More merger worries

[GUH]

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There's no way your MD friends had the opportunity to spend their two medicine rotations out of a hospital the entire time (unless they were in some primary care or rural track) or take house call. There's no way because LCME regulations have rules about what is expected exposure wise in that setting.

To which regulations are you referring, specifically? Link them if you want to lend credibility to your statement. The LCME standards are publicly available.

 

[AlteredScale]

To which regulations are you referring, specifically? Link them if you want to lend credibility to your statement. The LCME standards are publicly available.

From the LCME Self Study Assessment for Full Accreditation:

Standard 5.5 Evaluate the adequacy of the resources for the clinical instruction of medical students, including patient numbers and case mix and inpatient and ambulatory teaching sites. Note if the constellation of teaching sites used for required clinical experiences collectively can accommodate the assigned number of learners in each discipline and can meet the objectives for clinical education, including the required clinical encounters specified by faculty. Does each site used for required clinical experiences have sufficient and appropriate teaching and study space, information resources, and call rooms (if applicable)?

Standard 6.4 Comment on the adequacy of inpatient and outpatient experiences in the curriculum to allow the objectives of the educational program and the individual clerkships to be met.

Based of these two standards I would assume that having a preceptor and running house call for both of your IM clerkships would not be adequate to meet the objectives for clinical education. Moreover it lends nothing to inpatient exposure/experiences. Now, I am strictly speaking specifically to the case above and how that type of experience for IM blocks would not pass well with the LCME. @Med Ed , since you are more on the MD side of the things and are well versed on the LCME guidelines what would your input be? Would MD schools be allowed to have an entirely preceptor based, house-call exrience of both IM blocks based on these guidelines?

 

[Geraltofrivia]

The clinical evaluation requirements that are written in LCME guidelines is very very stringent with pathology exposure and types of experiences that are expected compared to coca.

At many DO schools you are allowed to do your medicine rotations (one of the most important) with a private practice preceptor and never step foot in a hospital the whole rotation. If you're lucky you can even take house call (where you drive around and visit patients). Or spend an EM rotations working from the harsh hours of 8am to 2pm. If it's the holiday season on your with a preceptor you're in luck because you don't have to come back for a week, enjoy the holidays.

None of these things would fly at an MD school for third year. Sure they get outpatient exposure but to never step foot in a hospital for your internal medicine rotations?

But by all means don't just take my anecdotal accounts, program directors notice that DO students are behind come fourth year when they don't know how to round nor how to work with residents. Instead of spending fourth year to shine as a Sub-I, they are getting their first exposure to ward based, resident lead medicine.


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And that is going to be me, and many many other students from my school. Just as an FYI

 

[Geraltofrivia]

I highly doubt that. A few might close, but even still a private med school is still a huge money maker. Even if they had to invest and beef up rotations, they'd still benefit from existing. Some may even be forced to affiliate with undergrad universities, like MD standalone med schools have had to do in the past, which honestly would probably be a good thing for future students.



Honestly, this is a constant problem. It's a problem I personally have as well, because of the nature of certain dual-accredited programs in my region of interest that by policy only take DOs in the AOA match.

It's also a problem if say your number 1 spot is ACGME, but 2-6 are AOA, because you have to decide if the chance of matching at your number 1 is worth the risk of matching at your #7 or below.

I also can't tell you the number of classmates I know that are borderline, who have a decent number of ACGME interviews, but not enough to risk not being in the AOA match for those couple of mediocre AOA programs that they'll most likely match into.



I have to be honest, I have not experienced a single rotation like that. I've had a bad day here or there, but honestly, having talked to plenty of MDs in my area, my experience seems no different than there's, save an OMM rotation and a bunch of required primary care focused rotations where MDs have vacations, "research months" or electives.

Now I don't doubt that some students experience what you've described (I've heard about them myself from DO students), but I can say with some confidence that the majority of students at my school don't regularly experience this. And to be honest, the people who do experience those types of rotations at my school tend to be the ones that seek them out.

I completely agree that those types of experiences should be eliminated, but while it may cost DO schools, I doubt it would be very hard for most to implement, they just need some incentive like a threat of losing accreditation.

You heard it here first. The people that seek "chill" rotations are the ones that actively seek out to be at the bottom of the lottery system used by many DO schools to figure out rotation sites for third year.

 

[IH8ColdWeath3r]

Honestly the truth is that the clinical years in medical education as a whole have some fairly large issues. The days of the student actually having a meaningful place in patient care and creating treatment plans are slowly disappearing. I think it's sad when I hear attendings talk about their experiences as a student and then hear students talk about their current experiences, they are often pretty different.

I agree with this sentiment, but it largely depends on the institution. From what I have experienced, the MD affiliated institutions or teaching centers allow students to actively participate and do more things hands on. I did my 3rd year rotations at a large hospital that only took DO residents at the time. Some of the rotations were excellent in that I saw wide mix in pathology that I could read up on. Sometimes, however, I was not actively involved in the management of the patient (seeing patient's on my own). Other rotations were awful and could largely be described as a shadowing experience, which, IMO is not beneficial at all. There is a huge learning opportunity and benefit of seeing your own patient's, presenting them, proposing a ddx and workup, and getting feedback on that. You remember these cases and you learn from them by reading on them. It makes it stick, so to speak, as opposed to *thinking* you know what to do because you WATCHED a physician do it. Basically, in a nutshell, DOING > WATCHING.

The current rotation that I am on allows me to see patients on my own, admit my own patients, call my own consults, and do the necessary procedures on my own patients. This has been SO beneficial and I have learned a ton from this. This was also the case at the other MD programs that I rotated at. I think the faculty, because they are clinical faculty and affiliated with the residency program, are more inclined to and feel comfortable allowing medical students to be actively involved in patient management vs some clinician from the community, who works in private practice or a place not affiliated with a medical school/residency institution who sees no reason to let the med student slow him down or make him do extra work by having to supervise him (a lot of DO rotations are with clinicians like this)

This is not a blanket statement at DO affiliated rotations but just what I have experienced throughout my two years from rotating at various MD affiliated institutions vs clinicians from the faculty who take DO students. Also, a lot of what you get to do depends on your level of confidence and how actively you seek learning opportunities. If you don't know anything, chances are the attending isn't going to let you drop a central line. If you display common sense and working fund of knowledge that pertains to that rotation, chances are that you will get to do more.

 

[Geraltofrivia]

I agree with this sentiment, but it largely depends on the institution. From what I have experienced, the MD affiliated institutions or teaching centers allow students to actively participate and do more things hands on. I did my 3rd year rotations at a large hospital that only took DO residents at the time. Some of the rotations were excellent in that I saw wide mix in pathology that I could read up on. Sometimes, however, I was not actively involved in the management of the patient (seeing patient's on my own). Other rotations were awful and could largely be described as a shadowing experience, which, IMO is not beneficial at all. There is a huge learning opportunity and benefit of seeing your own patient's, presenting them, proposing a ddx and workup, and getting feedback on that. You remember these cases and you learn from them by reading on them. It makes it stick, so to speak, as opposed to *thinking* you know what to do because you WATCHED a physician do it. Basically, in a nutshell, DOING > WATCHING.

The current rotation that I am on allows me to see patients on my own, admit my own patients, call my own consults, and do the necessary procedures on my own patients. This has been SO beneficial and I have learned a ton from this. This was also the case at the other MD programs that I rotated at. I think the faculty, because they are clinical faculty and affiliated with the residency program, are more inclined to and feel comfortable allowing medical students to be actively involved in patient management vs some clinician from the community, who works in private practice or a place not affiliated with a medical school/residency institution who sees no reason to let the med student slow him down or make him do extra work by having to supervise him (a lot of DO rotations are with clinicians like this)

This is not a blanket statement at DO affiliated rotations but just what I have experienced throughout my two years from rotating at various MD affiliated institutions vs clinicians from the faculty who take DO students. Also, a lot of what you get to do depends on your level of confidence and how actively you seek learning opportunities. If you don't know anything, chances are the attending isn't going to let you drop a central line. If you display common sense and working fund of knowledge that pertains to that rotation, chances are that you will get to do more.

There is some truth, but not a lot. Really the key statement is this one "I think the faculty, because they are clinical faculty and affiliated with the residency program, are more inclined to and feel comfortable allowing medical students to be actively involved in patient management vs some clinician from the community, who works in private practice or a place not affiliated with a medical school/residency institution who sees no reason to let the med student slow him down or make him do extra work by having to supervise him (a lot of DO rotations are with clinicians like this)"

Private practice people are running a business. They did not start working to teach medical students. Their incentive is even lower to teach if they aren't getting reimbursed for their time, which is the case for the vast majority of people who precept DO students. This is where education is hurt the most for DOs.

 

[IH8ColdWeath3r]

There is some truth, but not a lot. Really the key statement is this one "I think the faculty, because they are clinical faculty and affiliated with the residency program, are more inclined to and feel comfortable allowing medical students to be actively involved in patient management vs some clinician from the community, who works in private practice or a place not affiliated with a medical school/residency institution who sees no reason to let the med student slow him down or make him do extra work by having to supervise him (a lot of DO rotations are with clinicians like this)"

Private practice people are running a business. They did not start working to teach medical students. Their incentive is even lower to teach if they aren't getting reimbursed for their time, which is the case for the vast majority of people who precept DO students. This is where education is hurt the most for DOs.

Yeah and alot of what about my statement is not truthful?

 

[GUH]

From the LCME Self Study Assessment for Full Accreditation:

Standard 5.5 Evaluate the adequacy of the resources for the clinical instruction of medical students, including patient numbers and case mix and inpatient and ambulatory teaching sites. Note if the constellation of teaching sites used for required clinical experiences collectively can accommodate the assigned number of learners in each discipline and can meet the objectives for clinical education, including the required clinical encounters specified by faculty. Does each site used for required clinical experiences have sufficient and appropriate teaching and study space, information resources, and call rooms (if applicable)?

Standard 6.4 Comment on the adequacy of inpatient and outpatient experiences in the curriculum to allow the objectives of the educational program and the individual clerkships to be met.

Based of these two standards I would assume that having a preceptor and running house call for both of your IM clerkships would not be adequate to meet the objectives for clinical education. Moreover it lends nothing to inpatient exposure/experiences. Now, I am strictly speaking specifically to the case above and how that type of experience for IM blocks would not pass well with the LCME. @Med Ed , since you are more on the MD side of the things and are well versed on the LCME guidelines what would your input be? Would MD schools be allowed to have an entirely preceptor based, house-call exrience of both IM blocks based on these guidelines?

"Evaluate"
"Comment on"

Hard to guess what MD schools would be "allowed" to do based on what you posted.

 

[AlteredScale]

"Evaluate"
"Comment on"

Hard to guess what MD schools would be "allowed" to do based on what you posted.

I don't know what to tell ya then since now we are playing off the definition of those terms. Those are both core standards. The reason it says comment and evaluate is because I provided the documentation for self assesment by the school to prepare for an Lcme site visit.

I have yet to see an MD school curriculum where both IM core rotations are "allowed" to be house call. Of the many colleagues I have at MD schools, that has never ben the case. Obv this is rare even for DO schools. But i still do not beleive this would be okay by Lcme standards.


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[Med Ed]

@Med Ed , since you are more on the MD side of the things and are well versed on the LCME guidelines what would your input be? Would MD schools be allowed to have an entirely preceptor based, house-call exrience of both IM blocks based on these guidelines?

I would have to see the rest of the year to get more context. There has been an unfortunate proliferation of dodgy clerkship experiences in allopathic schools, commensurate with expanding class sizes and the opening of new schools in already-saturated areas. It has only been in the last 2-3 years that clinical training resources have become more important for preliminary accreditation. Some schools do have heavy preceptor-based 3rd years now, and some places have justified shifting toward ambulatory care because that's how most medicine is practiced now. Inpatient IM has become the land of hospitalists and hand-offs.

With regard to call, I know graduates of highly ranked medical schools who never took a single night of in-house call. Not that I'm bitter.

With regard to the LCME, the standards are mostly vague. They say something should be "adequate," you show them what you got, and then they pass judgement. Schools end up completing two separate documents for accreditation: the data collection instrument (DCI), which is a dry assemblage of the school's data, and the self-study, which comprises a digestible self-analysis of what is in the DCI, and whether the school thinks it has met the standards. Here are the ones which relate most clearly to core clinical instruction:

5.5 Resources for Clinical Instruction
A medical school has, or is assured the use of, appropriate resources for the clinical instruction of its medical students in ambulatory and inpatient settings and has adequate numbers and types of patients (e.g., acuity, case mix, age, gender).

5.6 Clinical Instructional Facilities/Information Resources
Each hospital or other clinical facility affiliated with a medical school that serves as a major location for required clinical learning experiences has sufficient information resources and instructional facilities for medical student education.

6.4 Inpatient/Outpatient Experiences
The faculty of a medical school ensure that the medical curriculum includes clinical experiences in both outpatient and inpatient settings.

6.7 Academic Environments
The faculty of a medical school ensure that medical students have opportunities to learn in academic environments that permit interaction with students enrolled in other health professions, graduate and professional degree programs, and in clinical environments that provide opportunities for interaction with physicians in graduate medical education programs and in continuing medical education programs.

In summary, I think a school could get away with preceptor-based IM, but there would have to be other compensatory experiences that give students exposure to residents.

 

[AlteredScale]

I would have to see the rest of the year to get more context. There has been an unfortunate proliferation of dodgy clerkship experiences in allopathic schools, commensurate with expanding class sizes and the opening of new schools in already-saturated areas. It has only been in the last 2-3 years that clinical training resources have become more important for preliminary accreditation. Some schools do have heavy preceptor-based 3rd years now, and some places have justified shifting toward ambulatory care because that's how most medicine is practiced now. Inpatient IM has become the land of hospitalists and hand-offs.

With regard to call, I know graduates of highly ranked medical schools who never took a single night of in-house call. Not that I'm bitter.

With regard to the LCME, the standards are mostly vague. They say something should be "adequate," you show them what you got, and then they pass judgement. Schools end up completing two separate documents for accreditation: the data collection instrument (DCI), which is a dry assemblage of the school's data, and the self-study, which comprises a digestible self-analysis of what is in the DCI, and whether the school thinks it has met the standards. Here are the ones which relate most clearly to core clinical instruction:

5.5 Resources for Clinical Instruction
A medical school has, or is assured the use of, appropriate resources for the clinical instruction of its medical students in ambulatory and inpatient settings and has adequate numbers and types of patients (e.g., acuity, case mix, age, gender).

5.6 Clinical Instructional Facilities/Information Resources
Each hospital or other clinical facility affiliated with a medical school that serves as a major location for required clinical learning experiences has sufficient information resources and instructional facilities for medical student education.

6.4 Inpatient/Outpatient Experiences
The faculty of a medical school ensure that the medical curriculum includes clinical experiences in both outpatient and inpatient settings.

6.7 Academic Environments
The faculty of a medical school ensure that medical students have opportunities to learn in academic environments that permit interaction with students enrolled in other health professions, graduate and professional degree programs, and in clinical environments that provide opportunities for interaction with physicians in graduate medical education programs and in continuing medical education programs.

In summary, I think a school could get away with preceptor-based IM, but there would have to be other compensatory experiences that give students exposure to residents.

At my school in KC, if one ends up doing rotations in the city then essentially all of third year is preceptor based. Students "make up" for this by doing sub Is at places with GME.

The particular example I have above about doing house call (not even a clinic experience) also had a similar year long strictly preceptor based exposure. Without a doubt this wouldn't have happened if they school didn't allow this person to train on the opposite end of the country for third year.


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[AlteredScale]

Hopefully the new agreement with KCU and HCA Midwest Health, will help with this.

The only residency available through HCA is Family Medicine at research so the first few groups that rotate with HCA will mainly be preceptor based still. Once the school starts opening residencies then for sure I think it'll help.

I think just overall it'll be nice to no have half the class leave the state because of a lack of spots.


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[DocEspana]

This thread: someone said something scary and also counterintuitive. His only justification for these claims is "idk if it will happen, but without years of analysis and absolutely no action... IT COULD!" But it also plays into my personal sense of inadequacy, so I feel like freaking out.

Also this thread:

My thoughts on part 1: everyone forgets this wasn't a happy little thing the AOA stumbled onto along the way and just happened to act (slightly) swiftly on. This was forced upon them with real and serious consequences for inaction.... AND THEY STILL CHOSE NOT TO ACT! They called the ACGME's and AMA's bluff and the latter two just laughed and shrugged their shoulders and did exactly what they said they would do. So the AOA came back groveling for a second chance and, in a turn of events that still blows my mind, GOT A BETTER DEAL THAN THEY WERE FIRST OFFERED! You can't analyze benefit or downside of this without remembering that 1) not taking part would have been literal catastrophe 2) there wasn't time to negotiate much and 3) despite the second point, they still did negotiate and got a better deal than initially offered... at least as far as the AOA itself retaining power and relevance. Deal didn't change much from the resident POV.

Thoughts on the second thing? What's the point in having a dead horse if you can't beat it? Whack away at all those old and rehashed arguments!

 

[Med Ed]

The particular example I have above about doing house call (not even a clinic experience)

I suppose I am confused by the term "house call."

 

[AlteredScale]

I suppose I am confused by the term "house call."

I guess it's just visiting patients in their house, they drive around in a doctor-mobile or something.




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[SurgDoc95]

I guess it's just visiting patients in their house, they drive around in a doctor-mobile or something.




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Even if I never do a single house call I want a doctor-mobile!

 

[Med Ed]

I guess it's just visiting patients in their house, they drive around in a doctor-mobile or something.

Ah, okay. I think the more recognizable phrase would be "making house calls."

House call sounded suspiciously like home call, which means that someone takes call after hours from home.

 

[hallowmann]

You heard it here first. The people that seek "chill" rotations are the ones that actively seek out to be at the bottom of the lottery system used by many DO schools to figure out rotation sites for third year.

I was speaking specifically of my own school that doesn't do a lottery system per se, but rather utilizes an algorithm based off your own ranks that is controlled/governed by your elected SGA president and vice president.

The only aspects of regulation that go in are for some sites that limit their rotating students based on GPA (e.g. only takes students with >3.0 in preclinicals), and for those deemed "struggling" (GPA <2.5) they are restricted to a handful of sites, some of which actually provide better oversight and rotations with residencies and regular didactics (don't get me wrong, one is horrible, another is at a site that has only had students and OGME since 2012 but has already started the ACGME accreditation process and now has at least one initially accredited program, a couple only have FM residencies).

I guess it's just visiting patients in their house, they drive around in a doctor-mobile or something.

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Honestly, I would have really liked to make house calls, maybe not for my IM rotation, but maybe for my Ambulatory one. I've never heard of an IM experience like this. The worst I heard about was a hospitalist preceptor that saw a handful of patients in the hospital in the AM and was in an outpatient clinic in the PM. That might be OK for 1 IM rotation, but you should have at least 1 purely inpatient based on a resident team, preferably on a busy service.

 

[SwordOfTheMorning]

Unrelated to the article, but can the ACGME, in the future require programs to accept only the USMLE? Even if they don't, is the COMLEX in its dying years anyways with the merger?

 

[AlteredScale]

Unrelated to the article, but can the ACGME, in the future require programs to accept only the USMLE? Even if they don't, is the COMLEX in its dying years anyways with the merger?

Yes ACGME programs can still require the only the USMLE. As of right now the NBME and the nbome have not been at all a part of the merger process and all licensing processes will remain as is.




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[hallowmann]

Unrelated to the article, but can the ACGME, in the future require programs to accept only the USMLE? Even if they don't, is the COMLEX in its dying years anyways with the merger?

Individual programs will limit what they accept, but it's not the ACGME's MO to limit what criteria program directors use for accepting applicants, just the manner in which they are accepted. Because of that, I find it incredibly unlikely that the ACGME would put that kind of restriction on PDs. That said, its certainly not impossible, and as DO, unless you're not doing well on NBMEs you should plan to take the USMLE.

The COMLEX is not going anywhere for the foreseeable future.

 

[GUH]

This thread: someone said something scary and also counterintuitive. His only justification for these claims is "idk if it will happen, but without years of analysis and absolutely no action... IT COULD!" But it also plays into my personal sense of inadequacy, so I feel like freaking out.

Also this thread:

My thoughts on part 1: everyone forgets this wasn't a happy little thing the AOA stumbled onto along the way and just happened to act (slightly) swiftly on. This was forced upon them with real and serious consequences for inaction.... AND THEY STILL CHOSE NOT TO ACT! They called the ACGME's and AMA's bluff and the latter two just laughed and shrugged their shoulders and did exactly what they said they would do. So the AOA came back groveling for a second chance and, in a turn of events that still blows my mind, GOT A BETTER DEAL THAN THEY WERE FIRST OFFERED! You can't analyze benefit or downside of this without remembering that 1) not taking part would have been literal catastrophe

Aside from exclusion from fellowship programs, what would the "literal catastrophe" have been?

2) there wasn't time to negotiate much and 3) despite the second point, they still did negotiate and got a better deal than initially offered... at least as far as the AOA itself retaining power and relevance. Deal didn't change much from the resident POV.

Thoughts on the second thing? What's the point in having a dead horse if you can't beat it? Whack away at all those old and rehashed arguments!

But from the student perspective, it definitely could change things, especially for students trying to match into specialties that are unrealistic for DOs in the ACGME.

And yeah we're bashing a dead horse but a lot of people on this forum haven't been around for as long to fully understand what happened.

 

[AlteredScale]

Aside from exclusion from fellowship programs, what would the "literal catastrophe" have been?
.

Do you not interpret that as a big deal that all AOA graduates would be barred from ACGME fellowship as well as anyone who did an AOA intern year looking to do an advanced residency?


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[GUH]

Do you not interpret that as a big deal that all AOA graduates would be barred from ACGME fellowship as well as anyone who did an AOA intern year looking to do an advanced residency?


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Definitely a big deal. But fellowships don't mean much for students who won't even be able to match to a PGY-1 year position in their chosen specialty to begin with once we lose those spots.

 

[DocEspana]

Definitely a big deal. But fellowships don't mean much for students who won't even be able to match to a PGY-1 year position in their chosen specialty to begin with once we lose those spots.

Pretty much every resident out there can tell you that nearly every DO resident in a given competitive speciality (urology, ortho, neurosurgery, little fuzzy if it would apply to derm) is more qualified both on paper and in a "gestalt assessment" of capability than all but a tiny outlier number of MDs who didn't match. And those MDs who didn't match but were more qualified didn't have matching problems because they didn't get in anywhere, those people had matching problems because they didn't apply wide enough.

Hubris won't change. The qualified but cocky candidate who doesn't match will still only rank his elite places and won't match. Nearly any other MD candidate who doesn't match wouldn't out compete an DO candidate who would have matched AOA.

People seriously misunderstand how statistics works and how these fields are a bell curve with left/negative skew. There is a totally significant number of people who are MDs and get in with really substandard credentials but because their total number of spots is bigger and most people are within a tall but narrow bell curve you just don't see these people in group statistical analysis but they exist quite commonly in the real world training situation. Those guys are getting into allopathic programs because 1) they have some rare but non-academic appeal despite academic issues 2) the program doesn't want to rank DOs and isn't able to pull quality MDs since *they are all already matched somewhere else* or 3) there really isn't enough DOs applying because of fear of skipping the AOA match.

The "highly qualified MD who would love to have our spot" is a total hobgoblin and just doesn't exist. It's like a fallacy of "more schools make it harder to match to competitive residences". It flies in the face of all reasonn and logic, but people don't like to think and so they just assume that schools magically make more high quality people sprout out of the ground, rather than what they actually do... lower the minimum threshold for who the worst matriculant at a school will be. Getting back to the point, the highly qualified MD who would have gone AOA if he could falls flat for two reasons 1) nearly all of these people are not highly qualified and wouldn't out compete a DO thst would normally have a spot with extremely few exceptions and 2) these exceptions are usually MDs with strong geographic preferences and would have taken the AOA spot due to geographic limitations if they could... and then you're getting into a conversation of those guys probably *did* match somewhere so you may be opening a spot elsewhere that the butterfly effect says eventually opens a spot for a DO grad in an ACGME program that wouldn't have been open it that first domino hadn't fallen into the AOA pool.

 

[LutGholein]

Do you not interpret that as a big deal that all AOA graduates would be barred from ACGME fellowship as well as anyone who did an AOA intern year looking to do an advanced residency?


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It would definitely screw anyone with the ambition to go beyond AOA internal medicine-- hematology...rheumatology....all shut out. Any -ologist ambition.

 

[DocEspana]

You know where you're gonna see really funny stuff happen overnight? Not surgical specialties. Not stuff like EM or anesthesiology.

You're gonna see massive (and hard to analyze) movement in internal medicine, pediatrics, and general surgery.

General surgery - the massive number of people who want to be surgeons but are stuck in preliminary year limbo is terrifying. That many of these people are actually really qualified US graduates further complicates things. My surgery friends tell me the issue witg the US grad and matching categorical isn't a matter of not being skilled enough... it's that the number of people wanting general surgery is so high and the number of spots per hospital is so low that you really can't afford to apply widely enough to make the math work and not go deeply in debt. So you apply as widely as you can and hope you cast wife enough of a net. And many don't. When the issue is like this it is possible you see some really interesting shifts of MD and DO within the AOA and ACGME. It may be entirely both ways or it may be one sided, but if one sided it should be temporary as everyone tells me acgme surgery applications are a numbers game and I haven't heard the same from AOA, so the DO candidate may not realize the wisdom the MD candidate is approaching it with.

Pediatrics - I'll be honest with you. I see tons of DOs at all the major pediatric centers and from what in gather we match insanely well in acgme fields. What will change here is "who the hell are we matching into AOA Pediatrics?". I'm sure there are a ton of qualified offshore and foreign trained students who will come in and pediatric applicants will be screaming gloom and doom not realizing that they should really just apply to ACGME spots. I know some *horrid* applicants who got into great ACGME pediatric spots, more or less because there are just way more quality spots than there are applicants. The AOA ones becoming heavily MD shouldn't cause any appreciable difficulty for a DO to match, it probably will just reflect more DOs taking advantage of the ACGME than already do.

Medicine: no one is gonna like this... but here is where you get hosed. There are a lot of substandard DOs taking up space in pretty good hospitals due to the AOA exclusivity. And you want to know where FMGs (and I mean foreign born and trained) doctors get seriously hosed? It's the ACGME internal medicine field. Idk how these brilliant people won't choose to compete at some of our best AOA sites and likely get them. It's not going to displace anyone who was *well qualified* at these sites... but because of what I've seen just in my travels... a lot of these really good AOA sites do have a few random residents that do make you go "wow he out kicked his coverage" and soon that person wont be Chad, slacker student with a lot of luck from Western, but Rajnish, previous gastroenterologist and damn near genius from Hyderabad.

 

[BurghStudent]

Fundamentally, are there enough hospitals in America to give all medical students, MD and DO, an LCME standard of clinical education? If the answer is no, then there's your eventual problem. If yes, then DO schools, and a few MD schools, need to start creating stronger relationships with hospitals, contribute to GME etc.

If you're applying to DO schools, be suspect of a school that is >30 minutes from a partnered teaching hospital.

I could educate thousands of medical students, MS1s and MS2s, from my basement. But clinical education requires a little more than headphones and First Aid.

 

[DocEspana]

Fundamentally, are there enough hospitals in America to give all medical students, MD and DO, an LCME standard of clinical education? If the answer is no, then there's your eventual problem. If yes, then DO schools, and a few MD schools, need to start creating stronger relationships with hospitals, contribute to GME etc.

If you're applying to DO schools, be suspect of a school that is >30 minutes from a partnered teaching hospital.

I could educate thousands of medical students, MS1s and MS2s, from my basement. But clinical education requires a little more than headphones and First Aid.

Yes. With thousands of extra spots. Thats not an exaggeration. Depending on how you do the math, we are talking 9,000-10,000 extra spots. There are thousands more spots than there are USMD + USDO. But I want you to think of the most vile thing anyone can say about the PPACA (obamacare) and thats "resource rationing". While its *completely untrue* when applied to PPACA, it is the single thing that makes american's stomachs churn the most and blood boil... that maybe they dont *deserve* every outrageous and expensive treatment ever thought up; that theyre not all special snowflakes. The problem is that we (the medical field) look at 10,000 viable training spots and turn up our noses, saying almost the same thing.

Well the thousands of extra spots are primarily in FP and pediatrics across the country, and in IM in places that are far from major cities. And as you can see earlier in this thread, the idea that someone should be qualified enough to deserve their surgical subspecialty spot is an anethema to the gentle hearts of many here. We all think we are entitled to the hyperspecilized residency in the major city of our choice, and that sort of spoiled attitude is why we constantly lose this battle for more resiency spots in congress.... because they know the ACGME (ALONE!) has 9-10k extra spots (really 12-13 but i forget how big the AOA match is. 3,000? 4,000? Im estimating them coming over to acgme in the modified lower number) so asking for more just comes off as entitled and ignorant of the reality of just how many spots the government is footing the bill for. So we act like there arent thousands of foreign physicians matching into our less desirable residency and we bemoan a "crunch" that doesnt exist. Why? Becuase we think ourselves better than those 10,000 spots... an maybe we need to re-adust our self-worth

note: original message left for posterity, but as will be pointed out below... I had to quickly look up the numbers and I looked up APPLICANTS rather than MATRICULANTS. The total number of open spots is around 7,000... and around 4K if you put all of the AOA residents into the ACGME

 

[the argus]

You know where you're gonna see really funny stuff happen overnight? Not surgical specialties. Not stuff like EM or anesthesiology.

You're gonna see massive (and hard to analyze) movement in internal medicine, pediatrics, and general surgery.

General surgery - the massive number of people who want to be surgeons but are stuck in preliminary year limbo is terrifying. That many of these people are actually really qualified US graduates further complicates things. My surgery friends tell me the issue witg the US grad and matching categorical isn't a matter of not being skilled enough... it's that the number of people wanting general surgery is so high and the number of spots per hospital is so low that you really can't afford to apply widely enough to make the math work and not go deeply in debt. So you apply as widely as you can and hope you cast wife enough of a net. And many don't. When the issue is like this it is possible you see some really interesting shifts of MD and DO within the AOA and ACGME. It may be entirely both ways or it may be one sided, but if one sided it should be temporary as everyone tells me acgme surgery applications are a numbers game and I haven't heard the same from AOA, so the DO candidate may not realize the wisdom the MD candidate is approaching it with.

Pediatrics - I'll be honest with you. I see tons of DOs at all the major pediatric centers and from what in gather we match insanely well in acgme fields. What will change here is "who the hell are we matching into AOA Pediatrics?". I'm sure there are a ton of qualified offshore and foreign trained students who will come in and pediatric applicants will be screaming gloom and doom not realizing that they should really just apply to ACGME spots. I know some *horrid* applicants who got into great ACGME pediatric spots, more or less because there are just way more quality spots than there are applicants. The AOA ones becoming heavily MD shouldn't cause any appreciable difficulty for a DO to match, it probably will just reflect more DOs taking advantage of the ACGME than already do.

Medicine: no one is gonna like this... but here is where you get hosed. There are a lot of substandard DOs taking up space in pretty good hospitals due to the AOA exclusivity. And you want to know where FMGs (and I mean foreign born and trained) doctors get seriously hosed? It's the ACGME internal medicine field. Idk how these brilliant people won't choose to compete at some of our best AOA sites and likely get them. It's not going to displace anyone who was *well qualified* at these sites... but because of what I've seen just in my travels... a lot of these really good AOA sites do have a few random residents that do make you go "wow he out kicked his coverage" and soon that person wont be Chad, slacker student with a lot of luck from Western, but Rajnish, previous gastroenterologist and damn near genius from Hyderabad.

I'm not sure your analysis about general surgery really lines up with reality. If you look at the data from the NRMP about USMD applicants, you see a very stark difference between those that match and those that don't. The mean step 1 for matched vs unmatched is 235 vs 218, and for step 2 is 247 vs 231. This is even better exemplified by the bar graphs for step scores. You can argue about the importance of step scores in being a competent surgical resident (or physician in general), but 65% (93/142) of USMDs that didn't match had a step 1 <220. Many people would argue that those people aren't in fact "skilled enough."

And as a US-IMG that applied to >100 programs, this idea that it's financially impossible to apply to enough programs is off-base. You could apply to all ~270 general surgery residency programs in the country for ~$6,600, which is a drop in the bucket compared to the cost of medical school.

Yes. With thousands of extra spots. Thats not an exaggeration. Depending on how you do the math, we are talking 9,000-10,000 extra spots. There are thousands more spots than there are USMD + USDO. But I want you to think of the most vile thing anyone can say about the PPACA (obamacare) and thats "resource rationing". While its *completely untrue* when applied to PPACA, it is the single thing that makes american's stomachs churn the most and blood boil... that maybe they dont *deserve* every outrageous and expensive treatment ever thought up; that theyre not all special snowflakes. The problem is that we (the medical field) look at 10,000 viable training spots and turn up our noses, saying almost the same thing.

Well the thousands of extra spots are primarily in FP and pediatrics across the country, and in IM in places that are far from major cities. And as you can see earlier in this thread, the idea that someone should be qualified enough to deserve their surgical subspecialty spot is an anethema to the gentle hearts of many here. We all think we are entitled to the hyperspecilized residency in the major city of our choice, and that sort of spoiled attitude is why we constantly lose this battle for more resiency spots in congress.... because they know the ACGME (ALONE!) has 9-10k extra spots (really 12-13 but i forget how big the AOA match is. 3,000? 4,000? Im estimating them coming over to acgme in the modified lower number) so asking for more just comes off as entitled and ignorant of the reality of just how many spots the government is footing the bill for. So we act like there arent thousands of foreign physicians matching into our less desirable residency and we bemoan a "crunch" that doesnt exist. Why? Becuase we think ourselves better than those 10,000 spots... an maybe we need to re-adust our self-worth

It's actually 6,500 - 7,000 extra spots (that's the number of IMGs matching in recent years), with the most in IM (~3,000) and FM (~1,100). And lots in major cities especially NYC. But otherwise your point is well taken.

 

[DocEspana]

I'm not sure your analysis about general surgery really lines up with reality. If you look at the data from the NRMP about USMD applicants, you see a very stark difference between those that match and those that don't. The mean step 1 for matched vs unmatched is 235 vs 218, and for step 2 is 247 vs 231. This is even better exemplified by the bar graphs for step scores. You can argue about the importance of step scores in being a competent surgical resident (or physician in general), but 65% (93/142) of USMDs that didn't match had a step 1 <220. Many people would argue that those people aren't in fact "skilled enough."

And as a US-IMG that applied to >100 programs, this idea that it's financially impossible to apply to enough programs is off-base. You could apply to all ~270 general surgery residency programs in the country for ~$6,600, which is a drop in the bucket compared to the cost of medical school.

It's actually 6,500 - 7,000 extra spots (that's the number of IMGs matching in recent years), with the most in IM (~3,000) and FM (~1,100). And lots in major cities especially NYC. But otherwise your point is well taken.

Actually no. It's >7k foreign born foreign trained and another >5k us born foreign trained.

And the preliminary people I know are all there because either they were foreign something (which is most of them) or US people who dramatically under applied. All of my successful surgical friends did apply to many programs... but it'd not the APPLICATION fees thst do you in, it's the INTERVIEW cost (both travel and time demands) that are rate limiting. The people who didn't succeed but were very qualified (and I'm talking like 25 people now between the four hospitals Ive worked at as a resident and a few I know from non-clinical shared activities) ended up prelim because they only applied to 20 and interviewed at 10 and turns out that they didn't match at those 10. And other very similar stories. I dont vouch for them because "I like them" I vouch for them because if they are in the state of new York I am actually a resource they are given to try to find spots; and when I know them personally from my job they tend to be fully open witg me about their strengths and weaknesses. (Again, fun part of being the only resident on the state medical society leadership for multiple years). They're never weak on paper. It's again, one of these things where you have to know how the numbers are divergent to understand how to interpret the stats. Most prelims are lower quality, BUT there is a *very big* contingent of prelims in surgery who were just a product of the system and gambled poorly despite good qualifications.

 

[the argus]

Actually no. It's >7k foreign born foreign trained and another >5k us born foreign trained.

And the preliminary people I know are all there because either they were foreign something (which is most of them) or US people who dramatically under applied. All of my successful surgical friends did apply to many programs... but it'd not the APPLICATION fees thst do you in, it's the INTERVIEW cost (both travel and time demands) that are rate limiting. The people who didn't succeed but were very qualified (and I'm talking like 25 people now between the four hospitals Ive worked at as a resident and a few I know from non-clinical shared activities) ended up prelim because they only applied to 20 and interviewed at 10 and turns out that they didn't match at those 10. And other very similar stories. I dont vouch for them because "I like them" I vouch for them because if they are in the state of new York I am actually a resource they are given to try to find spots; and when I know them personally from my job they tend to be fully open witg me about their strengths and weaknesses. (Again, fun part of being the only resident on the state medical society leadership for multiple years). They're never weak on paper. It's again, one of these things where you have to know how the numbers are divergent to understand how to interpret the stats. Most prelims are lower quality, BUT there is a *very big* contingent of prelims in surgery who were just a product of the system and gambled poorly despite good qualifications.

I'm not trying to get in a big argument here man, but both your points are wrong.

You can look at the ACGME Data Resource Book on pg 79. The graph clearly shows that the number of IMGs (US + foreign) entering first year positions in 2016 was 6,693. This is for total ACGME, not just NRMP. It includes all IMGs in GME as they are not eligible for AOA or military positions.
http://www.acgme.org/About-Us/Publi...Graduate-Medical-Education-Data-Resource-Book

And you can look at the NRMP stats on number of contiguous ranks for matched vs unmatched. Having 10 interviews gives a USMD an 85-90% chance of matching in gen surg. Again, there's a clear distinction between step scores for matched vs unmatched. If what you were claiming was true, i.e. that it's just a numbers game in applying to enough programs, than the matched vs unmatched stats would be much more similar. The strong majority of USMDs that went unmatched in categorical gen surg had step scores below the national mean, 65% <220 and 81% <230. Yes there are people with good step scores that went unmatched but they are in the small minority, <20% or <30 people total. I'll repeat that: there was <30 USMDs who went unmatched in general surgery that had a step 1 >230. Maybe all of them ended up in your hospitals, I don't know.
http://www.nrmp.org/wp-content/uploads/2016/09/Charting-Outcomes-US-Allopathic-Seniors-2016.pdf

And this monetary argument is ridiculous. Even if it's $15K total, that's nothing compared to $100-250K for medical school and an eventual salary of $200K+ yearly.

EDIT: year for the ACGME document is 2015 not 2016.

 

[DocEspana]

I'm not trying to get in a big argument here man, but both your points are wrong.

You can look at the ACGME Data Resource Book on pg 79. The graph clearly shows that the number of IMGs (US + foreign) entering first year positions in 2016 was 6,693. This is for total ACGME, not just NRMP. It includes all IMGs in GME as they are not eligible for AOA or military positions.
http://www.acgme.org/About-Us/Publi...Graduate-Medical-Education-Data-Resource-Book

And you can look at the NRMP stats on number of contiguous ranks for matched vs unmatched. Having 10 interviews gives a USMD an 85-90% chance of matching in gen surg. Again, there's a clear distinction between step scores for matched vs unmatched. If what you were claiming was true, i.e. that it's just a numbers game in applying to enough programs, than the matched vs unmatched stats would be much more similar. The strong majority of USMDs that went unmatched in categorical gen surg had step scores below the national mean, 65% <220 and 81% <230. Yes there are people with good step scores that went unmatched but they are in the small minority, <20% or <30 people total. I'll repeat that: there was <30 USMDs who went unmatched in general surgery that had a step 1 >230. Maybe all of them ended up in your hospitals, I don't know.
http://www.nrmp.org/wp-content/uploads/2016/09/Charting-Outcomes-US-Allopathic-Seniors-2016.pdf

And this monetary argument is ridiculous. Even if it's $15K total, that's nothing compared to $100-250K for medical school and an eventual salary of $200K+ yearly.

Ive never made a montary argument, you did. My argument has been from the start about time and travel as a resource. I wasnt clear about that in the first post, but went out of my way to make it clear in the second post. You also need to remember, the 20-30% who are well qualified are *exactly* who im talking about. Shifts I was suggesting may happen are in the hundred-ish range, not in the hundreds or thousands. Those 20-30% are the ones who would be contacting me asking for what resources I know of because theyre the ones who know they deserved better than what they got and those are the ones who may cause an interesting (but as i said, hard to actually predict) shift in the landscape early on. when 70-80% of the cohort is weak the stats your quoting are irrelevant if 20% exist as their own outlier cohort and combining the two is irrelevant: they got to where they are for totally different reasons and prognostication is different for the 4/5ths in one group from the 1-out-of-5 in the other group.

and you're right about the matriculant number. I was reading the chart earlier in the document and mistook applicants for matriculants. Ive been spouting these numbers for so long that I forgot what they were and had to look it up. I thought to myself "these seem high" as I was typing it but quickly google image searhed for the famous table of matriculants and looked at the table of applicants instead. That is my mistake and I apologize. Still remains that there are 6-7k spots yearly not filled by US applicants, which you did agree with on your first post too.

 

[the argus]

This is getting off topic, but just so we're historically accurate,

Ive never made a montary argument, you did. My argument has been from the start about time and travel as a resource. I wasnt clear about that in the first post, but went out of my way to make it clear in the second post...

from the original post I responded to,

General surgery - the massive number of people who want to be surgeons but are stuck in preliminary year limbo is terrifying. That many of these people are actually really qualified US graduates further complicates things. My surgery friends tell me the issue witg the US grad and matching categorical isn't a matter of not being skilled enough... it's that the number of people wanting general surgery is so high and the number of spots per hospital is so low that you really can't afford to apply widely enough to make the math work and not go deeply in debt. So you apply as widely as you can and hope you cast wife enough of a net. And many don't..

And your argument is fine I guess, just realize you are talking about <30 people per year, not a "very big contingent."

 

[DocEspana]

This is getting off topic, but just so we're historically accurate,

from the original post I responded to,

And your argument is fine I guess, just realize you are talking about <30 people per year, not a "very big contingent."

Talking about 20-25 people in NY state alone. So no. not <30 people. My estimate of ~100ish is probably pretty spot on. There are only like 165ish general surgery spots per year in the AOA. even if it was 30, thats relevant, but its gotta be closer to 100.

You leave out my second post where I clarified that I meant the cost of interviewing, not applying, and that said cost is both monetary cost and time cost.?

 

[DocEspana]

Are you lumping all unmatched surgical applicants into this supposed pool of qualified surgery applicants stuck in gen surg prelim spots?

Ie the unmatched ortho and plastics applicants?

If so your arguments make sense. If not as @the argus pointed out you're talking about literally 30 people.

yeah. I cant differentiate what they wanted to do, only tha they are in Gen Surg prelim and now they are looking for gen surg categorical. I cant equate for crushed dreams and hopes.

 

[DocEspana]

Are you lumping all unmatched surgical applicants into this supposed pool of qualified surgery applicants stuck in gen surg prelim spots?

Ie the unmatched ortho and plastics applicants?

If so your arguments make sense. If not as @the argus pointed out you're talking about literally 30 people.

It probably helps to remember that NY state probably represents 15% if not slightly more of all residency training.

was pretty much dead on. 1,538 programs in NY state out of 10,119 programs is 15.2%

 

[DocEspana]

The data from the NRMP is clear. For US Md applicants intending on going into general surgery the odds are very, very good.

The prelim pool is full on several hundred unmatched ortho/uro/plastics applicants who now have to reconsider their career choices. In fact I would argue that these are the "hobgoblins" you mentioned before who will potentially benefit from the merger by having access to additional options in their originally intended field in the match.

Except as someone intimately familiar with the urology match both as a DO who was in it and as a resident who works with the AMA and ACGME on these sorts of issue (but more tangentially than I used to as a medical student)... the urology people who dont match AUA are perhaps better than the rank-and-file surgery candidate, but they are about equal to or not better than the lowest urology resident on the AOA side. I imagine the same holds true even more so for other surgical specialites as uroloy has the nice-for-DOs element of matching BEFORE the AOA, while the rest still have thar pull of "I should just rank AOA and take a spot and not worry about gambling on ACGME".

They're not stealing urology or ortho spots from anyone in the AOA system except in super rare 1-or-2 people situations. They may give up on urology and take gen surgery spots without too much difficulty. and I know of a lot of them who want to.

Edit: this is why I often complain about 'intention to treat' analysis. They show what "realistically" happens, but then analyze it as if said thing didnt happen. Sure they didnt walk in wanting to be gen surg residents, but if they graduate as gen surg physicians 5-7 years later should we not acknowledge them as part of the pool after taking that first step to distinguish themselves as not part of the speciality surgeon groups?

 

[jw3600]

Wasn't there someone who posted from the newest outcomes that the average unmatched ortho applicant had like an average USMLE of 245? You think these people aren't gonna take formerly AOA spots in fields like urology ortho ent? I think you're underestimating how competitive the top ACGME specialties are.

 

[DocEspana]

Wasn't there someone who posted from the newest outcomes that the average unmatched ortho applicant had like an average USMLE of 245? You think these people aren't gonna take formerly AOA spots in fields like urology ortho ent? I think you're underestimating how competitive the top ACGME specialties are.

You're forgetting the "average" ortho resident who doesn't match isn't unmatched because he wasn't good enough. It's because he applied poorly. They will apply poorly with aoa spots there too. These are people who dont apply to minor-academic-center A (or b, c, d, e...) because its not major name brand academic center. They REALLY wont apply to random pretty solid AOA site. Everyone who deals with the numbers at the acgme tells you the same story and people constantly go back to the raw data and misuse it. The telling fact is the pretty huge chunk of people in ortho with less than that on their usmle, not the cohort that is again.... multiple mixed cohorts of people who don't make. It is an artificial combination of a few different cohorts and really shouldn't be used as a single number since their futures and their qualifications don't just suggest "wide variation" but "discrete groups without overlap". But you can't honestly/ethically say in an analysis "the people who deserved it buy were cocky" and "the people who didn't" even if you can look at the numbers and go "oh yeah, I can see the differences here"

It's why every dean, every program director, every person who has ever touched the acgme raw data, every mentor you've ever had says the same thing..... apply broadly. It's because most every field has these people. And most every field has quite a few of these people.