Open up much more residency spots in an era of physician shortage?

[donaldtang]

I'm currently a medical student in an international school and have known from various sources (including some articles in SDN) that the United States is in shortage of physician, especially in the field of primary care, and especially after the health care reform. Perhaps the number of physicians should increase by 100% to 200% to meet the need.

I'm just wondering why not open up more residency spots so that less American MD will go unmatched and IMG will also have better chance in getting into US residency? I think there should be a dramatic increase in the number of residency spots after the health care reform, and it should greatly exceed the increase in US medical school enrollment.

I'll be gratitude if someone can enlighten me on my question.

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[ShyRem]

More residency spots means more money needs to be allocated from the government- money we don't have. So I doubt there will be more spots. Currently there are roughly 20,000 residency spots and about 16,000-17,000 AMGs. These numbers don't make our government want to spend money on more positions.

 

[Law2Doc]

I'm currently a medical student in an international school and have known from various sources (including some articles in SDN) that the United States is in shortage of physician, especially in the field of primary care, and especially after the health care reform. Perhaps the number of physicians should increase by 100% to 200% to meet the need.

I'm just wondering why not open up more residency spots so that less American MD will go unmatched and IMG will also have better chance in getting into US residency? I think there should be a dramatic increase in the number of residency spots after the health care reform, and it should greatly exceed the increase in US medical school enrollment.

I'll be gratitude if someone can enlighten me on my question.

Won't happen for several reasons:
(1) As ShyRem indicated, it costs a ton to do this. It costs the government over $100,000 per year per resident. In a tight economy you can't raise the billions that would be required from taxpayers.

(2) There is a notion that US med schools should fill US doctor needs. The AAMC has been touting this party line since press releases of 2005. So the med schools have been aggressively ramping up the number of graduates precisely to bump IMGs out of the picture. We are getting close to that actually, with the number of US seniors closing in on the number of residency slots. So until US med schools have ramped up further, I wouldn't look to a substantial increase in residency slots. And of course that won't help the IMGs. The goal is to have a closed loop with you guys on the outside, just like every other nation does. And it is happening as we speak. Don't hope for some opening of the gates any time soon -- we are working to lock them shut.

(3) The current shortage is caused largely due to the aging baby boomer population. So nobody wants to ramp up too excessively only to find that when they die off there are a glut of doctors. This is bad for the profession (as it has been for the legal profession), and thus nobody wants to push too hard to increase capacity. Which has the negative of leaving the door open for midlevels to make a grab for the excess work, but the positive of not glutting the market down the road.

 

[Sneezing]

The amount that the government spends on Graduate medical education from CMS dollars is trivial. I hope they actually get out of graduate medical education. Less government influences the better. THey currently pay $100,000. How much goes towards salary? $44,000. Figure about another 10,000 in health insurance benefits.

Now how much does a hospital pay for a midlevel? $80,000 to $100,000. How many hours a week do these midlevels work? How much can they do? Are they paid for overtime and other things? Now matter how you look at a resident physician will always trump a midlevel.

Hospitals need to just leave the government system and simply open and fund residencies themselves. If anything it is winning proposition, all though not as much as it currently is when the government is paying for it...

 

[dragonfly99]

Nobody knows what is going to happen with residency spots. As Lawdoc mentions above, I doubt there will be a lot of short term enthusiasm for increasing the number of residency spots. However, if there is an increase it will likely be in specialties like IM, peds and fp.

Part of the reason for the primary care physician shortage is that for various reasons they don't tend to attract and keep graduates (or practicing physicians). There is too much paperwork, too much crap from insurance companies, too little respect and too much pressure to see too many patients (and take care of multiple, multiple problems in one visit). The reimbursements also aren't great compared with many specialists' (leading to more pressure to see too many patients in too little time). I don't have stats, but I think that in recent yearsmore primary docs probably work limited hours, try to do "lateral moves" to do more cosmetic stuff and less actual primary care, or try to quit primary care to be hospitalists. Or if not, they at least talk about wanting to do so. Increasing the supply of primary docs depends not just on the number of residency spots, but also on making the job itself more appealing so that docs will stay/keep doing it.

 

[NotAProgDirector]

Not all experts agree that there is a shortage. Some feel that there is simply a maldistribution -- with too many in dense urban areas and not enough in more rural areas. Plus, it's not clear how many docs you need for each 1,000 people -- some areas of the country have much higher densities of physicians, usually with much higher overall costs. Docs seem to "generate their own demand", hence having more docs in an area does not lead to empty appointments. No one really completely understands this, and there is great debate about whom is "right".

The amount that the government spends on Graduate medical education from CMS dollars is trivial. I hope they actually get out of graduate medical education. Less government influences the better. THey currently pay $100,000. How much goes towards salary? $44,000. Figure about another 10,000 in health insurance benefits.

Now how much does a hospital pay for a midlevel? $80,000 to $100,000. How many hours a week do these midlevels work? How much can they do? Are they paid for overtime and other things? Now matter how you look at a resident physician will always trump a midlevel.

Hospitals need to just leave the government system and simply open and fund residencies themselves. If anything it is winning proposition, all though not as much as it currently is when the government is paying for it...

This is not quite accurate.

First, salaries are higher than $40K at present. The mean salary in New England is pushing $50K. Perhaps salaries in NE are above the national mean.

Second, health insurance for $10K per year (hence less than $1000 per month) is a bargain. Although I can't quote numbers, I expect it's higher than this (although residents in general are a young crowd, and hence might be cheaper to insure -- although most will be included in their hospital's group program, so the rates might be averaged over the entire hospital workforce rather than just GME).

Even without all of that, there are all sorts of costs to running a program. You need to pay a PD's salary, and associate PD's. You need to pay for recruiting. You need to pay for site visits. You need secretaries and support staff.

And then, residents are a great source of work/service/hospital coverage when they are on a busy inpatient rotation. But when they are on electives, or perhaps outpatient blocks, they are much less "productive" than an NP/PA would be (since NP/PA's would be hired to do a job, they would not get "electives").

Last, most programs have residents grouped into Intern/Resident teams. So, I end up paying two people (an intern and a resident) (with an attending, of course) to do a job that one person (an NP/PA) could do (albeit with additional help from the attending).

The real "win" from having a resident program, at least in the past, was night coverage. However most programs are shifting to having faculty in house at night anyway, so much of this benefit is fading away.

I'm not trying to suggest that having residents is not a money making process. But it's not a cash cow, and it's probably break even at best. As the requirements for supervision increase, and the RRC scrutinizes everything we ask residents to do for the "educational benefit", NP/PA's start to look more appealing.

 

[medicinesux]

Thanks to our decaying economy mixed in with the explosion of NP schools pumping out doctorates as if they were GED degrees, our govt sees no reason to increase residency slots for primary care. NP's will be picking up an increasing "market share" of primary care providers in the future. This is sadly the direction our ever increasingly crappy healthcare system is heading.

Anyone thinking of going to an offshore medical school needs to seriously consider this. Sure, going abroad was a great loophole while it lasted but this door is slamming shut. For profit overseas med schools are still going to paint a rosy picture since they just want your student loan money. Can you only imagine what it must feel like to be 300K in debt and not be able to secure a residency (remember MD equals MASSIVE DEBT without a residency since we already established here in numerous posts how a medical degree is an essentially useless degree outside of medicine) while some 25 year old nurse who got her doctorate online and did a 1 month residency was able to open her own practice making low six figures? Oh, and she has NO debt because she was able to squeeze in nursing shifts around her online studies! AND THE WORST PART IS THAT WHILE YOU ARE GREETING PEOPLE AT WALMART IN HICKSVILLE WITH YOUR USELESS MD DEGREE, DR. NURSE WILL BE ABLE TO PRACTICE MEDICINE FOR YEARS TO COME. Why is this? Because no medical board will give you a license to practice medicine in any state unless you do some residency. Come to think about it, if there are any high school students who happen to stumble upon this post, I would HIGHLY recommend going the NP route if you see yourself doing primary care. Americans want optimal care but simply don't want to pay for it. You can't outdue the laws of economics. Americans are going to get what they wish for. It is like walking onto a car dealer's lot expecting to get a Lexus with only 15K and you find yourself walking out, scratching your head and wondering how you wound up with a Yaris. Sure if you go the medical school route you will be MUCH more knowledgeable in the science of medicine. But at what cost? You will be the one left with massive debts and lost time which you will not be appropriately rewarded for. If society wants substandard healthcare why sacrifice yourself?

 

[Obnoxious Dad]

I have attached an EXCEL spread sheet which details the number of residency spots Americans will soak up in the year 2017. This analysis assumes that the number of Caribbean grads from the US will decline by 75%, that there will be a 5% attrition rate in med schools and the med schools will follow through on their expansion plans.

Because I stink at the more sophisticated aspects of the Internet etc I could not paste it clearly and cleanly into the main body of a post. If someone could do that I would appreciate it.

After including the NRMP, San Francisco and AOA spots and excluding the 1 year transitional, rotating and prelim spots there are 24,000 residency spots in the US as of 2010 and there will be 25,000 graduating Americans in the year 2017. Things are going to get ugly.

 

[donaldtang]

First of all, thanks for all the imput!

Won't happen for several reasons:
(2) There is a notion that US med schools should fill US doctor needs. The AAMC has been touting this party line since press releases of 2005. So the med schools have been aggressively ramping up the number of graduates precisely to bump IMGs out of the picture. We are getting close to that actually, with the number of US seniors closing in on the number of residency slots. So until US med schools have ramped up further, I wouldn't look to a substantial increase in residency slots. And of course that won't help the IMGs. The goal is to have a closed loop with you guys on the outside, just like every other nation does. And it is happening as we speak. Don't hope for some opening of the gates any time soon -- we are working to lock them shut.


Actually I'm quite surprised at the notion that "US med schools should fill US doctor needs". This is almost equal to "US doctor needs should only be filled with US citizens", since it is extremely difficult for foreign citizens to get enrolled in US med schools, because they require a US bachelor degree which is almost impossible for foreign citizens (who can't afford the undergraduate school tuition). As far as I know, however, USA import large numbers of foreigners for almost every occupation. So I'm quite surprised that medicine is an exception and I think that by importing IMG, Americans save the money for their medical education, which are paid by the citizens of their home countries.

 

[docB]

Now matter how you look at a resident physician will always trump a midlevel.

How do you figure? My midlevels can suture, I&D and work up most patients without me having to stand over them as I have to with med students and residents. Experience counts. It doesn't make you a doctor but it counts. And residents are inexperienced.

 

[Roofie]

1. Primary care remains a lucrative business. It will be even more so under Obamacare.

PCP's need to adjust to the emerging market. The PCP's that treat medicaid and medicare efficiently now will emerge much stronger under Obama.

One secret is to form group practices with a full diagnostics suite. All the PCPs are partners and own the diagnostics so they circumvent kickback statutes. By forming business relationships, physicians become more efficient by reducing overhead and can afford to take a piece of the lucrative diagnostics business.

Most of the suffering you have heard about is from solo practititioners. It is truly hard for a solo to see the requisite volume to reduce his overhead significantly. It makes no sense to have separate offices when one big one will do. There is more than enough business to go around. At busy clinics, everyone is more productive and responsible for the bottom line.

An important assumption in this business model is that the physicians are owners. They eat what they kill. This model cannot support physicians who do not produce economically. This is not an attack on their clinical skills, but rather on their business skills. These physicians are best suited for employed postions at large institutions whose secondary focus is not even on profitability.

2. The problem with the misappropriation of physicians begins with medical school admissions. With the emphasis on "great personal skills," you end up recruiting people who are good at saying what you want to hear rather than telling the truth. We should de-emphasize academics and focus more on meaningful public service. We should select candidates that have served time in the military or the peace corps. These guys have seen the human condition. When one of them tells you that they enjoy serving others, they are much more believable that the fresh college grad who does the same thing. I prefer the gruff stoic whose integrity you can trust in the trenches over the emotionally intelligent candidate who knows how to manipulate others too well. These high eq people tell you they want to go into primary care, but instead go to where the money is plentiful and the lifestyle easy. High eq people love other high eq people. Nobody denies that its nice to get the ego stroked. However, this profession needs more physicians who like to get dirty and fix people, not more physicans who think they are entitled to respect because they are doctors. The profession needs more physicians focused on the mission rather than the thank-you. The satisfication of fixing someone and getting fairly compensated for it is all the thanks a good physician needs.

This argument is based on the assumption that medicine is not difficult in a traditional academic sense. More capable people are rejected than there are slots available.

3. Every patient deserves an M.D. I think that there is room to expand the number of residency slots. A big obstacle is not necessarily funding but rather the opposition of established physicians who fear more competition. They would rather compete against NP's and PA's that they can easily beat rather than a peer. The government will allocate funds if there is political support from established MDs, motivated by a desire to improve access to healthcare, rather than their own pocket at the expense of an all-American principle that favors competition over oligopoly.

The comparison of medicine to law is not entirely fair. Everyone needs an MD yet not many need a lawyer. There are 45000 law graduates competing for a smaller pie than 20000 med graduates competing for a larger pie. The optimal number of residency trained physicians has not been met if NP's and PA's are acting as de-facto independent practitioners in substantial numbers.

Indeed, all boarded physicians are the beneficiaries of institutionally sanctioned anti-competitive practices. If they cannot earn six-figures in this setting, they need not blame other physicians, but rather should take "Running a Business" 101.

 

[thrombin]

so exactly what is happening with the PG- residency spots. I heard that the new health-care bill will be increasing the primary care residency spots but decreasing the specialty spots; is that true or are residency spots going unchanged and simply american allo schools increasing their admission rates to plug that hole.

I heard from another source that by 2020 america will have a physician gap of around 100,000 what do they plan to do about that?

 

[SupercoolMD]

Not all experts agree that there is a shortage.

Shortage is in macro economics a relative term. The demand for medical care is not a fixed number. The more affordable and readily available care, the more people will see their doctor. I found that a bit puzzling the first time I read about it, but I guess there are some conditions that are relatively price-independent (fractures, autoimmune disease) and numerous small conditions and anxiety stuff esp for the FP that will just sky rocket as the prices drop.

Pretty much in every area, government regulation of supply to meet demand have distinct disadvantages. Doctors are willing to overlook those disadvantages because we are caught in a pyramid game.

We need to reduce the amount of doctors entering market in order to maximize our own profit at a later stage. Now, don't excuse this, or try to make up stupid moral rules for it. The base is self-interest, and it is a dog-eat dog world. No need to be ashamed of that.

Problem is, that a significant proportion of us are residents, meaning that we are put in the impossible position of having to please everyone, which is an impossible task. Threads and statistics provided on the forum by e.g exPCM illuminates the miserable position residents are facing.

The best solution for young doctors would be: strip US MDs of the need to finish a residency in order to practice, or alternately, the need to finish a US residency, allowing for training overseas in Europe to meet requirements.

That way, the hospitals would no longer be in the strong position they have now, and careers would no longer be ruined, if there were only common workplace difference issues the releases were based on.

All of a sudden, hospitals would have to fight for their residents.

Simultaneously, the absolute requirement would be either US citizenship OR US residency OR US graduation to practice in the states, effectively removing all IMGs from the market, further increasing our market values.

The first Hospital power reducing step could be achieved by a strong organization manipulating the public by using the same strategy as in Sicko, emphasizing how the residency requirements are abused to reduce the total number of doctors.

2nd, the monopolist position of US doctors themselves can be justified by claiming that we are much better suited than e.g mexican doctors, who would otherwise swarm the country.

It is a turf war. Make no mistake, you are all highly intelligent, and should know by now that everybody lies (quote House MD) and that people follow their self interest, especially when talking about big hospitals and big interest groups. Protect yourself and your own.

 

[medicinesux]

1. Primary care remains a lucrative business. It will be even more so under Obamacare.

Roofie, were you on roofies when you wrote this late last night??? This is so wrong I don't even know where to begin!

 

[docB]

1. Primary care remains a lucrative business. It will be even more so under Obamacare.

PCP's need to adjust to the emerging market. The PCP's that treat medicaid and medicare efficiently now will emerge much stronger under Obama.

One secret is to form group practices with a full diagnostics suite. All the PCPs are partners and own the diagnostics so they circumvent kickback statutes. By forming business relationships, physicians become more efficient by reducing overhead and can afford to take a piece of the lucrative diagnostics business.

when I first read your sentence on profitability I laughed but on further thought I see your point. But, is the model of "Primary care is viable only if the soca join big multidiscplinary groups with diagnostic centers" really viable? It's certainly a departure from the paradigm of primary care previously.

 

[cyclohexanol]

How do you figure? My midlevels can suture, I&D and work up most patients without me having to stand over them as I have to with med students and residents. Experience counts. It doesn't make you a doctor but it counts. And residents are inexperienced.

Why are you standing over residents as they suture or I&D? As an MS4 I was doing this autonomously very frequently. If there was any oversight at all, it was the resident looking at my work after I was done saying "good job." I'm either missing something here (very possible) or you are making your job harder than it needs to be.

 

[Winged Scapula]

How do you figure? My midlevels can suture, I&D and work up most patients without me having to stand over them as I have to with med students and residents. Experience counts. It doesn't make you a doctor but it counts. And residents are inexperienced.

Hmmm...maybe its the difference between students going into surgery and surgical residents, but I don't have to "stand over them" when they are doing procedures.

On our teams the surgical residents do the work of at least 2 PAs/NPs - they are faster at everything (whether a procedure, presenting a patient or a discharge summary), work longer hours, take fewer/no breaks - this the whole argument as to why hospitals don't want to hire more midlevels. It would take 2 PAs working 40 hours per week, at $90K per PA, to fill the workload of a resident...and even then a resident does more in 40 hours than a full time midlevel, at obviously much cheaper rates.

That's just been my experience in surgery. Perhaps its different with the midlevels and residents in EM.

 

[jbz24]

How do you figure? My midlevels can suture, I&D and work up most patients without me having to stand over them as I have to with med students and residents. Experience counts. It doesn't make you a doctor but it counts. And residents are inexperienced.

This isn't a great argument to me. Sure YOU may have your pick of midlevels to work with who have many years of experience, but let's face it, these midlevels have to gain experience somewhere. A recent midlevel graduate is nowhere near the same level as a starting resident in diagnosis and treatment. Also, couple in the fact that one year of residency is equal to many years of midlevel training due to work hour difference. So if you had to be paired with a recently-graduated midlevel, I don't think you would have the same opinion.

Also, if you have to stand over your residents as they suture, I&D, and work up patients, then something is either wrong with your residents, your program, or just your lack of confidence. Sure if you're paired directly with medical students then you need to watch over them, but if a resident is around you don't need to.

 

[wine is good]

How do you figure? My midlevels can suture, I&D and work up most patients without me having to stand over them as I have to with med students and residents. Experience counts. It doesn't make you a doctor but it counts. And residents are inexperienced.

Suturing. What'd you kidding? I was suturing in my early third year medical school w/o any supervision. Our current interns would run circles around your average NP. No NP would last a week doing an intern's work without resorting to whinning. It's hard work and you know it. I find your comment a typical display of an out of touch attending who's forgotten what it's like to be a resident. I don't know, maybe it's an ER thing, or it's your particular residency. Maybe you shouldn't be airing that out, dude. Don't feed the opposition with this nonsense.

 

[Law2Doc]

...

Actually I'm quite surprised at the notion that "US med schools should fill US doctor needs". This is almost equal to "US doctor needs should only be filled with US citizens", since it is extremely difficult for foreign citizens to get enrolled in US med schools, because they require a US bachelor degree which is almost impossible for foreign citizens (who can't afford the undergraduate school tuition). As far as I know, however, USA import large numbers of foreigners for almost every occupation. So I'm quite surprised that medicine is an exception and I think that by importing IMG, Americans save the money for their medical education, which are paid by the citizens of their home countries.

It shouldn't be surprising, (1) EVERY OTHER DEVELOPED COUNTRY in the world makes it difficult for foreign doctors to become licensed there, and the US was somewhat lagging. (2) The notion that US med schools should fill US needs was touted by the ACGME mainly because if folks aren't educated here, they have no ability to ensure the quality/quantity of the education. This press release statement was most likely targeted toward caribbean schools, where quality of some aspects can be pretty suspect, but the same can be true elsewhere -- if you aren't in charge of the med schools, you don't get to decide what people learn, what things should be expected of every US physician, what's covered, the credentials of the lecturers, what books people have access to, etc. The profession understandably has an interest in controlling what it expects of it's local members. (3) There is certainly some concern that while the US is suffering from a shortage, it should not be providing its training to folks who may at some point decide to return to their home country. There has long been a concern that the US was training the world at the expense of its own, and healthcare is good example. (4) Also while foreign doctors may serve a short term fix in terms of filling primary care slots, they don't have the kind of links to the community that might keep them working in rural West Virginia where the help is needed. Most post-residency tend to gravitate to the best jobs they can find even where the need isn't greatest. By contrast, the US med grad from rural West Virginia might actually end up wanting to practice there.

While you are right that "USA import large numbers of foreigners for almost every occupation" in general it's not something regarded as a positive, or something we are happy about. The US has already seriously damaged its competitiveness in fields like chemistry and engineering by training the world, rather than our own. Massive numbers of foreigners training at US graduate programs is not a big selling point for your argument. This is regarded as a huge negative, something most americans wouldn't mind putting an end to in a lot of fields. Most countries have erected barriers to this kind of thing, so as not to fill seats in their programs that will not be used to help the local industry (as opposed to competitors abroad). The US has not, yet. But healthcare is a bit different a field, as it's a service industry, and by its nature has to be provided locally. So expect the shutdown to occur here more than in multinational industry type training.

 

[docB]

Sigh. I forgot that emotions are running high around here. My point is that residents need to keep in check their opinions about how valuable they are. Having med students and residents around slows me down. And since I’m not paid out of the residency budget it’s a loss for me.

I should explain my practice environment. I work in a busy downtown ED and I have med students and IM and FM residents rotating through, not EM residents. So for the med students we have to teach them everything and for the residents we have to work to dial them back from a comprehensive H&P to an ED appropriate work up.

I also have to put up with all the typical ED agony of customer satisfaction scores, productivity requirements and utilization review. Med students and residents hurt you in all of those areas.

Why are you standing over residents as they suture or I&D? As an MS4 I was doing this autonomously very frequently. If there was any oversight at all, it was the resident looking at my work after I was done saying "good job." I'm either missing something here (very possible) or you are making your job harder than it needs to be.

If you’re getting no oversight when you’re doing procedures then whatever you’re doing is not billable. We also see every patient that comes through the ED. This again is a billing and a hospital bylaw issue.

Hmmm...maybe its the difference between students going into surgery and surgical residents, but I don't have to "stand over them" when they are doing procedures.

On our teams the surgical residents do the work of at least 2 PAs/NPs - they are faster at everything (whether a procedure, presenting a patient or a discharge summary), work longer hours, take fewer/no breaks - this the whole argument as to why hospitals don't want to hire more midlevels. It would take 2 PAs working 40 hours per week, at $90K per PA, to fill the workload of a resident...and even then a resident does more in 40 hours than a full time midlevel, at obviously much cheaper rates.

That's just been my experience in surgery. Perhaps its different with the midlevels and residents in EM.

How do your MS3s know how to do procedures unsupervised? I have to teach them how to do everything. And since I don’t have senior residents to do that teaching I have to take the time to do it personally.

Sure a team of surgical residents can function at a pretty high level. When I did surgical rotations we had med students, 2 interns, a 3 and either a 4 or a 5. That’s a lot of experience. Imagine a surgical service being run by all off service residents. That’s what I’m looking at in my ED.

This isn't a great argument to me. Sure YOU may have your pick of midlevels to work with who have many years of experience, but let's face it, these midlevels have to gain experience somewhere. A recent midlevel graduate is nowhere near the same level as a starting resident in diagnosis and treatment. Also, couple in the fact that one year of residency is equal to many years of midlevel training due to work hour difference. So if you had to be paired with a recently-graduated midlevel, I don't think you would have the same opinion.

Also, if you have to stand over your residents as they suture, I&D, and work up patients, then something is either wrong with your residents, your program, or just your lack of confidence. Sure if you're paired directly with medical students then you need to watch over them, but if a resident is around you don't need to.

Yes, the midlevels have to be trained (and it’s painful) but once they’re trained they work for me for years. Every July there’s a brand new crop of residents. Actually every month there’s a new crop.

You are right that an intern is superior to a new midlevel. But that’s not the comparison we’re looking at. We’re looking at experienced midlevels vs. residents.

I am paired with med students and off service residents. They require a lot of supervision.

Suturing. What'd you kidding? I was suturing in my early third year medical school w/o any supervision. Our current interns would run circles around your average NP. No NP would last a week doing an intern's work without resorting to whinning. It's hard work and you know it. I find your comment a typical display of an out of touch attending who's forgotten what it's like to be a resident. I don't know, maybe it's an ER thing, or it's your particular residency. Maybe you shouldn't be airing that out, dude. Don't feed the opposition with this nonsense.

Again if you’re doing stuff as a med student without any supervision there are issues.

That’s just insulting. I did residency before work hour restrictions so don’t tell me about whining. I’m not saying it’s not hard work. But a big part of the reason it’s hard work is that you’re learning. I can deal with situations easily now that really scared me during residency. That’s why I did a residency. Beyond that, what does how hard it is or whether I remember residency or not have anything to do with this? And who’s the “opposition” here? We’re not talking about the DNP issue. The OP wants more residency spots to accommodate FMGs. Who are we opposing?

Hopefully I have now clarified the situation I’m talking about, no EM residents so all supervision and instruction is done by me. There are no senior residents around to do the teaching. All procedures must be supervised and all patients seen by me to be billable. Granted things are different in academic centers where billing and UR are not as important.

I stand by my statement that in my ED an experienced midlevel makes my work easier than a med student or an off service resident.

 

[jbz24]

Sigh. I forgot that emotions are running high around here. My point is that residents need to keep in check their opinions about how valuable they are. Having med students and residents around slows me down. And since I'm not paid out of the residency budget it's a loss for me.

I should explain my practice environment. I work in a busy downtown ED and I have med students and IM and FM residents rotating through, not EM residents. So for the med students we have to teach them everything and for the residents we have to work to dial them back from a comprehensive H&P to an ED appropriate work up.

I also have to put up with all the typical ED agony of customer satisfaction scores, productivity requirements and utilization review. Med students and residents hurt you in all of those areas.



If you're getting no oversight when you're doing procedures then whatever you're doing is not billable. We also see every patient that comes through the ED. This again is a billing and a hospital bylaw issue.



How do your MS3s know how to do procedures unsupervised? I have to teach them how to do everything. And since I don't have senior residents to do that teaching I have to take the time to do it personally.

Sure a team of surgical residents can function at a pretty high level. When I did surgical rotations we had med students, 2 interns, a 3 and either a 4 or a 5. That's a lot of experience. Imagine a surgical service being run by all off service residents. That's what I'm looking at in my ED.



Yes, the midlevels have to be trained (and it's painful) but once they're trained they work for me for years. Every July there's a brand new crop of residents. Actually every month there's a new crop.

You are right that an intern is superior to a new midlevel. But that's not the comparison we're looking at. We're looking at experienced midlevels vs. residents.

I am paired with med students and off service residents. They require a lot of supervision.



Again if you're doing stuff as a med student without any supervision there are issues.

That's just insulting. I did residency before work hour restrictions so don't tell me about whining. I'm not saying it's not hard work. But a big part of the reason it's hard work is that you're learning. I can deal with situations easily now that really scared me during residency. That's why I did a residency. Beyond that, what does how hard it is or whether I remember residency or not have anything to do with this? And who's the "opposition" here? We're not talking about the DNP issue. The OP wants more residency spots to accommodate FMGs. Who are we opposing?

Hopefully I have now clarified the situation I'm talking about, no EM residents so all supervision and instruction is done by me. There are no senior residents around to do the teaching. All procedures must be supervised and all patients seen by me to be billable. Granted things are different in academic centers where billing and UR are not as important.

I stand by my statement that in my ED an experienced midlevel makes my work easier than a med student or an off service resident.

Yes, I do agree that you are sharing the brunt of the training, but I believe if you look at the system as a whole, it's less advantageous to train a midlevel than it is a resident. Plus, if you look at the OP's point of view, if we were to expand residency spots, including EM spots, that should be beneficial to you. An EM resident will run circles around a midlevel. Currently, you're just in an unfortunate position that the people you train don't stay on for more than a month (IM/FM residents and med students).

 

[Winged Scapula]

docB -

I see: off service residents.

You need say no more. I assumed you had EM AIs and residents rotating with you. You're right a newly minted MS-3 and an off service resident, especially one that comes from a less procedure oriented residency will need a lots more handholding and oversight. I have many stories of problems with off service residents. Fortunately, I tend to get final year students or more senior residents rotating with me know so I don't have to watch so closely, but they still do slow me down.

My POV is that midlevels are not as productive as a service resident, generally PGY1.5 and above, on average. Some of it is the length of hours worked and some of it is sheer speed and efficiency with which things are done. A good resident, even an intern does at least twice as much work as a midlevel.

Thanks for clarifying your situation.

 

[wine is good]

That’s just insulting. I did residency before work hour restrictions so don’t tell me about whining. I’m not saying it’s not hard work. But a big part of the reason it’s hard work is that you’re learning. I can deal with situations easily now that really scared me during residency. That’s why I did a residency. Beyond that, what does how hard it is or whether I remember residency or not have anything to do with this? And who’s the “opposition” here? We’re not talking about the DNP issue. The OP wants more residency spots to accommodate FMGs. Who are we opposing?

Hopefully I have now clarified the situation I’m talking about, no EM residents so all supervision and instruction is done by me. There are no senior residents around to do the teaching. All procedures must be supervised and all patients seen by me to be billable. Granted things are different in academic centers where billing and UR are not as important.

I stand by my statement that in my ED an experienced midlevel makes my work easier than a med student or an off service resident.

That's your experience and that's unfortunate. Majority of surgical residents have the ability to do all those that you mentioned w/o supervision and guidance. It is true, the experience is handed down by senior residents or attendings. They have been trained, so I guess it all depends on who you getting and where you are.

As for the opposition, it's in reference to the DNP movement and your comment that you prefer NP over residence and medical students because you can't trust them to do the job right. I did not know there were no senior residents there, which is a weird situation, but even if they are rotators, they should have seniors elsewhere to guide them. Anyway, you experience is interesting one that I am not familiar with. As a current resident I found that it was not a fair comment. It demonstrates that we have had different experiences.

The whinning comment had nothing to do with you in reference and it was in regards to a NP who would face a week of what a intern/resident experiences. So, I don't know why you getting bent out of shape for that. Also, I don't give a **** that you trained pre-80 hour week era. Who cares. Nothing to do with the argument at hand.

 

[Obnoxious Dad]

There are a few aspects of DocB's posts that I do not understand.

The University of Nevada Las Vegas is the only institution that sponsors residencies in Las Vegas. According to the NRMP that institution does in fact have an Emergency Medicine Residency. The EM program has 8 spots and every one of them were filled in the match in 2008 and 2009.

In addition you would think he's some kind of auto-didact who never learned from anyone else. Did he do clinical rotations? Did he go through a residency? Did he ever burden anyone with really stupid questions?

Finally if he doesn't like being at an institution with residencies why doesn't he leave and go some place where the great unwashed (i.e., students, interns and residents) aren't around?

 

[Winged Scapula]

There are a few aspects of DocB's posts that I do not understand.

The University of Nevada Las Vegas is the only institution that sponsors residencies in Las Vegas. According to the NRMP that institution does in fact have an Emergency Medicine Residency. The EM program has 8 spots and every one of them were filled in the match in 2008 and 2009.

In addition you would think he's some kind of auto-didact who never learned from anyone else. Did he do clinical rotations? Did he go through a residency? Did he ever burden anyone with really stupid questions?

Finally if he doesn't like being at an institution with residencies why doesn't he leave and go some place where the great unwashed (i.e., students, interns and residents) aren't around?

Did it occur to you that perhaps docB is NOT at UNLV? There are other hospitals in LV that residents rotate through. I'd be willing to be that, given the type of work done in that ED, the IM and FM residents are "farmed out" to someplace a little less busy and the EM residents are kept at the home institution.

 

[Substance]

Since the public loves family doctors(but doesn't want to pay for them) the powers-that-be will pander to them and increase residency spots in family medicine and other unpopular primary care fields. This is happening in Canada.

Then, the prohibitive cost of medical school combined with "debt-forgiveness" programs will force medical students from modest backgrounds to choose primary care, regardless of aptitude or ambitions. This is being discussed in Canada.

To quote Mr. Eko's statement to John Locke as he lay dying from wounds inflicted by the black smoke: "You're next"

 

[wine is good]

There are a few aspects of DocB's posts that I do not understand.

The University of Nevada Las Vegas is the only institution that sponsors residencies in Las Vegas. According to the NRMP that institution does in fact have an Emergency Medicine Residency. The EM program has 8 spots and every one of them were filled in the match in 2008 and 2009.

In addition you would think he's some kind of auto-didact who never learned from anyone else. Did he do clinical rotations? Did he go through a residency? Did he ever burden anyone with really stupid questions?

Finally if he doesn't like being at an institution with residencies why doesn't he leave and go some place where the great unwashed (i.e., students, interns and residents) aren't around?

What's funny is that he comes to a residency forum and says he prefers NPs to residents and expects to us not to call him out on it.

 

[docB]

There are a few aspects of DocB's posts that I do not understand.

The University of Nevada Las Vegas is the only institution that sponsors residencies in Las Vegas. According to the NRMP that institution does in fact have an Emergency Medicine Residency. The EM program has 8 spots and every one of them were filled in the match in 2008 and 2009.

In addition you would think he's some kind of auto-didact who never learned from anyone else. Did he do clinical rotations? Did he go through a residency? Did he ever burden anyone with really stupid questions?

Finally if he doesn't like being at an institution with residencies why doesn't he leave and go some place where the great unwashed (i.e., students, interns and residents) aren't around?

You are wrong that there is only one institution in Vegas that has residents. Valley Hospital Medical Center has several residencies including IM and FM and is affiliated with Touro Nevada. We currently have no EM residency and thus no EM residents.

Of course I learned from others. I also never said I don't like teaching. The statement that I responded to was about who is worth more in dollars, a resident or a midlevel. I like teaching the med students and residents. It costs me money to do so but I feel it's rewarding and a service for the community which is why I do it rather than picking up more shifts at other hospitals which is an option for me.

What's funny is that he comes to a residency forum and says he prefers NPs to residents and expects to us not to call him out on it.

I didn't say I prefer midlevels (we mainly employ PAs) to residents. I said that residents require more supervision than an experienced midlevel.

I understand that residency makes one feel persecuted and taken advantage of. But everyone needs to keep those feelings in perspective. What has come of this conversation is that in some environments residents are more valuable than MLPs such as in academic centers with senior residents in a specialty. In others they're not, such as a community setting without upper level resident supervision and teaching.

As for calling me out, that's fine. Remember that I'm looking at this from a real world perspective. My group makes decisions based on dollars and data. I'm not just making stuff up or saying how I think things should be based on how much I think I'm worth. Eventually you will all be faced with similar decisions and you will form opinions based on your experience and practice and spreadsheets. There's no use in getting angry about it.

 

[the fat man]

I shouldn't put words into DocB's mouth but he or she seems like he/she made a good argument for why academics and private practice don't mix. Making money and keeping your practice financially sound is your prerogative DocB, and believe me I don't fault you for that. I even admire your willingness to lose money in order to teach.

The real problem comes when private practices get their sticky palms into an academic setting. I can't speak for other specialties, but there have been major teaching hospitals (and by major, I mean the flagship hospitals for their medical schools) which outsourced their anesthesia departments to private groups, giving them full control over the residency program. Needless to say there are constant accusations at those hospitals that residency education takes a complete back seat to profitability...for example: 1) assigning basic cases to senior residents so that a single attending can cover 3-4 rooms by himself, while giving major cases to a junior because a senior would still need 1:1 supervision for the case. 2) pushing resident hours to the 80-hour limit, unusual in anesthesia these days, so they don't have to pay overtime to CRNAs whose standard hourly rate is 7-10X greater than a resident's.

 

[Law2Doc]

...2) pushing resident hours to the 80-hour limit, unusual in anesthesia these days, so they don't have to pay overtime to CRNAs whose standard hourly rate is 7-10X greater than a resident's.

It's hard to fault them for going up to the 80 hour limit when the ACGME tells them they can. So it's more profitable, so what -- it's still within the rules. I get why someone doesn't want to work 80 hours a week when a counterpart at an academic center nearby is working 70. But I don't see this as a negative of the for profit. It's the not-for-profit that had to outsource because it mismanaged this asset and didn't know how to make it profitable by pushing the rules to the max. The for-profit group looked at what was needed to make money under the rules and saw this as the way to do it. Guess what, that's not only not a negative (in terms of such person getting more training), but it's what the future holds as more and more not-for-profits make these outsourcing deals or find other ways to be more profitable in the wake of what is soon to be far more people in the system. Residents are capped at 80 hours average. Some fields are already at this number. Others will get closer to this number so long as that's the number the ACGME says is allowed. That's just good business, you maximize your profit centers, not a flaw of training with non-academics.

Now if you said you weren't getting as much training (as opposed to more) working with for-profits, I would call that a flaw, but getting "exploited" up to the max that the ACGME says is totally fine for you to be working, well your problem is with the ACGME, not the for-profit.

 

[ringerslactate]

lll

 

[Law2Doc]

This is absolutely false. All other DEVELOPED COUNTRIES have their own entrance exams (like USMLEs) to place into their training programs. So why don't you hear of AMGs (or IMGs for that matter) going to these "developed countries?" 1- the Attending salary is nowhere near what it is in the US; and 2- Besides a handful of English-speaking countries (UK, Australia, South Africa, etc...), you'd have to learn their national language to take their exams

We're not communist. Our gov't or AAMC doesn't control "what books people have access to." However, I do see a great importance in ensuring the quality of medical education abroad. I think the USMLE is steadily adapting. They're increasingly testing subjects (like genetics) that are more emphasized in our med schools vs. abroad. That being said, I'm sure they could do more.

There's ample financial incentive to practice medicine in the U.S. Nobody from abroad is even thinking of returning to "their home country," at least before retirement. They come (and stay) for the money more than education. You want to stop the flow, cut the $, and both you and I suffer.

Where's the proof of this so-called concern?

this "post-residency" group includes, by and large, American grads. The majority of educated, yuppie AMGs that I've known throughout my career are not looking forward to life in Hicktown USA. I've seen more IMGs ready to snatch up these spots, mainly because of the higher salary and benefits they bundle when luring them.

Definitely false. They had a whole presentation on this at last years GA-ACP conference. The "US med grad from rural West Virginia" wants to go where he/she can eat at expensive restaurants, spend $ at fine department stores, and educate their kids in prestigious private schools. I don't blame them. You make money and you want to spend it. Perhaps, your statement can be (sort of) true for DO grads (who have a higher trend of what you described) but don't compete in the same pool

Speak for yourself. That's why we have a wealth of intelligence in the US. Are you familiar with "brain drain?" That's what we're doing to the world, to our advantage. I'm a born and raised American who grew up in suburbia. While most of my high school constituted "White America," how come the overwhelming majority of kids in my AP/ honors classes were children of Asian or Middle Eastern immigrants? Brain Drain + procreation. Why is it that top universities are giving full rides for Engineering to mostly foreigners? Brain Drain. I'm not saying that foreigners are smarter than Americans. I'm saying we're cherrypicking the smartest of the foreigners. You might not be happy to see the face of America changing, but the defining American qualities of intelligence and capitalism are being sustained by these "foreigners."

In fact, US competitiveness is increased. And all the chem/eng undergrads i've ever known chose to make a new (wealthier) life in the U.S. - At the expense of their own countries' development.

"most americans" -errrrrrr, Glen Beck? Bill O Reily? Lou Dobbs?

Oh right, the inherent nature of the healthcare field. That's why you walk into any US hospital and see nothing but folksy, "aw shucks" American docs who can appreciate the apple pie you give them after they treat your malignant HTN. Not to mention, they ALL grew up just a couple streets behind the hospital - because this is the inherent nature of healthcare.

long winded, but necessary

First, the ACGME regulated all aspects of med schools including how well stocked their library and online resource access is. So yes, they do effectively keep tabs on what books a US student has access to, as well as other aspects of training at any institution that has and maintains LCME accredition. They, and I, think this kind of oversight is valuable in keeping a high standard of physician training. Tweaking the USMLE is meaningless because this doesn't gauge quality (and was never meant to), it is merely meant to be a bare minimum standard.

I'm not sure why you paint this as a right wing Fox News type conservative issue. (FWIW I'm not a conservative, nor do I have problems with the face of America changing). The reverse brain drain (US training the world rather than our own) concerns actually came up as a major debate during the Clinton administration, at that time concerning engineering, long before the Fox News era. If you want to see thousands of articles by not particularly conservative politicos, then Google is your friend.

In terms of US folks not able to practice elsewhere, you come up with lots of reasons why US folks might not even want to practice elsewhere (and I don't disagree with you on some) but do little to dispute my argument that the barriers do exist. It's simply not realistic to go from the US to a foreign residency for training, even if language was not an impediment. Which is why you never see it happen. So why does it happen in reverse? Partly because there is good money over here, but partly because the barriers only run one way.

Further you claim without much evidence that someone who grew up in a rural community was less likely to practice there than some foreigner. This is simply not accurate and your saying you disagree doesn't undermine the basic statement. Not sure why you think a DO is more likely to do this than an MD bound for something with a rural application, like FP, but that suggests your own bias against DOs, I guess. I happen to know plenty of MDs whose goal is to go home and practice. I also happen to know plenty of IMG's whose ultimate goal is to go home and practice. And therein lies the problem.


Shorter winded, but equally necessary. Your above argument, if you call it that, is not compelling. It gives me nothing to suggest that anything I've said above is inaccurate

 

[the fat man]

Now if you said you weren't getting as much training (as opposed to more) working with for-profits, I would call that a flaw, but getting "exploited" up to the max that the ACGME says is totally fine for you to be working, well your problem is with the ACGME, not the for-profit.

I see what you're saying. But I think you're equating raw work hours with true quality training.

 

[Law2Doc]

I see what you're saying. But I think you're equating raw work hours with true quality training.

I am, and that is kind of my experience. You log more hours, you do and see more. Sure you do more scut too, but in my experience the percentages stay about the same. So if your time is 30% scut and 70% actual useful time, those percentages still hold true whether you are working 65 hours or 80.