[acerjio]

This report highlights a big part of the problem in supplying physicians in the US. The issues with funding are captured well, as are the issues with the unmatched, that is medical school graduates who cannot secure a position and continue their training.

However, there are some important aspects of the modern residency system that are not captured well, that do contribute to the pipeline bottlenecks.

One major issue surrounds the UME - GME split, that is undergraduate medical education (that is medical students) vs. graduate medical education (that is residents). As a medical student now, one of the most striking comments is how our professors, especially those who are older, comment on how much they did during medical school. Right now, medical students learn under such close supervision most of the experience is shadowing-based, i.e. watching attending physicians, resident physicians, and midlevel providers. This means that on graduation as MDs, new interns have very limited experience in managing patients.

In turn, that makes intern year critical in training physicians. However, much of what is learned in intern year is often a retrenchment of what should have been covered in medical school by accreditation standards. The concerns about medical students graduating without a full set of the expected competencies have lead to the development of the Core Entrustable Professional Activities (EPAs), to create a framework by which students graduate with documented competency in each area.

Unfortunately, initial experiences with the EPAs have been mixed. This summer, an academic article reviewing schools experiences implementing the EPAs revealed that while most EPAs were being adopted well, some of the Core EPAs, specifically involving basic procedural competence (think drawing blood, starting IVs, basic bedside procedures), were considered more appropriate for GME [1], which adds to the GME curriculum in residency.

Given that the 4th year of medical school for most students consists of "elective time" and time off to interview for residency, shifting training from medical school to residency only adds to stress on the pipeline. For example, why should internal medicine residency be 3 years long? If graduates were documented as more competent on graduation, would a two year residency for primary care or prior to specialized subspecialty training be sufficient? In my experience working with residents at my medical school, 3rd year residents are in supervisory positions, dealing with less patient care than first and second year residents, the rest of their time seems to be consumed with applying for fellowship and studying for their Board certifications.

Of course, some of the dilution of undergraduate medical education comes as a result of defensive medicine, scope creep from midlevel providers, and excessive regulatory requirements. (Just look at all of the regulatory burden and turmoil around how attending physicians can attest medical student notes for CMS billing purposes. If anyone wants a migraine, I invite them to look into it.) Additionally, other causes of the dilution comes from the growth in US IMGs, mostly from the Caribbean medical schools. Those schools often pay to place students at US non-academic (often for-profit) hospitals that are less interested in the educational mission as they are in easy money from precepting students. In those cases, those students often have extremely circumscribed roles in the clinic, largely due to the institutional lack of emphasis and commitment to teaching [2].

Fixing the pipeline will require creating more residency positions, but it will also likely require changes all along the pipeline, such as making UME more meaningful and graduating MDs (or DOs) who are more ready for residency on Day 1, and then a serious look at residency length to ensure that GME experiences are meaningful and not simply "cheap labor [3]."

[1] https://journals.lww.com/academicmedicine/Fulltext/2021/0700...

[2] One of my preceptors who graduated from a Caribbean school flatly said that medical school was just for observation, and that she didn't actually do anything until residency. While she became an excellent physician, this attitude did not correspond to the educational expectations of our institution, nor do I think reflects the expectations of most of the US system.

[3] PGY (post graduate year) salaries are very, very low on an hourly basis. PGY-1 salaries are anywhere from $58k/year to $65k/year for FY22. However, as residents like to point out, when you calculate their salary across the hours they work, the rate is usually less than federal minimum wage.

[epmaybe]

This loses sight of the lack of incentive missing from hospitals and even residency programs from funding their own positions. There’s literally no regulation preventing a program from funding their own without Medicare dollars. They just need ACGME to sign off on it.

Turns out if you hand out free money for minimum wage employees that rely on your training to not kill people, there’s very little incentive to pay out of pocket. Especially so when programs realize that their trainees will just work harder/longer for the same pay without much complaining.

I also think there’s a method to the madness of training program length and number of spots (namely, ensuring you have enough exposure to the common things/uncommon things you will encounter on your own to be competent), but I agree more scrutiny would weed out inefficiencies in the training process. But like, there’s an obvious reason neurosurgery residencies don’t take that many trainees every year, not just to create artificial scarcity.

[giantg2]

On the financial side, we have to also look at opportunity cost and loan sizes. Why should I spend over 8 years post secondary and over $250k to become a doctor?