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Are medical school graduates being denied residency training?

In the April issue of the GME e-Letter, we looked at the 2011 Match data and noted "a worrisome tightening in the number of Scramble positions available for both seniors and prior graduates of US allopathic and osteopathic medical schools. The bottom line? A growing number of US medical school graduates are being denied a residency that leads to initial board certification."

In response, we received the following responses from e-Letter readers (identifying information removed).

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The word "denied" implies entitlement. Are all medical school graduates entitled to a residency education? Is every US medical school graduate entitled to a residency education in their chosen medical specialty field? Surely that is not what the AMA believes, but "denied" surely implies exactly that. This brings up several issues that have been burning in me, and provides the opportunity for me to express (vent) my concerns.

Firstly, there is a certain "entitlement" attitude that is creeping and growing in our nation. We are no longer a people that believe that working hard is the way to success. Success is an entitlement we have somehow retroactively read into our Bill of Rights. Our kids no longer fail at school, and games no longer have winners and losers, and everybody must be successful, even if they do nothing to deserve it.

Perhaps the e-Letter should have noted that "A growing number of US medical school graduates failed to recognize that excessive reimbursements to medical specialists at the expense of primary care physicians and growing time demands and paperwork/insurance hassles/denials and prior authorizations have lead to a health care system spiraling out of control while failing to meet patient needs and, in doing so, these graduates chose to apply foolishly to only the highest paid and best-work-hours specialties while ignoring what their future patients, our country and our health care system really need." Maybe he could throw in a little "US medical schools fail to educate their graduates on the health care needs for the future." Or maybe they do recognize where the need is, but are unwilling to be a part of the solution. Maybe they are motivated by greed or "lifestyle" issues.

Secondly, and sadly, US medical graduates have been passed through courses in medical school with inadequate training, despite enormous increases in tuition. Too much of their "clinical" education occurs on simulators or computers. You can pass a clinical surgery rotation without learning how to do a sterile scrub, prep a patient, or suture a wound. Most students pass obstetrics without delivering a single baby and they have never seen a pelvic exam done when they pass gynecology. Sure, they watch from the corner, but that falls short of truly educating them. Most are, however, quite adept at delivering a plastic fetus from a plastic pelvis. It is time to correct this deficiency in our medical education. The "clinical" years need to return to clinical medicine. Graduates should be able to suture, scrub, tie knots, maintain sterile technique, give at least a limited differential diagnosis, and write a progress note or operative report. If you can't do these simple things, you should not be labeled as a physician. Graduates should be able to talk to patients, not input data to manikins. I know that patient safety concerns have driven education away from direct patient care, but all this has accomplished is to defer the patient safety issues until the newly minted physicians finally do encounter real patients in residency. At some point, medicine must be learned by practicing (under supervision) on real patients.

Thirdly, our health care system still undervalues primary care. The evidence is fairly convincing that areas with a higher primary care physician-to-patient ratios have lower costs and equivalent or better medical outcomes than areas with higher specialist-to-patient ratios. Don't get me wrong—I value and appreciate my specialist colleagues for their in-depth knowledge and surgical expertise, and I can't imagine practicing without them, but do we need so many specialists?

Our medical schools brag that some "high" percentage of their graduates enter primary care, but they count family medicine, internal medicine, pediatrics and obstetrics/gynecology as primary care. Most of the students going into internal medicine and pediatrics are going to go on to specialty fellowships—they will never practice primary care. Let's quit lying about this to ourselves and the patients we are supposed to serve. Let's tell them that we are putting only ten percent of doctors in primary care because our system doesn't value what is good for patients, but is instead geared to what is good for physicians, medical schools, and the government and insurance bureaucracy.

If US medical school graduates want a position in a graduate medical education (GME) program, they generally need to look no further than family medicine or internal medicine residencies. We have fewer and fewer applicants from US schools to these programs each year. In the meantime, we have discovered that there are many very high-quality international medical graduates who are more than willing to take those disgusting, dirty, low-paying jobs that most US graduates are "above"—in primary care. It is what our country needs most right now. It is cost-effective and high-quality care. Our medical schools continue to subtly "teach" their students that only idiots and losers go into primary care, then lament that they have unmatched seniors with big loans and no hope of being able to practice. (If that is not what they are teaching, why are so many students learning this?—just look at the numbers.)

Like many other residency directors over the past few years, I have discovered that I can fill my program with excellent physicians who are eager to learn and practice primary care from the pool of international graduates. I learned this only because US grads would not enter primary care in adequate numbers to keep our programs viable, yet the demand for our graduates continues to grow. Now that I have found this pool of excellent, eager physicians, I doubt that I will ever rank an applicant higher on the Rank Order List simply because of the geographic location of their school. US medical schools and their graduates (for the most part) have turned their backs on primary care. Don't come whining to me that your residency position was "denied". You most likely were applying for the wrong residencies.

Maybe we need to change the way we do all of this. Let's determine how many of what kind of docs we are going to need in 15 years and make the GME funding available to residency programs to support these positions. Medical school applicants will then apply to residency programs before being accepted to medical school. When each residency program has matched the number of residents they will need in 4 years, US medical schools can then accept them into their schools. All their graduates would then have positions. We would have the right number of generalists and specialists. Throw in a few years of public health service in exchange for student loan repayment, and our health care system would flourish!

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The statement "A growing number of US medical school graduates are being denied a residency that leads to initial board certification" is very misleading and not consistent with NRMP published data.

Only 1,169 out of 2,384 positions in family medicine, and 2,722 out of 4,947 positions in internal medicine, were filled this year with US medical school seniors. That leaves plenty of positions for US medical school graduates with acceptable academic records in residencies that lead to board certification.

The real problem is that a larger number of US grads are applying for residencies in highly specialized fields that are much more competitive, and hence winding up unmatched. Likewise, residency programs in primary care fields are tired of having to scramble for residents who really want to be in another discipline, and hence are accepting international medical graduates (IMGs) in pre-Match arrangements and placing them in competitive positions on their rank order lists in order to fill their slots with acceptable candidates.

The solution lies with increasing the number of US medical students interested in primary care fields, which is highly dependent on increasing the support for primary care physicians in our workplace and respect for primary care physicians in academic medical centers. This is the direction in which the AMA needs to direct its resources. The National Resident Matching Program (NRMP) can't fix your "concern" by modifying the rules of the Match process.

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It sounds like you are suggesting that more residency slots should remain available for the Scramble such that US graduates will have them available when they do not match. US graduates must be educated while in medical school regarding the needs of the US health care system and their individual odds of matching to their desired specialty. Matching in a residency is just like finding a job—the applicant must have skills worth hiring, and the applicant must seek a job with a program that need those skills. If those 971 unmatched US seniors had always planned to practice family medicine and had applied to family medicine residencies with those intentions, I'm certain that most of them would have matched. The shortfall is not in leaving positions for the scramble, but in how we educate and prepare our medical students.

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The issue of "denial" of a residency for US medical students proves two things:

1. Too many US medical students are deluded into thinking they can get into highly competitive specialties when they do not have competitive CVs, and

2. Medical schools continue to graduate very poor students who should not be physicians.

I saw multiple applications from US medical students showing multiple failures on USMLE exams and multiple failures of the medical school curriculum, with no evidence of significant improvement. Until US medical schools do a better job assessing and preparing students for residency, there will continue to be US medical students who will not be selected for a residency.

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You must be kidding! They are only "denied" being ophthalmologists, dermatologists, and plastic surgeons. If American medicine and medical schools got their priorities straight and supported primary care, virtually all would match!

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Who is denying them? Isn't this misleading? There are only 16,500 MD grads of US schools trying to fill 25,500 spots. With odds like that, job scarcity is not what is causing the 971 go unmatched.

I believe the real story is the primary care dead zone. The match is for the other specialties. Of the 5,100 internal medicine and 3,400 family medicine slots, less than 40 percent are filled by US MD grads. Those who apply to family medicine or internal medicine are very competitive for slots with both US IMGs and foreign-born IMGs.

So one reasonable conclusion is that the 971 unmatched graduates applied only in the most competitive specialties and had no "Plan B" or safety applications to primary care. In a sense, we must respect these choices. Students do not want to go on interviews and pretend to be interested in family medicine or internal medicine when that is not the case.

I think the market has delivered the result that is expected in light of the very low interest in internal medicine and family medicine by US MD grads.

This recruitment season we had only 13 applications from students at US MD schools. Three withdrew, two were very high risk academically and two had really troubling interpersonal skills. So of the 55 students we interviewed, only six were US MD students who I would have wanted to work with. It's ironic, too, that family medicine and internal medicine require a broader skill set than many other specialties, yet many US grads do not seem to want this challenge or responsibility.

I believe even the "NRMP only" methodology being proposed for 2013 will not be a remedy for the issue of ummatched students. If they do not apply for family medicine or internal medicine and do not interview in these specialties, no strategy can save them.

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Are there any data explaining the drop in the number of positions in the Match since 2008 and the tightening in the number of Scramble positions available for both seniors and prior graduates of US allopathic and osteopathic medical schools? These data might go a long way toward elucidating the problem. The positions are no longer funded; the programs are on probation or no longer exist. Is this some unforeseen consequence of duty hour limits?

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Doctors will go where they are wanted, needed and fairly compensated. Neither the government nor the AMA should try to adjust the numbers. Let individuals choose. Don't meddle.

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Why not have the match place US grads first and only then open up any available slots to individuals from other nations (perhaps through a secondary match)? I believe this is how the match works in Canada.

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A 94 percent match rate seems like a pretty comforting statistic, but that means that six percent, or about US 1,000 medical school graduates, are not matched. Of those who do scramble, 60 percent are put into preliminary positions. These numbers are growing, and as someone who will soon participate in the Match (I’m a fourth-year student who took a one-year leave to engage in clinical research), this trend worries me. I find it worrisome that despite such a large sacrifice of time, effort, and money, so many US medical school graduates are not able to match into a program that leads to board certification.
 
I find it perplexing that, despite the pressing demand for more physicians, the number of unmatched medical school graduates remains so high. The physician assistant and nurse practitioner fields, for example, have grown to meet the nation’s increased need for health care services. In these fields, growth is tightly tied to demand. The demand is clearly there. The supply is also available.

So, why are so many medical school graduates going unmatched? Is it because they are unqualified? I have friends who did not match and had to enter the Scramble. They were not incompetent, poorly trained, or poorly educated graduates. While “competency” in the form of scores and evaluations may play a role, it is likely not the sole factor.
 
From these numbers and from the GME e-Letter, I have learned that our matching system could be and should be improved. There is a demand for more physicians. There are people who desperately want to be a physician. Is it because of a lack of funding from the government that more residency positions are unavailable? If so, then as an industry, we need to lobby and clamor for more slots.