It’s a fearful time for medical students

Imagine you, like most traditional medical students, went to college for four years to earn an undergraduate degree. Like many, you might also have obtained a graduate degree or worked for a period of time. You then spend time and money fulfilling extracurricular activities, taking the Medical College Admission Test (MCAT), applying to schools and traveling for interviews. If you are part of the lucky minority — roughly 40 percent — you will gain entrance to a medical school to spend four more years and tens of thousands of dollars to graduate as a physician.

Imagine you do all this, only to find you have no job.

Jobless doctors? At one point, that would have been preposterous, but just last year more than 500 MD graduates in the United States did not obtain residency positions. This total does not include the thousands of osteopathy students and international medical students who were not matched. According to the National Resident Matching Program, the organization that matches allopathic medical students with their graduate medical training sites, more than 13,000 applicants were unmatched in the initial process and participated in a supplemental program instead. In all, 34,355 U.S. and international medical students were competing for 26,392 positions.

This seems like an interesting predicament for a country that fears an imminent physician shortage. By some estimates, the United States will be short more than 60,000 physicians in the next two years. This is also devastating to students. Without a residency position, you cannot practice medicine and therefore cannot earn a living. That is scary news to the average medical student who graduates with more than $160,000 in debt.

At this point you might be wondering what the problem is. Where is the hang up in the system we trust to train an adequate physician workforce? There are actually several problems, all of which come down to the funding of graduate medical education, or GME. GME funding is directly tied to Medicare and indirectly tied to Medicaid. Anything that affects Medicare and Medicaid will invariably affect residency training positions.

The most prominent example is the Balanced Budget Act of 1997. In essence, this bill mandated that reimbursements to hospitals for training doctors would be frozen at 1996 levels. An increase in the number of doctors a hospital trained would bring in no extra government reimbursements. Basically, we can’t train any more doctors than we did in 1996 — even with an aging population and looming shortage.

Unfortunately — or fortunately, depending on how you see the picture — medical schools have increased class sizes and the number of graduating doctors in an effort to stall and/or prevent a national shortage. By 2017, 30 percent more students will be enrolled in medical school than in 2002. As you can probably see, this creates a bottleneck, one that became evident this year. It will only get worse as students who did not match this year apply again next year only to find themselves competing with an increasing number of graduating applicants.

If things continue, further cuts in residency positions will occur. The 2014 fiscal budget proposes $11 billion in Medicare cuts over the next 10 years. This equates to a decrease in GME funding from Medicare by roughly 10 percent a year. We cannot afford to lose 10 percent of our residency positions.

Residency positions are important to the health of our nation and the health care system. They represent a large portion of care for the elderly, disabled and indigent. Residents also reflect the future of medicine. As our nation ages and faces a dramatic increase in the insured population, we cannot afford to face a shortage. As a student of public health, I fear the repercussions for the U.S. health care system. As a medical student, I fear the repercussions for myself. I want to treat patients. I want to work in a community. I want to provide charity care.

Lately, though, I just want a job.

Nathanial Nolan is a medical student.

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  • Mengles

    Your generation was one of Mr. Obama’s biggest supporters propelling him into office. Then your millenial generation supported Obamacare (http://archinte.jamanetwork.com/article.aspx?articleid=1362939), while actually not knowing that was in the actual bill. Older attendings who have been in the business much longer than you have tried to warn you, but were dismissed. Please see your former American Medical Student Association (AMSA) president saying in comparison to in-the- trenches attending physicians, “Physicians-in-training have an unsoiled perspective on the health care system. While we may not have a wealth of experience, we have a commitment to patients that is unencumbered by competing financial interests or relationships with industry.”

    I see that you seem to have left out, intentionally or not, who is the one that is cutting the 11 billion dollars from GME. http://savegme.org/gme-funding-remains-in-critical-condition/ “That’s the portion of federal GME funding that **President Obama’s** administration proposes cutting over the next decade in its fiscal 2014 budget.” Thus resulting in your generation’s situation of potentially losing tons of residency positions – most likely many of them being the highly sought after specialty positions in the ROAD your generation wants, which in an unintended consequence will result in those specialties’ salaries going up even higher. See Dr. Ezekiel Emmanuel’s, an Obama advisor and author of Obamacare, position regarding cutting residency training years, and then see Dr. Karen Siebert’s blog post here on KevinMD on WHY this is being recommended. Hint, it’s not for your benefit.

    Elections have consequences, Mr. Nolan and your group of medical students are figuring it out the hard way now. Just think of it as a medical school version of “If you like your doctor, you can keep your doctor. Period.”

    • FEDUP MD

      Why this presumption all millenials think alike? Don’t blame some poor kid who was probably 18 or 19 when Obama took office, if even that. He’s never posted that he supported any of it. Thinking all medical students support AMSA is like thinking all doctors support the AMA. I am a Gen X but feel bad for the generation after me, they really are getting the short end of the stick and then are told it is all their fault, even when they have had little say in it.

  • Guest

    Medicare and Medicaid are going broke. The amount being paid in to these government healthcare programs is less than the amount pouring out to provide.

    It’s no good having the government borrow yet more money from China to make up the shortfall, because that eventually has to be paid back. We either have to jack up the proportion of citizens’ wages confiscated for Medicare and Medicaid services, or we have to admit that our 50-year experiment with government healthcare just didn’t work out, and try something new.

    But if there’s less money going in than coming out, that’s the very definition of “unsustainable”. Something that can’t go on forever, won’t.

  • NewMexicoRam

    What do you mean 500 graduated students couldn’t find residency positions?
    I know for a fact that family practice positions did not all fill.
    Wait…that can only mean one thing…….

    It’s better to be jobless than to go into primary care.

    • buzzkillerjsmith

      Hah! Hah! Good one. And I might add that it is way better to be a retired family doc than a good. C’mon stock market. You’re my only slim hope.

    • PreMedGirl

      Look at it this way. If you just spent 8 years in school and are 130K+ in debt — would you really want to “settle” with your residency or wait a year or two and see what’s available?

      Just a thought. If these new mds don’t want to go into primary care — should they?? Probably not. They MAY fall in love with it but what if they don’t? That wouldn’t exactly be ideal for their future patients.

  • buzzkillerjsmith

    The downgrading started long, long ago, but Obamacare certainly could give it a boost.

  • Michael_S_Harris

    Perhaps a four year degree is not really a prerequisite for entering medical practice schooling. Perhaps young people should start medical training in their teens. Perhaps if a society wants medically trained citizens to take care of their health they should pay for the training of physicians. Perhaps if healers and silencers of suffering are as dedicated to their vocation they will not demand such high fees. Perhaps people should take better care of their health.

    • PrimaryCareDoc

      Do you really want teenagers making the kind of decisions that doctors have to make? There is a level of maturity necessary for proper decision making.

  • Jess

    Hello, there are no “free markets” in medicine or health insurance at the moment, and there haven’t been for decades.

  • Jess

    When there was a 94% top rate in 1944-45, there were so many deductions and exclusions that the taxable income was not comparable to someone’s entire income. First, the top rate started at $200,000, which today is equal to $2,413,059.90 — so the maximum EMTR would apply only to incomes of $2.5 million. But, that’s still taxable income, not earned income.

    In 1944, you could deduct business meals, all business travel, all forms of interest payments, and much more. You could even deduct spousal travel expenses on a business trip! (Why travel alone?) Companies could also “loan” or “provide” almost anything to an employee, from an apartment to standard benefits. It was possible to shelter tens of thousands of dollars from taxable income. Three-martini lunches and expense accounts were important realities, skewing tax calculations.

    As a result of deductions and exclusions, even the theoretical maximum Real Rate of taxation at 60% in 1944 overstates taxation dramatically. The reality? On earned income, the richest U.S. taxpayers paid close to 40 percent of their earned incomes in taxes in 1944. We simply didn’t count much of the compensation as taxable income.

    Allow me to introduce you to Hauser’s Law. Published in 1993 by William Kurt Hauser, a San Francisco investment economist, Hauser’s Law suggests, “No matter what the tax rates have been, in postwar America tax revenues have remained at about 19.5% of GDP.”

    At some point, you’re going to have to cut entitlement spending. It’s just that simple. There are not enough “evil rich” in America to fund all the free cheese the 99% want.

  • Jess

    How many times do you want to tax each dollar I earn? You tax it once when I earn it, fair enough. And you tax it again when I invest rather than spend it. And you tax it again through death taxes.

    If you take 35 cents of each dollar I earn, then 35 cents of each dollar the remaining 65 cents earns me, then 50 cents of each dollar I still have left (of the 1 dollar you’ve already taxed twice) when I die, you’re going to incentivize me to spend it all on champagne, caviar and pretty boys rather than bother to invest it and let the vultures take 75%+ of it. I don’t see how that’s going to help you buy more free cheese.

    • Aquifer

      No, the money you invest is not taxed, its the unearned income it returns to you that is taxed, at a lower rate than your “earned income” which is why Buffet pays a lower rate than his secretary – how perverse is that?

      You are taxed by death taxes – you heirs are taxed on their inheritance, more unearned income ..

      • Jess

        So basically you want to de-incentivize saving and investment by successful people. Make it so that, if you don’t blow your salary immediately, the State will end up confiscating 90% of it. Sounds like a great plan.

  • Robert Luedecke

    As a Texas physician who has been active in medical legislation, I know the shortage of GME here is because the Texas Legislature has been cutting state funds that pay for primary care residencies. Despite the state asking medical schools to increase enrollment so there would not be a doctor shortage, at the same time the state cut GME funds. Texas pays about $200,000 in state funds to graduate a medical student. Most doctors stay and practice near where they do their residency, so Texas pays for a lot of other states to have good doctors. Very generous of the Texas Legislature, but not a very wise use of our tax dollars.

  • Loree Kalliainen

    Options include: increase the number of residency slots, expand the role of physician extenders, or accept fewer IMGs into US residencies. Given that there are discussions about cutting current GME funding by up to 30%, this is not likely. Physician extenders are less expensive to train and are already doing a lot of work similar to physicians. 10-15% of current residents are international (AMA-IMG Section Governing Council. International Medical Graduates in American Medicine: Contemporary Challenges and Opportunities. 2010. http://www.ama-assn.org/resources/doc/img/img-workforce-paper.pdf. Educational Commission for Foreign Medical Graduates. 2011 Annual Report. 2012. http://www.ecfmg.org/resources/ECFMG-2011-annual-report.pdf.) It does go against some of the values of inclusion and acceptance of immigrants that we have had.
    The whole argument about who is going to do primary care (currently many foreign educated physicians and IMGs) is an interesting and larger one, but if the cost of med ed continues to rise, it will be more difficult to find a US trained student with $250K in debt to take a relatively low salary job in a rural area.