What is the value of an unmatched US-trained medical school graduate?
Apparently, not enough to change our system's handling of them. Our society's idea of what it means to graduate medical school has propelled a well-intentioned movement towards further postgraduate training opportunities, rather than alternatives to it. The
2018 GAO report on graduate medical education funding reiterates its recommendations from 2015 that federal agencies need to gather more information before funding increases.1 The followup 2019 GAO report discusses diverting Medicare GME funding from medical residents to NPs and PAs, noting that “expanding the scope of the Medicare GME program to include NPs and PAs could help mitigate the effects of a physician shortage.” Others responded that such a move would negatively impact the available funding for physician training.2
Since 1998, the number of Medicare-funded residency positions has been frozen at 1996 levels. The 2019 Resident Physician Shortage Reduction Act of 2019 (S. 348/H.R. 1763) would add 15,000 Medicare-funded residency positions over five years. Its purpose is to alleviate physician shortages that threaten patients' access to care.3,4 Ideally, all physicians would receive residency training. Until that is feasible, what about giving new physicians without residency training a separate title (such as "Assistant Physician"), and permitting them to practice under the same restrictions as a PA? I doubt this would take that many jobs away from PAs. It might actually help address the primary care shortage.
When we decided to require a high-stakes selection process for postgraduate medical training and then subsequently permit the creation of NPs and PAs to replace the “general practitioner”, we purposely excluded physicians without postgraduate training from that level of care. Perhaps funneling new physicians towards residency keeps physician reimbursement high.5,6 Does it reduce medical errors in primary care, or just reduce competition? Is it ethical to require postgraduate training of medical students in a system that also permits NPs and PAs to practice?7 The US GAO report stated an intention to increase GME funding to expand residency spots, but we aren’t there yet.
Originally, most postgraduate medical education in the United States was accomplished using the mentor system. Then, in the late 1800s, a push began for more highly trained surgeons and other specialists. This led states to formally begin licensing physicians through state medical boards.8,9 Residency programs began shortly thereafter, in the late 19th century, as opportunities for advanced training. By the early 20th century, only a minority of primary care physicians participated in residency training. By the end of the 20th century, very few new doctors did not. Today, medical school graduates cannot proceed directly from medical school into independent, unsupervised medical practice because state and provincial governments require one or more years of postgraduate training before medical licensure.10–13
Proponents of residency training correctly point out that more supervised practice increases mastery, overall skill, and patient safety. This is an often-cited reason why residency is required for all physician specialty board certifications.14 Opponents question whether residency training restricts patients’ access to primary care. They cite the scope of practice of nurse practitioners and physician assistants. Many ask, “why are medical school graduates excluded from that role as an option?”15,16 It makes sense, then, that many residents report dissatisfaction and burnout during training. If postgraduate training were not a requirement, but rather an opportunity, would there be as much disrespect, poor pay, crushing work schedules, and lack of autonomy for those who chose it?17–20
Either way, postgraduate training doesn’t completely ensure competency to practice medicine.21–23 No such post-graduate requirement exists for pharmacists,24 veterinarians,25 dentists,26 PAs,27 nurses,28 CRNAs,29 CNMs,30 NPs,31 PTs,32 RTs,33 or LCSWs34 – although the option for postgraduate training exists and is beneficial for those who pursue it. The professions that most commonly require postgraduate training include most psychologists35,36 and podiatrists.37 Various postgraduate training programs are options for NPs and PAs, but none are officially required.38,39
The US healthcare system praises the contributions of nurse practitioners and physician assistants for meeting the primary care needs, yet does not provide alternatives for medical school graduates other than residency.40 Some states provide a temporary certification as an “Assistant Physician” for unmatched medical students to practice in a primary care setting, but this is a new movement. They are supervised by a board-certified physician for a year while re-applying to the Match.41
PGY-2s and beyond are going to be more competent and skilled than fourth-year medical students. However, data on the difference in competency after intern year, as it relates to primary care, is lacking.42–46 There is very little comparison between NPs, PAs, and interns. Currently, the third part of the USMLE or COMLEX must be passed before a full license is acquired,47,48 but we don’t have many other objective ways to assure competency besides licensure, hospital credentialing, attending evaluations,49 and board certification.50
If you think this is a rare issue that won’t affect enough people to be worth your time, think about the results of the NRMP Match in recent years. 2019 was the “most successful Match Day to-date,” with only 6% of U.S. allopathic seniors going unmatched, only 15.4% of U.S. osteopathic seniors going unmatched, and less than 41% of internationally trained medical graduates going unmatched. Some of these students found a PGY-1 position sometime during the year through a residency vacancy, but the rest were left without a role in medicine at the end of the process. In 2018, of the unmatched US seniors, approximately 3.8%, or ~1,100 brand new US-trained MDs, were still unmatched after SOAP.40 These physicians had to wait and re-enter the Match the next year, in the same or different specialty.51
We should celebrate each other, but we shouldn’t forget each other, either. Due to its’ ramifications for those that do not succeed, such as the dwindling probability of matching each year without a successful match, unforgiven debt burdens, and emotional trauma, the Match is a damaging process for those that fail.51 Imagine sacrificing so much spirit, entertainment, wealth, and hopefulness during nearly a decade of your youth, only to have a very limited path forward while your peers celebrate their futures.52 The NRMP Match creates a cohort of US physicians annually that are propelled into a future with few options for employment, despite their broad skill set and knowledge base. From this perspective, the struggle for unmatched US medical school seniors to use their training contradicts our ethical principles of autonomy, beneficence, and justice.7
As it stands now, the NRMP Match Day is a tone-deaf celebration. Perhaps we should celebrate more when there are fewer consequences for those that fail. However, most medical schools offer a “Match Day” celebration. There is a joint NRMP, AMA, AAMC Match Week celebration on social media, complete with “I Matched!” images, #Match2020, submitting videos to <
[email protected]), and the
Tagboard and YouTube playlist pages.53 I see the point: these successful students have worked hard and deserve to be excited. But, those that fail also worked hard and deserve compassion. We need to create alternative options.
To limit the options for unmatched US medical graduates seems misguided. If we allowed medical student graduates the option to avoid residency and practice a limited scope of medicine, under supervision, in primary care specialties, it would meet a primary care need. It would deemphasize the competitiveness of the Match. It would increase postgraduate pay, respect, autonomy, and overall wellbeing because resident physicians would now have “walk-away” power.
You can play a role in the change to this nonsensical structure. When it comes to policy formation and political advocacy, most physicians are discouraged but not nearly as powerless as they think. We must contact our representatives, be vocal to news outlets, talk to each other, and reflect on the changes we want. We must start thinking outside the box about the structure of our healthcare system and physician shortage.54-57 We must remember our ethics, especially regarding the utilization of available resources,58 the goals of our medical training, and what would ultimately be best for our patients.
I am a fourth-year medical student. I believe in using communication to bring about positive changes and encourage physicians to talk to politicians, political organizations, and medical associations. I previously authored this essay, "Are We Tolerating The Status Quo Too Much?"
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