exploit young people's desires to become physicians at the cost of a proper education and those should not be treated equally.

I agree with you that caribbean grads should work harder to get less sought after residencies. And I agree that the quality of education is lower, especially in terms of clinical rotations. However I will still stick to the fact that only those from the Big 4 should be strongly considered and that they are taking the less desired residency spots, which otherwise would go towards promoting the agenda of the much less qualified NPs. Their education standards, although not up to the quality of LCME schools are still alright.

Anyways some bad news on the residency front. A sign of things to come perhaps?
http://www.aafp.org/online/en/home/...ent-student-focus/20091130kelsey-seybold.html

 

[exPCM]

http://www.aamc.org/workforce/enrollment/enrollmentreport.pdf
A picture is worth a thousand words. Can you imagine what this will do as far as competition for residency slots?

 

[dragonfly99]

exPCM,
this is a good thing for premedical students. It shows that there are now more medical school spots open for qualified US premedical students to go to medical school in the US, and that we are (finally) producing more doctors. Now maybe we won't have so many people with 3.7 GPA, hundreds of volunteer hours in hospitals and 30+ MCAT scores who can't get into any US medical school.

 

[pillowhead]

those budget numbers from stanford and tufts are just obscene. when the budget for one year of medical school exceeds the entire income of the average US household, we've clearly got a problem.

 

[exPCM]

exPCM,
this is a good thing for premedical students. It shows that there are now more medical school spots open for qualified US premedical students to go to medical school in the US, and that we are (finally) producing more doctors. Now maybe we won't have so many people with 3.7 GPA, hundreds of volunteer hours in hospitals and 30+ MCAT scores who can't get into any US medical school.

Agree.
However in the end it is the number of residency slots that primarily determines how many doctors we produce. Residency slots are not increasing commensurately. The IMGs that formerly took many slots generally (over 90%) stayed in the US to practice after residency.

those budget numbers from stanford and tufts are just obscene. when the budget for one year of medical school exceeds the entire income of the average US household, we've clearly got a problem.

I agree that obscene is a term that sums it up well. Looking at these reports is amazing: https://services.aamc.org/tsfreports/
Tuition continues to spiral up much faster than inflation and there seems to be no end in sight.

 

[Law2Doc]

...
However in the end it is the number of residency slots that primarily determines how many doctors we produce. Residency slots are not increasing commensurately. ..

It's not accidental. There have been press releases since 2005 from the AAMC that US students should fill US residency needs and that doctors should not be trained outside of the states where the LCME isn't able to set standards of education. So this increase in school slots without a commensurate increase in residency slots is a very calculated step toward pushing the offshore crowd out of the applicant pool. It's no secret that US residencies take US med school grads first, and caribbean students fight for the remaining spots. Once those remaining spots are gone, expect the offshore schools to disappear. This is a calculated attack on the offshore programs by the AAMC. They telegraphed their punch years ago.

 

[Doctor Bagel]

It's not accidental. There have been press releases since 2005 from the AAMC that US students should fill US residency needs and that doctors should not be trained outside of the states where the LCME isn't able to set standards of education. So this increase in school slots without a commensurate increase in residency slots is a very calculated step toward pushing the offshore crowd out of the applicant pool. It's no secret that US residencies take US med school grads first, and caribbean students fight for the remaining spots. Once those remaining spots are gone, expect the offshore schools to disappear. This is a calculated attack on the offshore programs by the AAMC. They telegraphed their punch years ago.

I'm wondering if it will go as smoothly as all that based on the # of programs that are so used to filling with IMGs and don't even bother with the match. If you look at last year's match, more US grads went without a spot than before because of more people entering the match, even though overall there were still more spots than US grads. And if there's no mandate, are you sure programs would always opt to fill with US grads (even subpar ones) over IMGs? We assume that will happen, but it might not. And changing the culture in programs that are so used to relying on the pre-match and on recruiting (and sometimes abusing) IMGs won't happen seamlessly, meaning that it's possible more US grads in the future will be left out in the cold.

 

[Spiker]

One thing that I never get is why do they cry so much about 10-15 billion. It is literally nothing compared to the country's total budget.

Why does government pay 100k per slot. Resident get paid like 40k. So the net productivity of a resident is -60k? Is a resident such a toxic asset?

Maybe to solve that problem they should alot a resident to bill for their service under supervision. NP can do it right out of school, why are we so scared about letting residents do the same (maybe after 1 year of residency already so they know more of what they are dong)?

 

[JackADeli]

...Why does government pay 100k per slot. Resident get paid like 40k...

It can actually be more the $100k. Again, most residents get full benefits to include "cadillac health insurance plans", malpractice insurance coverage, most get dental and optical as well, some get retirement accounts, etc.... In addition there are other costs associated with teaching.... simulation labs, animal labs, etc.... I can not speak to if $100k is too much or not enough. But, there is clearly more costs then just the salary.

 

[Spiker]

It can actually be more the $100k. Again, most residents get full benefits to include "cadillac health insurance plans", malpractice insurance coverage, most get dental and optical as well, some get retirement accounts, etc.... In addition there are other costs associated with teaching.... simulation labs, animal labs, etc.... I can not speak to if $100k is too much or not enough. But, there is clearly more costs then just the salary.

But it is not like the resident dont do **** and just sit there all day? I mean at worst I would think they can produce the same amount of work as two nurses? (or 1 nurse working 80 hours).

Do you know how much profit-if any- the program itself takes?

 

[Winged Scapula]

But it is not like the resident dont do **** and just sit there all day? I mean at worst I would think they can produce the same amount of work as two nurses? (or 1 nurse working 80 hours).

Do you know how much profit-if any- the program itself takes?

I think you're missing the point.

Whatever CMS gives programs to educate residents, on top of the salary, the program may provide health insurance, life insurance, malpractice insurance, meals, book funds, retirement plans, etc. and faculty who teach get a teaching salary usually from those funds. Its not like the programs are pocketing $60K per resident.

Clearly, residents are a money saver for hospitals when you consider you'd have to hire (and pay) at least two allied health professionals to replace a single resident. Residents work longer hours, see more patients and are more efficient than allied health care professional.

But no one can tell you how much money/profit hospitals make from having residents because the amount paid, the costs, etc. vary between programs. Hospitals claim they lose money on residents due to inappropriate test ordering and the cost of teaching...whether that's true or not is difficult to assess, but it seems unlikely to me that a single resident would order $80K (a PA salary) worth of extra tests a year.

 

[dannyboy1]

It's not accidental. There have been press releases since 2005 from the AAMC that US students should fill US residency needs and that doctors should not be trained outside of the states where the LCME isn't able to set standards of education. So this increase in school slots without a commensurate increase in residency slots is a very calculated step toward pushing the offshore crowd out of the applicant pool. It's no secret that US residencies take US med school grads first, and caribbean students fight for the remaining spots. Once those remaining spots are gone, expect the offshore schools to disappear. This is a calculated attack on the offshore programs by the AAMC. They telegraphed their punch years ago.

Why are people in support of this policy. Until now we had a good thing going with US allo grads getting the best residency spots and the crappy residencies going to IMG/DO. Instead what will happen is that there will be more unhappy US grads who now have to fill these spots. This policy of the AAMC to stick it to the carribean schools will also screw many US grads.

 

[samuraiR]

but it seems unlikely to me that a single resident would order $80K (a PA salary) worth of extra tests a year.

Really? An average CT scan cost 2k - 3k. If an average resident orders 2 unnecessary CT scans a MONTH, that's almost 50k-70k a year. You don't think that's plausible?

 

[Winged Scapula]

Really? An average CT scan cost 2k - 3k. If an average resident orders 2 unnecessary CT scans a MONTH, that's almost 50k-70k a year. You don't think that's plausible?

Nope because residents are not ordering tests like CT scans wily nily without some faculty input. I think you overestimate the autonomy of residents. Besides, a CT scan does not cost the hospital 2-3K. That may be what it says on your insurance paperwork, but if you were self-pay, you'd be charged a ton less. For example, chest MRI for self-pay patients at one local facility cost $862; insurance charge? Around $2600.

The major cost of residents comes in things like unnecessary lab work, delay of discharge because other services weren't consulted, multiple kits/materials used when training residents or when they make a mistake (ie, contaminate a central line kit), decreased OR through-put (due to being able to do fewer cases per day). As a resident, we used to order daily labs on our patients and all post-op patients got a post op HCT, even if the amount of blood lost was in drops. This was old-school and cost the system a lot. Now that I'm in charge, I say, "why?" and only do things that make sense. Somehow the patients are still alive.

 

[Eta Carinae]

exPCM,
this is a good thing for premedical students. It shows that there are now more medical school spots open for qualified US premedical students to go to medical school in the US, and that we are (finally) producing more doctors. Now maybe we won't have so many people with 3.7 GPA, hundreds of volunteer hours in hospitals and 30+ MCAT scores who can't get into any US medical school.

True, but to what end? So that they can accumulate $2-300,000 worth of loans and plunge into govt-funded care that barely covers the cost of care let alone leave them with enough to pay back loans along with the exhorbitant interest amounts they have accrued?

The rush to medicine is a poorly thought out venture for MOST premeds who are caught in the throes of living up to their parents', their families' or misplaced personal ideals of "success". And to open up the floodgates (into med school) does nothing but perpetuate the frustration, angst and lack of fulfilment that comes with having sacrificed a very crucial period of one's life to chase some foolish dream and having to face the uncertainties of the future of medicine.

It will do nothing, IMHO, to address the primary care physician shortage...because if historical trends of med students' selection of a specialty are anything to go by, most will be allured by prestige, reimbursement and lifestyle into the non-primary care specialties.

As has been mentioned earlier in this thread, the solution does not lie in increasing med school class sizes but in addressing the reasons med students by and large would prefer to avoid primary care ie reimbursement (primarily for internal medicine) and reimbursement + lifestyle/reimbursement comparable to lower-liability specialties (where gen surg is concerned).

 

[michaelrack]

Why does government pay 100k per slot. Resident get paid like 40k. So the net productivity of a resident is -60k? Is a resident such a toxic asset?

Maybe to solve that problem they should alot a resident to bill for their service under supervision.

It sounds like you are suggesting reducing direct government subsidies for residents and in return allowing residents to bill, and cover their salaries that way.

Since most of the patients a typical resident sees are Medicare and/or medicaid, this would essentially change the government pot of money that resident salaries are coming from, but leave overall government funding of residents unchanged.