A Case Study! Unmatched US Doctors!

The “Doctor Shortage” is not a “Doctor shortage.”  It is a residency shortage.  The Balanced Budget Act of 1997 (BBA) limited the number of allopathic and osteopathic medical residents that would be counted for purposes of calculating Medicare indirect medical education (IME) and direct graduate medical education (DGME) reimbursement to the unweighted number on each hospital’s most recent cost report as of December 31, 1996 (BBA Section 4621). Effective October 1, 1997, to the extent the number of allopathic or osteopathic residents being trained at a teaching hospital exceeds the 1996 limit, teaching hospitals receive no additional IME or DGME payments; podiatry and dental residents are excluded from the resident limits.  The ACGME and AOA are merging in 2020 which will make the residency program worse.  On average there are 44 AOA programs closing.  Only 70% of the AOA programs received ACMGE accreditation.  

Medical school graduates cannot work without completing residency. Many people are using this to profit and putting the public at risk.  Medical schools have increased class sizes to combat the doctor shortage.  Nurse practitioner (NP)and Physician Assistant (PA) schools have increased class sizes to combat the Doctor shortage.  Other fields such as NP, midwives, PA, Certified Registered Nurse Anesthetists (CRNAs), Naturopathic doctor (ND), pharmacist and psychologist have all been pushing for unsupervised practices or prescribing authority.  Foreign born graduated are also capitalizing on the doctor shortage.  

When medical schools increase class sizes they prey on students.  Medical schools are not helping the students get into residency so they can find jobs and pay back the debt.  The medical schools increase class sizes, get federal funding or take money from the students.  The schools know that there is not a doctor shortage but a residency shortage, however, the general public does not.  By the time students are finished paying off their loans, they’ve typically shelled out over $400,000.  That is if they get into residency and start working.  This is not the case anymore.  Students now have $400,000 in student loans that is usually 10% interest. These medical school graduates have no quality of life.  They can not buy houses with this amount of debt.  The jobs that these graduates can get are non-healthcare related.  Making the Average income in 2017 nominal median income per capita was $31,786. The mean income per capita was $48,150. The Census Bureau reports those in the Current Population Survey, Table PINC-01. Real median household income was $61,372.  There is no way to pay this debt off.  The loan forgiveness doesn’t help much either.  

The problem with NP’s and PA’s increasing class sizes and becoming unsupervised are training differences. The minimum schooling for a doctor takes 4 years of undergrad followed by 4 years of medical school plus an additional 3 years of residency at the bare minimum.  That is a total of 11 years.   Medical school education and residency is not shortened.  As for exams you have the MCAT which is 8 hours just to get into school.  Once in school you have 3 Step examinations. Step 1 is 9 hours, step 2 ck 9 hours and step 2 cs 8 hours, step 3 being 16 hours encompassing 2 days.   Last exam is board certification which is 9 hours. Total exam time is 59 hours.

For an NP you can get an accelerated BSN in 33 months. Vanderbilt has a year NP program which is 12 months so someone could become an NP in as little as 45 months.  The NCLEX is a 6-hour exam.  To be an NP you have an option of 2 exams ANCC and AANP.  The ANCC is 4 hours.  The AANP exam is 3 hours.  Total exam hours are 9 Minimum.

The online NP schools are “rigorous” again I think that depends on how hard your life has been.  Majority of NP students work in conjunction with school.  It is almost impossible to work in medical school because it is so “rigorous.”  Doctors do a minimum of 9 year of school with 59 hours of exams with a minimum of 15,000 hours of clinical training. NP’s complete a minimum of 45-month of school, 9 hours of exams and 500 clinical hours.  You would have to increase the clinical hours by almost 30-fold in order to rival the “rigorous” training that doctors have to complete at a minimum.   

The other issue is that Doctors and nurses do not learn “the same sciences” doesn’t mean learning things to the same level. Pharmacists learn more pharm than doctors do, but both study “pharm.” PhD basic science profs teach doctors Cell Bio and Immunology, so doctors and PhD learn the “same sciences” but a PhD in the subject is learning those subjects at a much greater depth. Likewise, nurses learn pharm and physiology, but not at the same level. Not an insult to say this because this is by design as nurses and doctors don’t have the same roles. Nurses are trained on nursing theory which is not medicine, but they want to practice medicine?

As for a CRNA, on average, a nurse anesthetist program can last between 24 and 36 months–not including the 4 years of BSN training and at least one year of work experience prior. But with the right strategy and perseverance, you can bypass at least 2 years and still become a certified nurse anesthetist.

To become a midwife you’ll need a degree in midwifery, which takes three years to complete. If you’re already a registered adult nurse, you can undertake a shorter course instead, which takes 18 months.

Various mainstream media outlets have the assertion that these immigration restrictions would adversely impact our healthcare system, by making it more difficult for foreign-born medical

The online NP schools are “rigorous” again I think that depends on how hard your life has been.  Majority of NP students work in conjunction with school.  It is almost impossible to work in medical school because it is so “rigorous.”  Doctors do a minimum of 9 year of school with 59 hours of exams with a minimum of 15,000 hours of clinical training. NP’s complete a minimum of 45-month of school, 9 hours of exams and 500 clinical hours.  You would have to increase the clinical hours by almost 30-fold in order to rival the “rigorous” training that doctors have to complete at a minimum.   

The other issue is that Doctors and nurses do not learn “the same sciences” doesn’t mean learning things to the same level. Pharmacists learn more pharm than doctors do, but both study “pharm.” PhD basic science profs teach doctors Cell Bio and Immunology, so doctors and PhD learn the “same sciences” but a PhD in the subject is learning those subjects at a much greater depth. Likewise, nurses learn pharm and physiology, but not at the same level. Not an insult to say this because this is by design as nurses and doctors don’t have the same roles. Nurses are trained on nursing theory which is not medicine, but they want to practice medicine?

As for a CRNA, on average, a nurse anesthetist program can last between 24 and 36 months–not including the 4 years of BSN training and at least one year of work experience prior. But with the right strategy and perseverance, you can bypass at least 2 years and still become a certified nurse anesthetist.

To become a midwife you’ll need a degree in midwifery, which takes three years to complete. If you’re already a registered adult nurse, you can undertake a shorter course instead, which takes 18 months.

Various mainstream media outlets have the assertion that these immigration restrictions would adversely impact our healthcare system, by making it more difficult for foreign-born medical graduates to be accepted to residency training in our country, leaving many residency spots unfilled and worsening our current national physician shortage.

This assertion, however, is false.  In fact, we have a minimum of 3,000 U.S.-citizen medical school graduates who have not been able to gain employment for several years. The National Resident Matching Program (NRMP), the system through which United States and international medical school graduates obtain residency positions in U.S.-accredited training programs, announced the results of the 2019 Main Residency Match (referred hereinafter and colloquially as “the Match”) as the largest application pool on record, encompassing 44,603 registered applicants and 35,185 positions.  Among US allopathic (MD) medical school graduates, there were 18,925 seniors who applied for 32,194 first year post-graduate training (PGY-1) positions.   Of those, 18,925 applicants submitted program choices and 17,763 matched to first-year positions, leaving a pool of 1,162 applicants who did not match into residency. U.S. osteopathic medical school students and graduates 6,001 only 5,076 (84.6%) matched leaving 925 unmatched. 

Out of the 5,080 U.S. citizen international medical school graduates (USIMG’s) who submitted program preferences, 2,997 (59%) applicants were matched to first-year positions leaving 2,083 USIMG’s unemployed. NRMP reported that the number of non-U.S. citizen IMGs increased to 7,460 applicants.  Of the 6,869 IMG participants who were not U.S. citizens, 4,028 (58.6%) matched (ECFMG).

Let’s do the math with the numbers we were given, even though those numbers do not accurately account for applicants who apply to residency positions solely using ERAS, which are the real application pool.  We have a total of 32,194 first-year residency spots. If we matched every AMG (American medical graduate); 18,925 and 6,001 D.O. graduates (Doctor of Osteopathic Medicine), that would leave 7,286 open positions.  If 5,080 USIMGs matched, 2,188 unfilled positions would still be available. However, this probably is not the case since many more applicants who are U.S. citizens and non- U.S. citizens IMGs apply to residency and do not receive interviews.   Since 2010 an average of 11,000 applicants went unmatched from year to year.  Considering that a majority of those applicants will not be able to match in subsequent years it reasonable to estimate that roughly 110,000 doctors are unemployed half of which are US graduated or US citizens.

The real numbers can be calculated through ERAS.  The Electronic Residency Application Service, abbreviated ERAS, is a service of the Association of American Medical Colleges (AAMC) through which M.D. and D.O. graduates of medical schools apply to residency and fellowship programs in the United States. It transmits applications, letters of recommendation (LoRs), Medical Student Performance Evaluations (MSPEs), medical school transcripts, USMLE transcripts, COMLEX transcripts, and other supporting credentials from applicants and their designated dean’s office to residency program directors. This is where students apply to post graduate residency training programs and receive interviews. 

Keep in mind that the percentages reported in the NRMP do not account for applicants that did not submit their rank order list, which would exclude applicants that pre-match (not using the NRMP to rank programs and are offered a “pre-match” contract), applicants who did not receive interviews invitations and applicants who felt hopeless. It is not uncommon for an IMG not to be offered interviews, resulting in zero invitations and an empty rank list, thus NRMP’s IMG match rate is not accurate.  In order to look at the true number of U.S. citizens that apply for residency we need to look at ERAS. (The number of tokens that were issued for all applicants, intended to fill PGY-1 resident positions.)  When I chatted with an ERAS/ECFMG representative, I inquired about the number of applicants who have applied for PGY-1 positions, they quoted “around 40,000”. I then asked for an exact number and he redirected me to the NRMP.  Logically, I replied that the number he quoted could not be correct because the number (40,000) does not account for the total number of applicants who apply to residency PGY-1 positions.  I then asked how many IMGs are apply to PGY1 positions, and he responded, “around 19,000.”  I proceeded to ask, how many of the 19,000 are non-US citizens?  He would not provide that information and stated, “no one has that data.”  

Using the numbers quoted by the ECFMG representative, about 21,000 U.S. grads apply for residency positions. So, there are about 2,813 U.S. grads that go unmatched and do not apply to the NRMP. Therefore, the USA does not need to outsource U.S. residency positions.

According to the AMA (American Medical Association), there are about 280,000 international medical graduates currently practicing in the United States. That’s about 1 in 4 physicians practicing medicine in the U.S. Some are U.S. citizens who’ve gone abroad for medical school, but most are not.  Even residency programs who have foreign program directors in leadership, have started to discriminate against U.S. citizens.  Many residency programs no longer update residency profiles online and have even failed to post a pictorial roster of their current graduates with medical school stats. 

For example, let’s look at information posted on several residency training programs. We can clearly assume that most of the residents training at Hurley Medical Center/Michigan State University Program in Flint, Michigan are foreign trained, non- U.S. citizens. The program director Ghassan I Bachuwa MD, MS, MHSA coincidentally is also foreign born and trained. In Grand Rapids Michigan, the internal medicine residency program has a soft spot for King Edward’s School in Pakistan possibly because of Dr. Nasir Khan’s background as a Pakistani graduate. Central Michigan University emergency medicine reserve positions for only Saudi Arabia applicants, not even an AMG could fill those residency positions.  Cleveland clinic internal medicine residency does not publicly publish a list of their trainees. The program, however, has posted information about their AMG house staff. Texas Tech University Health Science Center neurology residency, appears to hire only non-us citizens and not one resident

appears to be an AMG. Interfaith Medical Center in Brooklyn, N.Y.has also failed to post their residency profiles publicly, possibly because there are non-US citizens.  Many programs in Ohio, Michigan, Texas, and New York all favor foreign national IMGs over US citizen IMGs and AMGs. 

Clearly, the system is corrupt.  The Match and program directors who rank applicants, favor an applicant’s board scores. In-fact, when applying for residency training positions, minimum score requirements are posted publicly, through application materials and rank lists are based on “preference.”  However, the general population including program directors are not aware that the USMLE (U.S. medical licensing exam) Step 1 and Step 2CK (clinical knowledge) can be taken anywhere in the world.  For example, why would India or Pakistan care about enforcing fair and accurate exams for the USMLE? Their economy depends on their citizens immigrating to the U.S. and earning a $200,000 to $1,000,000 USD salary occupation. It is not uncommon for residents and physicians to send portions of their salary back to their country of origin to support their families. Some even plan for relocation and retirement, without actual investments in American society.  India’s system along with many other foreign countries have become notorious for inadequately training doctors. (BBC)(Bennett). It is plagued by rampant fraud and unprofessional teaching practices, exacerbating the public health challenge. These ramifications spread beyond the country’s borders: India is the world’s largest exporter of doctors, with about 47,000 physicians currently practicing in the U.S. and about 25,000 physicians in the United Kingdom (MacAskill, Stecklow, and Miglani).   About 45 percent of India’s population who practice medicine have no formal training, according to the Indian Medical Association. These 700,000 unqualified doctors have been found practicing at some of India’s biggest hospitals, giving diagnoses, prescribing medicines and even conducting surgery (MacAskill, Stecklow, and Miglani).

According to ECFMG.org , you can sit for the USMLE Step 1 and Step 2CK anywhere in the world. U.S. hospitals and program directors are unaware whether the same biometric security used to administer these exams are congruent to U.S. standards. The following is a list of countries that administer these tests without any U.S. oversight of their identification security methods: 

Africa: Ghana, Kenya, South Africa, and Uganda

Asia: Bangladesh, Malaysia, Nepal, Pakistan, People’s Republic of China, Philippines, and Singapore

Australia: Australia and New Zealand

China: People’s Republic of China

Europe: Armenia, Croatia, Denmark, France, Germany, Greece, Ireland, Israel, Italy, Latvia, Netherlands, Portugal, Spain, Switzerland, Turkey, and the United Kingdom.

India: India

Indonesia: Indonesia

Japan: Japan

Korea: Korea

Latin America: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Dominican Republic, Guatemala, Mexico, Peru, Trinidad and Tobago, and Venezuela

Middle East: Egypt, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, and United Arab Emirates

Taiwan: Taiwan

Thailand: Thailand

In reflection, the lack of a system of strict regulation and standardization for an exam that holds such a high level of importance for residency admission is rather alarming to say the least.  Take the recent 10-year statistics for mean Step 1 scores.  The mean step 1 score in 2009 was 221.  In 2019 the mean step 1 score is 232.  The scores started to have a huge jump after 2009.  During that same time frame Step 2 scores have risen from 226 to 247- a tremendous increase.  While Step 3 which can only be taken in the United States the averages have remained largely unchanged around 216.  Additionally, there are many anecdotal cases of foreign-born IMG scoring outrageously high on both Step 1 and Step 2 CK with sub-par Step 3 scores. Most recent average reported at 205 a sharp contrast to the mean Step 1 score of 234 for those same foreign IMG’s.  Now is something amiss here or is there a more nefarious process at hand that may warrant further scrutiny and a thorough investigation to ensure that the test is taken fairly across all areas of administration.

Another disadvantage to U.S. IMGs not acquiring residency positions or being “unmatched” is student loan debt. The average student debt for a medical school graduate in 2018 was more than $192,000. 21% of graduates had debt totaling more than $300,000. The average four-year cost for public school students is $243,902. For private school students, the cost is $322,767.  Thus, when U.S. citizens go unmatched, they are unemployed without jobs and without salary to repay these debts.   Many have multiple degrees and many medical graduates will default on student loans, which affects our economy.  Their years of education wasted, because, to be frank, where else can you utilize your medical degree without resident training to actually practice medicine? The answer is, nowhere. The truth is, many medical school graduates find mediocre jobs assuming some financial responsibility unrelated to their degree. The other problem with matching non-U.S. citizens over U.S. citizens is that they usually go to medical school for free.  They have no debt. They fill U.S. residency positions, train and return to their home countries.   There is residency fraud going on from bribing hospital CEOs to hiring someone who has better English/ interviewing skills to do the interview for the foreign graduate.  The programs have admitted they have never seen some of the people who show up on match day.

In conclusion, U.S. citizens are being discriminated against in their own country. Non-U.S. citizens immigrate to the U.S., become head of their departments favoring and supporting foreign born medical school graduates.   The foreign-born medical students have an advantage over U.S. citizens because the USMLE allows them to take OUR medical boards in their home county where there are no standards.  The program directors are usually foreign born and have a bias to accept other foreign naturals.  The USMLE, ERAS, NRMP, USMLE, AMA, AAMC are withholding data that reflects our broken system, protecting foreign born doctors and hurting U.S.-citizen doctors and patients.  The Medical schools, NP, PA, Certified Registered Nurse Anesthetists (CRNAs), Naturopathic doctor (ND), pharmacist and psychologist have all capitalized on this residency shortage.  We have doctors who are unemployed who can not get jobs in any field while other fields, some who have zero medical training are getting to be doctors.  This will hurt America and the public.   

Steps to be taken.  Stop foreign born doctors from taking American residency spots.  Increase funding for residencies and terminate the Balanced Budget Act of 1997 (BBA).  Allow medical school graduated to become licensed out of medical school.   Make a federal law to prohibit anyone who is not a doctor to get doctor privileges.  Increase standards on NPs.  

CITATIONS:

BBC. “Vyapam: India’s Deadly Medical School Exam Scandal.” BBC India. BBC News, 8 July 2015. Web. 28 Feb. 2017.http://www.bbc.com/news/world-asia-india-33421572

MacAskill, Andrew, Steve Stecklow, and Sanjeev Miglani. Special report: Why India’s medical schools are plagued with fraud. Reuters, 17 June 2015. Web. 28 Feb. 2017. http://www.reuters.com/article/us-india-medicine-education-specialrepor-idUSKBN0OW1NM20150617

(MacAskill, Stecklow, and Miglani)

Bennett. Proxy examinees caught taking US college entry test. The Times of India, 17 Jan. 2016. Web. 28 Feb.2017.http://timesofindia.indiatimes.com/city/ahmedabad/Proxy-examinees-caught-taking-US-college-entry-test/articleshow/19551486.cms

(Bennett)

“Testing regions and international test delivery surcharges for USMLE step 1 and step 2 CK.” n.d. Web. 28 Feb. 2017.http://www.ecfmg.org/fees/usmle-surcharge.html

(“Testing Regions and International Test Delivery Surcharges for USMLE Step 1 and Step 2 CK”)

NRMP Program, National Resident Matching. Learn more. 2002. Web. 28 Feb. 2017. http://www.nrmp.org/match-data/main-residency-match-data/

(NRMP Program)

ECFMG. “IMG performance in the 2016 match – ECFMG news.” 2016 Match. ECFMG News, 30 Mar. 2016. Web. 28 Feb. 2017.http://www.ecfmg.org/news/2016/03/30/img-performance-2016-match/

(ECFMG)

http://www.nrmp.org/wp-content/uploads/2016/04/Main-Match-Results-and-Data-2016.pdf

http://www.ecfmg.org/forms/factcard.pdf

“United States medical licensing examination.” n.d. Web. 28 Feb. 2017. Performance Data”http://www.usmle.org/performance-data/default.aspx#2015_step-3

(“United States Medical Licensing Examination”)

“United States medical licensing examination.” n.d. Web. 28 Feb. 2017. Performance Data”http://www.usmle.org/performance-data/default.aspx#2015_step-3

(“United States Medical Licensing Examination”)

AAMC news “7 ways to reduce medical school debt” https://news.aamc.org/medical-education/article/7-ways-reduce-medical-school-debt/

https://www.cheatsheet.com/money-career/how-much-does-med-school-really-cost.html/

Average Income in the USA by Family and Household  https://www.thebalance.com/what-is-average-income-in-usa-family-household-history-3306189

Medicare Resident Limits (“Caps”)

https://www.aamc.org/advocacy/gme/71178/gme_gme0012.html