Create a residency spot

[surgicel]

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Is there anyway a program director could create an unfunded approved residency spot for a candidate.

There is this one program that I want to do a prelim year at, but essentially I don't know if my app will be complete by their rank list date.
If I wanted to go there for a year and was willing to do a prelim year without any pay (unfunded) could I get that, I know that residency funding is an issue that's why there are a limited number of spots each place can have unless they get approved funding for more spots, is it still possible?

 

[Law2Doc]

Is there anyway a program director could create an unfunded approved residency spot for a candidate.

There is this one program that I want to do a prelim year at, but essentially I don't know if my app will be complete by their rank list date.
If I wanted to go there for a year and was willing to do a prelim year without any pay (unfunded) could I get that, I know that residency funding is an issue that's why there are a limited number of spots each place can have unless they get approved funding for more spots, is it still possible?

No. There are a variety of legal and liability reasons for this. Given this countries history of slavery, the government takes a very dim view of unpaid exploitation -- we have explicit minimum wage laws and the like. There's also an issue of fairness -- we can't give away internships to rich kids who can afford to forego a salary while better qualified poor kids can't afford it. Also interns cost the hospital money, even beyond salary -- there are very real training costs, liability insurance, GME staff and overhead -- so just because an unpaid slot doesn't draw a salary wouldn't mean it's not expensive to the hospital. But mostly, it's unworkable to have someone on a call schedule etc who you really have no control over because you don't sign their paycheck, can't fire them, etc. I wouldn't hold your breath for this.

 

[Promethean]

Agreed. I've seen someone try and fail to do what you are talking about, and he was actually rich enough to offer the program funding to take him. They explained that no, just no.

What he ended up doing was an unpaid "research fellowship" with the PD & attendings from the department that he was interested in joining. He got a year of audition time and two publications, while they got free labor in the lab, and he matched there the next year. If you have that kind of money, I guess, and are really set on one place, there are ways to make yourself look appealing to them for next year.

There are other routes in. You can look for off cycle positions that open up. Get your app ready and contact the program directors of every program you would consider. Let them know that your application is going to come late for ranking, but if they found themselves with an unfilled seat, that you'd be very interested. Follow up with them as July 1 approaches, so that if any IMG's they may have taken on can't turn up due to visa issues, etc. you will be poised to drop in and get to work. Meanwhile, you can be working or volunteering at something that will improve your chances for next year. I just supported a friend through this process and can tell you it isn't easy, but if it is your only hope to get where you need to go, you will make it work.

 

[surgicel]

Currently, I'm doing a research year, but I don't want to extend that. So essentially my application won't be complete until mid to late Jan, which at many places leaves only one or no interview slots that may already be filled by other interviewees. I don't want to go through soap and land a prelim spot at a malignant place with poor chances for categorical next year, that's why I was asking about this, I guess not though from the replies.

 

[gutonc]

If you're already doing an extra year, why is your app so late? Also, what makes you think that this program wants you as much as you want them? What other programs have you applied to? Are you just doing a prelim or applying advanced as well?

As is typical for this kind of post, you've left a lot of relevant information out. But the answer to your original question is "absolutely not".

 

[surgicel]

IMG, Grauduated October of this year.

You're right maybe they don't want me, just haven't applied anywhere yet, maybe that's a bad idea step 2 score coming out in Jan, still need to verify my degree (that's what im most concerned about)

 

[j4pac]

The military has something called "Full-time Outservice", in which your military branch pays you while in residency and NOT your residency program. Because you are being paid O-3/O-4 pay with allowances, it is usually significantly higher than residency pay. I am not sure what the residency program does with that money...I assume they keep it.

The ASGME only approves a specific number of spots and that is usually the number that the program offers. So even if I get FTOS this year for PM&R, I don't think that I could use that as leverage for a program director to use me as a "free extra body". Someone correct me if I am wrong.

 

[surgicel]

IMHO one of the biggest ways people screw up this process is by trying to rush it and this perceived notion of not wanting to "waste" time.

Your best shot will be when you have everything lined up. Getting your app in in January so you can try to scramble into a dead end prelim spot (*the only thing you'll have a chance for in the SOAP/scramble) is not the best way to further your career.

In fact it might even hurt you next year if you end up in a prelim year and try to reapply because (a) you'll probably get fewer interviews as a prelim than you would as a "fresh" applicant, (b) you'll have to put together your application while under the pressure of intern year, and (c) you might not be able to attend all the interviews you get due to your clinical schedule.

Not to mention that if you are starting research now, your application won't have the benefits of that research actually being productive, which hopefully in a year from now it will be.

I do agree with some of your points, but honestly I feel that regardless if I apply this year or next year I'm doing a prelim year, since I'll be in reach only for lower tier community categorical spots or prelim spots. I feel a solid prelim year will put me in a better position for next year when applying for catergircal which is why I would take that over a lower tier categorical spot. the only problem now is getting into a program which as you mentioned is difficult given my application is

 

[gutonc]

I do agree with some of your points, but honestly I feel that regardless if I apply this year or next year I'm doing a prelim year, since I'll be in reach only for lower tier community categorical spots or prelim spots. I feel a solid prelim year will put me in a better position for next year when applying for catergircal which is why I would take that over a lower tier categorical spot. the only problem now is getting into a program which as you mentioned is difficult given my application is late.


My only concern about applying next year is the perception that an applicant is 2 years out from their clinical experience or med school would look worse and I may not get me a better spot next year, as the number of applicants increase by a large extent.

I'm not sure if you are intentionally deluding yourself or if you're just terminally naive (or if that's just a distinction without a difference). But in either case, there is nothing remotely rational about your approach.

 

[atomi]

If your GME office is anything like mine, they treat you like high schoolers trying to get an internship at wal-mart. You have zero bargaining power and will essentially be forced to sign documents and policies you don't agree with or would never otherwise sign in a free labor market. There is zero chance they would ever consider stepping outside of the box and letting you work without pay or pay them. The $50,000 or so they pay you is inconsequential to them, and especially to the PD.

Your concerns about taking a lower tier categorical spot don't make any sense unless you are applying for medicine and want to do a fellowship, and even then trying to do a crappy prelim year in order to land a great categorical spot make even less sense.

Do not, I repeat DO NOT, take a crappy prelim surgery spot because it is the only thing you can get this year. If you want a prelim spot, get your ducks in a row and apply to a solid academic prelim medicine program the following year. Or if you don't need a prelim spot and want a categorical residency, apply to that instead. Use the extra 6 months or so off this year to do some research, knock out step 3, and put together a solid app for next year. Get some rest, do some part-time work if you need money. The time will fly by.

 

[backrow]

The military has something called "Full-time Outservice", in which your military branch pays you while in residency and NOT your residency program. Because you are being paid O-3/O-4 pay with allowances, it is usually significantly higher than residency pay. I am not sure what the residency program does with that money...I assume they keep it.

The ASGME only approves a specific number of spots and that is usually the number that the program offers. So even if I get FTOS this year for PM&R, I don't think that I could use that as leverage for a program director to use me as a "free extra body". Someone correct me if I am wrong.

Some programs are approved for more slots than they are funded, so if you can find a program that has that the FTOS money can help as you can slide into that slot.

 

[j4pac]

Some programs are approved for more slots than they are funded, so if you can find a program that has that the FTOS money can help as you can slide into that slot.

I just had an interview and the PD essentially told me that if I get full time out service that I've got a spot. He told me that he wants to expand his program and will get the spot if the funding could be provided. I doubt that it is a strategy that would work for programs like Harvard and Mayo...but it appears that it could work for smaller programs. I don't know how it would work as far as the match goes. Would have to check on the legalities.

 

[link2swim06]

No. There are a variety of legal and liability reasons for this. Given this countries history of slavery, the government takes a very dim view of unpaid exploitation -- we have explicit minimum wage laws and the like. There's also an issue of fairness -- we can't give away internships to rich kids who can afford to forego a salary while better qualified poor kids can't afford it. Also interns cost the hospital money, even beyond salary -- there are very real training costs, liability insurance, GME staff and overhead -- so just because an unpaid slot doesn't draw a salary wouldn't mean it's not expensive to the hospital. But mostly, it's unworkable to have someone on a call schedule etc who you really have no control over because you don't sign their paycheck, can't fire them, etc. I wouldn't hold your breath for this.

This happens in the dental world. There are residencies where you pay to do them. Not saying it is fair but it happens.

 

[altap]

No PD would give a spot to someone just because that someone would forego his salary.
But given the lack of residency slots due to supposed lack of funding this is a topic that needed consideration IMHO.

 

[Law2Doc]

Early on when I joined this board there was big backlash because one of the California specialty programs "created" a residency slot (from allocated but unfunded slots) for a guy whose family made a huge donation to the hospital. Got a ton of backlash and hostility and I'm pretty sure the upshot is this isn't allowed anymore (and never actually was allowed). Foregoing salary and finding your own earmarked funding isn't an option.

 

[altap]

The creation of residency slots for those who would forego their salaries (or even pay for it) is a way to increase the number of primary care physicians in underserved areas.
As a side note,5 or 4 years ago, I was (and still is) an advocate for the placement/employment of AMGs and FMGs who did not match to work as PAs in areas of clinical need. I believed that this was a win - win situation (I still do). As these doctors would have decent paying jobs and underserved areas would get the much needed medical providers.
A few months ago, MO Gov. Nixon signed into law a bill authorizing med school grads who passed Steps 1 and 2 to work as Assistant Physicians in areas of clinical need. This is a step in the right direction. And so is the creation of residency spots for those who would forego their salaries and or pay for their training.

 

[altap]

What is the solution to the lack of primary care physicians in underserved areas? Recruit physicians from other countries who would be willing to forego their salaries during residency training (or even pay for their training) and who would be willing to work in underserved areas for at least 5 years.

 

[Law2Doc]

...
As a side note,5 or 4 years ago, I was (and still is) an advocate for the placement/employment of AMGs and FMGs who did not match to work as PAs in areas of clinical need. I believed that this was a win - win situation (I still do). As these doctors would have decent paying jobs and underserved areas would get the much needed medical providers.
A few months ago, MO Gov. Nixon signed into law a bill authorizing med school grads who passed Steps 1 and 2 to work as Assistant Physicians in areas of clinical need. This is a step in the right direction. And so is the creation of residency spots for those who would forego their salaries and or pay for their training.

There's already another thread on this on the board, and honestly I think most in the medical profession disagree with you that it's a "step in the right direction" for the specific reason that what politicians (and you) don't seem to understand is that medical school is just foundation -- it doesn't actully make you qualified to "do" anything in healthcare. You still need training before you ought to try to take care of people, and the couple of supervised months described in the MO plan is laughable. All if us in the later years of long residencies and fellowships and those early in their attending careers still have a lot of trepidation about taking care of people. We know a lot and with that know a ton of things we could miss or that could go wrong. A med student grad knows little of that. To us, the thought of trying to take care of people without this extensive training is a lot like saying I'm going to pilot a commercial jet tomorrow because I've been a Passenger once or twice. It's just a Horrible idea, proposed by politicians, not doctors, who probably have never heard of residency, don't understand it's role, and think people who come out of medical school are ready to practice medicine because people who come out of law school are ready to practice law.

 

[Law2Doc]

What is the solution to the lack of primary care physicians in underserved areas? Recruit physicians from other countries who would be willing to forego their salaries during residency training (or even pay for their training) and who would be willing to work in underserved areas for at least 5 years.

Meh -- if you provide loan forgiveness you can probably convince a lot of US grads to stay there for a few years too. The problem is people still relocate and change specialties after 5 years or whatever. Physicians from other countries have fewer roots and are much more likely to relocate. you really need to get more locals from those underserved areas to become doctors so maybe they move back home after. But even they are sometimes going to chase $ or derm and never turn back.

 

[altap]

In my country of origin there are GPs, in order for you to become a GP you have to have a bachelor's degree and then 3 years of med school then 2 years of internship. The GPs are good. They function as frontlines in medical care in larger communities but in smaller ones they are the only ones doing everything .
Are you telling me that med school grads in the US and elsewhere cannot function as doctors/GPs?

 

[ThoracicGuy]

In my country of origin there are GPs, in order for you to become a GP you have to have a bachelor's degree and then 3 years of med school then 2 years of internship. The GPs are good. They function as frontlines in medical care in larger communities but in smaller ones they are the only ones doing everything .
Are you telling me that med school grads in the US and elsewhere cannot function as doctors/GPs?

Yes.

 

[Mad Jack]

There's already another thread on this on the board, and honestly I think most in the medical profession disagree with you that it's a "step in the right direction" for the specific reason that what politicians (and you) don't seem to understand is that medical school is just foundation -- it doesn't actully make you qualified to "do" anything in healthcare. You still need training before you ought to try to take care of people, and the couple of supervised months described in the MO plan is laughable. All if us in the later years of long residencies and fellowships and those early in their attending careers still have a lot of trepidation about taking care of people. We know a lot and with that know a ton of things we could miss or that could go wrong. A med student grad knows little of that. To us, the thought of trying to take care of people without this extensive training is a lot like saying I'm going to pilot a commercial jet tomorrow because I've been a Passenger once or twice. It's just a Horrible idea, proposed by politicians, not doctors, who probably have never heard of residency, don't understand it's role, and think people who come out of medical school are ready to practice medicine because people who come out of law school are ready to practice law.

And yet PAs and NPs are allowed to practice independently in many states immediately after graduation...

 

[DermViser]

And yet PAs and NPs are allowed to practice independently in many states immediately after graduation...

According to occupational licensing, yes.

 

[DermViser]

What would be far more likely is that the government maintains funding for primary care fields and/or underserved fields - and takes funding away from everything else (i.e. the competitive "lifestyle" specialties and areas with a relative surplus of physicians). That would be, in their minds, (a) helping address the doctor shortage and (b) saving money overall by reducing GME funding.

BINGO:
http://advancement.jefferson.edu/s/1399/index.aspx?sid=1399&gid=2&pgid=1077

As millions of people gain insurance for the first time, a shortage of primary care physicians poses the most significant workforce concern. Nasca says academic health centers will have to “get creative” if GME funding decreases.

“Institutions can expand internal medicine, pediatrics and family medicine residency programs by ceasing to pay residents in more competitive programs like dermatology, orthopaedic surgery and radiology. They could use federal funds that previously supported the competitive programs to pay for new primary care positions and could start charging residents in the more competitive programs tuition,” Nasca says.

“We could also see residencies become funded by device manufacturers or pharmaceutical companies,” he says. “And the conflict of interest issues and influence on the physician’s future practice in that case would be disastrous.”

 

[Mad Jack]

According to occupational licensing, yes.

I'm just saying, if a PA can function with minimal supervision after 24 months of school, a physician should be able to serve under supervision after 38 months of school. We have as many months of clinical rotations as most physician assistants have months of schooling with preclinical and clinical combined.

 

[rokshana]

In my country of origin there are GPs, in order for you to become a GP you have to have a bachelor's degree and then 3 years of med school then 2 years of internship. The GPs are good. They function as frontlines in medical care in larger communities but in smaller ones they are the only ones doing everything .
Are you telling me that med school grads in the US and elsewhere cannot function as doctors/GPs?

yes.

 

[Law2Doc]

In my country of origin there are GPs, in order for you to become a GP you have to have a bachelor's degree and then 3 years of med school then 2 years of internship. The GPs are good. They function as frontlines in medical care in larger communities but in smaller ones they are the only ones doing everything .
Are you telling me that med school grads in the US and elsewhere cannot function as doctors/GPs?

Yes. The point being those "two years of internship" matter a lot more than everything prior. Just as residency matters much much much more than med school in becoming a competent doctor.

 

[Law2Doc]

And yet PAs and NPs are allowed to practice independently in many states immediately after graduation...

Two wrongs don't make a right. There is no logic to allowing additional untrained people to practice medicine just because some groups have already been given too much autonomy.

But more importantly a PAs incompetence doesn't reflect negatively on doctors like an untrained "MD" would. I'm fine with Midlevels gaining a negative perception. But I don't want to be put in a position where I have to defend my own training when untrained "doctors" start screwing up. the public won't know one MD from another and I don't want a hit to the brand when people start coming away with the idea that an MD doesn't mean much more than a PA.

 

[Mad Jack]

Two wrongs don't make a right. There is no logic to allowing additional untrained people to practice medicine just because some groups have already been given too much autonomy.

But more importantly a PAs incompetence doesn't reflect negatively on doctors like an untrained "MD" would. I'm fine with Midlevels gaining a negative perception. But I don't want to be put in a position where I have to defend my own training when untrained "doctors" start screwing up. the public won't know one MD from another and I don't want a hit to the brand when people start coming away with the idea that an MD doesn't mean much more than a PA.

The best arguments I've heard yet against the whole assistant physician BS.

I'm not saying it's a good thing to do or not- personally I think that any physician should have a minimum of an internship before engaging in any sort of practice, as has always been the base standard.

 

[altap]

I have to diagree. I still think that AMGs and FMGs who passed Steps 1 and 2 have the capabilityto work as GPs in underserved communities. If NPs and PAs can do the job why not med school graduates who passed Steps 1 and 2 of the MLE. I'm pretty sure that these doctors are better than any fresh grad NP or PA. Would a year of internship or passing step 3 help? Sure. But the bigger question is how are we going to give medical care to rural folks who are in desperate need of a doctor.

 

[deleted480308]

I have to diagree. I still think that AMGs and FMGs who passed Steps 1 and 2 have the capabilityto work as GPs in underserved communities. If NPs and PAs can do the job why not med school graduates who passed Steps 1 and 2 of the MLE. I'm pretty sure that these doctors are better than any fresh grad NP or PA. Would a year of internship or passing step 3 help? Sure. But the bigger question is how are we going to give medical care to rural folks who are in desperate need of a doctor.

You aren't listening...np and pa grads aren't good enough either without a fully trained physician supervising

 

[j4pac]

Med students coming out without attending oversight? Scary.

It's a bad idea and it would mean setting the bar too high. I believe that most will be ready to be a GP post-internship...but definitely not post-med school. Not enough clinic experience...and definitely not enough experience with autonomy.

 

[Law2Doc]

I have to diagree. I still think that AMGs and FMGs who passed Steps 1 and 2 have the capabilityto work as GPs in underserved communities. If NPs and PAs can do the job why not med school graduates who passed Steps 1 and 2 of the MLE. I'm pretty sure that these doctors are better than any fresh grad NP or PA. Would a year of internship or passing step 3 help? Sure. But the bigger question is how are we going to give medical care to rural folks who are in desperate need of a doctor.

You don't become a good clinician by passing the steps. You learn most of what you need to practice independently during residency. You aren't much use until you've done that and every person on here who is a doctor is going to attribute pretty much all of their useful clinical know how to things they learned after med school. Sorry but while we get why someone lacking a residency might want it not to be a barrier of entry to medical practice that doesn't mean it's not a good barrier to have.

 

[DermViser]

Two wrongs don't make a right. There is no logic to allowing additional untrained people to practice medicine just because some groups have already been given too much autonomy.

But more importantly a PAs incompetence doesn't reflect negatively on doctors like an untrained "MD" would. I'm fine with Midlevels gaining a negative perception. But I don't want to be put in a position where I have to defend my own training when untrained "doctors" start screwing up. the public won't know one MD from another and I don't want a hit to the brand when people start coming away with the idea that an MD doesn't mean much more than a PA.

Don't they already feel that about MD and NPs? Look at primary care where many patients feel their NP listens to them more and cares more. 🙄

 

[DermViser]

But the bigger question is how are we going to give medical care to rural folks who are in desperate need of a doctor.

So people in rural areas should have worse care that could probably kill them bc of that desperation?

 

[DermViser]

You aren't listening...np and pa grads aren't good enough either without a fully trained physician supervising

NPs can practice independently in many states.

 

[deleted480308]

NPs can practice independently in many states.

Can legally does not mean qualified or "should"

 

[DermViser]

Can legally does not mean qualified or "should"

My point is that we can't live in a bubble, esp. since the govt. is convinced we charge too much for our services.

 

[Law2Doc]

My point is that we can't live in a bubble, esp. since the govt. is convinced we charge too much for our services.

The answer to that is educating the government and public as to what is involved in training a doctor versus a midlevel, not a race to provide discount medicine. The average consumer "gets" top shelf versus "bargain basement" distinctions in other facets of their lives. They just aren't informed of the differences here, for political reasons. But it becomes infinitely more confusing when the person treating them has MD on the white coat.

 

[Law2Doc]

My point is that we can't live in a bubble, esp. since the govt. is convinced we charge too much for our services.

Again I don't think we are in the bubble. The public and government are. We see the bigger picture in terms of training and risk. Maybe it's time to break that bubble and let them see that what they are being fed as healthcare is not the best.

 

[DermViser]

The answer to that is educating the government and public as to what is involved in training a doctor versus a midlevel, not a race to provide discount medicine. The average consumer "gets" top shelf versus "bargain basement" distinctions in other facets of their lives. They just aren't informed of the differences here, for political reasons. But it becomes infinitely more confusing when the person treating them has MD on the white coat.

The govt. does not listen by being educated at congressional hearings. We've reached a stage in medicine where the govt. has said we can't allow healthcare expenditures to push out other areas of the budget. Healthcare costs are why the American public has not seen an increase in their salary and wages, which has largely stagnated.

They respond to lobbying and cash - something the nursing lobby has caught onto and used to their advantage - there are articles on this. It's also how the NP movement was able to get more clout esp. at the state level. The only reason the govt. doesn't have everyone be seen by a midlevel to lower costs overall is bc the general public is very much attached to their doctors and will "throw the b******* out!" to a politician who recommends it. Look at the huge hullabaloo when people were told "if they like their doctor they could keep their doctor" and ended up finding out it wasn't true.

 

[DermViser]

Again I don't think we are in the bubble. The public and government are. We see the bigger picture in terms of training and risk. Maybe it's time to break that bubble and let them see that what they are being fed as healthcare is not the best.

Not the smartest of perspectives when you think everyone else is crazy but you (not you personally).

 

[Law2Doc]

Not the smartest of perspectives when you think everyone else is crazy but you (not you personally).

Well, I think the example here -- where the public is insulated from facts that would be helpful to informed healthcare decisions is apt here.

 

[DermViser]

Well, I think the example here -- where the public is insulated from facts that would be helpful to informed healthcare decisions is apt here.

Except they don't think we're educating them. They think we are being protectionist and feel that if physicians can't treat people, other people shouldn't be allowed to treat people. See Matt Yglesias columns on this issue - who normally I wouldn't care what he thinks, but he has the ears of policy makers esp. the White House.

 

[Law2Doc]

The govt. does not listen by being educated at congressional hearings. We've reached a stage in medicine where the govt. has said we can't allow healthcare expenditures to push out other areas of the budget. Healthcare costs are why the American public has not seen an increase in their salary and wages, which has largely stagnated.

They respond to lobbying and cash - something the nursing lobby has caught onto and used to their advantage - there are articles on this. It's also how the NP movement was able to get more clout esp. at the state level. The only reason the govt. doesn't have everyone be seen by a midlevel to lower costs overall is bc the general public is very much attached to their doctors and will "throw the b******* out!" to a politician who recommends it. Look at the huge hullabaloo when people were told "if they like their doctor they could keep their doctor" and ended up finding out it wasn't true.

I agree congressional hearings are a waste of time. Nobody watches cspan. If you want to get the government and public informed you need to inundate the 24 hour cable news networks. Find those horror stories where people have been misdiagnosed or mistreated by midlevels (it has to have happened) and make some noise about how a three year residency program would have made that oh so much less likely. You don't think your favorite talking head couldn't make that a show?

 

[altap]

Correct me if I'm wrong but if dental medicine can pay for some of their residencies then I don't see any reason why it would be illegal to pay for a residency training in medicine (precedent). SouthernIM, I'm not doing this for my own benefit.

 

[altap]

Post deleted

 

[altap]

The problem started when physicians started training those who did not graduate from med school to do the job of physicians.
So what is your solution to primary care physician shortage in underserved communities, that would help these communities get the much needed healthcare and provide good paying jobs to otherwise underemployed or worse unemployed med school grads? MO is doing a common sense approach.

 

[gutonc]

Correct me if I'm wrong but if dental medicine can pay for some of their residencies then I don't see any reason why it would be illegal to pay for a residency training in medicine (precedent). SouthernIM, I'm not doing this for my own benefit.

You (like most people) confuse illegal (i.e. against some sort of municipal, state or federal statute) with "against the rules" in this case of the ACGME. Just because the dentists are willing to financially victimize their trainees doesn't mean the physicians are...yet. Call it a night bro...not gonna happen.

 

[IMPD]

Creating paid-for (e.g. loans) positions was part of the "GME payment reform" options discussed for the past several years. Could still happen for some fellowships in a scenario where Medicare decided to drive training agendas. That possibility is, admittedly, extremely unlikely. Teaching hospitals and AAMC stand united against payment reform.

As for how to help create care for those in rural areas, I have no idea. Medicine takes a while to learn and we are unlikely to accept an official "B" grade primary care (think Walmart primary care). The push to diversify medical schools is likely somewhat in response to this perception that government dollars are primarily paying for a non-diverse workforce.

I think states will continue to experiment with pushing for expanding medical care access through unconventional means.