Tuesday, December 5, 2017

Chronic shortage of training sites worries medical schools

The Association of American Medical Colleges (AAMC) says many of its members are worried about a shortage of training sites for students and residents.

The AAMC’s 2016 Medical School Enrollment Survey found that 80% of schools were concerned about the number of available clinical training sites. There were also issues with the numbers of primary care and specialty preceptors.

The graphic below shows that these problems are not new, but in general seem to be worsening. [Click on the figure to enlarge it.]

The situation is exacerbated by increasing competition for clinical sites from osteopathic schools, offshore medical schools, and nurse practitioner and physician assistant schools.

Most of the offshore schools pay hospitals for training their students, but 64% of AAMC schools pay nothing for clinical rotations. I blogged about this in 2012.

Twenty-two new MD and 13 new DO medical schools have opened since 2002, and nearly all other medical schools have expanded their class sizes because of what many predict is an impending shortage of physicians.

In the 2017 match, 43,157 applicants applied for 27,860 PGY-1 positions. In 2016, there were 21,030 first-year students enrolled in MD schools and 7369 first-year DO students which equals 28,399 combined. This means that by 2020, the supply of US graduates will exceed the number of currently available positions.

This is worrying US medical schools who so far have not been significantly affected by the problem of graduates not being able to find residency positions.

In 2014, I wrote about the false assumption that new surgery residency programs will simply materialize to accommodate the growing numbers of applicants. I felt there were not large numbers of community hospital surgeons who were dying to have residents around. I still believe this is true.

I said, “I find it hard to believe that a hospital that has previously not had a residency program and has private practice surgeons who do nothing but operate can turn itself into a setting where surgical education is important.

“Who is going to let the residents operate? Who will give didactic lectures? Who will write the research papers that are required by the RRC to prove that the faculty engages in scholarly activity?”

Established surgery programs are expanding their resident rosters while some educators continue to publish research saying residents are not doing enough surgery to be able to operate independently after graduating from training. Where are the additional cases going to come from?

The AAMC says it has a five-year plan to optimize graduate medical education in the US with “three strategic areas of this initiative: investing in future physicians; optimizing the environment for learning, care, and discovery; and preparing the physician and physician-scientist for the 21st century.”

It all sounds lovely, but somewhat vague. Crunch time is coming soon.


artiger said...

Our friend Jack should be weighing in at any moment.

Seriously, if I had a magic wand (and an unlimited supply of cash), I'd extend general surgery residency to 6 years. Duty hour limits could remain in place and would be easier to manage with extra bodies, and residents would have an extra year to accumulate case experience.

Of course, I have neither the wand nor the cash.

Just a thought said...

Why add just one year why not two?

Really we need to address the real issues occurring in training, if residents don’t learn in 5 why would they learn in six. I just recently graduated from residency and several programs that I looked at did not even let their intern in the OR and some even waited until there 3 year to really start operating any real sort of case typical of a general surgeon. Instead of just doing scut, why not have the doctor be trained.
Again just a thought!

Anonymous said...

Artiger would you drop fellowships if you did 6 yrs general?

artiger said...

Just--Back in the early 90's, when I was shopping for a residency, I had heard stories of exactly what you were talking about at some of the major academic programs. It was exactly what you described in the present day...first years did scut work, lots of H&P's, etc. Second years handled ICU and didn't leave the hospital for a few months at a time, and so forth. I never knew if they were just horror stories or if they were really true, but maybe things haven't changed as much as we think (that was not my experience, which was divided between both community and academic programs). No matter, it's not a matter of being able to "learn" with the additional year. An additional year of operating experience would go a long way (see my last paragraph).

Anon 1054--No. If someone wanted to do plastics, hearts, or other specialized surgical training, I think the fellowships need to remain in place, but perhaps the general surgical residency could be shortened a bit to fast track people into their respective fields of interest.

Another thought I had would be making the 6th year a hybrid between a "chief resident" and a "rookie attending" (for lack of a better term). Given the 6th year resident privileges to operate without direct supervision, but have an established attending (or attendings) to sign off on cases, be available for help, etc. The sixth year resident would be allowed to bill third party payors but the proceeds would go toward his/her salary, with any excess staying in the institution.

Skeptical Scalpel said...

Artiger, I wrote this post partly to rebut Jack's argument that there should be more residency programs. I don't think many more hospitals are capable of starting residency programs or accepting rotators from existing programs.

Extending the length of surgical training from 5 to 6 years is not a good idea. Surgical residency is too long already. The ABS has recognized this and is developing ways to shorten the pathways to many subspecialties.

We have to start making training more efficient. And we need to find a way to give residents more autonomy so they can operate independently as soon as they graduate. I've blogged about this before.

artiger said...

Points noted. The case for creating more residency programs at community hospitals and even rural facilities, I think that has a place in primary care. Not so sure elsewhere.

When I mentioned extending surgery residency, I meant for those intending to go into general surgery practice, not subspecialties. I agree that surgery residency is too long; I did it too. The point I made in my last paragraph is to maybe create a hybrid type position for the additional year, with not only autonomy but also at a higher salary, say, 100K or so.

My first job in the late 1990's was with a medium sized group at a large hospital in an urban area; the setup was to start in an employed position, but to share call, caseload, etc just as a partner. Starting salary was 72K. It was considered a privilege to be invited to work there. Although I only stayed there for a little over a year, I will say that having half a dozen or senior colleagues to help in what was a high volume practice served me very well when I left to go all alone in my current solo rural setting. In a sense, that year or so was just what I was proposing for today's residents, just at the end of their five year residency and at their current program.

Skeptical Scalpel said...

You mean like a "Transition to Practice" fellowship (now called a "program")? That was tried by the American College of Surgeons a few years ago. I haven't heard anything about it lately. I blogged about it in 2013.

Does it still exist?

Skeptical Scalpel said...

Here's the link to that Transition to practice post http://skepticalscalpel.blogspot.com/2013/04/what-american-college-of-surgeons.html

Just a thought said...

Artiger -

I see your point with the transition and I think it sounds good in theory, but it would just mean that institutions would have an extra worker for a year that they really don’t have to pay. I bet in 5 years from starting this you would just have an extra year of scut and lose what I see your trying to do.

The real issue is autonomy, it is harder than ever to give residents autonomy. My example is I trained at a community program and my attendings did give me autonomy. It started by leaving the case early or just not scrubbing straight forward cases and hang out on the room. Then it graduated to them being out of the room. I also rotated to other ivory tower sort of places and all but one did I ever see the attending not scrubbed in the whole case. When could you learn autonomy?

We need another culture shift!

artiger said...

I think the transition to practice idea was a good one, but I'm just not sure the execution was ideal. More autonomy with the ability to bill but yet some senior oversight, and making it mandatory for the regular general surgeon before going out to the private world is how I'd do it. No one in authority has asked me for my opinion just yet.

Anonymous said...

Medical Schools should include one-year internship that satisfies most of the state medical boards for licensure before granting MD or DO. In doing so, and instead of leaving their graduates to the mercy of federal fund which may or may not be available, they extend a safety net to their graduates so that they at least can practice general medicine in case of federal fund is not available for residency. In addition, that would reduce the demand on residency because some graduates choose to practice at least temporarily before doing specialty, if any.
I think that the AAMC and AACOM can help in transitioning their members into that instead of keeping their addiction on federal funds. The AAMC and AACOM can't claim their private entity status or independence and depend on socialist program, namely medicare funding, to finance the mentioned internship, to say the least. The LCME and the states can through accreditation or licensing use leverage on medical schools to do that. If a medical school doesn't comply with that the state should revoke its license to be a medical school. That's why we believe that the states are in a better position than the federal government or the hospitals to manage the federal funds for the GME. In this way, for instance, we avoid a scenario in which a hospital would create a new residency program that serves its financial interest but not the need of the state and its population.

Skeptical Scalpel said...

A readre informed me the transition to practice program still exists. I do not know how many people have entered it.

Regarding schools including a one-year internship, who would pay for it and where would those who enroll go for this training? The post you commented on is about an existing chronic shortage of training sites.

Anonymous said...

"If you can't stand the heat, get out of the kitchen.", president Harry Truman.
It is common practice nowadays that business leaders meet with university officials to convey to them the need for modification in preparing the students for the workplace.
Medical Schools are lagging behind in this regard. They should have gotten the message a century ago. In 1913, Pennsylvania was the first state to require a one-year rotating internship after gradu-
ation from medical school as a prerequisite for physician licensure, other states followed suit.
Medical Schools should adjust to that. In particular, new or prospective medical schools should demonstrate that they include one-year internship before they can get licenses. If they can't afford that they shouldn't get into the business. That would establish an important balance that the medical school has the responsibility to secure one-year internship necessary for its graduates to enter the workforce. Otherwise, the medical school should not open at all. Current medical schools should be given reasonable time to adjust. Medical Schools have to be creative in securing that and in managing their way to finance it. They may contract with hospitals or their universities may already have hospitals and so on. When states require medical schools to include one-year internship for licensing the schools, the schools will find the money and subsequently the training sites, if they can't they should get out of business.

artiger said...

Anon, I too would like to see one-year internships for all med school graduates, and I have mentioned it before here (perhaps enough times to annoy Scalpel). However, giving such control to each of the 50 states and various territories would allow politics to enter into the fray (just look at how much difference we have between red, blue, and "purple" states already), which I can't see as healthy. This would be especially true as the U.S becomes more and more mobile. There is already a wide variation in all of our states' medical boards. If anything, medical training (and practice) needs more uniformity; otherwise, we start down a slippery slope of wide variations in standard of care across state lines.

Anonymous said...

Artiger, thank you for your comment. I guess we both agree on many things including Scalpel being annoyed. But seriously, I do share your concerns about the uniformity of medical training and practice and that's why I mentioned in a previous comment that the AAMC and AACOM can help in transitioning their members meaning voluntarily. Also, I mentioned that the LCME (The Liaison Committee on Medical Education) and the states can through accreditation or licensing use leverage on medical schools to do that. Yes, I prefer that they do it voluntarily and I leave the state as last resort even then, the mandate by the state and the mentioned uniformity are not necessarily mutually exclusive because state officials are professional and responsible people too. Lastly, regardless of the way it is done, the mentioned uniformity should not be compromised.

artiger said...

Just to be clear, my comment about annoying Scalpel was made in fun.

Skeptical Scalpel said...

I'm not annoyed. I appreciate the discussion.

State medical boards can't even agree about licensing. Just as there will never be a nationwide medical license [http://skepticalscalpel.blogspot.com/2014/02/universal-medical-licensing-for.html], your dreams about a one-year internship as a part of medical school will not come true.

Anonymous said...

That's true about the internship as long as they are allowed to abuse the entitlement program.

Anonymous said...

One solution to the problem is to increase access for residents to private practice settings and outpatient surgical centers as part of their training. This issue was recently addressed in psychiatry - https://www.fairfaxmentalhealth.com/news/2017/11/13/a-solution-for-fixing-healthcare.

Skeptical Scalpel said...

As I said in the post, assuming hundreds or thousands of practitioners are wishing they had residents to slow them down in their offices is a plan that has not been validated. I would bet that a poll of those physicians would find I am correct.

Anonymous said...

“Twenty-two new MD and 13 new DO medical schools have opened since 2002, and nearly all other medical schools have expanded their class sizes because of what many predict is an impending shortage of physicians.”

Each medical student is a $30k-50k annual revenue stream for a medical school’s operating budget. My 4th year med student moved home this year to be able to save enough money to do away rotations in surgery and fund 17 separate interview trips, hotel stays and food, all while paying tuition. She was told by her residency program director to interview at a minimum of 15 sites to maximize her liklihood of matching.

Skeptical Scalpel said...

Regarding the tuition, you will note that many students spend portions of their third years and large portions of their fourth years away from the medical school base hospital. I have blogged about where that money goes or doesn't go [http://skepticalscalpel.blogspot.com/2012/04/medical-school-tuition-follow-money.html].

At least 15 interviews seems to be the standard recommendation these days. Good luck to your daughter.

Anonymous said...

I am a Urology intern at a program that I believe will give me adequate surgical training. But I also expecting to have many job options and expect choosing wisely will be important. I don’t see why choosing a practice with a few other more experienced surgeons cannot suffice. I imagine scheduling a case I have less experienced with on a day I know I will have partners to call on if I get stuck, have a question, etc. As a sub-I I saw a very experienced surgeon in a tough open pelvic case do just that. I was shoved aside but learned a lot by seeing the two partners problem solve together. The case case off without a hitch. Isn’t this a realistic expectation? I certainly hope so. Don’t see why mentorship needs to end with graduation. If I don’t have that experience I will then plan on a one-Year fellowship as a fall-back.

Skeptical Scalpel said...

Your plan sounds good to me. Good luck.

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