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.
