Tuesday, October 25, 2011

Things we don't know about residency

New York Medical Students,
Let’s discuss the most important thing to any medical student: having a job once you get out of medical school. Namely, I want to talk about residencies. We’re New York medical students, the cream of the crop (or so we tell ourselves)! Residency is something we’re concerned about, but we’re still pretty confident it will turn out well for us. I thought it was somewhat of a “given” that hard work and the New York State aura would carry me into a residency someplace; I think many people feel this way. It’s why I want to take a few minutes to simply discuss some of the things no one tells you about medical school. These will be things everyone seems to get wrong in casual discussion of residencies. Some of them will worry you: good. It won’t all be doom and gloom, but frankly, if you’re not concerned about residencies by the end of this I can only assume you’ve stroked out and lost the capability for concern.

One of the first incorrect thoughts about residency is that residency is a sure thing, a “given” for any American graduate who can pass the boards. Recently, the New England Journal of Medicine released a report on the future of residencies. For those who want to read it, here is a link: http://www.nejm.org/doi/pdf/10.1056/NEJMhpr1107519. The basic conclusion of the report is that there are currently three likely growth patterns that residencies will take in the future and all three show that in the next few years we will RUN OUT of residencies. I will repeat this: the report shows that, even with the most optimistic projections, the number of United States trained MD and DO graduates will outnumber the total residency spots of all American graduate medical education accrediting agencies. The most optimistic projections seem to suggest the tipping point will be the year 2020; more pessimistic projections based on current debate in the US congress suggest 2015 may be the tipping point. This means that unless there is dramatic change in congress to secure more spots we may very well have students in United States medical schools right now that will NOT have a job when they graduate. Recently the president of the Greater New York Hospital Association was asked what his take home message to students of NY would be. His response was that we should be marching in Washington and Albany en masse with sandwich boards around our necks because very soon jobs will not be there for us and right now almost no one understands nor cares about our problem with this, plain and simple. What is a medical graduate in the US without a residency? Given the debt I’m in right now, I don’t even want to think about that.

Yet somehow this problem is not caused by an absolute lack of residencies, or a residency freeze, which is the second common misconception. It seems pretty much everyone has heard, to some extent, about the balanced budget act of 1997 (BBA-1997). If you haven’t then a simple explanation is this: residencies are overwhelmingly funded by a cut of Medicare’s budget. In 1997, in an attempt to reign in Medicare’s cost, the federal government put a freeze on the expansion of any residency program. This freeze is one of the most misunderstood concepts in medicine as many people seem to believe it capped the number of residencies in an absolute sense, which it did not. The BBA-1997, along with its amendments in 1999 and 2000, prevented any existing program from expanding its residency programs indefinitely. What it did not do is prevent any new programs from opening, and over 100 new programs open in the ACGME every single year. The one issue with this is that the program, generally, only gets one chance to be evaluated for new residencies so they must carefully plan out when they throw their hat into the residency ring. To show an example of this growth: there were 8403 ACGME programs in 2006 and 8967 in 2011. Additionally almost 1,700 residency positions open each year (103,106 positions in 2006, 111,586 in 2011) in the ACGME, and 200-250 additional spots in the AOA open every year. Unfortunately the “nearly 2000” figure is over all years of residency training, the actual number of new first year spots is less than 500 per year. 

So why, if residencies are expanding by around 500 combined spots per year, are we about to run out of residencies? Simply put, we are building medical schools at an unprecedented rate. In the past five years 15 medical schools have opened in the US and 12 more will open in the next 2 years. Among those numbers are two new medical schools in New York, Touro and Hofstra. There are many simple reasons for this massive expansion. One of the simple reasons is that running a medical school is usually a profitable endeavor, despite medical education in the US being primarily non-profit. Perhaps a more pertinent reason is that many people feel that American students should be taking American residencies and should be trained in America. Much of the inertia behind all the new schools being built is to provide sufficient schooling to allow all qualified students to stay within the country for medical education. The issue is that this medical patriotism comes at a time when congress is contemplating cutting Graduate Medical Education (GME) funding as a way to say they “cut Medicare” without harming any patient coverage. It also is happening far too quickly for the system to react to, and the massive influx of students that has already began pouring in with the graduating class of 2011 will only continue to rise precipitously as each new school has its first graduating class.

The last misconception is that it’s a lost cause and we, as students, don’t have the time or power to stop anything. It’s not a lost cause. There is so much more to be done. There is so much already in motion. I want to draw your attention, at the very end of this, to a bill currently on the floor of the Senate. This is the link: http://thomas.loc.gov/cgi-bin/query/z?c112:S.1627:#. This bill seeks to do the seemingly impossible and ask for the 1997 cap to be lifted so that 3,000 additional spots can be added each year until a proper number of residency positions are attained. The bill is co-authored by NY’s own Chuck Schumer. In addition MSSNY recently penned a “kitchen sink” letter where they listed out every major demand of the medical society. In a lead position among those demands were the need to expand GME in any local or national way feasible to both protect current NY students and graduates and to strengthen the number and strength of funding of programs for future all future graduates. Medical students, ones you’ve elected, are in the MSSNY-MSS trying constantly to make sure students are represented in every debate in New York and that the student bodies stay educated on the issues at hand.

There is a lot we still don’t know about the future of graduate medical education in the United States and New York itself. One thing is for certain, if we as students sit aside idly and simply say “we are too busy for this” we will have no say and our needs will be ignored as they cost the system money. The fact that our very educational system is on the brink of non-sustainability and an occupational bottleneck will not register in anyone’s mind unless we actually begin a conversation within our schools, within our communities, in the state and on the national level. Until students put down the books, albeit very briefly, and make our voices heard, the chances of having a catastrophe on our hands rises every week. You’ve worked so hard to get this far, what have you done to secure your future lately?