Residency Cap Legislation Introduced

LADoc00 said:

Increasing the number of training slots for primary care does NOTHING to actually increase the number of practicing primary care doctors. It only serves to increase the number of foriegn trained/born refugees that draw money from medicare.

Increase PAY for primary care docs, not training positions.

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I usually think you're a well-meaning sociopath, but I completely agree with this part of your post.

BobA said:

I usually think you're a well-meaning sociopath, but I completely agree with this part of your post.

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BobA : precisely why do you feel that this particular statement of his is anything but fantasy? As of right now, 2009, every primary care residency slot is filled by someone. A doctor is graduated at the end of that residency, and there's very little attrition because residency programs will slot in "preliminary" residents as PGY-2 residents to fill in gaps when people quit.

Given that over 6,000 folk fail to match, and that several thousand more medical students are being trained for the upcoming graduating classes of 2012 and onwards, it's delusional thinking to not believe that increasing slots won't increase the number of trained physicians.

GeraldMonroe said:

BobA : precisely why do you feel that this particular statement of his is anything but fantasy? As of right now, 2009, every primary care residency slot is filled by someone. A doctor is graduated at the end of that residency, and there's very little attrition because residency programs will slot in "preliminary" residents as PGY-2 residents to fill in gaps when people quit.

Given that over 6,000 folk fail to match, and that several thousand more medical students are being trained for the upcoming graduating classes of 2012 and onwards, it's delusional thinking to not believe that increasing slots won't increase the number of trained physicians.

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I agree with you about the numbers.

But I also think that the real way to fix the shortage of quality primary care doctors is to increase their salaries (or eliminate their debt, which is the same thing).

BobA said:

I agree with you about the numbers.

But I also think that the real way to fix the shortage of quality primary care doctors is to increase their salaries (or eliminate their debt, which is the same thing).

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BoBA : think your statement through.

Let's suppose that, arbitrarily, they increased reimbursements for primary care five times. They also went ahead and decided to cancel your student loan debt on day 1 of residency.
This is a made up example, but it's theoretically possible for medicare to pay the billions it would cost if they raised taxes and transferred money from the military budget.

Now, everyone would want to do primary care. Those docs would be making about $800,000 with a 3 year residency! Everyone would be jumping over each other to get in.

Oh, and they left the total number of slots the same.

How many total physicians would be trained every year? Oh yeah, the same number. So if there's a nation-wide shortage of doctors, it would grow worse.

Now, programs would start cutting back on specialties and using their GME funding for primary care. Good luck getting an appointment with a dermatologist or a neurosurgeon.

GeraldMonroe said:

BoBA : think your statement through.

Let's suppose that, arbitrarily, they increased reimbursements for primary care five times. They also went ahead and decided to cancel your student loan debt on day 1 of residency.
This is a made up example, but it's theoretically possible for medicare to pay the billions it would cost if they raised taxes and transferred money from the military budget.

Now, everyone would want to do primary care. Those docs would be making about $800,000 with a 3 year residency! Everyone would be jumping over each other to get in.

Oh, and they left the total number of slots the same.

How many total physicians would be trained every year? Oh yeah, the same number. So if there's a nation-wide shortage of doctors, it would grow worse.

Now, programs would start cutting back on specialties and using their GME funding for primary care. Good luck getting an appointment with a dermatologist or a neurosurgeon.

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That's a strawman argument though. First of all, I don't think anybody is arguing that primary care docs should be paid twice the average of a neurosurgeon. That's just wacky. Second, I don't think we should be describing it as an either/or situation. Just because we raise salaries doesn't mean we can't also make some targeted increases in residency slots. In my opinion, the best solution is one that is multidimensional; increase salaries, loan repayment programs, a calculated increase in residency spots, in addition to any other reasonable ideas to alleviate the problem.

This thread is about a proposed increase in slots. More pay for primary care is fair. Nevertheless, it will do absolutely nothing to solve the problem unless there are also more slots in primary care.

GeraldMonroe said:

This thread is about a proposed increase in slots. More pay for primary care is fair. Nevertheless, it will do absolutely nothing to solve the problem unless there are also more slots in primary care.

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If it weren't for the idiotic comments posted in this thread , my response to your post would be ...D-UH..

Indeed more residency spots are absolutely needed .

Beware of wolves in sheeps' clothing who are against an increase in spots .( traitors unite ?)..snakes !

Every possible indicator points to a shortage of docs .An immediate increase in residency spots is crucial !

GeraldMonroe said:

BoBA : think your statement through.

Let's suppose that, arbitrarily, they increased reimbursements for primary care five times. They also went ahead and decided to cancel your student loan debt on day 1 of residency.
This is a made up example, but it's theoretically possible for medicare to pay the billions it would cost if they raised taxes and transferred money from the military budget.

Now, everyone would want to do primary care. Those docs would be making about $800,000 with a 3 year residency! Everyone would be jumping over each other to get in.

Oh, and they left the total number of slots the same.

How many total physicians would be trained every year? Oh yeah, the same number. So if there's a nation-wide shortage of doctors, it would grow worse.

Now, programs would start cutting back on specialties and using their GME funding for primary care. Good luck getting an appointment with a dermatologist or a neurosurgeon.

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If you read my post you'll see that I write: "I agree with you about the numbers."

I'm taking the thread in another direction, and probably could've been more clear in my first post.

Increasing the number of primary care spots is a temporary fix that ignores the larger problems US Health care faces. What we really need is to increase the utilization of high-quality primary care. This is the best way to both promote health and control costs. We need to increase salaries in primary care to attract more high quality physicians to those fields. Increasing PCP salaries would ensure that they have the time and financial incentive to think problems through before ordering tests and referring to specialists.

aprogdirector said:

this is the crux of the issue. If all 12 treatments yield identical outcomes overall, then if they have wildly different costs, are we ok with that? Let's say that patients arrive with a headache without any other concerning features at all. One physician decides to get a head ct (or mr) for every patient. They feel that they simply don't want to miss anything. perhaps that's what they were trained to do.

if you sort the table on this column, and we focus on large population centers (randomly defined by me as > 1 million people) you'll see that the lowest cath rate is in albuquerque nm and portland or (at 17/1000) and the highest is in birmingham al (at 40/1000). therein lies the question --- are the people living in birmingham really much sicker than those in portland and hence require twice as many caths, or is it just that there are twice as many cath labs in birmingham hence they just do more caths there? The dartmouth data would suggest that the latter is true. The question for "us" who are paying for all of this is how much variation like this we are willing to tolerate.

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. . . . .

aProgDirector said:

This is the crux of the issue. If all 12 treatments yield identical outcomes overall, then if they have wildly different costs, are we OK with that? Let's say that patients arrive with a headache without any other concerning features at all. One physician decides to get a head CT (or MR) for every patient. They feel that they simply don't want to miss anything. Perhaps that's what they were trained to do.

If you sort the table on this column, and we focus on large population centers (randomly defined by me as > 1 million people) you'll see that the lowest cath rate is in Albuquerque NM and Portland OR (at 17/1000) and the highest is in Birmingham AL (at 40/1000). Therein lies the question --- are the people living in Birmingham really much sicker than those in Portland and hence require twice as many caths, or is it just that there are twice as many cath labs in Birmingham hence they just do more caths there? The Dartmouth data would suggest that the latter is true. The question for "us" who are paying for all of this is how much variation like this we are willing to tolerate.

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I think that the analogy of a doc ordering head CTs for every headache patient while well-intended is unrealistic. FPs are very good at figuring out the red flags for headaches and when or when not to get a head CT.

Given that Birmingham Alabama is in the stroke belt they might also have higher rates of cardiovascular disease. If so, then perhaps there would be more cath labs there.

I did an IM clerkship at a quarternary center and a rural elective and availability of diagnostic procedures affects clinical decisions big time, no doubt. However, it was great having in-house PET and EEG and other tests available as we could work up our patients to a great extent when these diagnostic procedures were available. If not available, then the patients were referred to a tertiary center sometimes or given a presumptive diagnosis of a disease without being able to definitely rule it in or out. I would bet that if you look at the caths done in Alabama that the vast majority of them were justified.

There are plenty of silent epidemics that don't get properly treated in the U.S. Take sleep apnea for example, if you are able to easily refer for a sleep study then you do so, if in a rural or community setting these patients slip through the cracks if there isn't an easily available sleep lab.

While more cath labs may equal more caths getting done in very similar populations (assuming Ala and Portland are similar) this doesn't mean that this is wasted money or inefficient care. It could mean that folks in Alabama actually get better care as it may be easier to get caths there and this could be masked by being an overall less healthy population. It would be hard for studies to figure out how to remove the bias of all the variables involved. . . The best way is to do EBM and get clearer indications for cath and have cardiologists document more precisely why the patient needs a cath. However, having seen tons of patients getting caths, the vast majority needed them IMHO and the cardiologist did and was required to document why they needed it.


There are bound to be regional variations in healthcare, no doubt about it, due to:

1. Different populations around the country with different distributions of healthcare problems.
2. Physicians practice varies, overall most physicians are up to date on the standard of care for common medical problems which make up the bulk of healthcare spending, but there are differences which perhaps haven't been studied well enough to know what is worth it and what is just too expensive. For example, there was debate about what thrombolytics are best for MI patients and cost does enter into these discussions, but, this is normal as cardiologists everywhere grapple with what the best care and what is not needed or excessive care. Time fixes this as medical care becomes more refined in terms of Evidence Based Medicine.
3. Medical care is tailored for specific patients, sure two patients may have the same diagnosis say infectious arthritis in two teenagers, but the irresponsible one who can't be counted on to take his/her medication is hospitalized and the other is not. That is why this Darthmouth study and other studies focusing on patient care in regions misses is that there is a human component which can't be quanitified.
4. Issuing Guidelines about when to do a head CT is important, sure you can do a study about regional variation of head CTs across the country but if there aren't clear guidelines then you really haven't accomplished anything. This Darthmouth study and other studies don't really add to the body of knowledge in terms of standard of care, are more finger pointing and in the end made by somebody who is under the pressure of publish or perish and it shouldn't be applied to any healthcare policy decisions, IMHO it is worthless, interesting sure, but absolutely worthless as cardiologist who actually do caths are swayed by evidence based medicine and not regional differences in caths.

People can run around with their heads cut off screaming about how we can't afford all these head CTs and caths in patients who don't need them (if that could ever proven is another question), but it doesn't change anything and is just northeastern handwringing and northeastern pseudo-intellectual analysis of healthcare. Really. If they did a paper on how to be judicious with cardiac cath and showed specific guidelines and results and presented them at a cardiology conference then this would address the issue, this paper doesn't as things are vastly different in different parts of the county.

I could do a study on how many bandaids are used in different states and maybe claim that if say Alabama used 50% more bandaids than Portland then imply that Alabama should decrease band aid use and saved "us" millions a year it would never happen, not one bandaid would be saved as I am just reporting stastics without any meat. Bad paper, iffy conclusions IMHO.

The Darthmouth paper isn't a revelation and doesn't really help address healthcare spending or practice, interesting, but it has no utility in the real world and because of probably a dozen types of bias you can't really say that docs in Alabama are doing too many caths at all. What would help is a study in an Alabama (or Portland) hospital where there are a lot of caths and have cardiologists in one group use their professional opinion for cath, and educate the other group of cardiologists on the latest in indications for cath (as if they already didn't know), and then compared to see which group did better. This Darthmouth paper is not a scientific study but more of a stastical commentary, it has no teeth.

I mostly agree w/Darth on this. The populations in places like Louisiana/Mississippi/Tennessee/Arkansas are quite different than somewhere like Oregon or Washington or northern CA. The rates of obesity and diabetes and smoking are >> in those southern places. I've lived in both those type places and there is a BIG difference in the lifestyle and overall rates of obesity and what people eat as far as their daily diets, and whether they get any type of exercise...although people all over the US are generally getting more and more fat to a degree that is truly scare.

However, if you observe the practice patterns of interventional cardiologists vs. just even general noninterventional cardiologists, you will see that some interventionalists will try to cath anyone who has a pulse - well, not quite but you get the picture. I don't really think it is greed or even the availability of more cath labs (at least in the academic setting I haven't seen that happening). It is more this idea of if you have a hammer in your hand then everything starts to look like a nail...

dragonfly99 said:

It is more this idea of if you have a hammer in your hand then everything starts to look like a nail...

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That's true, I think a lot of us having finished medical school and residency use the knowledge to encourage even family members to get a colonoscopy or a lipid panel. . . When you have the knowledge and the skill you like to see it applied!

When looking at the bottom line if insurance companies or the government made it harder to justify cardiac caths such that some procedures didn't get paid for then cardiologists might look more closely at whatever guidelines are adopted. Not because interventionalist are greedy, but if you get paid for doing something then you feel that it has instric value even if perhaps it is not warranted in some cases.

It would be easy to do a study and see what percentage of cardiac caths lead to a change in management or further surgical intervention. General surgeons are OK with around a 10% false positive rate on Ex-Laps for appendicitis as it is a clinical diagnosis.

dragonfly99 said:

The populations in places like Louisiana/Mississippi/Tennessee/Arkansas are quite different than somewhere like Oregon or Washington or northern CA. The rates of obesity and diabetes and smoking are >> in those southern places. I've lived in both those type places and there is a BIG difference in the lifestyle and overall rates of obesity and what people eat as far as their daily diets, and whether they get any type of exercise...although people all over the US are generally getting more and more fat to a degree that is truly scare.

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It is really fascinating the higher rates of stroke in the south, and southern cooking has always seemed to be very fried and unhealthy, at least to me. There was recently a study that tried to shine light on this mystery and it has linked the increased rates of cerebral vascular accidents to low birth weights in infants which apparently predisposes to HTN later in life. At any rate I can see why there would be a whole lot more candidates for cardiac cath in these southern states. I also feel that people in southern states mentioned exercise far less than people in the northwest in places like Portland and Seattle.

December 17th, 2008

The mystery of the Southern stroke belt is solved



Dr. Daniel Lackland at the Medical University of South Carolina has been working for years to unravel a mystery. It's called the "stroke belt," a swath of Georgia and the Carolinas where strokes are prevalent and often happen to people younger than me. (I turn 54 next month.)
"Even an African-American born outside the Southeast has a 50% lower risk of stroke than those born in the Southeast," he told the Emory-Georgia Tech Predictive Health Symposium this week.
Strokes are bad enough. Folks in this region are also twice as likely to require dialysis — 5,000 of every 1 million black folks in this area must go through the procedure every few days or they die.
Lackland found the cause was clear enough — hypertension.
"Even lean African-Americans often have high blood pressure," he said. Were we more aggressive in treating hypertension death rates among my black neighbors could drop 50%, he added
But why the hypertension? People here are no fatter than elsewhere. Finally Lackland feels he has isolated the variable.
Low birth weight. Some 14% of black babies, and 7% of white, in the stroke belt have low birth weights. The rate is going up, as we learn how to save more very premature infants.
When a very tiny infant survives it's a miracle. But what Dr. Lackland has shown is it's one with a definite sell-by date.
If your weight at birth was under a few pounds (six and a half is normal) you are at significant risk of hypertension, stroke, and kidney failure in later life.
(For readers outside the U.S., under a kilogram is bad, while 2.7 kg. is about normal.)
So what causes a higher risk of low birth weight? The CDC has known the cause of that for 20 years.
Smoking. Dr. Lackland has found that the solution to the mystery of the stroke belt was there all along, at the tip of your nose.

DarthNeurology said:

I would bet that if you look at the caths done in Alabama that the vast majority of them were justified.

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Here is the perfect study to answer this question. Don't look at absolute numbers of caths per 1000 patients, look at the number of therapys (stents, CABs) done per cath.

GeraldMonroe said:

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Ok, so right now there's 6,000 more people who apply for residency spots than there are available positions. All these folk have gone to medical school, and passed the boards. Nearly all the people who fail to match are foreign trained docs, IMGs, or folks who didn't do too well in medical school - but all of them finished. All these folk who fail to match have undergone far more training the PAs/NPs.

Right now, the AMA and other major organizations claim there is a growing shortage of physicians. They have hard numbers to back up these claims, based upon
1. Increasing U.S. population size
2. Aging population
3. Current medical school graduates working fewer lifetime hours than their cohorts 20 years ago

As well as other factors. I've never read evidence suggesting there are enough doctors but they are poorly distributed : references, please? In any case, I see no reason to believe such claims : in order for there NOT to be a shortage of doctors in 15-20 years, there has to be a large (20%+) surplus of doctors right now overall. Sure, in a few wealthy cities there are lots of doctors, possibly more than the minimum needed, and it's harder for a doctor to get a job there. That doesn't equate to a huge surplus. If there were a surplus, physicians working 40-50 hour weeks because they couldn't get enough patients would be common. I've never met an attending anywhere that had this problem.

Credible evidence says there's a looming shortage of doctors and of PCPs. Now, there's several thousand (~6000) folk who would probably go to work for a mere $140k a year who are willing to become PCPs if there were enough training slots. Just because foreign grads want specialties doesn't mean they won't take a PCP residency spot : all of them fill every year.

Seems straightforward enough to me.

Maybe LADoc0 doesn't want an immigrant who's working for peanuts and barely speaks English as the PCP who calls him up to perform a referral. I'm sure it's quite frustrating, having to deal with someone you can't even understand who calls him/herself a physician. But it's better than nothing.

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Wow dudes. There ARE some IMGs out there who aren't as incoherent as you make us out to be. A lot of us had to come to the Caribbean because there simply weren't enough spots in the US. Especially Cali/Texas residents. I am from a Caribbean med school myself, yet grew up in the states just like you all did.

It seems kind of mean spirited to put down IMGs so callously. I know of many IMGs who did better than the average Step score of US med students. So please do not categorize us all as inferior.

Don't worry monsoon, don't be swayed by the ignorant posts of some AMGs like LaDoc00. Most are very reasonable. Just know that you will get out of med school what you put into it, if you want to beat the majority of AMGs in the only objective measure of med school performance (board scores), then work hard. And yes, I am an IMG who is going into primary care by CHOICE.

As for the physician shortage: though many IM and FM spots went unfilled in the match, many were later filled in the scramble. Increasing the number of spots will most certainly help. Although most freshly minted residency grads will flock to the larger cities, not all will. A certain percentage of the increased number of slots will undoubtedly go to underserved areas, at least IMPROVING the maldistribution problem.

The real answer is somewhere in a combination of increasing primary care residency positions and increasing reimbursement (across most/all insurance providers) for commonly coded items. Employers in underserved areas must continue to make their offers more lucrative to lure in physicians.

Two pages of this stuff and no mention of residency salaries! My god, people!

Seriously, could this mean an increase of residency salary?

chameleonknight,
why would you think they will raise residency salaries?
I don't see that happening. They already raise it every year for cost of living/inflation. Medicare is having financial trouble. Giving physicians in training a raise is not going to be high on their list of things to do, I don't think. Nobody in the general public worries about residency salaries, in general...they assume that it's a couple years and out for us, and that we then become filthy rich.

aProgDirector said:

OBJECTIVES: We evaluated whether appropriateness and baseline risk of cardiac catheterization varied according to regional intensity of invasive therapy after acute myocardial infarction (AMI), and whether AMI mortality varied according to invasive intensity regions. BACKGROUND: Marked regional variations exist in cardiac invasive procedure use after AMI within the U.S. METHODS: We performed an analysis of 44,639 Medicare fee-for-service beneficiaries hospitalized with AMI between 1998 and 2001. Invasive procedure intensity was determined based on overall cardiac catheterization rates for Medicare enrollees. Cardiac catheterization appropriateness was determined by the American College of Cardiology/American Heart Association classification and baseline risk was estimated using the GRACE (Global Registry of Acute Coronary Events) risk score. The primary outcomes of the study were cardiac catheterization use within 60 days and 3-year mortality after hospital admission. RESULTS: Higher invasive intensity regions were more likely to perform cardiac catheterizations on class I patients (appropriate) (RR 1.38, 95% confidence interval [CI] 1.27 to 1.48), class II patients (equivocal) (RR 1.42, 95% CI 1.31 to 1.53), and class III patients (inappropriate) (RR 1.29, 95% 0.97 to 1.67) compared with low-intensity regions after adjusting for patient and physician characteristics. The overall cardiac catheterization use was 5.2% lower for each increase in GRACE risk decile, and this relationship was observed similarly in all regions. Risk-standardized mortality rates of AMI patients at 3 years were not substantially different between regions. CONCLUSIONS: Although higher-risk patients and those with more appropriate indications may have the most to benefit from an invasive strategy after AMI, we found that higher-invasive regions do not differentiate procedure selection based on the patients' appropriateness or their baseline risks.

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Hold the phone, the abstract of this article says that "higher invasive intensity regions" are more likely to perform caths on class III patients (inappropriate), but the confidence interval is 0.97 o 1.67 --- or overlaps one so doesn't make as strong stastical significance as most people are used to. The data could be interpreted as being statistically significant for higher use areas using cardiac cath more in "equivocal" and "appropriate" patients, but not in "inappropriate" patients.

There *may* or *may not* be overue of cardiac cathm until a randomized study is done you can really finagle the statistics however you want, another big question is whether the increased used of cardiac cath leads to unecessary PCI? OR maybe the northeast takes a more medicine based approach whereas other regions are more procedurally oriented, it is anybody's gues which is worse and nobody has satisifed me that the higher incidence of cardiovascular disease in southern states is not confounding these studies. To truly know the answer you would need to know what happens to patients with cardiovascular diseases in the northeast that don't get the cardiac cath they might have needed. Southern states/regions with higher rates of cardiovascular disease should do randomized controlled studies themselves to evaluate use of cardiac cath. Believe me, Maine Medical Center is not close to being the best medical center in the world (see below article) and might be underutilizing cardiac cath. There are plenty of northeastern doctors who don't council patients appropriately in terms of weight control, stop smoking, and being compliant with their medications --I have seen them--and could indicate that the northeastern part of the country is less involved in treating and preventing cardiovascular disease and doesn't think to order caths as much, states where there are more problems with cardiovascular disease are more aware of the problem and perhaps approach it differently, nobody knows which approach is better. The study cited by APD is from a northeastern group which just might not be the perspective that southern areas need. Next thing is that somebody will complain that docs in the Histo belt are ordering too many CXRs, just kidding, but same mentality.

December 15, 2008

Study Examines Possible Overuse of Invasive Cardiac Treatments


December 15, 2008 - In regions of the country where cardiologists perform high numbers of cardiac catheterizations to diagnose heart problems, patients may be receiving percutaneous cardiac interventions (PCI) more than they need or want, according to a study published online last week in the journal Circulation.


In the study, funded by the Foundation for Informed Medical Decision Making headquartered in Boston, Maine Medical Center researchers analyzed the relationship between cardiac catheterizations and the two most common invasive cardiac treatments used to restore blood flow — PCI and coronary artery bypass graft (CABG) surgery. They found a very high correlation between cardiac catheterization rates and PCI rates; researchers noted a much weaker connection between cardiac catheterization and the number of CABGs.

"Several recent studies on managing heart disease have touted the benefits of treatment with medication and lifestyle changes — as opposed to invasive treatment," said Lee Lucas, Ph.D., principal investigator at the Maine Medical Center Research Institute. "The results from our study reflect what might be a tendency for physicians to opt for treating invasively rather than conservatively if they see anything unusual during the diagnostic process."

"Our research indicates that patients may be getting PCIs that aren't necessary," said Lucas. She says that her findings might reflect the fact that criteria for PCIs are not as clearly defined as those for CABG.

"In addition, performing the diagnostic test and treatment in the same procedure, which is common practice, results in a situation in which patients have little opportunity to share in the decision making process before a PCI is performed." The concern, Lucas notes, is that catheterizations and PCIs are often done during a single procedure, where there is little opportunity for doctors to review results of the catheterization.

In a cardiac catheterization, a physician threads a catheter through an artery in the groin into the heart to evaluate that organ and surrounding blood vessels. If the test reveals a lesion, the physician will perform a PCI. This involves keeping the catheter in place after the diagnosis, inserting a tiny balloon to compress the narrow area in a blood vessel, and then inserting a small stent to permanently hold the vessel open. If blockage is severe enough to require CABG, the physician removes the catheter and sends the patient to surgery where a piece of artery is used to bypass the blocked areas.

To obtain their findings, the research team reviewed a 20 percent sample of Medicare part B claims nationwide and calculated the rates of testing and treatment by region of the country, adjusting for regional demographic differences.

They found that cardiac catheterization rates varied substantially across regions, ranging from 16 per thousand in some regions to 77 per thousand in others. And, they saw a strong correlation of cardiac catheterization rates to total treatments (R2 = 0.84). However, they also discovered a much weaker correlation between the tests and CABG rates (R2 = 0.41) with the suggestion of a threshold, beyond which further testing did not result in additional surgeries. On the other hand the correlation between cardiac catheterization testing rates and PCI rates was very strong (R2 = 0.78) and linear, meaning the more tests conducted, the greater the numbers of PCIs performed.

The Northeast region, including Maine Medical Center, has some of the lowest cardiac catheterization rates in the country. These low rates indicate conservative treatment and the likelihood that PCIs done here are more likely to be done appropriately.

Lucas and her team believe this study sheds light on the real challenges that now face the medical community in the management of heart disease — the need for developing clearer criteria for performing these procedures, which are not without risks and the importance of taking the individual patient's preferences into account.

In their paper, the researchers cite a Canadian study that demonstrated that if patients used a decision-making aid before PCI, they would opt out of treatment 28 percent more frequently than for treatment. Another study also suggested that physicians often performed PCIs, even when not supported by evidence did not support, to avoid a feeling of "regret" and because of a belief that opening an artery can only be beneficial to a patient even if the blockage was unrelated to symptoms.

"Most older people will eventually show some signs of cardiac lesions during catheterization testing," said Lucas. "What we need to ask ourselves is 'Should we be testing more people?' And, once tested, should we treat every lesion, even if the individual's symptoms and quality of life are not likely to be impacted?"

In the future, Lucas and her team plan to assess the impact of randomized trials that indicated that PCI may be overused.

Source: Maine Medical Center

For more information: www.mmc.org

Acherona said:

FMG's have no debt.

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Wrong assumption.

If you check on the link aprogdirector posted at the beginning of this thread it appears these bills in the House and Senate are going nowhere fast. I would bet big bucks you will not see an expansion in residency slots due to the cost and the fact that the government is already effectively broke.

I think a better approach for medical students is to work hard and get ready for the increasing competition for residency spots rather than hope for these bills to miraculously pass.

It's September now, so I was wondering did this bill ever pass?
It seems like it would be a Godsend for IMGs.
I wonder what the implications it would have for those who want to switch specialties or for those with lower board scores who can't get in anywhere. Maybe those with previous residency spots could finally get back into the system. I would hope there would be less cutoff scores so it would be like it used to be in the old days, where everyone gets a chance if they passed. If so, it would be great. I look forward to a bill like this. It's seriously like a dream come true. I've always wanted there to be enough residency spots to go around to prevent MD's from becoming homeless and jobless, having to find non-MD jobs that they don't really want.

I have heard that the reason they don't want to fill the shortage (if there is one) is that they want to keep physician salaries sky high. I wonder if physician salaries will decrease, and by how much, if there are enough doctors around, due to more supply, and less demand.

turquoiseblue said:

It's September now, so I was wondering did this bill ever pass?

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I doubt that this bill will be passed as I think the politicians will worry about what to do with healthcare reform, and then based on those changes look at increasing the number of residents.

It is interesting that the bill apparently provides more funding for training residents in outpatient clinics, perhaps this bill will be tacked on to whatever health care reform bill is passed, otherwise it will likely die in committee.

I think that a good chuck of the 40+ million without health insurance, perhaps 8 to 10 million are the young "invincibles", i.e. young adults that don't believe that they will get sick, or are gambling they won't get sick, and haven't bought insurance.

If they are required to buy insurance, or it they change their mind and do buy insurance, then likely they will need to be triaged, in terms of annual doctor visits and preventive care. This work, i.e. basically H and Ps on adults who are for the most part healthy can easily be done by residents. This is why it appears to me that there is extra outpatient funding tucked into the residency bill.

So I am guessing that outpatient services will need to be significantly ramped up with NPs, residents or PAs, and inpatient services will only need to be slight expanded. If the AMA and MDs are smart they would lobby for the increased residency spots, otherwise, the work will be given to mid-levels.

aProgDirector said:

Last I heard (and this was very informal, grape-vine type information) the cap increase has been watered down significantly due to costs, and will mostly involve redistributing currently unused slots.

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Probably a good thing. If a certain residency hasn't filled for multiple years, it should probably lose some of its funded positions. They can start with some of those osteopathic FP and IM spots (50%) that don't fill every year.

As someone said above, the best way to get people into primary care is to make it pay better. Who thinks people would do a 3 year card or GI fellowship if it only netted them a 20% increase in salary, for example, rather than more like 100%?

aProgDirector said:

Last I heard (and this was very informal, grape-vine type information) the cap increase has been watered down significantly due to costs, and will mostly involve redistributing currently unused slots.

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Do you know where I could confirm this?

I have tried looking at govtrack and other political websites but cannot find any current info on the bill

Fortunately these bill are stalled right now and hopefully will not get out of committee.
See: http://www.govtrack.us/congress/bill.xpd?bill=h111-2251
See: http://www.govtrack.us/congress/bill.xpd?bill=s111-973

The constituents who are in favor of this:
Med students who think this will make it easier for them to match.
Hospitals and residency programs who want more money for DME/IME and more resident labor.
Med schools who have been increasing enrollments rapidly to grab more tuition money (using the excuse of an alleged physician shortage) and now are worrying that all these extra students they have enrolled will have more trouble matching.

The reasons I am totally against this:
The government is hugely in debt and it is completely irresponsible to add more debt - spending needs to be cut not increased. We should not be mortgaging our children's futures.

The physician shortage is in many ways a myth perpetrated by the AAMC and AOA to justify increasing enrollment to grab more tuition money.

While it is true that there is a shortage of primary care doctors there is no shortage of primary care providers overall as PA and NP schools have ramped up their production to a record pace. There are rural and undesirable locations with shortages but good places to live generallly have enough or an oversupply of doctors. The problem is in the distribution and not the overall number of docs.

In net passing this bill will just lead to an increased number of unemployed docs in the future - PAs and NPs are already displacing docs as we speak. Go to any Minute Clinic and you will see they are all staffed by PAs and NPs. MSNBC just did a story on how Minute clinics are as good or better than doctor's offices: http://www.msnbc.msn.com/id/32681973/ns/health-health_care/

If the hospitals want to increase residents there is nothing to stop them if they are willing to pay for it.

An area that really needs reform is med school tuition as debt levels are going up to insane levels as med school tuitions keep going up much faster than inflation. There is another thread here about students with 300K debts. You won't be able to pay that back on a PA salary or if you are unemployed. PAs and NPs will certainly be used to drag down pay, especially in primary care.

P.S. There are now 145 accredited PA programs with 11 of these being new over the last 2 years.
http://www.arc-pa.org/Acc_Programs/acc_programs.html
There are over 800 NP programs: http://www.rntomsn.com/programs/nurse-practitioner/