Unmatched, But Not Forgotten

I recently read an anonymous post by a medical student who was applying to the residency match…for the second time. He was a bit melancholy and disheartened with the entire match process. He had good grades, performed decently on the MCAT, had great letters of recommendation and received many interviews. Yet he did not match. It broke my heart–I’ve been in his position.

Over 25 years ago, I applied for a slot in an emergency medicine residency. I had attended a great medical school, one of the top 25% in the nation. I performed well and graduated on time. I successfully completed an acting internship in EM at a major trauma center and received a magnificent LOR from the assistant residency director. When applying for the match, I selected my schools carefully and realistically. And I did not match. I was devastated. I entered the scramble(now known as SOAP). The APD of the program at which I had completed my AI knew the PD of a new program in New York and recommended me. I was interviewed by telephone and the PD offered me a position on the spot. He asked me how he could guarantee I would accept (as there were other new residency programs). I told him to send me a contract. He faxed it, I signed it and the rest is history. I segued from feeling like a total failure to a total success. In one week.

My entire residency class(except for one) consisted of people who did not match. We were all great candidates with all the right stuff. No clear understanding of why we did not match and others did. There is a presumption that most medical students who don’t match were simply not good candidates. After my experience, I questioned that presumption. Nevertheless, I was given a second chance and now, nearly 25 years later, I have had a successful career in emergency medicine. Back then, if one didn’t match the first time, they almost always matched during the scramble or if they re-applied a second time. The numbers of those who remained unmatched were relatively small. Nothing like the numbers we see today.

Currently, there are many more medical students than there are residency slots. As a result, we have had an unprecedented number of graduated medical students not matching and having to re-apply as many as five times before they give up or are successful at being accepted into a residency. This residency bottleneck is a result of a decision made over 20 years ago: the 1997 Balanced Budget Act that placed a cap on the number of residencies that Medicare would fund. Prior to that, the AMA, AAMC and other organizations predicted a physician glut that never occurred. Ironically, the number of medical schools has increased. What good does it serve to increase the number of medical schools when there is a residency bottleneck? It serves no purpose other than to make money for the school and create an astronomical debt for a student who may not have the ability to pay off that debt.

There is a physician shortage, but it is not due to a lack of candidates, it is from an insufficient number of residencies. Unfortunately, this false “shortage” is a goldmine for opportunists who believe they can step in and fill this “gap”. Logic dictates that if there is a physician shortage, one must consider filling that shortage with a physician. The question is where do we get those physicians? Well, there is a huge pool of unmatched, highly qualified doctors just clamoring for a slot. There are also foreign medical graduates(FMGs) and international medical graduates(IMGs) who are perfectly viable candidates to address this “gap”. There is a tremendous amount of bias against FMGs/IMGs for unfathomable reasons. Medical education is structured. The hoops that these graduates have to jump through to practice as physicians in the United States is significant. Because they have to follow the same standard as U.S. graduates. For example, there are 60 Caribbean medical schools in the world. Five have been approved by the U.S. Department of Education as having medical school curriculums EQUIVALENT to that of U.S. medical schools. Those graduates can complete their clinical rotations and residencies in the U.S. Students who attend schools that are not approved by the DOE must begin again…pre-med>>MCAT>>medical school>>residency. It takes years for foreign medical schools to be granted that stamp of approval by the Department of Education. No easy feat. The false narrative of FMGs/IMGs being unqualified is just that–false.

In February 2019, a bipartisan bill, the Resident Physician Reduction Shortage Act was introduced by Senators Menendez(D-NJ), Boozman(R-AR) and Schumer(D-NY). The bill would increase funding from Medicare for 15,000 residency slots over 5 years. In my opinion, every physician, every program director, every dean of every medical school and the public should be pushing their legislators to support this bill. The cap has persisted for too long. It makes no sense to discuss filling the physician gap with non-physicians when this option is on the table. It is not fair to the medical students who worked so hard to fulfill their dream to serve and it is most certainly not fair to the public.

Associate Physician, also known as Assistant Physician(AP), programs (not to be confused with physician assistant), which exist in Missouri, Kansas, Arkansas, and Utah with pending legislation in Georgia and New Hampshire (https://assistantphysicianassociation.com/), provide yet another option to fill the “gap”. The AP program began in Missouri as a bill proposed by an orthopedic surgeon who wanted to address the healthcare needs in underserved and rural areas of his state. The sponsor saw the value in utilizing these unmatched medical doctors who were being ignored by the medical establishment. The bill was opposed by nurse practitioners, physician assistants and members of the Missouri Academy of Family Physicians. It was supported by the Missouri State Medical Association. Working as APs allowed these doctors to maintain their knowledge and clinical skills while being supervised until they could again apply for a residency the following year. In Missouri, APs now have a license to practice provided they have a collaborating physician. And true to their word, they are working in these underserved areas. What they are not doing is opening medspas, hormone, dermatology and ketamine clinics under the guise of serving the underserved.

“Residencies” and “fellowships” for nurse practitioners and physician assistants are being developed and supported by some of my colleagues who choose to believe they have no other options to relieve the “shortage” but to use non-physician practitioners(NPPs). There are bills being introduced in various states which permit some limited primary care practice by naturopaths, chiropractors, and pharmacists. I’m baffled because of the various opportunities that exist to increase the physician pool and yet we choose other options. Many of my colleagues could be supporting the senate bill mentioned above but don’t either because they don’t know about it or don’t care. Some demonstrate no support for the unmatched students and have no compassion for their situation. These are unusual times that call for unusual measures. The “rule” that once an unmatched student has not matched in three years the likelihood of them not being accepted to a residency should be adjusted to account for the residency bottleneck that prolongs their time. Take that into consideration. Give them a chance. Make exceptions. Don’t leave that talent sitting on a shelf collecting dust. It’s not right. We should not turn our backs on them. Not when they need us the most. We should provide the same support for them that are given to NPPs.

To the unmatched doctors, our future physicians, I say this. Do not lose hope. You are not forgotten and you are not invisible. We see you.

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