Residency Bottleneck Real Or a Myth?

[DubbiDoctor]

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I often hear people bring up that expanding US med school enrollment won't alleviate the projected physician shortage, because available residency positions represent a bottleneck, preventing an increase in the physician-to-population ratio. It is said that residency funding has been frozen since the mid-90s, due to AMA lobbying. However, NRMP data shows a consistent increase in residency positions, coinciding with the increase in medical school enrollment. If the government hasn't allocated funding toward additional spots, how has this increase occurred? And is it mistake to predict a coming residency availability crisis, in which a significantly greater percentage of qualified US MD/DO applicants fail to obtain residency spots?

 

[ERDOC555]

The residency shortage is a myth made up to scare MDs and DOs. Currently and for the last several decades there have been far more residencies than American Graduates. Hence why we take 7000+ FMG/IMG each year.

With the massive increase in DO schools (and some MD) and the increasing class sizes, we may eventually get to the point where there aren't enough spots, but that is still years down the road and will depend on whether we keep pumping out new schools at the same rate we are now. If we keep up this pace we could theoretically get there in a decade, but it's hard to predict.

tldr: Residency shortage has been a boogeyman, but may someday be a problem if we keep up creating new schools.

 

[Chillbo Baggins]

The residency shortage is a myth made up to scare MDs and DOs. Currently and for the last several decades there have been far more residencies than American Graduates. Hence why we take 7000+ FMG/IMG each year.

The problem for AMGs is lack of interest in the fields where the majority of these new spots are being created.

 

[Redpancreas]

The problem for AMGs is lack of interest in the fields where the majority of these new spots are being created.

Agreed. They should shorten the requirements for certain fields and start fast-tracking people. Undergraduate studies can be cut by a year without much loss and do you really need 4th year aways to apply to Family Medicine? After Step 1, FM applicants can complete a Family Medicine/IM rotation/Pediatrics/OB-GYN rotation, and then they can take Step 2 while taking other rotations in the spring (for completion-not gunning for honors with apps submitted) and then they can start residency after M3. That two years is a huge difference and most of the training comes in residency anyways.

 

[Chillbo Baggins]

Agreed. They should shorten the requirements for certain fields and start fast-tracking people. Undergraduate studies can be cut by a year without much loss and do you really need 4th year aways to apply to Family Medicine? After Step 1, FM applicants can complete a Family Medicine/IM rotation/Pediatrics/OB-GYN rotation, and then they can take Step 2 while taking other rotations in the spring (for completion-not gunning for honors with apps submitted) and then they can start residency after M3. That two years is a huge difference and most of the training comes in residency anyways.

My school has a fast track FM program that is only 3 years (full UG still) and it's been very successful.

 

[Redpancreas]

My school has a fast track FM program that is only 3 years (full UG still) and it's been very successful.

That’s excellent. That’s like +200K salary+40K less in loans, plus a year less to endure medical school and enjoy your youth. I have heard of these and hope this starts gaining traction nationally.

 

[VA Hopeful Dr]

That’s excellent. That’s like +200K salary+40K less in loans, plus a year less to endure medical school and enjoy your youth. I have heard of these and hope this starts gaining traction nationally.

I enjoyed fourth year of medical school more than I have any year of being an attending.

Financially the 3-year plan makes more sense, but I had a lot more free time and did a lot more stuff then and I do now.

 

[Anti-PD1]

AAMC has been pushing this idea since the Balanced Budget Act of 1997, which capped the number of resident positions funded by Medicare money.

You and I both know residency positions have increased since then. Hospitals and others have filled the gap.

Now, there not being enough derm spots or ortho spots etc is a whole other issue (manufacture demand by reducing supply).

Rest assured, there will be a GME spot for you if you school on American soil.

 

[Lnsean]

I hope the gap widens even more so that it discourages people from going to Carribean

 

[Goro]

I hope the gap widens even more so that it discourages people from going to Carribean

I hear you, but one of the problems with many people heading to the Carib is magic thinking....they think they're the ones who will score 260 on Step I...with MCAT scores <490 and/or GPAs < 3.0

 

[Raryn]

I often hear people bring up that expanding US med school enrollment won't alleviate the projected physician shortage, because available residency positions represent a bottleneck, preventing an increase in the physician-to-population ratio. It is said that residency funding has been frozen since the mid-90s, due to AMA lobbying. However, NRMP data shows a consistent increase in residency positions, coinciding with the increase in medical school enrollment. If the government hasn't allocated funding toward additional spots, how has this increase occurred? And is it mistake to predict a coming residency availability crisis, in which a significantly greater percentage of qualified US MD/DO applicants fail to obtain residency spots?

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AMA actually lobbies the other direction: For an increase in GME spots. The balanced budget act of 1997 capping the # of GME spots was more the feds trying to save money.

Regardless though, Medicare funding isn't the only way GME spots get their money: They also get funding from states, from the VA, from the children's hospital fund (another federal source theyre always threatening to cut) and internal funding amongst the various hospital systems. The # of spots has been increasing over the last 20 years... just slower than the total medical school enrollment.

There may come a day when the total # of PGY1 spots is less than the # of US MD/DO graduates, but it's not anytime soon. FMG/IMGs will just be pushed out more and more.

 

[Chillbo Baggins]

I'm just wrapping up my third year and going into FM, but my only curiosity with these programs is whether somebody who has just finished M3 is well enough prepared to function effectively and efficiently as an intern? Particularly in FM where you're being bounced around to different departments and being expected to function at the level of a peds intern, an obgyn intern, an IM intern, etc. depending on what month it happens to be. Even if you don't do aways, it seems like the sub-i and 4th year electives (depending on which ones you do, obviously) would go a long ways towards preparing you for residency.

They make it work. They also do focused rotations in the summers.

 

[Raryn]

I'm just wrapping up my third year and going into FM, but my only curiosity with these programs is whether somebody who has just finished M3 is well enough prepared to function effectively and efficiently as an intern? Particularly in FM where you're being bounced around to different departments and being expected to function at the level of a peds intern, an obgyn intern, an IM intern, etc. depending on what month it happens to be. Even if you don't do aways, it seems like the sub-i and 4th year electives (depending on which ones you do, obviously) would go a long ways towards preparing you for residency.

Honestly, probably better prepared than many people who just finished M4.

 

[VA Hopeful Dr]

Honestly, probably better prepared than many people who just finished M4.

Depends on your rotations, but as a general rule I agree

 

[GrignardsReagent]

Agreed. They should shorten the requirements for certain fields and start fast-tracking people. Undergraduate studies can be cut by a year without much loss and do you really need 4th year aways to apply to Family Medicine? After Step 1, FM applicants can complete a Family Medicine/IM rotation/Pediatrics/OB-GYN rotation, and then they can take Step 2 while taking other rotations in the spring (for completion-not gunning for honors with apps submitted) and then they can start residency after M3. That two years is a huge difference and most of the training comes in residency anyways.

Pretty much just described my program.

Sent from my SM-G955U using SDN mobile

 

[DubbiDoctor]

I enjoyed fourth year of medical school more than I have any year of being an attending.

Financially the 3-year plan makes more sense, but I had a lot more free time and did a lot more stuff then and I do now.

Don't think you can justify the 50-60k tuition of a 4th year by pointing out the free time it offers med students. You can always take a year off - though better to wait until you finish residency - if you're feeling burnt out. Realistically a summer off is probably all you will need. NYU (and now stony brook) allows students to choose a speciality when they enter medical school, and match directly to an NYU residency after their third year. It's a good program but it wouldn't be feasible to implement it nationwide. NYU med may be comfortable guaranteeing a derm or even neurosurgery residency to a first-year; most programs nationwide would not, insisting on traditional applications and interviewing during 4th year.

 

[Chillbo Baggins]

Honestly, probably better prepared than many people who just finished M4.

Can confirm.

 

[Cath Up]

The residency shortage is a myth made up to scare MDs and DOs. Currently and for the last several decades there have been far more residencies than American Graduates. Hence why we take 7000+ FMG/IMG each year.

With the massive increase in DO schools (and some MD) and the increasing class sizes, we may eventually get to the point where there aren't enough spots, but that is still years down the road and will depend on whether we keep pumping out new schools at the same rate we are now. If we keep up this pace we could theoretically get there in a decade, but it's hard to predict.

tldr: Residency shortage has been a boogeyman, but may someday be a problem if we keep up creating new schools.

While you are technically correct that the # of DO schools has proportionally increased much more than MD schools, I think it is important to point out that the actual number of seats at MD schools has increased substantially as well, reasonably on par with DO expansion.

I think I remember seeing some more recent data that shows DO schools have now (as of 2017/2018) added more seats than MD, but a quick search yielded the following paper, which shows 20 new MD schools between 2002-2016 and 13 new DO schools (though there is likely some mischaracterization here given the likely higher rate of "remote teaching sites" and branch campuses of DO schools that might not always be counted as a new school in this data). Regardless, though, the raw increase was comparable in this 14 year timespan.

MD seat increase: 4576
DO seat increase: 4251

My point being that the massive increase in DO schools can only be considered massive when looking at the relative growth. The raw growth appears to be about equal (slightly less or slightly greater when adjusting the time period you look at) as MD programs. When we are assigning blame for this I am not sure either party should have more to bear.

http://www.amjmed.com/article/S0002-9343(16)30554-X/fulltext

 

[VA Hopeful Dr]

Don't think you can justify a 4th year by pointing out the free time it offers med students. You can always take a year off - though better to wait until you finish residency - if you're feeling burnt out. Realistically a summer off is probably all you will need. NYU (and now stony brook) allows students to choose a speciality when they enter medical school, and match directly to an NYU residency after their third year. It's a good program but it wouldn't be feasible to implement it nationwide. NYU med may be comfortable guaranteeing a derm or even neurosurgery residency to a first-year; most programs nationwide would not, insisting on traditional applications and interviewing during 4th year.

Please tell me more, pre-med, about what medical students need.

Snark aside, it wasn't just about the free time. I had a great ECG course one month. Ran from 8am to 11am. Maybe another hour to do the homework. So not only did I get a bunch of free time, I was easily the best resident in my program at reading ECGs. My wife, who took the same class, challenged her program's ECG final exam as an intern.

I did a similar radiology rotation - roughly 8-noon. Must've gone over a thousand x-rays of various types. Gave me a great leg up intern year AND still lots of free time.

There was the derm rotation, 8-5 but only 3.5 days/week. Prior to that, I sucked at derm (most med students do). Afterwards, I was decent at it. Plus, lots of practicing my suture work which is always a good idea.

 

[Redpancreas]

I'm just wrapping up my third year and going into FM, but my only curiosity with these programs is whether somebody who has just finished M3 is well enough prepared to function effectively and efficiently as an intern? Particularly in FM where you're being bounced around to different departments and being expected to function at the level of a peds intern, an obgyn intern, an IM intern, etc. depending on what month it happens to be. Even if you don't do aways, it seems like the sub-i and 4th year electives (depending on which ones you do, obviously) would go a long ways towards preparing you for residency.

As an M4, this is a very fair point but let me say ive learnt nothing life changing this year that magically prepared me. A little more confidence, sure... but I believe you ultimately have to bite the bullet somewhere.

 

[Raryn]

Fourth year of medical school is whatever you make of it, but in general, you learn nothing vital that you won't learn in more depth during residency (if relevant).

During my fourth year, I did a subi, an ambulatory block, three months of vacation, a urology subi (surgical subi requirement for everyone sucked, my school has since gotten rid of it), and 5 months of bull****. During the 5 months of bull****, there were some rotations I learned valuable information (my blood banking and transfusion medicine rotation was nice learning in detail about transfusion reactions, indications for pheresis...) but most of it was just timewasters until graduation.

If I had started third year a couple months earlier, and then just went straight through from the new third year into a subi and went straight from there to residency, I'd be almost as well prepared from an intellectual standpoint to be an intern - and far more prepared from a practical standpoint. Skills atrophy during fourth year, and it isn't at all unusual for the subis to be "better" than the brand new interns in July (that rapidly changes within the first few months, but we're talking about July here).

Doing a radiology rotation as a fourth year student may make you better at radiology as an intern - but you'll get all the relevant radiology at some point in your 3+ years of residency, and I personally doubt it will make a significant different in your skills as an attending.

Some people did "intense" fourth years all the way through so they had a leg up when they started... that lasted until maybe September of intern year. Even the most intense student rotation doesn't really compare to being an actual doctor.

 

[kb1900]

Please tell me more, pre-med, about what medical students need.

Snark aside, it wasn't just about the free time. I had a great ECG course one month. Ran from 8am to 11am. Maybe another hour to do the homework. So not only did I get a bunch of free time, I was easily the best resident in my program at reading ECGs. My wife, who took the same class, challenged her program's ECG final exam as an intern.

I did a similar radiology rotation - roughly 8-noon. Must've gone over a thousand x-rays of various types. Gave me a great leg up intern year AND still lots of free time.

There was the derm rotation, 8-5 but only 3.5 days/week. Prior to that, I sucked at derm (most med students do). Afterwards, I was decent at it. Plus, lots of practicing my suture work which is always a good idea.

These seems like the best way to make the most of 4th year.

 

[LizzyM]

Keep in mind, too, that IMGs are not only Americans who went off shore for medical school but also some of the best and brightest practicing physicians from around the world who come to the US to practice and are required to repeat their residency in order to obtain a medical license in the US.