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Tags: advocacy, doctors, healthreform, match, medical student, policy, primary care, residency, shortage
Categories : residency training
Yesterday, after the mayhem and jubilation of celebrating a successful match at the Pritzker School of Medicine with our students, I went onto Twitter to follow the #match2013 hashtag to understand what the reactions were. Most were positive, but one headline caught my attention ‘In Record-Setting ‘Match Day,’ 1,100 Medical Students Don’t Find Residencies.”
It is true this was the largest match because it was “All-in” – programs either were in the match for all their positions (including international medical graduates or IMGs) or they were not. Obviously, many programs put more positions up for grabs in the Match. After I reposted this article to Twitter, there were many theories and questions about who these unmatched students were and why – some of which I have tried to answer to the best of my ability below. I welcome your input as well.
- Are these IMGs? This number is US Senior medical students who have been admitted and graduated from US medical schools but now have no place to go to practice medicine.
- Does this include those that entered the “scramble” now called SOAP. Technically, those that entered SOAP and were successful would have been counted as “matched” on Friday. Last year, 815 Us seniors went unmatched after the SOAP.
- Did they choose to go into competitive specialties? We have to wait for the 2013 NRMP statistics, which will likely address this. The 2012 data shows that more unmatched seniors did choose to go into competitive fields. Last year, the % unmatched is much higher for students applying to radiation oncology, dermatology, and competitive surgical fields for example.
- Did they go unmatched to due to poor strategy or poor academic performance? While poor strategy such as ‘suicide’ ranking only one program is related to the risk of going unmatched, the truth is getting into residency is competitive and there are some who will not match because of poor academic performance. Some even argue that medical schools have little incentive to fail students and a portion of these students should not be graduating to begin with.
- If they had gone into primary care, would they would have matched? I hear this myth that program directors in primary care fields only take international medical graduates (IMGs) since not enough US medical graduates apply. This is due to the largely untested assumption that any US Senior would be preferred to an IMG. However, I personally know program directors who would definitely take a seasoned and high performing IMG over a below-average US Student. The reason this is important is the rationale for not lifting the GME cap is that we have 50% of certain fields filled by IMGs and those spots would naturally be filled by US grads. Interestingly, many of these spots happen to be primary care driven fields. Yet, it is still unclear if US Seniors will displace IMGs for spots in IMG oriented residencies. It is also unclear if they will be willing to apply to programs that typically cater to IMGs, since they are often not considered as prestigious or geographically desirable to US students.
- Is this related to the lack of GME spots? Certainly, it is true that more effective career advising may have resulted in applicants being more strategic about their rank list and not reaching for a competitive field. However, we cannot ignore the supply/demand side of this equation. At a time when there is a shortage of physicians and a call to increase the number of physicians, the US medical school system by responded to this call. New medical schools have opened. Existing medical schools have increased their enrollments. So, there are now more US Seniors entering the match and there will be even more in the future as new medical schools mature their entering classes to graduating students over the next four years. Given that the supply of matched candidates includes both foreign-born IMGs and US-born IMGs, there are more candidates than spots. And while many believe IMGs will be the ones that get “squeezed out” in this shortage situation, again this is an untested assumption. It is also important to recognize that IMGs often play a significant role in ensuring primary care for rural populations and underserved communities,which are often not geographically desirable by US graduates.
We are left with a fundamental question: Do we owe it to our entering medical students who successfully graduate from medical school to have a residency spot? At a time when we have a shortage of physicians and a call for medical schools to increase in size, should we not expand our residencies? Unfortunately, GME funding is on the chopping block because of the belief that too much money is being wasted on residency training. Moreover, hospitals seem less enthusiastic about expanding residencies, as it is not as much of a bargain due to caps on hours residents work, and all the other new accreditation standards for residency training.
There is a potential solution. The “Training Tomorrow’s Doctors Today Act” by Reps. Aaron Schock (R-Ill.) and Allyson Schwartz (D-Pa.), and the “Resident Physician Shortage Reduction Act of 2013” sponsored by Sens. Bill Nelson (D-Fla.), Charles Schumer (D-N.Y.), and Majority Leader Harry Reid (D-Nev.) would enable training 15,000 more physicians over 5 years. Moreover, spots would be distributed to programs and specialties in critical shortages, like primary care.
Given the time that it takes to train a physician, now is the time to act to ensure we have the doctors we need for the future.
–Vineet Arora MD MAPP
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Tags: advocacy, doctors, match, patient safety, payment, policy, primary care, residency, shortage, writing
Categories : doctor
I recently watched Dr. Atul Gawande on video describe how what American healthcare needs is pit crews and not cowboys. This sentiment is also memorialized in his thought-provoking writings for the New Yorker.
Interestingly, Dr. Gawande is not the first person I have heard to suggest such a thing. A colleague named Dr. Ken Catchpole actually studied Formula 1 pit crews and used the information to guide improvements in pediatric anesthesia handoffs. His observations were astounding and really highlighted how the culture of medicine is different from Formula 1. In Formula 1, pit crews have a ‘fanatical’ approach to training that relies on repitition. In healthcare, the first time we often do something is “on the fly”. Moreover, on-the-job training usually means ‘checking the box’ by attending an annual patient safety lecture. Perhaps the most important was the role of the “lollipop man” in pit crews. And yes, even thought it’s a funny name, it’s a critical job. As shown in the video, the Lollipop man is responsible for signaling and coordinating to the driver the major steps of the pit stop. When it is safe to step on the gas, the Lollipop man will signal to the driver. Sounds like a thing so perhaps it can be automated. Wrong. When Ferrari tried replacing the Lollipop man with a stop light that signaled the driver, the confusion created (does amber mean stop or go?) led to a driver leaving the pit with his gas still connected. Quickly after this incident, Ferrari announced it would go back to the tried and trusted Lollipop “hu”man.
So, who are the Lollipop men (or women) in healthcare? Turns out that Dr. Catchpole and his team observed that it was often unclear who was leading the handoff process that they were observing in healthcare. With team training and system reengineering, Dr. Catchpole’s team was able to reorganize the pediatric handover so there was a Lollipop man (anesthesiologist) at the helm.
While these handoffs represent a critical element of healthcare communication in a focused area, it is symbolic of a larger problem in healthcare – we are still missing “Lollipop men” to coordinate healthcare for patients across multiple sites and specialties. This is even more critical on the 2-year anniversary of healthcare reform and this month’s match results. At a time when we need to cultivate and train more “Lollipop men” to coordinate care for patients, we have had stable numbers of students who enter primary care fields. And like the lessons from the Ferrari team, it is doubtful that a computer (even Watson who is now working in medicine apparently) will be able to do the job of a Lollipop man.
So, how can we recruit more Lollipop men? While it is tempting to blame the rise or fall of various specialties and market forces, it is important to recognize that being this is a difficult job to do when the Lollipop is broken or even nonexistent. Without the tools to execute the critical coordination that Lollipop men rely on, they cannot do their job. So, the first order of business to ensure that the Lollipop, or an infrastructure to coordinate care for patients through their race that is their healthcare journey, exists. As the Supreme Court debates the future of the Accountable Care Act, there is no greater time to highlight the importance of the Lollipop.
–Vineet Arora MD
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Tags: advocacy, attending, hospital, medical student, payment, technology, writing
Categories : doctor
Recently, I was asked to speak about innovations in inpatient medical education for leaders in general internal medicine. Knowing that I would be last in a distinguished lineup of speakers and that my charge was to discuss novel ways to teach in the inpatient setting, I thought it would be important to review how its been done for a long time — so long that it is embodied in one of my favorite fairy tales…
You see, Cinderella dreamed of one day becoming the best clinical educator in the academic kingdom. Unfortunately, her evil stepmom “Mrs. Dean” scoffed at Cinderella and said “teaching does not pay…look at your hard working and loyal stepbrothers….“Bill” has been our primary breadwinner due to his high volume of Patient Care and “Grant” –yes, while its feast or famine with him, just got a big payout for his Clinical Research. Teaching? That’s no way to make a living. Go work work for them until you figure you what you want to do.”
So Cinderella toiled away…until one day, she met the Godmother of a grateful patient “Mrs. Fairy” who donated a small sum money to improve inpatient teaching…and with this Cinderella was able to transform herself into one of the leading teachers of the new curriculum (she was also able to get a raise to update her wardrobe!). She quickly became a hit among all the medical students and residents who were truly “charmed”. Then one day, at the stroke of midnight, Cinderella’s protected time ran out…and all of her work went up in smoke as she was forced back to her life of hardship seeing patients and doing research. The students and residents were distraught at the thought of losing their most prized teacher and searched the academic complex for her –they were so moved they wanted to award her the precious “Glass Slipper” teaching award, which not only is bestowed with honor, but also a promotion to become a tenured educator in the academic kingdom. And she lived happily ever after…
While you may think that this is the stuff of fairy tales (especially happily ever after), we all have Cinderellas at our institutions. And those Cinderellas want to teach, but they struggle not only with funding, but also the realities of today’s inpatient environment. So, what are these Cinderellas to do? Well, there are few of the ways to ensure that clinical teaching is rewarded – and possible resolutions for the New Year for medical educators.
- Focus on a gap that needs to be filled: Protected time is most likely be awarded to someone who is filling a need – think new curriculum that is mandated by LCME/ACGME or other alphabet soup organizational body. What is the specific need that you can fill with teaching? Often this may require thinking about a topic that may not exactly match your initial interest, but it is more likely to lead to funding for your teaching.
- Learn new teaching methods: Teaching methods for today’s wards are not well developed in the land of an organized chaos. By incorporating a new platform for teaching (think case blogs, video reflection, standardized patients, or a host of other ideas), you can breathe new life into an old topic. For example, using simulation to teach end of life discussion, or using blogs to teach about professionalism, can result in a novel curricular program that not only engage next generation learners, but also gains attention of leaders in medical education.
- Document the effectiveness of the teaching – it is only through methodological evaluation that one can document that teaching translates into practice. By showing that teaching can be linked to improvements in knowledge, attitudes, or practice, it is more likely that someone (maybe a fairy) will finance this teaching as critical to the mission of the hospital. Think about procedural training that shows reduction in central lines.
- Work with a mentor – Just like ‘big research’, mentorship is still important although not always emphasized. To be honest, mentors can serve to mobilize resources or promote your work with senior leaders.
However, regardless of these strategies, funding for teaching requires institutional leadership to recognize that the academic mission of teaching hospitals is still ‘to teach’. Of course, this mission is sometimes lost in the chaos of teaching hospitals surviving budget crisis in an increasingly competitive environment. So during this holiday season as everyone is reminded of the time of giving, now is a great time to remind the fiscally minded Mr. Scrooge in your C-suite that the greatest gift they can give is enabling a teacher to teach the future doctors of our nation.
–Vineet Arora MD