It has been many years since students graduating from law school were guaranteed employment. The nation's institutions of higher learning used to think that most folks considered law school a great way to secure a high-paying job. These same universities also knew that building a law school was relatively cheap. A private school with an extra building and a library could hire some professors and charge an average of $40,000 per year. One hundred students per class provided $4 million of gross income, and three classes gave you $12 million per year to work with. Not bad. (Forbes Jan. 31, 2013; http://onforb.es/1eHjH5h.)
But a funny thing happened on the way to the bank. These graduates could not find work. Like, a lot of them could not find work. Only 56 percent of law school graduates secured full-time, long-term legal employment in 2012. That means 17,600 lawyers without legal jobs each year. Simply put, too many law schools and not enough jobs. You might be a bit nervous if you are a law school professor. (Slate April 2, 2013; http://slate.me/1javGLI.)
Why should we care? Doctors are often at odds with attorneys anyway, and once you get into medical school, you are guaranteed a secure long-term job, right? This has always been the trade-off for the years of hard work, delayed gratification, and the monumental student-loan debt (median medical school graduate debt in 2012 was $170,000).
Guess what? Approximately 1,400 MD and DO graduates from schools in the United States did not match into any residency position in 2013. Several really solid applicants in my program panicked on Match Day last year when they not only did not match into an emergency medicine residency but also didn't have a job after graduation! Some 6,400 international residency applicants (30 percent of whom were U.S. citizens) also could not secure U.S. residency training. More than 8,000 doctors were turned away from U.S. training last spring. (Check out this video for more information: https://vimeo.com/77727683.)
How can this be? There is no shortage of illness. In fact, our society is getting older and has more complicated chronic medical problems than ever before. And we have been hearing about “doctor shortages” for years. Well before the Affordable Care Act, back in 2003, it was predicted that the United States would have a physician shortage of 90,000 doctors by 2025. How can we afford to turn away 8,000 doctors in one year when we have so much ground to make up?
The answer is not really a surprise. It's our government. Most folks do not realize that the federal government picks up the tab for the residency training of medical school graduates. This all started in 1965 with the beginning of Medicare. Before this, residents actually lived in a hospital dormitory (hence the term “resident”). But with Medicare, funds were provided to pay residents, allowing them to make a living, even though the currently average is only $16 an hour before taxes.
But the federal government passed the Balanced Budget Act in 1997, and GME funding from the federal government was capped. No additional residency training slots were going to be funded until Congress fixed the budget deficit, and we all know how that is going.
Universities ramped up production of medical school graduates over the past decade because the nation needs doctors, and these efforts have produced more graduates. What we do not have is a way to train them to do their job. (To be honest, it seems medical students now are barely allowed to touch patients, much less suture, intubate, perform a lumbar puncture, or put in a central line.) Every state requires them to have at least one year of post-graduate training to get a medical license, and many states require two or three years. The bottom line is you cannot practice medicine in the United States without residency training in the United States.
How can we increase the number of available physicians when we do not have enough residency positions to train them? Will it be additional funding from a Congress that never agrees on anything? Will it be up to hospitals to pay for additional residents without funding from the federal government? Will we roll back the clock and have residents live in dorms at the hospital? I have even heard suggestions of residents paying to have the “privilege” of being a resident.
What should we do? I really don't know, but I can tell you that the United States cannot treat more patients or offer more services without more health care providers. I suspect the best solution is a combination of innovative ideas that includes more physicians, midlevel providers, efficient alignment of services, electronic medical records, and streamlining patient throughput. But seriously, for all its successes, medicine has never been a rapid adopter of innovation. It usually takes years for us to agree on anything, and older physicians seemingly do not want to change anything. Have you ever watched an older surgeon yell at the poor guy trying to teach him how to use an EMR? It's not pretty.
Can we come up with viable solutions in this fractured political climate? Or will we see physicians waiting tables at our local restaurants hoping for the opportunity to use their medical degrees and climb out of their hopeless pit of debt? This might get a little rough.
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- Watch a video of Dr. Cook's past trip to China at http://bit.ly/153OPaW.
- Visit EMN's Going Global blog, written by residents in Dr. Cook's residency program at Palmetto Health Richland, at http://bit.ly/EMNGoingGlobal.
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