In today's medical culture, are we undervaluing physicians by tolerating the status quo? The status quo of rising medical school costs, poor mental health, mistreatment in residency, broken technologies, inflated administrative costs, etc?… We limit medical student postgraduate options to internship and residency, yet we graduate NPs and PAs to begin supervised practice with a starting average salary of $105,000.<1,2>(
https://paperpile.com/c/cfDTYD/nnQn+Rhob) Meanwhile, medical students graduate unable to practice medicine without an internship (that pays an average starting salary of $56K.)<3>(https://paperpile.com/c/cfDTYD/DW0u) I'm not arguing against physician extenders or residency. I'm arguing against the status quo in medicine.
To be licensed as a physician in most states, you must complete a year-long internship.<4>(https://paperpile.com/c/cfDTYD/GKZv) California is requiring multiple years of post-graduate training.<5>(https://paperpile.com/c/cfDTYD/KWbu) Our status quo provides no in-between licensure options for medical students, while we are simultaneously graduating NPs and PAs into supervised practice. In 26 states, NPs can practice autonomously in their field immediately.<6>(https://paperpile.com/c/cfDTYD/g0nU) Why are physicians that graduate from a US medical school and cannot match into a residency (for whatever reason) less able to practice medicine than NPs and PAs? Is it just the status quo?
Right now, of the medical student graduates who do not go to residency, some become scribes, MAs, and consultants. <7>(https://paperpile.com/c/cfDTYD/1zpK) Very few find research jobs, and even fewer gain a temporary license that allows them to practice at the level of a mid-level under the supervision of a physician like you can in Missouri.<8>(
https://paperpile.com/c/cfDTYD/JJ9P) So what are you, the physician, to do? The Flexner report of 1910 gave us the gold standard of medical training for the time,<9>(
https://paperpile.com/c/cfDTYD/qNBL) yet we act like no future improvements are needed today.<10>(https://paperpile.com/c/cfDTYD/6v56)
If you're like me, you have some changes in mind. I can list several improvements I'd like to see. First, rising school costs are trapping students.<11,12>(https://paperpile.com/c/cfDTYD/zFeu+P40u) Medical school graduates have, on average, $251,600 in debt these days.<13>(https://paperpile.com/c/cfDTYD/ggr7) The debt doesn't disappear, either, for those who cannot match into a residency. Medical schools are increasing tuition annually and federal loans accrue interest from the beginning.<14>(https://paperpile.com/c/cfDTYD/P50Q) Why do we allow interest to begin accruing so many years before employment is possible, and why do we pay so little?
Medical schools should aim to produce autonomous physicians, but not every graduate can achieve an internship. What are they supposed to do? Physicians should create a "supervision-required" midlevel-style license for medical school graduates that haven't completed an intern year. Otherwise, less painful routes to the top of medicine will continue to gain steam. Administrators need to fill gaps in their hospital systems with providers from somewhere, after all.
We have a physician shortage, despite an increasing number of medical schools and residencies.<15>(
16) In fact, the total number of residencies available has increased at the same rate as medical school enrollment.<17>(https://paperpile.com/c/cfDTYD/FMlm) However, in 2019 there were still 44,603 students competing for 35,185 PGY-1 spots.<18>(https://paperpile.com/c/cfDTYD/u0o7) You have a huge discrepancy between PCPs and subspecialists, so applicants are unevenly applying to the higher-paying fields. Also, IMGs are applying for US residency positions.
Then there is the status quo of mental health crises among trainees and other physicians. Still, physicians and students commit a substantial number of suicides every year.<19–23>(https://paperpile.com/c/cfDTYD/MMMm+XOXG+2G4w+VDdC+9f6k) That's not a fun fact. Perhaps you're like me and have known someone to take their own life. Medical training and practice are toxic because of the high stakes. There are board exams used as gatekeepers to certain competitive specialties. You are often sleep-deprived and stressed. Not to mention, if you are careless then someone dies (no pressure). Also, healthcare costs are skyrocketing due largely to administrative expansion.<24>(https://paperpile.com/c/cfDTYD/bwu3) Overall, there are fewer and fewer resources for physicians to utilize.<25>(https://paperpile.com/c/cfDTYD/HShL) It's a tough environment right now. We have to buck the status quo.
You can fix the illogical things we are doing in medicine, medical education, and healthcare policy without sacrificing quality. Where to start? Talk to each other. Share your goals, struggles, and challenges. Join together. Drop the poisonous attitudes, the fights, and the competition. Smell the roses. It just takes some common sense, optimism, and compromise. It takes all of us.
Physicians need to get more active in politics. Policymakers aren't going to require changes without pressure from a coordinated movement by you, the physicians. For example, we have 1,100+ EHR vendors, in 2020, that cannot communicate data between each other. That is the status quo. However, if forced to do it, I argue EHRs could share data. How? If policymakers mandated some standard changes to the requirements for all EHRs. We would need to mandate the creation of a unique identifier that all healthcare providers use to find common patients, a mapping between coding languages, and a system to distribute stored data storage between systems.<26–28>(https://paperpile.com/c/cfDTYD/LV9u+oIpW+20oA)
Today, I'm hoping to encourage all of you to remember your leadership roles in the hospital, the community, and beyond to seek progress. Physicians need to acknowledge this responsibility before things worsen. If we can do that, we don't have to worry about anything. The problem is, there are very few physicians with enough of a spine to stand up to the status quo. Perhaps you're discouraged, isolated, and overworked. You're not alone. We are waiting for others to fix medicine, but it's got to be us. It's got to be the physicians.
The status quo has got to go. How will you stand up to it?
Nurse Practitioner (NP) Salary Data | All Nursing Schools. All Nursing Schools https://www.allnursingschools.com/nurse-practitioner/salary/.
California Physician Professional Licensing Guide – Upwardly Global. Upwardly Global https://www.upwardlyglobal.org/get-hired/california-professional-licensing-guides/california-physician-professional-licensing-guide/.
Duffy, T. P. The Flexner Report–100 years later. Yale J. Biol. Med. 84, 269–276 (2011).
U.S. medical school enrollment rises 30% | AAMC. AAMC https://www.aamc.org/news-insights/us-medical-school-enrollment-rises-30.
Is your physician colleague at risk for suicide? Signs to look for. American Medical Association https://www.ama-assn.org/practice-management/physician-health/your-physician-colleague-risk-suicide-signs-look.
Knowles, M. Patients likely to suffer when EHR systems can’t talk to each other, researcher says. https://www.beckershospitalreview.com/quality/patients-likely-to-suffer-when-ehr-systems-can-t-talk-to-each-other-researcher-says.html.
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