I have been reading a number of articles recently about Nurse Practitioners and Physician’s Assistants lobbying for total autonomy particularly regarding primary care.
A bit about me. After earning two Bachelor’s degrees [Biology and Chemistry] in 2004, I decided to join the United States Army and was commissioned through the Health Professions Scholarship Program (HPSP). This is a direct commissioning program for aspiring DOs and MDs. Briefly, the United States Military pays for four years of tuition including books, supplies and a monthly stipend. This is in return for 4 years of active duty service (a one for one contract). If you decide to complete a residency (and are lucky enough to match to your first choice residency) the payback is again one for one (one year of training requires one year of additional active duty time). If you do not match into your first choice, the military places you into a program of their choosing based on need. If you choose not to complete a training program in one of these undermanned specialties (typically Family Practice, Internal Medicine, Psychiatry) you are sent out into an operational position as either a General Medical Officer [GMO] or a Flight ‘’Surgeon’’ [FS]. These are slots designated as primary care in support of operational units throughout the Armed Forces and are relatively independent. Once you have completed at least two years in one of these positions you can either: 1) reapply for your specialty of choice, 2) continue as a GMO or FS until your service obligation in completed (and then separate from service), 3) apply for one of the underserved specialties within the military system, 4) or resign your commission and return to Civilian life.
After I graduated from medical school in 2008 with an 88% average, I applied for a residency with Army Radiology via the Military Match. Despite Step 1 and Step 3 licensure scores in the 97th and 95th percentile respectively, successful travelling rotations during the 3rd and 4th year of medical school, and many letters of recommendation, I did not match and was ‘’placed’’ into a specialty of particular need within the Military system (MEDCOM), specifically Neurology. I elected not to accept this position as I had very little interest. None-the-less I completed this specialty’s internship as there were no transitional spots available. After a very successful internship (I qualify this as I received numerous letters of recommendation) I was placed in a Flight Surgeon’s slot supporting an Aviation Unit in Kansas. Towards the end of my obligation, I applied successfully to a Preventive Medicine residency.
After beginning this program my 2 year old son became sick. Due to this, I was forced to resign my position in order to care for him and my family, attend his sundry medical appointments and finally, after 3.5 years, receive a diagnosis: DOCK8 syndrome. This is an exceedingly rare primary immune deficiency discovered, finally, by the National Institutes of Health (NIH) and only after a very dedicated Hematologist from Johns Hopkins with a high level of suspicion decided to refer us to NIH. During the years leading up to his diagnosis, we had been passed around to a number of specialties including Allergists and Immunologists (some ‘’world renowned’’) while I watched by beautiful son become ever more sick and disabled. We finally had to pull him out of school during 1st grade. This all culminated in a haplo-bone marrow transplant with me as the donor the day after my son’s birthday, June 23, 2015. This required that NIH lower their own age requirement for this experimental Transplant protocol from 8 to 6. During the time he was hospitalized, two of his friends died from this insidious disorder however, he has had a remarkable outcome.
During this period of time spanning from the end of 2010 to present I continued to work for the US Army as a Flight Surgeon. I am currently a Physician at a Community Hospital. For these past 5 years I have averaged over 150 CME’s per year, drafted literally hundreds of templates for common patient presentations, authored 6 articles in peer reviewed journals, spent any free time I have had with PM & R as well as Radiology at my current institution, gained a reputation as a meticulous, thorough and knowledgeable clinician among colleagues (specialists and primary care alike), and earned a fervent and dedicated patient following averaging between 10 and 20 patient encounters per day among a patient demographic aged between 18 and 65 years old.
Why am I telling you all of this? What I neglected to mention above was that I have been applying for residencies through the Civilian match for the past 2 years with absolutely no success. In 2014 I applied to a number of Family Practice residency’s throughout the United States receiving a grand total of 0 interviews. This year I applied to 24 Physical Medicine and Rehab positions, and despite a stellar recommendation from a mentor in the field, I received a total of 3 interviews (one of which was a phone interview with the military’s only PM-R program). I have wondered why. Are there any so-called ‘’red flags’’ in my history? I suppose there is. 1) I had a relatively low Step 2 score (compared with steps one and three). 2) I failed my first of attempt at the Clinical Skills portion of the Step 2 licensure examination. 3) I pulled out of a Preventive Medicine residency (I do not offer the reason why unless I am asked).
Assuming that there is a looming shortage of primary care medical services (there have been conflicting reports, aging population, the ACA) and being certain that there is an inadequate number residency positions available to Medical School graduates (even in the face of new medical schools seemingly popping up like weeds) my question is this: why is all the rhetoric concentrated on Nurse Practitioners and Physician’s Assistants? What about all of these graduating medical students and Physicians like me? Now I have worked with some great Nurse Practitioners and Physician’s Assistants and support them fully but this conversation needs to include Medical students as well as those outliers in my position. All things considered, my situation is relatively benign but no less distressing. At least I have an internship certification and can be licensed (I have been licensed since 2008 however, this means nothing in the civilian world as I still cannot practice and provide for my family). I do not have the massive debt that these medical students have incurred [the military paid my tuition]. While I have a very significant primary care experience and profound confidence in my clinical acumen, medical students also have a compelling amount of training. Rotations last for 2 years and are widely varied. I spent, on average, 55 to 60 hours per week for 24 months rotating through many Surgery subspecialties, Internal Medicine, Psychiatry, Family Practice, Anesthesiology, Neurology, etc.
Some will argue that many of these students who don’t match are defective in some way and are not fit to practice medicine in the first place. I point those towards the issue of the international medical school graduate and Foreign Physicians. A review of one of the Family Practice Residencies I applied to in 2014 revealed that at least 8 out of 20 were International Medical School graduates [2 Saint Kitts, 1 West Indies, 2 Saint Georges University, 2 Saint James, and 1 Curacao]. Keep in mind that these are the ones I could find via general internet search. The proportion is likely much higher. Apparently these foreign medical School graduates squelch this argument as thye have graduated successfully and are practicing. It does not, however, remedy the problem of too few spots for home grown medical students as these very same international students are vying for these same positions.
Can you imagine successfully completing the crucible of medical school, studying for hours and hours every day for 4 years, sacrificing all things social, and incurring massive debt only to find out that you cannot practice medicine because there are not enough residency positions and your cannot get a certification? I wonder how that would make you feel. Anxious and depressed? Yes. Desperate? Most likely.
Many of you may be asking yourselves: why don’t you stay in the Military? First, I became involved in Medicine to interact with patients and practice medicine. As I have moved up the ranks in the Army there has been a noticeable and ever increasing pressure to take on more of an administrative role [this is common in the Military]. I have seen this in many of my colleagues, wonderful clinicians who have been turned into bureaucrats. This is NOT my goal. I went to school to be a clinician. I see Physicians at my own hospital who are required to attend meeting of all sorts. Many would rather sit in meetings than interact with patients. This is disheartening and disappointing. Second, a talented colleague with whom I work closely found herself in the same situation. She applied to Family Practice within the Military system. The Office of the Surgeon General told her that since she had completed a prior internship she could only apply for a 2nd year position (an advanced position in the parlance) even though she was willing to recapitulate her intern year. Since there were no 2nd year slots available, she could NOT apply nor interview. Due to this administrative myopia, she had to consult congress. They have not gotten back with her and the match is 2 weeks away. Apparently bureaucratic inertia is impossible redirect no matter the consequences to the real people involved.
The Huffington Post recently reported that ‘’this year [2014] in the ‘residency match’ 412 US graduates did not find a position’’ [down from 528 in 2013]. In 2012, according to the National Residency Matching Program [NRMP], 971 graduates of U.S. medical schools were shut out, accounting for 5.9% of U.S. graduates. Moreover, Congress has not changed its annual $10 billion allocation to fund those residencies since 1997. In 2013, state representatives introduced two bills, the Resident Physician Shortage Reduction Act and the Training Tomorrow's Doctors Today Act. Neither bill passed the House of Representatives. Additionally, there are huge areas of the nation, especially rural and inner-city areas, which lack any primary-care coverage. The Department of Health and Human Services estimates that the shortage is at least 16,000 doctors. Dr. Janis Orlowski, the senior director in health care affairs for the Association of American Medical Colleges, predicts a shortage of 130,000 physicians by 2025. Dr. James E. Wilberger, a neurosurgeon and vice president for graduate medical education at Allegheny Health System noted: ‘’I know of one graduate who failed to get a residency this year’’. Describing the graduate as a "top-notch student," an aspiring orthopedic surgeon with "excellent credentials," he said there is sometimes no predicting which students will fail to match. Apparently, and to the detriment of those who argue only inadequate or inferior medical students do not procure residency training, even some highly competitive students do not get a residency in their chosen specialty.
This is where I am left after all of the above. The state of Missouri [other states like Michigan that are considering following its lead] seems to be opening up to Physicians stuck in purgatory. A recent Op-ed in the Los Angeles Times reported that Missouri will allow medical school graduates to work as "assistant physicians" treating patients in underserved rural areas, even though they have not been trained in a residency program. Under the new law, an assistant physician must have passed the first two sections of the national licensing exam for doctors but not the final one. If they want to become full-fledged physicians, they will still have to pass the last test and do a one-year residency. I fall into this category. According to the Open Editorial: ‘’These assistant physicians — not to be confused with physicians' assistants, who are not medical school graduates — must work in person with a collaborating physician for 30 days and could prescribe most medications. They then may treat patients on their own if they practice within a 50-mile radius of that supervising doctor. They also must be approved by the state Board of Healing Arts, which issues medical licenses’’. The Missouri State Medical Association, which represents the state's 6,500 physicians, helped draft the legislation. It argued the law was needed to address a severe shortage of healthcare professionals in the state. At least one-fifth of Missouri's residents lack adequate access to a doctor.
Also according to the article (and not unexpected), there are many national medical groups who oppose the idea [Physicians are a suspicious bunch who will guard their territory at all costs]. Letting someone practice without a residency in the view of critics is to dangerously weaken professional competency. Would this apply to even me? So who will these new doctors be? According to the article: ‘’Some will be graduates of medical schools who failed to get into a residency program. Others will have failed or gotten low scores on Step 1 or Step 2 of the U.S. Medical Licensing Examination on the first try, even if they passed or did better on subsequent attempts. Some will have gone to non-U.S. medical schools [apparently this does not matter to some residency programs – as detailed above]. A few medical school grads will choose to be an assistant physician rather than enter residency’’. Unfortunately the article concludes with this pejorative: ‘’the bottom line is that assistant physicians are not likely to be the cream of the U.S. medical school crop’’. This being said, current classes are not yielding many primary-care providers, most likely because of the lower salaries primary care pays is not commensurate with the level of debt new graduates face [among many others]. Add this to the fact that new residency slots are not going to open any time soon and you have a recipe for a perfect storm. I will conclude with this question: Can these providers deliver high-quality primary care? The jury is out. I know I can given the chance. I think it is likely that most can. What do you think?
Any constructive comments? Please, if you have comments like ''there must be other red flags'' keep them to yourself. There aren't. I will gladly supply my e-mail address to anyone who asks for it.
