The Real Issue with the Match
Imagine for a second that you really want to be a doctor. Like really, really want to be a doctor (and if you’re reading this, I’m guessing you probably don’t really need to imagine).
But anyways, imagine that you take the general path to becoming a doctor. You go to college, pick a major, complete medical school pre-requisites, get clinical experience, volunteer, go through the difficult medical school admissions process (all while building up debt from tuition and living expenses), and luckily you are one of the 42% of medical school applicants each year that gets accepted (as of 2013). You think that you’ve just surpassed the largest hurdle toward becoming a doctor and while the coursework and clinical experience that lies in your future will be challenging, as long as you excel, the next opportunity will be available for you.
Then you actually go to medical school. You make it through with good enough grades, USMLE score, and recommendations to be competitive for your choice of specialty (again while building up debt – this time up to hundreds of thousands of dollars). In your fourth year, you apply to residency, the next step in your journey to becoming a physician. You spend money on application fees. You take time away from your fourth year clinical rotations while spending money to travel the country and interview. You eagerly wait for that day in the spring when all applicants are told whether they match.
To your dismay, you find out that you do not have a residency position waiting for you. You jump into the scramble to try to get in to one of the unfilled residency positions, but again, no such luck.
What do you do? You’ve just committed four years of undergrad and four years of medical school while building up debt only to not be able to take the next step toward the career that you’ve been specifically trained to do. While you can try again next year, you’re still faced with a mound of debt and no job to help pay it off.
Some in this situation have gone on to hold such job titles as… security guard.
Unfortunately in the past year this happened to 25% of residency applicants. I hope by the end of this you will understand why and what we can do to stop this from happening.
Supply and demand
With an aging population and an expansion of healthcare access due to policy reform, the American Association of Medical Colleges (AAMC) estimated that we will need 91,500 new doctors by 2020 and 130,600 new doctors by 2025. To face this oncoming crisis, they recommended a 30 percent increase in medical school and residency positions from 2002 levels.
Medical schools have responded adequately. Between expanding class sizes and creating new medical schools altogether, we are on track to meet that 30 percent goal by 2017. Unfortunately the same cannot be said about residency positions. In the same time period, residency positions have increased only 8 percent. This means we are facing a greater number of graduated medical students (especially when adding in those trained abroad) that are applying for residency positions than are available.
Why is this? Well, a major reason is that back in the day, Congress passed the Balanced Budget Act of 1997 as a means to even out the government’s finances. Through this, they created a cap to the number of medical residents supported by Medicare, the largest funding source for Graduate Medical Education (GME) aka residency. Despite this cap, residency positions have slowly been increasing but nowhere near the extent that is necessary considering our current circumstances.
This is a problem on many levels and something needs to be done. For the sake of the medical students who are devoting so much of their life to this profession while risking the chance that they will not be able to practice medicine in their area of preference or even practice medicine at all, we need to balance out these numbers. Our choices are either to decrease medical school positions or increase residency positions. Otherwise with compounding numbers of students who do not match each year, the population of students who are out of luck will only continue to increase.
If we additionally consider the needs of the country, which is facing a shortage of physicians as is, we can narrow down these two options to just one – increasing residency positions.
From speaking with Congressional staff from both Democratic and Republican offices, it seems agreed upon that we need more GME positions. Yet, we are at a roadblock. Why? Well, of course it’s the usual culprit, money.
As I’ve previously said, Medicare is the primary funding source for GME providing $9.5 billion in 2009. This money comes in the form of both direct graduate medical education payments (DGME) to hospitals for residents’ stipends, faculty salaries, administrative costs, and institutional overhead as well as indirect medical education payments (IME) to compensate for the higher costs associated with teaching hospitals. While DGME is a rather straightforward value, IME is not and there is concern within the government as to whether teaching hospitals deserve as much IME as they receive. Because of this, there have actually been threats for cuts to GME funding.
This is not the only source of GME funding though. Medicaid provides $5 billion annually (as of 2010) with this support coming from both federal and state funds. Nonetheless this too has been threatened due to financial constraints in state budgets. Other sources include the Department of Veterans Affairs (VA), the Department of Defense, and the Children’s Hospital Medical Education Program administered by the Health Resources and Services Administration (HRSA).
With many contributors to GME funding and concern about the use of those funds, there are many changes with our system that can occur to produce a greater number of residency positions. First things first, the cap put in place by the Balanced Budget Act of 1997 needs to be lifted so that residency positions funded by GME’s largest supporter are less restricted. Second, to address concern over use of GME funds, it has been suggested that the Secretary of Health and Human Services publish an annual publicly accessible report that describes the use of these funds and the need for residency positions across the United States. Third, many medical associations have supported an all-payer GME system that would create a GME trust fund so that Medicare, Medicaid, and other payers could contribute to a pool of GME funding thus providing stability to the GME funding stream.
Some of these changes are rather extensive and some are quite costly (mainly lifting the GME cap). In the mean time, smaller changes can occur that work toward increasing residency positions. Current legislation regarding the matter include The Resident Physician Shortage Reduction Act that will increase the number of Medicare-supported training positions for medical residents who choose careers in primary care and the Training Tomorrow’s Doctors Today Act that aims to increase the number of GME slots by 15,000 over the next five years with an emphasis again on primary care. Thus by selectively increasing GME funding based on the nation’s needs particularly for primary care, we will hopefully decrease that applicant to residency position differential while increasing our physician workforce.
Are we entitled?
As talk transitions to increasing residency positions for certain medical specialties, this enhances a concern held by many medical students of not just whether they will match but whether they will match into the specialty of their choice. For example, Amy Ho, a fourth year medical student, expressed this concern in her Forbes article published this past April. In a rebuttal, Jack DePaolo, an MD/PhD candidate and Student Director of the National Resident Matching Program, bluntly stated that medical school graduates are not entitled to ‘the residency program, specialty, and/or geographic location of his/her choice, or to any kind of “dream job.”’
Ultimately, there is some truth in both of their arguments. Based on the competitive nature of medicine, there is no entitlement of a graduate to any of the specifics that Jack describes. Instead, it must be emphasized to medical students that their job is to serve where service is needed. If everyone was able to get the specific job they wanted, we would probably have a lot more neurosurgeons than we need and a lot less primary care physicians with a lot more regions of the United States that are underserved.
Since we do have a physician shortage, there must be an emphasis on optimizing the use of our physician workforce to maximize the benefit to the American people. That means increasing residency positions in areas of the country that are most in need especially rural areas as well as selectively increasing specialty positions in those areas based on their needs. With this emphasis on distributing our physician workforce (and residents) to best match the needs of the public, surely this does not guarantee every medical graduate the job that they dreamt of having as a medical student, but it does mean that those who do match will be best serving the country. It is important that medical students understand this as they decide where they will apply for residency and for what specialty.
That being said, perhaps “entitled” is too strong of a word, but one would hope that after four years of training to specifically become a doctor that one would actually be able to do just that. Nonetheless, in our current situation that is no guarantee. Instead, we are wasting time and money to train people as medical doctors who do not get to practice while we face a shortage of practicing physicians. This is by no means a fault of the Match system since the number of applicants exceeds the number of positions and all the system does is fill the existing positions. Instead blame lies on the inadequate number of residency positions that exist, which in turn shifts the focus to funding of GME.
I hope from this you’ve gained a better appreciation of where we currently stand with regards to Graduate Medical Education, why medical graduates are by no means entitled to their dream job, and some of what is being done to see that more medical graduates are at least able to get a job. No, not a job working as a security guard, a job working as a physician that they have spent years and hundreds of thousands of dollars to become.
This is an issue that is not just important to those of us who hope to some day match into a residency. GME is a public good and it benefits all of society. It trains more physicians that can care for the nation’s people. The government recognizes this and therefore is the largest contributor to GME. Nonetheless, with the federal deficit at an all time high, this fiscal environment poses a barrier to what we all know needs to be done. What we can do now is continue to advocate for an increase in GME positions and hope that the government will find a way to make it happen.