Categories
Medical Education

Every Residency Program Should Offer Virtual Interviews

In the “before times”, all interviews for residency and fellowship positions were performed in-person. Then came COVID when in 2022, 94% of programs offered virtual interviews exclusively and an additional 4% of programs performed more than three quarters of interviews virtually. With the pandemic fading, programs are facing the decision of whether to return to in-person-only interviews. There are compelling reasons why they should not.

The advantages of the in-person interview

I have interviewed hundreds of students applying to residency and residents applying to fellowship. As a faculty member who served for many years on our internal medicine resident selection committee and our pulmonary and critical care fellow selection committee, I believe that in-person interviews are usually preferable to virtual interviews.

For the interviewer, you get better information about the applicant’s communication skills, both verbal and non-verbal. It is also insightful to observe how the applicants interact with other applicants being interviewed on the same day and how applicants interact with the non-physician members of the office staff. The in-person interview day usually includes a lunch or dinner with some of the current residents or fellows – this is a time when applicants often reveal more of their true personality and behavior. All of these observations can impact how high an applicant is ranked on the program’s match list.

For the interviewees, an in-person interview is an opportunity to see what the facilities are like. This can include the layout of the hospital(s), inpatient rooms, outpatient clinic sites, the educational facilities, the call rooms, the library, and even the cafeteria. The applicant can get a better idea of how the current residents interact with each other, with the faculty, and with the hospital staff. One of the most overlooked advantages of in-person interviews is the opportunity to talk with other applicants being interviewed on the same day – they can often provide first-hand knowledge of other training programs and that knowledge can help an applicant decide which additional programs to interview at (or not interview at).

But in-person interviews are costly

The main disadvantage of in-person interviews is the cost – both to the applicant and to the residency (or fellowship) program. For the applicant, the time cost of each interview is considerable. To interview at a residency program within a 2-3 hour drive requires a full day to drive to that program, interview, and drive back home. To interview at a residency program farther away, it can take 2 or 3 days when factoring in travel time. This means that the senior medical student must either make arrangements to be absent from their clinical rotation for that time period or to schedule a vacation month and try to fit as many interviews into that month as possible. In addition to the time cost, there is considerable financial cost for each interview. The travel costs for interviews that the applicant can drive to are relatively low but for those interviews that require an air flight to reach, costs can add up quickly. This is especially true if an overnight hotel stay is necessary. For many applicants, there is a wardrobe cost – medical students who have been wearing kakis or scrubs with a white coat for clinic rotations for the past couple of years need to buy one or two sets of business wear for interview days. To successfully match to a residency program, students must interview at an average of 14 programs, costing them thousands of dollars in travel and wardrobe expenses. Because 71% of medical students owe debt on educational loans (with the average amount of those loans about $200,000), most students have to take out additional loans just to go to in-person interviews.

Interviews are also expensive for residency programs. A staff member must be dedicated to chaperone the interviewees and coordinate all of their schedules. Programs must usually pay for a lunch and/or dinner for the interviewees. Many programs will also cover the cost of a hotel room for interviewees traveling from out of town.

The greatest advantage of virtual interviews

In the past, here at the Ohio State University, we did not get a lot of residency applicants from students at west coast medical schools – it was just too costly for them to travel to Columbus to interview. An interview generally would require three days for a west coast medical student – one to fly to Columbus, one to interview, and one to fly back to the west coast. Instead, most of our applicants came from midwestern medical schools where applicants could drive to Columbus – often making the roundtrip drive on the same day as the interview.

For residency programs, the greatest advantage of virtual interviews is that they give you access to a larger pool of applicants. This allows the program to be more selective about the applicants that the program decides to offer interviews to and rank on the program’s match list. For some residency programs, this can mean interviewing more students with high medical school grades or test scores. For other programs, it can mean interviewing more students who fit best into the residency program. As an example, some residency programs emphasize didactic teaching whereas others emphasize more hands-on autonomy in patient care. One applicant may thrive in a residency program with a lot of lectures and research opportunities whereas another applicant may thrive in a residency program that requires residents to function more independently in patient care.

For applicants, the greatest advantage of virtual interviews is that they improve the chance that you get into a residency program that you will be happy and successful in. The most important factor in choosing a particular residency program is whether that program will allow you to reach your greatest potential as a doctor. In turn, that requires two things: the program must match your preferred method of learning and you have to enjoy being around the people that you work with. To learn any skill requires a combination of three things: observing experts, didactic education, and practice. For example, to learn how to golf requires watching how golf pros play the game, taking golf lessons, and then getting on the course and practicing. Medicine is the same but each of use has our own personal optimal ratio of observation to didactic education to practice. Finding a residency program with that offers a similar ratio of these three to your personal optimal ratio is the key to reaching your potential. The residency program that is optimal for one student may not be optimal for another student. But no matter how well a residency program fits your mode of learning, if you do not like the people that you are working with, you can never reach your fullest potential. Using virtual interviews allows the student to expand the geographic area of residency programs they consider and increases the chance of finding programs that best match the student’s preferred mode of learning, that has other residents the student enjoys being with, and has faculty that the student would like to have as mentors.

My recommendations

For residency programs: When feasible, do in-person interviews – you will get more information about an applicant than you can by a virtual interview. But offer virtual interviews as an option, especially for those applicants who would otherwise not apply to your program if in-person interviews were mandatory. For example, offer out-of-state medical students the option of either in-person or virtual interviews. Or offer virtual interviews to students living more than 120 miles away. For a residency program in Seattle, the best candidate might be a medical student in Florida but there is little chance that student is going to even apply for residency if it would require flying across the country for an in-person interview. Your future chief resident might be a senior student currently in a medical school 2,500 miles away.

For medical students: When feasible, do in-person interviews. You will learn more about the facilities and the people you will be working with than you can get from the residency program’s website and virtual interviews with two or three faculty members. You can often improve your chances of getting into a residency program because an in-person interview can make you more of a known entity to the program. Interviewing in-person can also indicate your interest in the program since you took the time and expense to travel for the interview. But take advantage of interviewing virtually for those residency programs that you would not have applied to if it required traveling for in-person interviews. This can allow you to interview at more programs that you would have interviewed at had you needed to travel to for in-person interview. It can also save you money for interviewing at residency programs that you would otherwise need to fly to. For more information, see my previous post on making the most of your virtual interview.

Remember who you are competing with

The purpose of a residency program’s resident selection committee is to identify and recruit the best possible medical students. Each residency program competes with all of the other residency programs for those best students. The residency program that offers virtual interviews has a competitive advantage over programs that only offer in-person interviews.

The reason a medical student interviews with multiple residency programs is to get into the residency that he or she is going to learn best in and be happiest in. Each student is competing with all of the other students for the best residency programs. The student that interviews virtually at geographically distant residency programs has an advantage over students who are only willing to do in-person interviews.

April 12, 2024

Categories
Medical Education

Abortion And OB-GYN Residency: Training In Jeopardy

20% of OB-GYN residents receive their training in states that outright ban abortion. An additional 14% train in states that severely restrict abortion. As a result, one-third of OB-GYN residents face barriers to get adequate training in performing abortion. Unless these residents make special training arrangements, they will be unprepared to safely perform abortions as practicing physicians, even in cases of rape or medical threat to the mother’s life.

ACGME training requirements in OB-GYN

The Accreditation Council for Graduate Medical Education (ACGME) is the organization that sets training requirements for all specialties, including residencies and fellowships. If a residency program fails to meet ACGME requirements, that residency risks losing its accreditation, which can have implication for funding and physician recruitment. Residency programs that are not accredited by the ACGME cannot receive Medicare funding from CMS for Direct Graduate Medical Education (DGME) and Indirect Medical Education (IME). For physicians to obtain board certification, they must train at an ACGME-accredited residency program. Training programs that lose their ACGME accreditation must assist residents to transfer to another residency program and cannot participate in the Match Program. The work that these residents had done must then be performed by attending physicians, at significant cost to the hospital.

The ACGME publishes the requirements for every specialty, including the requirements for OB-GYN residencies. One of these requirements is that OB-GYN residents must be trained to perform abortions; however, residents can opt-out of abortion training if they have religious or moral objections. The converse is not true – residency programs cannot “opt-out” of providing residents training in abortion procedures. In states where abortion is illegal, to be compliant with ACGME requirements, OB-GYN residency programs and their sponsoring hospitals must make arrangements and provide financial support for its residents to get abortion training in another state. The specific wording of these ACGME requirements are:

IV.C.7.a).(2) Residents must be involved in educating patients on the surgical and medical therapeutic methods related to the provision of abortions.

IV.C.7.a).(3) Residents must participate in the management of complications of abortions.

IV.C.7.a).(4) Programs must provide clinical experience or access to clinical experience in the provision of abortions as part of the planned curriculum. If a program is in a jurisdiction where resident access to this clinical experience is unlawful, the program must provide access to this clinical experience in a different jurisdiction where it is lawful.

IV.C.7.a).(4).(a) Residents who have a religious or moral objection may opt out and must not be required to participate in training in or performing induced abortions.

IV.C.7.a).(4).(b) For programs that must provide residents with this clinical experience in a different jurisdiction due to induced abortion being unlawful in the jurisdiction of the program, support must be provided for this experience by the program, in partnership with the Sponsoring Institution.

 

This year, there were 1,557 first-year residency (PGY-1) positions in OB-GYN offered in the 2024 Match. OB-GYN residency lasts for 4 years and thus there are about 6,230 OB-GYN residents in training at any given time in the United States. About 1,260 of these residents are in states where abortion is completely illegal. Unless these residents attest that they have moral or religious objection to abortion, their hospitals must arrange and provide financial support for them to get this training in another state. An additional 848 OB-GYN residents are in states that severely restrict abortion and many of these residents are unable to obtain adequate experience in first and second trimester abortions, as required by the ACGME.

As an example, the University of Texas Southwestern Medical Center in Dallas has the country’s largest OB-GYN residency – 1 out of every 80 OB-GYN physicians in the U.S. did their residency at UT Southwestern. In Texas, abortion is illegal and a physician who performs an abortion is subject to first or second degree felony prosecution. The OB-GYN residency program at UT Southwestern states on its residency website regarding its 4-week family planning rotation: “During this rotation, fourth-year residents have the ability to travel out of state to receive induced abortion training.

What states ban or restrict abortion?

Since the U.S. Supreme Court overturned Roe v. Wade, it is now up to each state to make its own laws regarding abortion. As a result, these state-specific laws now range from outright bans to restriction based on the number of weeks of gestation to no restrictions on abortion.

In 14 states, abortion is illegal: Alabama, Arkansas, Idaho, Indiana, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, and West Virginia. In an additional 7 states, abortion is severely restricted to less than 6 weeks (Georgia and Alabama), less than 12 weeks (Nebraska and North Carolina), less than 15 weeks (Arizona and Florida), or less than 18 weeks (Utah). In the remaining 29 states, as well as in Puerto Rico and the District of Columbia, abortion is legal with either no gestational limit or a gestational limit sometime in the second trimester of pregnancy.

Implications for the future

In most states, abortion training is a regular component of family planning rotations for OB-GYN residents. Any OB-GYN resident can opt out of this training for religious or moral reasons. OB-GYN residencies in states that prohibit abortion must still provide abortion training as the default option for residents. In the words of the ACGME: “Programs must be structured such that residents may “opt out” rather than needing to “opt in” to this experience.” Nonetheless, there are obstacles that residents in these states face in order to get training in abortion procedures. They have to travel to another state for a month or more of their residency, they have to find and pay for housing in that state, they have to obtain hospital credentialing where they will get the additional training, they have to obtain a state medical license in that state, and they have to be separated from their families for a month or more. There are also burdens on the residency programs. The residency program must still pay the resident’s salary when that resident is out of state getting additional training. Also, when a resident is out of state, that resident has to be taken off of the call schedule and as a result, the rest of the residents must pick up additional nights on-call.

So far, OB-GYN residencies in states that ban or severely restrict abortion have not had their recruitment significantly impacted. In the 2024 residency match, there was no difference in the percent of available PGY-1 resident positions filled in states with an outright ban (99.0%), states with severe restrictions (99.5%), and states with no or minimal restrictions (99.2%). Similarly, there was no difference in the percent of available positions filled by U.S. senior medical (MD) students in states where abortion is illegal (70.5%), states with severe restrictions (73.6%), and states with minimal or no restrictions (71.1%).

But the 527 OB-GYN residents currently training in states that ban or severely restrict abortion face challenges in arranging and paying for out-of-state abortion training during their residency. For many of them, the obstacles attendant to out-of-state training will be too great and they will elect to opt-out of abortion training. As a result, in the future, it may be difficult for them to get jobs in states where abortion is legal. If they do not get training in abortion procedures and post-procedure patient management, then they cannot get hospital privileges to do abortions. This means that even if a woman has a life-threatening complication of her pregnancy, an obstetrician without hospital privileges for abortion procedures must find someone else to perform a life-saving procedure. In states where abortion is legal, given two otherwise equally qualified applicants, the obstetrician applying for a job who is able to perform an abortion will have an advantage over the obstetrician who is not trained in abortion.

Obstetric residents who are not trained in abortion can always get a job in a state where abortion is illegal. However, even in these states, there is usually a provision allowing an obstetrician to perform an abortion if the mother’s life is imminently threatened. An abortion in these women is generally much more complicated and much higher risk than an abortion in an otherwise healthy woman. But if none of the obstetricians in town were trained in performing abortions and in the management of abortion complications, there will not be anyone who can safely do an abortion in a women dying from a complication of pregnancy. You can’t learn how to do any medical or surgical procedure competently by just watching a YouTube video five minutes before you perform your first one. Competently performing an abortion in a high-risk patient is no different.

There are also legal uncertainties in the future for OB-GYN residency programs in states that are dominated by politicians with extreme social conservative stances. For example, will these states withdraw state government funding from hospitals that send their trainees out of state for abortion training? Will they require state-supported hospitals to publicize the names of OB-GYN residents who do out-of-state family planning rotations that include abortion training? Will they revoke the state medical licenses of OB-GYN residents who participate in abortion procedures in other states?

Idaho has one of the most restrictive abortion laws in the country. Since that law went into effect, 22% of its total obstetricians and 55% of its high-risk obstetricians left the state. Idaho is one of six states without an OB-GYN residency program so Idaho’s abortion law has not affected residency training. But medical students are not stupid – if they see that obstetricians are leaving states that ban abortion, they will be a lot less likely to rank OB-GYN residency programs in those states very high on their match rank list.

What can we do now?

It is in our country’s best interest to have our obstetricians trained in the safe performance of abortions and the management of complications of abortions. Otherwise, where will the 12-year-old pregnant rape victim go? Or the woman with an anencephalic fetus? Or the woman with a 15-week pregnancy needing to start chemotherapy for newly diagnosed acute leukemia? Fortunately, there are some specific tactics we can take today.

  1. Create training opportunities in OB-GYN residencies in states where abortion is legal. As a general rule, residency training programs do not like to accept visiting residents for a 1 or 2 month rotation. There is a lot of paperwork, there is uncertainty about the skill and ability of visiting residents, and the visiting residents can encroach on the training opportunities of the regular residents. Residency programs and hospitals need to create formal pathways for these OB-GYN residents and take down barriers for these guest residents coming from states where abortion is illegal or severely restricted.
  2. Hospitals need to have expedited pathways for credentialing “visiting” OB-GYN residents and should assist them in obtaining state medical licenses for the state that they will be doing their additional training. This could include partnering with residency programs in states with abortion bans in order to streamline the credentialing and licensure process.
  3. Not-for-profit organizations need to create funding to assist OB-GYN residents in states where abortion is illegal or severely restricted in order to obtain additional training. This could create grants to help pay for the cost of travel, housing, childcare, medical licensure, etc. Most residents owe money on educational loans with the average amount of those loans about $200,000. Without such grants, many debt-burdened residents simply cannot afford to travel out of state to get abortion training.
  4. Medical schools should advise students applying to OB-GYN residencies about the implications of attending residencies in states that ban abortion. This includes how training in these states could potentially affect job prospects in other states where abortion is legal.
  5. OB-GYN residency programs in states where abortion is legal can promote to applicants the advantages of training in their program versus programs where abortion is banned. This is a particularly good tactic when the applicants are on-site for their residency interviews and can give the residency program a competitive advantage over residency programs in states where abortion is illegal.
  6. OB-GYN residency programs should offer virtual interviews, especially for students applying from out-of-state medical schools. It could be cost-prohibitive for a medical student in Texas to fly to Ohio to interview for an OB-GYN residency position. But by allowing that student to interview virtually from Texas, the OB-GYN residency program in Ohio can open itself up to a larger pool of applicants and potentially end up with a higher quality group of students matching to the residency program. OB-GYN residency programs in states where abortion is legal should now be able to recruit the best student applicants from medical schools in states where abortion is illegal.
  7. Hospitals in all states need to review credentialing procedures for obstetricians applying for hospital privileges to perform abortion, even if abortion is only permitted when a pregnant woman’s life is in immediate jeopardy. With one-third of OB-GYN residents training in states where abortion is banned or severely restricted, is is less certain than ever before that an obstetrician who did residency in those states can competently perform an abortion or manage complications of an abortion. This may require hospital credentials committees to remove abortion procedures from the “core privileges” list for OB-GYN and moving them to the “optional privileges” list. Documentation of training should be required.

It’s a new era in OB-GYN

One of the most important (and most frequently forgotten) rules of law-making is that there is always unintended consequences. For example, let’s say that the anti-necktie lobby group got the state legislatures in 21 states to pass a law making it illegal for men to wear a necktie except for Leap Year Day. That would mean that a man could only wear a necktie on one day every 4 years in those states. Eventually, no man in those states is going to remember how to competently tie a necktie and no boys are ever going to learn how to tie a necktie. Men in the 29 states where neckties are legal would have a competitive advantage when it comes to dressing in formalwear. The same thing happens in states with abortion bans – it will not be too long until no one in those states knows how to competently perform an abortion even in the event of rape or the mother’s life being in danger. OB-GYN residency programs in the states (plus Puerto Rico and the District of Columbia) where abortion is legal now have the opportunity to take a competitive advantage in recruitment.

April 8, 2024

Categories
Medical Education

The 2024 Residency Match

This month, the results of the main residency match for 2024 were released by the National Residency Match Program (NRMP). The results of the match give important insight into how medical students see prospects for different specialties in the future and also give hospitals insight into the future supply of various specialists. A record-high 50,413 applicants registered for the match this year and 44,853 applicants ultimately submitted a residency rank list. Overall, 80.2% of applicants submitting a rank list for a PGY-1 residency position successfully matched.

A little background on the match

In about September every year, senior medical students decide what specialty they would like to practice and send applications out to residency programs that they are interested in. The residency programs then select which students to interview for those positions and those interviews are carried out in the fall and winter. In February, after all of the interviews have been completed, the medical students create a ranked list of all of the residency programs that they would consider. Residency programs also create a ranked list of all of the medical students they would consider. In March, the NRMP computers “match” the medical students’ ranked lists with the residency programs’ ranked lists. On March 15th (“Match Day”), the NRMP releases the results of this match and the medical students find out where they will be spending the next 3 – 7 years of residency training.

The applicant pool is divided into six groups: (1) senior students at MD schools, (2) previous graduates of MD schools, (3) senior students at DO schools, (4) previous graduates of DO schools, (5) U.S. citizens who attend foreign medical schools, and (6) non-U.S. citizens who attend foreign medical schools. Students from U.S. medical (MD) and osteopathic (DO) schools tend to be more competitive than students from foreign medical schools.

U.S. citizens who attend foreign medical schools are categorized as U.S. international medical graduates (U.S. IMGs) and often attend medical schools in the Caribbean. Non-U.S. citizens who attend foreign medical schools (also known as non-U.S. IMGs) typically come to the United States on a training visa because high-quality specialty training is not available in their own country. Non-U.S. IMGs tend to be less competitive for residency positions than U.S. citizens. Although many non-U.S. IMGs return to their home country after completing residency, some elect to stay in the U.S. and pursue citizenship.

The largest number of applicants were U.S. MD senior students (19,755), followed by non-U.S. citizen IMGs (10,021), U.S. DO senior students (8,033), U.S. citizen IMGs (4,751), previous graduates of U.S. MD schools (1,662), and previous graduates of U.S. DO schools (616).

How many residency programs do students list?

This year, the average applicant who got into a residency ranked 12.14 residency programs and the average applicant who did not get into a residency ranked 4.13 residency programs. The implication is that the more residency programs a student interviews at and ranks, the more likely they are to obtain a residency position. However, these results can be a bit misleading because applicants to highly competitive residencies (such as vascular surgery) may need to rank more residency programs in order to ensure they get a residency position whereas applicants to less competitive specialties (such as family medicine) may only need to rank a small number of residency programs in order to insure that they match. The average number of residency programs that students ranked varied by the type of student:

There is also variation by specialty. For example, although the average U.S. MD senior student ranked 11.3 residency programs, the range was from a high of 21.9 programs per vascular surgery residency applicant to a low of 4.0 programs per internal medicine primary care track residency applicant. An important factor that influences the number of programs any given applicant ranks is how many programs that applicant interviews at. This in turn is influenced by how selective residency programs are in offering applicants interviews and whether those interviews are in-person or virtual. It is easier and less costly for applicants to interview at a large number of residency programs if those interviews are conducted virtually, thus obviating the time and expense of travel to those residency locations.

Residency programs that filled in the match ranked an average of 81.47 applicants (12.76 ranks per available position). Residency programs that did not fill in the match ranked an average of 63.05 applicants (8.73 ranks per available position). Because residency programs vary in size, the average number of ranked applicants is not terribly informative. However, the number of ranks per available residency position is informative and indicates that the more applicants any given residency program ranked, the more likely that program was to fill all of its available positions.

Results by specialty

As in previous years, categorical internal medicine had the largest number of filled positions (9,767). This is the traditional internal medicine track and a large percentage of these residents go on to do subspecialty fellowships after completing their internal medicine residency. The second most positions were in family medicine (4,577).

Every year, some specialties are more competitive than others. Competitive specialties have most or all of their residency positions fill in the match whereas less competitive specialties have a lower percentage of available positions that fill. Four specialties were highly competitive and filled all available residency positions: internal medicine/pediatrics, neurosurgery, plastic surgery, and thoracic surgery. Twelve specialties filled between 99% and 100% of available positions: anesthesiology, orthopedic surgery, otolaryngology, general surgery, radiology, neurology, OB/GYN, psychiatry, physical medicine, dermatology, internal medicine primary care, and vascular surgery. The specialties with the lowest percentage of filled positions were PGY-1 (first year after graduating from medical school) transitional and surgery preliminary; however, these are 1-year slots that are meant for applicants who are going on to do another specialty that does not begin until the PGY-2 year after medical school (such as some physical medicine and neurology residencies). The graph below includes residency positions that begin in both the PGY-1 and PGY-2 years.

Another way to determine which specialties are most competitive is to look at the percentage of available positions that were filled by U.S. MD graduates. Four specialties filled ≥ 90% of positions with U.S. MD graduates: thoracic surgery (98%), plastic surgery (94%), otolaryngology (91%), and neurosurgery (90%). These are considered to be extremely competitive specialties. At the other extreme, five specialties filled < 50% of their filled positions with U.S. MD graduates: family medicine (30%), categorical internal medicine (36%), emergency medicine (45%), pathology (46%), and pediatrics (49%). These are less competitive specialities. The graph below includes residency positions that begin in both the PGY-1 and PGY-2 years.

Specialties taking non-U.S. IMGs

The number of non-U.S. international medical graduate applicants increased significantly this year. In 2023, there were 8,469 of these applicants and that number rose to 10,021 in 2024, an increase of 1,552. This represents an 18% increase in non-U.S. IMG applicants in 2024. This has been a trend for the past decade as American residency programs become increasingly desirable to foreign medical students. The number of non-U.S. IMG applicants who matched to a residency position also increased from 5,032 in 2023 to 5,864 in 2024.

Non-U.S. international medical graduates tend to get into residencies that are not filled by U.S. MD and U.S. DO senior students. Four specialties had > 20% of available positions filled by non-U.S. IMGs: categorical internal medicine (30.3%), pathology (27.2%), neurology (22.6%), and internal medicine primary care (21.9%). On the other hand, five specialties had fewer than 2% of available positions filled by non-U.S. IMGs: thoracic surgery (0%), orthopedic surgery (0.2%), otolaryngology (1.3%), physical medicine (1.7%), and dermatology (1.9%).

Other notable observations

There were 1,218 couples who entered the couples match in 2024. This number has been relatively stable for the past 5 years. The match rate for couples match applicants was 93.6%, which has been relatively stable for the past 45 years.

Emergency medicine applicants have rebounded after a 3-year decline. Last year, only 81.6% of emergency medicine residency positions were filled but this year, that percentage rose to 95.5%. This increase was largely due to an increase in U.S. DO applicants applying to and accepted into emergency medicine residencies. In 2023, U.S. DO applicants comprised 24.3% of filled positions and in 2024, that number increased to 34.6% (an increase of 317 accepted applicants). The number of U.S. MD applicants applying to and accepted into emergency medicine was unchanged. Overall, this is good news for hospitals. Had the decline in filled positions that occurred during the COVID pandemic continued, hospitals could face staffing shortages in emergency departments. The increase in filled emergency medicine residency positions ensures that there will be an adequate future supply of emergency physicians.

OB-GYN remains competitive, but with a caveat. Historically, OB-GYN residency programs have had a low number of unfilled positions in the match. Similarly, there have been relatively few international medical graduates matching to OB-GYN because the vast majority of positions are filled by U.S. MD and U.S. DO senior students. Between 2018 – 2022, less than 1.5% of OB-GYN matched applicants were international medical graduates (including both U.S. citizen IMGs and non-U.S. IMGs). In 2023, the percentage of OB-GYN matches filled by international medical graduates rose to 5.8%, leading some observers to postulate that the overturning of Roe v. Wade was making OB-GYN a less desirable specialty to U.S. medical and osteopathic students. In 2024, 6.2% of OB-GYN residency matches were filled by international medical graduates. The majority of these were U.S. citizen IMGs (53 vs. 43 non-U.S. citizen IMGs). Overall, 99.6% of OB-GYN positions filled in the 2024 match, indicating that it remains competitive. However, the increase in international medical graduates matching to OB-GYN positions relative to historical numbers indicates that OB-GYN may have lost a bit of allure to U.S. MD and U.S. DO students since the overturn of Roe v. Wade.

What happens to applicants who do not match?

There were a total of 8,869 applicants to PGY-1 residency positions who were unmatched. Of those, 1,290 were U.S. MD senior students, 902 were previous graduates of U.S. MD schools, 621 were U.S. DO senior students, 323 were previous graduates of U.S. DO schools, 1,570 were U.S. citizen IMGs, and 4,157 were non-U.S. IMGs. There are a number of options for these unmatched applicants

After the results of the match are released, a program called the Supplemental Offer and Acceptance Program (SOAP) opens to allow applicants who did not match to a residency position to obtain a position in a residency program that did not fill in the match. This year, there were 2,562 residency positions in 787 residency programs that went unfilled. Historically, about 95% of unfilled positions ultimately get filled in the SOAP. The majority of these SOAP positions go to U.S. MD and U.S. DO senior students or graduates. For example, in 2022, there were 2,111 residency positions filled in the SOAP. These positions were filled by 911 U.S. MD senior students (43%), 125 U.S. MD graduates (6%), 511 U.S. DO senior students (24%), 91 U.S. DO graduates (4%), 305 U.S. citizen IMGs (14%), and 168 non-U.S. IMGs (8%). The data from the 2024 SOAP is not yet available but is likely to be similar to previous years.

Applicants who do not obtain a residency position in the SOAP can pursue a variety of career options. Some get non-physician jobs in a clinical setting, such as a scribe or an electronic medical record trainer. Some enroll in another graduate program, such as a PhD, MPH, or MBA. Some obtain jobs in research laboratories. Some obtain a job in an industry where an MD or DO degree is valued, such as insurance or pharmaceuticals. Some take a year to study and take the USMLE step III exam (usually taken by physicians during their first year of residency) – a favorable score on this exam can improve an applicant’s chances of matching to a residency program in the future. Others drop out of the workforce altogether; however, for the majority of U.S. applicants who have large education debts, this is not really an option.

Lessons for future residency applicants

After deciding on a specialty, medical and osteopathic students need to decide which residency programs to apply to. Once offers to interview are extended, they then have to decide how many programs to interview with. After all the interviews are completed, they then have to decide how many residency programs to rank and what order they will rank those programs. Each of these decisions is influenced by how competitive the specialty is and how competitive the applicant is.

A student who chooses a highly competitive specialty, such as vascular surgery, will need to apply to dozens of residency programs, interview at as many as possible, and rank at least 22 programs to ensure getting a PGY-1 position. On the other hand, students applying to a relatively non-competitive specialty, such as family medicine, may only need to apply to, interview at, and rank a handful of residency programs. Applicants to non-competitive specialties can afford to limit the geographic parts of the country that they are willing to consider for residency but those applying to highly competitive specialities must be less geographically selective. Applicants to the most competitive specialities, such as neurosurgery, plastic surgery, orthopedic surgery, and otolaryngology may need to have a back-up plan and apply to residencies in a second specialty in case they do not match to their primary choice.

An applicant can never make too long of a rank list but they can (and frequently do) make too short of a rank list. You never know what is going through the minds of residency program selection committee members and there is a great danger for applicants who overestimate their competitiveness. In general, applicants should rank all residency programs that they would even remotely consider. Even the lowest ranked program on an applicant’s rank list is usually preferable to whatever residency programs are left unfilled after the match in the SOAP.

Applicants must be realistic in their assessment of their own competitiveness, also. A student at a prestigious medical school who has excellent grades and USLME scores can afford to apply to, interview at, and rank a relatively small number of residency programs but students from lesser known medical schools and those with less than stellar academic performance must apply to, interview at, and rank a larger number of residency programs. This is particularly complicated for students entering the couples match – the student entering the more competitive specialty or with the lower grades may need to dictate the number of programs that both students in the couples match ultimately rank on their match lists.

An event like no other…

In the United States, match day is a day like no other. It is the one day out of the year that all senior medical students learn where they will do their residencies – what state, city, and hosptital they will be doing the most important part of their medical training in. It can be a day of great joy for students who land a residency that is high on their rank list and can be a day of despair for those who do not match to a residency program. The best way to fall into the former category rather than the latter is to have a high degree of self-awareness and be strategic in creation of the rank list submitted to the match.

March 28, 2024

Categories
Hospital Finances Medical Education

What Hospitals Need To Know When Hiring Foreign Medical Graduate Physicians

International Medical Graduates (aka, foreign medical graduates) account for 325,000 of all practicing physicians in the United States or about 25% of the U.S. physician workforce. However, not all specialties are equal. In the most recent internal medicine fellowship match, the majority of endocrinology and nephrology positions were filled by international medical graduates, indicating that in the future, most endocrinologists and nephrologists in the U.S. will be international medical graduates. Almost every hospital in the nation has at least one international medical graduate on the medical staff and in many hospitals, there are more international medical graduates than U.S. medical graduates. As a result, hospitals must be familiar with the visa requirements when hiring an international medical graduate.

First, and I cannot stress this enough, get legal help. If the hospital’s in-house attorney does not have the expertise, then hire an outside immigration attorney. The cost of overlooking a seemingly minor piece of paperwork or failing to meet a filing deadline can result in the hospital no longer being able to employ a particular international medical graduate. Furthermore, immigration laws are subject to the vagaries of Congress and the U.S. Presidential office. So, the rules one year may be different than the rules the next year.

First, some definitions

There are dozens of different types of visas in the United States but only a few of them apply to physicians. Here are the most common:

J-1 Visa sample

J-1 visa. This is the most commonly used visa for non-U.S. citizens who went to medical school in another country. The J-1 visa is a training visa and is used by international medical graduates who do residencies and fellowships in the United States. This visa is only valid during residency and fellowship – the physician must return to his/her own country within 30 days of completing training. In addition, the physician holding a J-1 visa cannot be have any employment other than their residency or fellowship. In other words, they cannot moonlight. The maximum duration of the J-1 visa is 7 years, which allows completion of most residencies and subspecialty fellowships. After completion of their training program, the J-1 visa holder must return to practice medicine in their own country for at least 2 years, after which time, they are eligible to apply for a U.S. H-1B visa that would permit them to return to the United States to practice medicine. There is an important exception to this requirement, the “J-1 waiver”. This waiver allows the physician to stay in the U.S. to practice medicine without having to return to their own country after completing training (see below).

H-1B visa. This is a work visa and allows a foreign national physician to practice medicine in the United States for a maximum of 6 years. Requirements to obtain an H-1B visa include (1) passing all three USMLE exams, (2) meeting state medical board licensure requirements, and (3) obtaining certification by the Educational Commission for Foreign Medical Graduates (ECFMG). The physician must have completed an ACGME-certified residency and/or fellowship in the United States. Canadian physicians are unique in that completion of a Canadian residency and/or fellowship is acceptable in most states. A physician on an H-1B visa must have a sponsoring employer that files an H-1B petition on behalf of the physician and that completes a Labor Condition Application (LCA) attesting that the employer will fulfill Department of Labor prevailing wage requirements. Physicians with H-1B visas can only practice in the specific geographic location listed on the LCA. H-1B visa holders can apply for an immigrant visa which is the next step in obtaining U.S. citizenship.

Green Card sample

Immigrant visa (“green card”). This visa allows a foreign citizen to remain permanently in the United States. After 3-5 years, an immigrant visa holder can apply to become a naturalized U.S. citizen. To obtain an immigrant visa, the international medical graduate physician must have a sponsoring employer. The employer must first submit a Permanent Labor Certification (PERM) attesting that the physician will be hired for a permanent full-time position and then the physician must file an I-140 form ($700) followed by an I-485 form ($1,140). Although there is no cost to file the PERM, there is a requirement that the physician’s job be advertised to ensure that no U.S. citizen physician is willing to take the job and a need for an attorney to complete the process – this can total an additional $4,000 – $5,000. There is no specified amount of time that the physician must remain employed by the sponsoring employer however the law’s intent is that it is a permanent job.

O-1 visa. These are less commonly used and are reserved for non-citizens possessing “extraordinary ability” in the sciences, arts, business, education, or athletics. This can be applied to physicians with unique skills, particularly in medical research. The advantages of O-1 visas is that there is no annual limit to the number that can be approved, there is no requirement for the physician to return to their home country (unlike the J-1 visa), there is no need to do a comparative wage attestation (unlike the H-1B visa), and there is no time limit to the O-1 visas which can be held indefinitely. The standards for the O-1 visa are quite high for physicians and generally require publication of research that demonstrates exceptional ability.

NAFTA TN visa. This visa is reserved for physicians from Mexico or Canada. The TN program was established by NAFTA as a temporary work authorization. Mexican citizens must obtain a TN visa. Canadian citizens do not require a TN visa but can elect to obtain one at a U.S. port of entry. A TN visa permits employment in research or teaching. Direct patient care is allowed only when it is incidental to teaching or research. Canadian or Mexican physicians who intend to mainly perform patient care should apply for an H-1B or O-1 visa instead.

The J-1 waiver

Many international medical graduates on a J-1 visa during their residency and fellowship will return to their home country for the required 2-year period after completion of training. However, some elect to stay in the United States without returning to their own country by obtaining a “J-1 waiver“. This generally involves working for a government organization or working in an underserved area of the country. Physicians must also obtain a “no-objection” statement from their home country. The J-1 waiver then allows the physician to apply for an H-1B visa without having to return to their own country for 2 years. There are several pathways to get a J-1 waiver:

  • Persecution waiver. If the physician believes that he/she will be subject to persecution based on race, religion, or political opinion if he/she returns to their home country, then the physician can apply for a persecution waiver. These are uncommon.
  • Veterans Administration (VA) waiver. The VA will sponsor waivers for both primary care and specialist physicians. Because of this, the VA is generally the J-1 waiver of choice for specialists. There is a 3-year commitment.
  • Health and Human Services Administration (HHS) waiver. The HHS will sponsor waivers for only primary care physicians (family medicine, internal medicine, pediatrics, psychiatry, and OB/GYN). Physicians cannot have performed a fellowship. There is a 3-year commitment and physicians must practice in a Health Professional Shortage Area (HPSA) with a score of 7 or higher. The HPSA areas are shown in the county map to the right (click on the image to enlarge). The authorized employers and their HPSA scores can be searched for by county on the HPSA Find website.
  • Conrad 30 Waiver Program. Each state is allocated 30 Conrad waiver positions every year and each state has its own state-specific application requirements. Positions can be offered to both primary care physicians and specialists although in many states, primary care applicants are given preferential treatment. Applicants must work in a Health Professional Shortage Area, in a Medically Underserved Area, or serve a Medically Underserved Population. Medically Underserved Populations are those that face economic, cultural, or linguistic barriers to health care such as people experiencing homelessness, low-income, Medicaid-eligible, Native American, and migrant farmworkers. Medically Underserved Areas/Populations and their index of medical under service scores can be searched on the MUA Find website. Specific areas are designated by their GEOID number. Physicians must work full-time for at least 3 years.
  • Appalachian Regional Commission (ARC) waiver. This is limited to specific counties in the Appalachian area (click on the map to enlarge). Although designed for primary care physicians, specialists are sometimes accepted. Full information can be obtained on the ARC website. The physician must work full-time in a Health Professional Shortage Area.
  • Southeast Crescent Regional Commission (SCRC) waiver. This is limited to states in the southeastern United States. This waiver is designed for primary care but specialists are sometimes also accepted. Full information can be obtained on the SCRC website. Physicians must work in a Health Professional Shortage Area, in a Medically Underserved Area, or serve a Medically Underserved Population for a minimum of 3 years.
  • Delta Regional Authority (DRA) waiver. This is limited to states in the Mississippi River basin. Both primary care and specialists are accepted. Full information can be obtained on the DRA website. The physician must work full-time at a site in a Health Professional Shortage Area, Mental Health Professional Shortage Area, Medically Underserved Area, or Medically Underserved Population.

There is a substantial cost to the employer to obtain a J-1 waiver. The ARC, SCRC, and DRA each require a $3,000 application fee. There is no fee for the Conrad 30 or HHS waiver application. However, all of these programs have a requirement that the employer advertise the position nationally and demonstrate that no American physician is available to fill the position. Advertising expenses and legal expenses typically run about $8,000 – $10,000.

Academic medicine and international medical graduates

Foreign medical graduates at academic medical centers are treated slightly different than those employed by other hospitals or other clinical employers. First, they may be eligible for an O-1 visa or a TN visa, both of which are generally only used by physicians at academic medical centers. Most academic medical centers have experience employing foreign medical graduates because of the large number of these physicians who are residents or fellows in training programs. In the most recent internal medicine and pediatrics fellowship match, 26.2% of physicians matching to an available fellowship position were foreign medical graduates. In last year’s residency match, 14.5% of physicians matching to a PGY-1 position were foreign medical graduates.

Board certification/eligibility is usually required by hospitals for employment in order to perform patient care. In addition, health insurance companies may require physicians to be board certified or board eligible in order to participate in their insurance plans. In order to be board eligible, a physician must have completed a U.S. residency and/or fellowship. However, for some specialties, an exception can be obtained by foreign physicians practicing at an academic medical center who completed their residency or fellowship in another country. For example, the American Board of Internal Medicine permits foreign physicians working at a U.S. academic medical center to be eligible to take the board examination if they have an academic rank of at least assistant professor and are employed full-time for at least 3 years supervising medical trainees in clinical settings. The American Board of Surgery had a similar pathway for foreign medical graduates at academic medical centers however they did not accept applications for this pathway in 2023.

A complex process

As state above, legal counsel is essential when employing a physician who is a foreign medical graduate and not a U.S. citizen. If required documents are not submitted on time, it could result in the physician being sent back to their own country or not being eligible for the next step in the process of obtaining U.S. citizenship. Because of the need for an attorney with expertise in immigration law, as well as the need for job advertisement and various application fees, it can be costly to hire a foreign medical graduate. However, it can be hard to attract U.S. physicians to practice in medically underserved parts of the country, leaving hospitals with no other option than hiring foreign medical graduates. An advantage of these physicians is that the employer sponsorship requirements for work visas makes them less likely to resign than U.S. physicians, thus reducing physician turnover. Because of this, the added cost of hiring a foreign medical graduate may actually be less than the recruitment costs of a revolving door of U.S. physicians.

Given the high demand for foreign medical graduates, sending your hospital’s in-house attorney to attend a course in immigration law could be the best investment you will make this year.

December 18, 2023

Categories
Emergency Department Inpatient Practice Medical Education Outpatient Practice

The New DEA Opioid Education Requirements For Physicians

In March 2023, the U.S. Drug Enforcement Agency (DEA) announced new education requirements for all physicians applying for new or renewal DEA licenses. This was the result of provisions in the Consolidated Appropriations Act of 2023 that enacted a one-time requirement of 8 hours of continuing medical education (CME) on the treatment and management of patients with opioid or other substance use disorders. The requirement went into effect on June 27, 2023. Because DEA licenses are renewed on a rolling 3-year basis, all physicians with DEA licenses must meet this requirement sometime in the next 3 years.

Another provision of the Consolidated Appropriations Act of 2023 was to eliminate the DATA-Waiver (X-Waiver) Program that was previously required for physicians to prescribe buprenorphine. In the past, hospitalists, emergency medicine physicians, and other practitioners needed to obtain an X-Waiver to initiate buprenorphine when patients with opioid use disorder were admitted to the hospital or seen in the emergency department. Because only a small number of physicians took the time and effort to obtain an X-Waiver, the requirement was seen as a barrier to getting patients started on treatment. Now, any practitioner with a current Drug Enforcement Administration (DEA) registration may prescribe buprenorphine for opioid use disorder (if permitted by state law). The trade-off for elimination of the X-Waiver was the requirement that all practitioners with a DEA license be trained in the treatment of opioid use disorder, including the use of buprenorphine.

Who does this affect?

Any practitioner with a DEA registration must meet this requirement. This includes physicians, dentists, nurse practitioners, and physician assistants. However, only practitioners who prescribe controlled substances need to register with the DEA and obtain a DEA number. Although the majority of U.S. physicians have DEA numbers, some physicians do not, either by nature of their practice (for example, pathologists and researchers) or by choice (for example, general practitioners who do not want the hassle of prescribing opioids and other controlled substances).

To obtain a DEA number, a physician must apply to the DEA and pay an $888 fee. DEA numbers are valid for 3 years at which time the physician must re-apply. The DEA waives the fee for certain physicians including those who work in the military, for U.S. government hospitals or institutions, and for state government hospitals or institutions. As an employee of the Ohio State University (a state government institution), my DEA fees were waived. However, even if the fee is waived, the practitioner must still apply for and obtain a DEA number and the practitioner must still meet the new education requirements.

Certain practitioners are exempt from the new educational requirement including veterinarians, physicians board-certified in addiction medicine, and practitioners who have graduated from their professional school within the past 5 years. The latter means that most residents in training are exempt.

What are the specifics of the requirement?

When applying for a new or renewal DEA number, physicians (and other practitioners) must check a box attesting to having completed 8 hours of training on treatment and management of patients with opioid or other substance use disorders. This is a fairly broad topic area and it is up to physicians to maintain their own documentation of completion of education in the event of an audit. In addition, if the physician faces legal action (such as a medical malpractice lawsuit), documentation of completion may be necessary to establish physician competency. The details of the requirement are as follows:

  • The 8 hours of education do not need to occur in one session and (for example) can be 8 individual 1-hour CME events.
  • This is a one-time requirement and will not need to be repeated every three years when re-applying for a DEA number.
  • Education can take the form of grand rounds, classroom sessions, on-line materials, or professional society meetings.
  • Education hours obtained prior to the new requirement also count. For example, attending a grand rounds on buprenorphine in past years can count; just be sure that you have documentation of participation or attendance. Physicians with an X-Waiver can count the training hours from their original X-Waiver application.
  • The education can come from any organization accredited to provide CME credits by the Accreditation Council for Continuing Medical Education.

What do hospitals need to do?

Although the DEA requirement is left to the responsibility of the individual practitioner applying for a DEA number, hospitals do have an obligation to facilitate education. First, if practitioners fail to get the required 8 hours of training and are unable to obtain a DEA number, the hospital’s ability to dispense controlled substances or manage patients requiring controlled substances will be compromised. Second, in the event of a medical malpractice lawsuit involving a practitioner on the medical staff who lacks documentation of completion of the educational requirements, the hospital could be accused of being complicit by not confirming that their practitioners were appropriately trained. Specific steps that hospitals should take now include:

  • Make sure that all members of the medical staff are aware of the new DEA requirements.
  • Inventory practitioners’ DEA license expiration dates and remind practitioners at least 6 months in advance of that date that they must fulfill the educational requirements prior to the renewing their DEA number.
  • Require practitioners with DEA numbers to submit documentation of completion of the educational requirements and then maintain that documentation in each practitioner’s employment record.
  • Require any new practitioners to include documentation of completion of substance abuse treatment CME as part of their application to the medical staff. Those lacking documentation should be required to complete training during their provisional/probational appointment period.
  • Schedule grand rounds or other CME events covering treating and managing patients with opioid or other substance use disorders.
  • Provide practitioners with links to on-line CME resources. For nearly a quarter of a century, I moderated the CME webcast, OSU MedNet-21. We produced many CME webcasts on substance abuse disorders and these webcasts are available to anyone. A recent example is:
  • Many professional societies have included sessions on substance abuse disorders as part of their annual meetings or have prepared on-line CME sessions to help fulfill the requirements. Examples of on-line education programs include:
  • The Centers for Disease Control offers a free on-line 1-hour CME activity about substance abuse disorders
  • Journal subscription materials can count. Practitioners with subscriptions to resources such as UpToDate, JAMA, and the New England Journal of Medicine can obtain CME credit by reading relevant articles and then applying for CME hours.

Why has Congress required this?

The primary impetus for the new requirement is a directive of the U.S. Congress to address the opioid epidemic. Eliminating the X-Waiver program was seen as a way of improving access to treatment for patients with opioid use disorder. But to justify elimination of the X-Waivers, Congress needed a mechanism to ensure that all practitioners were knowledgable in initiating treatment for opioid use disorder.

In 2021, a total of 106,699 Americans died of a drug overdose. Although street-purchased fentanyl was the most common drug implicated, prescription opioids accounted for 16,706 of the overdose deaths in 2021. In fact, the number of deaths from prescription opioids exceeded the number of deaths from heroin (9,173).

Drug overdose deaths are particularly high in Appalachian states. West Virginia has the highest overdose death rate at 90.9 per 100,000 population, followed by Kentucky and Tennessee (each 56.6 per 100,000 population) and Louisiana (55.9 per 100,000 population). My state of Ohio ranks 7th highest at 48.1 per 100,000 population. Nebraska comes in lowest at 11.4 per 100,000 population.

To put these numbers in perspective, last year, the U.S. COVID death rate was 61.3 per 100,000 population. Opioids are abused by more than 10 million Americans each year (3.8% of Americans) and 2.7 million Americans have an opioid use disorder. About half of those who become addicted to opioids first use opioids in the form of prescription pain medications. An estimated 3% – 19% of people who take prescription opioid pain medications will become addicted to opioids. Addiction can occur with only 3-5 days of prescription opioid use.

The good news is that there are effective treatments for opioid use disorder including buprenorphine (often combined with naloxone), methadone, and naltrexone. In addition, the FDA has now approved naloxone to be sold over-the-counter to treat opioid overdose. The goal of the DEA education requirements is that any practitioner in the U.S. who is licensed to prescribe opioids is also trained in identifying and treating opioid abuse.

A quarter of a century of change

In the 25 years since the American Pain Society advocated that physicians adopt “pain as the 5th vital sign” and since Purdue Pharmaceuticals falsely promoted OxyContin as a non-addictive opioid, physicians have become much more aware of the role that we have played in catalyzing the current opioid epidemic. The new DEA education requirements were created as one step in remedying the epidemic. By helping our physicians meet these new requirements, hospitals can help reduce the number of Americans who become addicted and help increase the number of Americans who get their addiction treated.

August 28, 2023

Categories
Medical Education

The COVID Generation Of Doctors

This summer, newly trained physicians completing residencies will be entering the medical profession workforce as attending physicians. These are the first group of physicians who did their residency training entirely during the COVID pandemic. Their education and view of medicine has been uniquely affected by their experiences. So, what can we expect from them?

Emergency medicine, internal medicine, pediatrics, and family medicine residencies are 3 years long. Other specialties are longer. U.S. hospitals were first affected by the COVID pandemic in March 2020. The physicians who started 3-year residencies in July 2020 have now completed residency and are either going out into practice or are continuing training in subspecialty fellowships. Residency is the most important experience that molds physicians and residency experience influences physicians’ practice for the rest of their lives. COVID has had an out-sized affect on these newly-trained physicians.

How did resident training change during COVID?

Almost overnight in the spring of 2020, education in the United States changed and residency education was no exception. What did these residents experience that previous generations of residents did not?

  • Lost training time. In March 2020, outpatient clinics shut down, elective hospital admissions were canceled, and medicine, except for COVID, came to a standstill. Early on, there was a prevailing attitude from residency program leaders that as trainees, residents should not be required to care for patients with COVID infection. Across the country, residents were sent home. As a result, the effective duration of residency was shortened by weeks or months for many residents. Attending physicians had to prioritize caring for COVID patients rather than preparing lectures for residents and engaging in bedside teaching. For those residents who remained in the hospitals, procedural experiences were often limited. For example, in the months of the pandemic, I performed intubations and bronchoscopies on suspected COVID patients by myself, without residents or fellows in the room, in order to reduce the number of people exposed to aerosolized virus. Family medicine residents had virtually no sports medicine experiences in the first year of the pandemic since high school and college sports were cancelled.
  • They didn’t attend national medical conferences. In 2020, national medical society annual meetings, such as the American College of Physicians, were canceled. In 2021 and 2022, attendance at medical conferences was down and many people attended virtually, rather than in person. This resulted in a loss of an important networking opportunity for residents during these years in addition to a loss of cutting edge knowledge about new developments in medicine.
  • Remote learning. Prior to 2020, classroom space in most hospitals was premium real estate. Rooms had to be reserved for conferences and lectures months in advance and sometimes, there was simply no convenient place to hold these lectures. Furthermore, residents who either were off-duty due to working night shifts or were doing rotations off-site from the main hospital were unable to attend lectures. With the onset of COVID, lectures were all changed to remote learning by WebEx, Zoom, and Teams video conferencing. Although many educators lamented the loss of the in-person lecture, video conferencing allowed residents to attend more educational conferences than in the past, thus enriching their didactic training. Today, primary and secondary education has largely returned to in-person classroom instruction but residents still mostly attend lectures by video conferencing because it is more efficient. A few months ago, I gave a talk to our fellows – there were dozens of attendees on-line but I was the only person in the lecture hall.
  • Telemedicine. When the pandemic hit and outpatient appointments were converted to telemedicine appointments, many older physicians had a difficult time adapting to new workflows, effective use of video, and the lack of physical exams. But for new residency graduates, telemedicine is normal medicine. Many of them performed telemedicine patient visits during residency before they performed in-office visits. These physicians are not only more comfortable using telemedicine but they will demand that Medicare and commercial health insurance companies continue to reimburse for it.
  • A hostile segment of the population. Early in the pandemic, healthcare workers were revered heroes in the United States. But soon, anti-maskers, anti-vaxxers, and COVID-deniers became increasingly vocal skeptics of the medical community. Across the country, health department medical directors were threatened, public health officials were fired, and even Anthony Fauci was vilified. As a result, these newly trained physicians have felt hostility from a loud group of Americans and have developed a jaded view of public health.
  • Compassion fatigue. The COVID pandemic desensitized many residents to grief. When patients are dying all around you, emotions become hardened. Early in the pandemic, it was the sheer numbers of the dead. Later in the pandemic, most of those hospitalized with COVID or dying of COVID were the unvaccinated and as a result, all too often, we ended up blaming the patients for their illness.
  • More burnout. The pandemic stressed residents in training but also stressed the attending physicians who were their mentors. When the doctors that you are trying to emulate become cynical or want to leave the practice of medicine, the flames of burnout can spread to trainees. COVID brought out both the best and the worst in us. When it brought out the worst in an attending physician or a group of physicians, their trainees were impacted. This year’s group of residency graduates have experienced more burnout than previous groups – both personally and in their colleagues.
  • An unbalanced clinical experience. I am a physician member of the AIDS generation. As a resident, I spent 2 months on the inpatient AIDS service. During my first year of pulmonary and critical care fellowship, I performed 350 bronchoscopies, more than half of which were performed to diagnose opportunistic pneumonia in patients with HIV infection. AIDS dominated my clinical experience. For this year’s group of graduating residents, it is COVID that has by necessity dominated many of their clinical experiences. This has made them very good at managing COVID infections but has often reduced the number of patients that they have seen with non-COVID medical conditions. Many have treated more patients with COVID than patients with heart failure. ICU rotations have been particularly unbalanced with disproportionately more COVID respiratory failure than other critical illnesses such as ketoacidosis and septic shock.
  • Better attention to infection control. Before the pandemic, hospitals had to continually remind physicians to wash their hands after examining patients. Doctors frequently came to work despite having a cold or the flu. That all changed in the spring of 2020 when not wearing a mask or washing your hands could cost you your life. This year’s residency graduates are more attentive to nosocomial transmission of infections and this could make our hospitals and medical offices safer in the future.

What hospitals can do

In the United States, the majority of physicians are now employed by a  hospital or health system. Newly trained physicians are even more likely to be hospital-employed. Our hospital leaders need to be aware that these new internists, pediatricians, ER physicians, and family practitioners are different than previous physicians – not better or worse, just different. In order to maximize the potential of these physicians, there are steps we can make today to ensure that they are happy, productive, and practice high-quality medicine.

  •  Optimize telemedicine capabilty. These doctors have learned to do telemedicine very effectively so give them the tools to do it. This means updating patient teleconferencing hardware, ensuring telemedicine seamlessly integrates into the electronic medical record, and the ensuring that the revenue cycle department is fully up to date on telemedicine billing. Dedicated telemedicine IT support is essential. Outpatient workflows and scheduling need to be re-engineered with telemedicine efficiency in mind.
  • Enhance educational videoconferencing capability. Winding down the pandemic should not mean winding down videoconferencing. Teaching conferences, grand rounds, and departmental meetings should always have video options available.
  • Promote career mentor relationships. Navigating the post-pandemic world could prove challenging for physicians who have only known the pandemic during their training. Ensure that every new physician has an assigned senior physician mentor from the first day of their employment. Over time, physicians usually identify their own career mentors but having an designated experienced physician who a young residency graduate can go to for career advice from day one is ideal.
  • Smother the embers of smoldering burnout. Many of these newly trained physicians are already experiencing burnout and others are teetering of the edge of burnout. There are several practical measures that hospital leaders can take to fireproof their doctors against burnout. Making workplace wellness a priority is essential to bring out the best in the COVID generation of doctors.
  • Step-up your CME program. By attending fewer (or no) national medical meetings during residency, newly trained physicians were dependent on their hospitals’ own attending physicians and on-line sources for their education. They often lacked exposure to opposing or innovative viewpoints on disease diagnosis and management. More than any other generation of physicians, they will benefit by continuing medical education in their first years in practice. Include CME expense allowances in their employment contracts to encourage them to attend regional and national meetings. At the risk of shameless self-promotion, consider a hospital subscription to the medical education webcast, OSU MedNet, that I moderated for 25 years.
  • Keep momentum on infection control. This generation of physicians is more attuned to hand-washing and prevention of nosocomial infections than any other generation of physicians. It is much easier to maintain a culture of attention to infection control than to change a culture of inattention to infection control. Normalize healthcare workers staying home when they are sick and maintain adherence to hand-washing.
  • Encourage proctoring. Because of an imbalance in clinical experiences during training and fewer opportunities to perform procedures during training, some recent residency graduates may not have adequate experience performing office procedures, performing hospital bedside procedures, and interpreting bedside tests. A proctoring program can ensure that they competent to perform these procedures. For example, a hospital could require a new internal medicine hospitalist to have 2 or 3 central venous catheter placements proctored before full central line privileges are granted. Or 2 or 3 IUD placements for a family medicine physician. Or 2 or 3 intubations for an emergency medicine physician.
  • Re-kindle compassion. Compassion is not created by a CME lecture or by reading words in a book. Compassion is created when there is a culture of compassion among one’s peers. It is fostered by the example that is set by senior physicians and medical directors. That means being inspirational, showing empathy, and being considerate to not only patients but other healthcare workers.

The newly graduated residents represent the future of medicine. But they are different from previous generations of physicians with different strengths and weaknesses. It is up to us as medical leaders to ensure that they are able to grow to their full potential.

August 15, 2023

Categories
Medical Education

Is It Time To Do Away With MOC?

MOC, or maintenance of certification, is the requirement used by medical specialty boards for physicians to maintain board certification. But do we really need board certification MOC?

The American Board of Medical Specialties is a non-profit organization consisting of 24 member board organizations. These include the American Board of Internal Medicine (ABIM), American Board of Pediatrics, American Board of Surgery, American Board of Family Medicine, among others. Each board determines the requirements for board certification in its specialty, which is generally completion of an appropriate residency or fellowship followed by successfully passing a board examination in that speciality.

After a physician successfully completes a residency or fellowship, they are then “board-eligible” in that specialty. To become board-certified, the physician must take and pass a board examination in that specialty. These board examinations consist of a 1-day written test and some specialty boards additionally require an oral examination. In the 1970’s becoming board-certified was considered optional and most hospitals did not require a physician to take a board examination in order to practice in that particular specialty. By the 1980’s, many hospitals began to require new physicians to be board-certified in order to have hospital privileges in any given specialty but older, non-certified physicians were generally grandfathered in for hospital privileging. Until 1990, physicians only had to take and pass a specialty board examination once and then they had lifetime board certification. However, after 1990, the specialty board organizations moved to a time-limited board certification and required physicians to re-take the specialty board examination every 10 years in order to maintain their certification.

Although taking and passing the board examination periodically initially sounded like a good idea, it became immediately apparent that this created a problem for many physicians. For example, an internal medicine hospitalist had to take the general internal medicine recertification exam that largely focused on outpatient medicine topics which were irrelevant to inpatient hospitalist practice. Or the oncologist who sub-specialized in prostate cancer treatment would have to take the general oncology recertification examination that tested about breast cancer, colon cancer, and lung cancer treatment, all of which were irrelevant to the prostate cancer subspecialist’s practice. The recertification tests were hard and many physicians had to take a week-long board review and preparation course in order to pass the tests.

In an attempt to maintain relevancy, specialty boards have added maintenance of certification modules in addition to or instead of the every 10-year recertification exam. These MOC modules are generally a series of annual open-book examinations that physicians could take at home, on their own time. The argument for open-book exams is that by making the physician research questions using medical references, the physician would learn about the topic in order to answer the question correctly. However, with the widespread availability of artificial intelligence resources, such as ChatGPT, a person would not even need to have a high school diploma to pass an open-book specialty board MOC module. Each module is worth a certain number of MOC points; as an example, the American Board of Internal Medicine requires a physician to have 100 points every 5 years to maintain certification.

MOC points can also be awarded for other activities, such as attending CME (continuing medical education) events. Thus, MOC points can be awarded for going to a medical conference, attending grand rounds, or viewing on-line medical education webcasts. MOC points can even be awarded for viewing on-line medical reference resources, such as UpToDate.

Physicians already have other educational requirements

Maintenance of certification by specialty boards is not the only on-going educational requirement that physicians face. Here are a few of those that I was required to do in order to practice at our hospital:

  1. Continuing medical education. The Ohio State Medical Board requires all physicians to have 50 hours of CME credits every 2 years to maintain licensure. CME credits are commonly acquired by attending hospital grand rounds or annual specialty medical conferences.
  2. Advanced cardiac life support. In our hospital, critical care medicine privileges and sedation privileges require ACLS certification. Re-certification is necessary every 2 years and consists of a four-hour course in-person course that includes a written examination. Prior to attending the re-certification course, attendees must first read and study the 202-page ACLS manual. Over my career, I took the ACLS course 19 times.
  3. Collaborative Institutional Training Initiative. The CITI course is required for any physician who is involved with clinical research and takes approximately 4 hours. This must be repeated every three years.
  4. Electronic medical record training. Initially, this takes about 10-20 hours. However, once you are facile with it, you just need to get trained on the periodic software updates – about 1 hour per year.
  5. Compliance training. At our hospital, we have a mandatory 2 hours per year for billing/coding compliance training to ensure that we are documenting our services and billing correctly. In addition, there is a 1-hour annual HIPAA compliance module requirement.
  6. Hospital training. These annual modules consist of on-line content with a post-test that requires a passing score of > 80%. They cover everything from what to do in a fire, to how to read a hazardous materials label, to the hospital’s sexual harassment policy. They vary in number from year to year but typically total about 10 hours per year.

The argument for MOC

Advances in medicine happen rapidly resulting in significant changes in medical practice every few years. For example, the way that we manage a patient with a myocardial infarction today is totally different than the way we did 20 years ago. The main argument for MOC is that it is a way to ensure that physicians keep up with the changes in their specialties.

The arguments against MOC

A petition to end the American Board of Internal Medicine’s MOC requirement started 2 weeks ago already has 10,500 signatures. The authors of the petition stated that signers “firmly believe that the MOC program has become burdensome, costly, and lacks evidence to support its effectiveness in improving patient care or physician competence.” So, what are the objections?

  • Cost. The cost of the American Board of Internal Medicine initial specialty examination is $1,430 and subspecialty examinations are $2,325.  The ABIM’s MOC program costs $220 per year to maintain board certification. Each additional subspecialty costs $120 per year. In my case, as an internist who subspecializes in pulmonary medicine and critical care medicine, the initial cost would be $6,080 and then $440 per year after that. Many physicians have expressed concern that the MOC programs are used by the subspecialty boards to increase their revenues and have pointed to the ABIM president’s annual salary of $1,031,924 for his 32-hour work week (more than four times the average salary of an internist).
  • Redundancy. State medical boards already require 25 hours or more of continuing medical education per year in order to maintain a medical license. Most CME activities are also eligible for MOC points so many physicians say that they are paying the boards to keep track of education that they are already doing for their state medical boards.
  • Irrelevancy. As physicians become more sub-specialized, MOC tests that cover diseases that the physicians do not treat in their regular medical practices are irrelevant. Because a physician does not normally manage a particular group of diseases, it takes much more time to prepare for unfamiliar subjects. An analogy would be to require a professor of 20th century American literature to pass an annual test covering 10th century Chinese literature. In my situation, I do not and have never practiced sleep medicine yet 10% of the pulmonary board recertification exam consists of sleep medicine questions. I can remember driving from Columbus to Cincinnati to take my 10-year pulmonary recertification exam and calling one of my colleagues from the car to tell me everything I needed to know about interpreting a sleep study.
  • Unproven benefit. To date, there is no evidence that passing MOC tests and modules makes a specialist a better doctor. In an era where evidence-based medicine is championed, there is no evidence that MOC is effective in determining physician competency.
  • Discriminatory. In the past, once a physician passed the board examination, the physician was board-certified for life and there was no requirement for MOC or re-certification. For hospitals that require board certification for credentialing, older physicians who are board certified for life do not need to do MOC but younger physicians whose board certifications are time-limited to 10 years do need to do MOC.
  • Physician burnout. There is not a single physician in the U.S. who looks forward to taking a recertification examination. Many choose to take board exam review and prep courses (the course offered by the American College of Physicians to prepare for the ABIM exam costs $1,095). This requires time off work and creates anxiety about a tedious process that does not make them better doctors. Many physicians time their retirement to coincide with when their 10-year recertification expires just so they do not have to go through it another time.

So, what is the solution?

Board certification was initially created to document successful completion of a specialty residency or subspecialty fellowship. It was similar to the final exam for a college course. You completed a 3-year residency and then at the end, took the ABIM exam to certify that you learned what you needed to know to be an internist. The board exam should go back to being the final exam of a residency or fellowship. I believe that the specialty boards should not be involved with any form of recertification after that initial test. The practicing physician specializing in breast cancer oncology does not need to be held to the same knowledge level about colon cancer as a physician who just completed a general oncology fellowship.

Specialty board organizations need to be down-sized. Re-certification is big business. The ABIM alone has annual revenues exceeding $71 million. The increased income from recertification has resulted in bloated salaries for senior executives and expansion in the number of employees. These boards were created to serve the medical profession but now, the medical profession is increasingly serving the board organizations. They have become feudal lords over fiefdoms of medical specialists.

Health insurance companies should abandon recertification requirements for physicians. Currently, one of the main reasons that physicians spend so much time and money on board recertification is because it is a requirement to be paid by many health insurance companies. The insurance companies have no way to know whether or not a physician is competent so they have adopted board re-certification as a surrogate marker for competency. The problem is that it is not.

“Open book” MOC tests are no longer valid in an era of on-line artificial intelligence programs. All a physician has to do is copy and paste the question into an AI program and the program will tell you the correct answer. These take-home tests are now meaningless.

We should replace the concept of “maintenance of certification” with “maintenance of competency”. Competency determination should be left to the state medical boards and hospital credentials committees. There is no evidence that completing MOC modules ensures that a physician is competent in their area of practice. State medical boards should dictate the number of annual continuing medical education hours required for maintenance of licensure and continue to sanction or revoke licenses of physicians determined to not meet the standards of medical practice. Hospitals should use their credentials committee to confirm that specialists on the medical staff are practicing medicine and surgery competently. As a hospital medical director, I believe that the people who can best judge the competency of a physician are the other physicians who practice in the same hospital. Over the years, I have seen plenty of physicians who always passed their board re-certification exam but were kicked off of our hospital’s medical staff because they were incompetent.

So, is it time to do away with MOC?

…Yes.

August 7, 2023

Categories
Medical Education

Physicians, Race Disparities, And The Supreme Court Ruling On Affirmative Action

In striking down affirmative action last week, Chief Justice Roberts stated of race-based college admission practices: “Those policies fly in the face of our colorblind Constitution.” This decision will also affect medical school admissions and thus the demographics of the U.S. physician workforce in the future. Affirmative action was created to overcome disparities caused by racial discrimination but the Supreme Court has determined that affirmative action itself is discriminatory.

Summary Points:

  • There are significant racial disparities in the U.S. physician workforce resulting from racial discrimination in the U.S. decades ago and from the racial demographics of our foreign medical graduates
  • To overcome those disparities, U.S. medical schools have relied on affirmative action
  • The Supreme Court has recently ruled that affirmative action is itself discriminatory
  • Simultaneously, the U.S. Senate is proposing to increase the number of Medicare-funded residency positions by 14,000
  • These new residency positions will largely be filled by foreign medical graduates
  • The combination of residency position expansion and affirmative action elimination will likely worsen racial disparities in the U.S. physician workforce

 

For years, medicine has embraced efforts to improve diversity. Our medical schools strive to increase the percentage of underrepresented minorities in admissions. Our deans take pride in publicly stating that “This class is the most diverse that we have ever had.” Our hospital leadership search committees are directed to include increasing diversity as a criteria when identifying job candidates. We champion implicit bias training in our medical centers. Even the NFL has the “Rooney Rule” that requires that league teams to interview minority candidates for head coaching positions. However, under the sociopolitical threat of being accused of practicing critical race theory or wokeness, it is now becoming increasingly dangerous to embrace diversity. The Supreme Court decision was made specifically in regard to undergraduate college admissions but has the potential to be extrapolated to medical school admissions, hospital leadership search committees, and yes, even the NFL’s Rooney Rule.

The racial composition of the U.S. physician workforce 

It has long been recognized that some racial minority groups are under-represented in the physician workforce. As physicians, we are disproportionately White and Asian.  The figure below shows the percentages of the U.S. population (left) and practicing U.S. physicians (right) by race from the 2022 report by the Association of American Medical Colleges.

The U.S. population is 59% White but 64% of U.S. physicians are White. There is an even greater discrepancy for Asians who constitute 6% of the population but 21% of U.S. physicians. On the other hand, although 19% of the population is Hispanic, only 7% of physicians are Hispanic; 14% of the population is Black but only 6% of physicians are black. 1.6% of the population is Native American/Native Hawaiian/Pacific Islander but this group comprises only 0.4% of physicians.

The reasons for these racial disparities are complex and I’ve written in the past about my own thoughts on why there are so many Asian physicians in the U.S. The hard truth is that Black, Hispanic, and Native Americans are far less likely to become physicians than White or Asian Americans.

Race and medical student demographics

When we look at the most recent medical school admissions data from the AAMC, we see that there are notable changes in the racial demographics of our future doctors (who are currently first year medical students) compared to our current practicing doctors.

Notably, fewer of our medical students identify as being White (45%) compared to either currently practicing physicians (64%) or the U.S. population in general (59%). The percentage of medical students who identify as Hispanic (7%), Black (8%), or Asian (24%) are reasonably similar to the percentages of currently practicing physicians. However, the percentage of medical students who report being of mixed race is much higher (11%) than either that of practicing physicians (< 1%) or the U.S. population (1%). It is possible that this reflects a greater willingness of the younger generation of medical school applicants to identify as mixed race either because of greater comfort in professing to be of mixed race than previous generations or because of a perceived advantage in being mixed race when affirmative action was used as a criteria for deciding medical school admissions.

We are facing a physician shortage

Twenty five years ago, many medical economists projected that we would face a surplus of physicians in the future and recommended reducing the number of medical school admissions. Those projections have made a 180 degree turn. The AAMC now projects that by 2034, our country will face a shortage of somewhere between 37,800 and 124,000 physicians. Because completion of residency is required for medical licensure, the rate limiting factor in the number of practicing U.S. physicians is the number of residency positions in this country. Most residency positions are paid for by Medicare graduate medical education (GME) funds and consequently, Medicare determines the number of doctors entering the U.S. workforce. For many years, Congress did not increase Medicare funding for GME until 3 years ago, when Congress expanded the number of Medicare-funded residency positions by 1,200. A new bi-partisan bill proposed by Senators Bob Menendez, John Boozmen, Chuck Schumer, and Susan Collins would further increase the number of Medicare resident positions by 2,000 per year for seven years (14,000 in total). Because most residencies are 3 – 5 years in length, the net effect would be to increase the number of new practicing physicians by approximately 4,000 per year.

But where will those 4,000 new physicians come from? Unless we increase the number of U.S. medical students, these new physicians will be foreign medical graduates. Last year, U.S medical and osteopathic schools graduated 25,051 MD students and 7,303 DO students for a total of 32,354 new graduates. The majority of these new graduates then enter the National Resident Matching Program to be assigned to residency positions. Those medical school graduates who do not do residencies instead go into industry, research, or some other profession. Some medical school senior students apply to the few residency programs that do not participate in the Match. However, last year, 19,748 MD senior students and 7,436 DO senior students did apply for residency in the Match. In other words, there were a total of 27,184 US graduates of MD and DO schools applying for the 40,375 residency positions offered in the Match. Although not all U.S. medical and osteopathic school senior will match to a residency during the formal Match, most of those who do not get a residency position in the Match will get a position during the Supplemental Offer and Acceptance Program (SOAP) when unfilled residency programs seek out unmatched U.S. senior students. The bottom line is just about every U.S. MD or DO graduate who wants a residency position can get one (although it may not be their top choice).

The United States has long depended on international medical graduates to fill our physician workforce. Currently, 25% of licensed U.S. doctors attended a medical school outside of the U.S. Because there are more residency positions than U.S. medical and osteopathic school graduates, we depend on foreign medical graduates to fill our residency positions. Last year, 5,032 non-U.S. citizen foreign medical graduates matched to first year residency positions. In addition, 3,356 U.S. citizens attending international medical schools matched to residency positions. Since there is currently no surplus of U.S. MD and DO graduates to fill the 14,000 residency positions that the Senate proposes to increase, these positions will by necessity have to be filled by international medical school graduates.

So, where will all of these new foreign medical graduates come from? The most recent data indicates that 23% of foreign medical graduates in the United States come from India, 18% from the Caribbean, 6% from Pakistan, 6% from the Philippines, and 5% from Mexico. The remainder (52%) come from a wide variety of countries. Because Asian countries have the largest number of medical schools, we can expect that in the future, a disproportionately large percentage of foreign medical graduates entering U.S. residencies will continue to be Asian and a disproportionately small percentage will be Black or Hispanic. For example, India has 304 medical schools, China has 147, and Pakistan 86. On the other hand, there are only 143 medical schools on the entire continent of Africa (54 countries).

The implication is that in the future, as the number of residency positions increases, unless we increase the number of graduates from U.S. medical and osteopathic schools, we will likely see even wider racial disparities in the U.S. physician workforce due to the racial demographics of foreign medical graduates who apply to U.S. residency positions. It is incredibly expensive to build new medical schools – most are constructed using state government funding and few states are currently able (or willing) to pay for them. It is not just the cost of the physical buildings but also the cost of the faculty salaries for years 1 & 2 and the challenge in finding enough clinical preceptors for years 3 & 4. Consequently, it is unlikely that the proposed increase in Medicare-funded GME positions will be accompanied by a proportionate increase in the number of U.S. medical students, at least in the near future.

To improve physician racial disparities, start in kindergarten

Stating that college (and medical school) admissions should be colorblind turns a blind eye on racial disparities that exist during the 13 years of education before a high school senior applies to college. With public education supported by property taxes, poorer communities have less money for schools. This is amplified when state governments re-direct money for public education to pay for private schools and charter schools. Add in crime, gang violence, poverty, teenage pregnancy, and insecure housing in many communities with high percentages of Black, Hispanic, and Native Americans, and it is not surprising that high school seniors from these communities are at a competitive disadvantage when applying to college and medical school compared to those from more affluent communities.

To level the playing field for those coming from those communities, we must level the educational playing field starting in elementary school. That means ensuring that all American children have access to high quality education in our public schools. It means that a college degree needs to be affordable to all qualified applicants and not just those whose parents can afford the cost of tuition. It means increasing scholarships for low income high school seniors applying to college. It means improving financial literacy for students seeking educational loans and financial aid. It means that any American child should be able to have the audacity to dream of becoming a physician if they are smart enough and willing to work hard enough, regardless of their race or the neighborhood they grow up in.

Ask a room full of doctors how they came to choose a speciality and the majority will tell you that they were influenced by an admired mentor who served as a role model. Doctors live in affluent neighborhoods and serve as career role models for the children that live in those neighborhoods. Those doctors attend the neighborhood churches/synagogues/mosques/temples and the children of those doctors attend the neighborhood schools. One of our challenges in the United States is that Black, Hispanic, and Native American children often do not live in affluent neighborhoods and often lack physician role models. I don’t pretend to know how to fix this but it is a major barrier to overcoming the racial demographic disparities among practicing U.S. physicians.

In an ideal world, I would agree with Chief Justice Roberts that college and medical school admissions should be colorblind. The problem is that the U.S. educational system before getting to college and medical school is not colorblind. Eliminating affirmative action does nothing to address the root cause of racial disparities in the U.S. physician workforce. Indeed, it may make these disparities worse.

Discrimination versus disparity

Although similar, there are important differences between the terms discrimination and disparity. Discrimination is the unjust or prejudicial treatment of different categories of people, particularly on the grounds of race, ethnicity, age, sex, or disabilityDisparity is a lack of similarity or equality, particularly with respect to race, ethnicity, age, sex, or disability. Discrimination usually results in immediate disparity but disparity does not always result from discrimination and when it does, it can be from historical discrimination decades or even generations previously.

Disparities in U.S. medical student demographics is the result of historical racial discrimination in our country. However, disparities in our foreign medical graduate demographics is not a result of racial discrimination in our country but rather a result of where the world’s non-U.S. medical schools are located. These two disparities combine to cause the current racial disparities in the U.S. physician workforce.

Now that the Supreme Court has determined that affirmative action is itself discriminatory, we will have to find other ways to overcome the glaring racial disparities within the medical profession.

July 3, 2023

 

Categories
Medical Education Operating Room

In The Future, Your Nurse Anesthetist Will Be A Doctor

Certified registered nurse anesthetists (CRNAs) are advanced practice nurses who deliver anesthesia. In 2025, the training requirements to become a CRNA will change and require that all new CRNAs have a doctorate degree. In the past, a 4-year bachelors degree followed by a 2-year masters degree in nurse anesthesia was required to become a CNRA. This is similar to other advanced practice providers such physician assistants, nurse midwives, and nurse practitioners. In 2009, the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) voted to require all nurse anesthesia educational programs to transition to 3-year doctoral programs. The deadline for conversion from masters to doctoral programs is 2025. Therefore, after 2025, all newly graduated nurse anesthetists will have doctorate degrees. In order to meet that deadline, beginning this year in 2023, all students enrolling in CRNA programs must enroll in a 3-year doctorate program.

There are six possible doctoral degrees that a nurse can pursue in becoming a CRNA:

  1. DNP (Doctor of Nurse Practice): a degree for a clinical career
  2. DNAP (Doctor of Nurse Anesthesia Practice): a degree for a clinical career
  3. PhD (Doctor of Philosophy): primarily a degree for a career in academics
  4. EdD (Doctor of Education: primarily a degree for a career in education
  5. DNS (Doctor of Nursing Science): primarily a degree for a career in research
  6. DMPNA (Doctor of Management Practice in Nurse Anesthesia): primarily a degree for a career in administration

The vast majority of new CRNAs will have either a DNP or DNAP degree. Both are 3-year programs that require a previous bachelors degree, usually a BSN (Bachelors of Science in Nursing). Both require one year of prior clinical work practice as an RN in a critical care setting but some individual programs may require 2-years of practice as an RN. Both have similar curricula but there are minor differences between the two types of doctorate degrees.

DNP versus DNAP

Doctor of Nurse Practice (DNP). This is a doctoral degree offered at a school of nursing that is accredited by the American Nurses Credentialing Center (ANCC) which is a subsidiary of the American Nurses Association. There are many specialty pathways within the DNP program and a student choosing to become a nurse anesthetist would enroll in the the CRNA pathway. A DNP is considered a “terminal degree”, meaning it is the highest degree that can be obtained in a field. Terminal degrees are usually required for university faculty members seeking tenure.

Doctor of Nurse Anesthesia Practice (DNAP). This is a doctoral degree specially designed for nurse anesthetist students at a training program approved by Nurse Anesthetists Council of Accreditation (NACA). Unlike the DNP, the DNAP is only for nurse anesthetists and not other nurse practitioner specialties. Some, but not all universities consider a DNAP to be a terminal degree; therefore it may not be appropriate for someone who plans to pursue an academic career at a university in order to ensure universal eligibility for faculty jobs.

For the hospital, both the DNP and DNAP programs can be considered equivalent from a training standpoint.

A certification exam is required after training

After graduating from an accredited nurse anesthetist program, individuals must then take the National Certification Exam (NCE) administered by the National Board Certification and Recertification for Nurse Anesthetists (NBCRNA). In 2022, the pass rate for first-time takers of the exam was 83.4%. After passing the certification exam, individuals must then apply for CRNA licensure in their state.

After initial certification, CRNAs are required to be re-certified every four years. Recertification involves having 100 hours of continuing education credits and completion of one core module from each of four core areas: airway management, pharmacology, human physiology & pathophysiology, and anesthesia technology (the core modules provide 60 of the required continuing education credits). CRNA licensure is state-specific and individual states can have additional requirements to practice as a CRNA.

Implications for hospitals

The result of the new requirements is that newly trained CRNAs will have one additional year of training than CRNAs trained in the past. However, because that one year will be nurse anesthetist-specific training, the net result will be a 50% longer training in anesthesia than previously. The additional training should result in greater anesthesia knowledge. The implication is that hospitals may change their utilization of CRNAs:

  • Ability to start cases independently at night. CRNAs are required to work under the supervision of a physician – in Ohio, the “supervising physician” does not have to be an anesthesiologist. The rules on CRNA scope of practice are state-specific but in most states, CRNAs can start surgical cases without a physician anesthesiologist present in the OR area. However, many individual hospitals have rules over and above state regulations and require the presence of an attending anesthesiologist for the CRNA to start a case. This has relevance to cases at night when there can be a delay starting emergency operations while waiting for the anesthesiologist to arrive. Hospitals may find that it is more practical to have in-house CRNAs at night to expedite cases. In this situation, the surgeon would become the CRNA’s supervising physician rather than the anesthesiologist. However, because emergency cases at night are often some of the most physiologically complicated and high-risk, hospitals may still want to have attending anesthesiologists on call from home at night for back-up purposes.
  • Endoscopy sedation. In the past, sedation for colonoscopies and other procedures performed in hospital endoscopy suites was administered by the gastroenterologist or surgeon performing the procedure. In recent years, procedural sedation has increasingly been administered by anesthesiologists. The new requirements may give hospitals more comfort in having CRNAs perform procedural sedation without the physical presence of a physician anesthesiologist in the endoscopy suite area. In this situation, the gastroenterologist or surgeon would become the “supervising physician”.
  • Emergency airway management. In the past, hospitalists were routinely trained in intubation and airway management, such as occurs in the intensive care unit or during cardiopulmonary resuscitation. Because intubation is no longer required during internal medicine or family medicine residency, many hospitalists no longer perform intubation, leaving airway management to critical care physicians, emergency medicine physicians, anesthesiologists, and respiratory therapists. The new training requirements may give hospitals more comfort in designating CRNAs to be responsible for emergency airway management, particularly at night.
  • But, be prepared to pay more. The U.S. Bureau of Labor Statistics reports that CRNAs have a median hourly wage of $97.64 per hour. This equates to an annual income of $203,090 per year. There is considerable variation between different states. For example, the median annual income for CRNAs in California is $246,510 whereas in Oklahoma, the median income is $168,470. Here in Ohio, CRNA income is at about the U.S. average with a median income of $197,630. In contrast, the MGMA reports that the average income for a physician anesthesiologist in academic practice is $407,681 and in private practice is $468,106. In other words, a CRNA costs half as much as an anesthesiologist. However, as the length of CRNA training increases, CNRA incomes are likely to rise in the future.

The trend throughout healthcare has been to increasingly utilize advance practice providers (such as nurse practitioners and physician assistants) to perform services historically performed by physicians. Because these advance practice providers are less expensive than corresponding physicians, they can reduce healthcare costs. The new requirement of a doctoral degree to become a CRNA will likely result in an expansion of the use of CRNAs for anesthesia, sedation, and airway management.

May 3, 2023

Categories
Medical Education Physician Finances

Physician Income By Specialty: Does Length Of Residency Determine Compensation?

Physicians earn high incomes but those incomes come at a cost of investing between 7 and 12 years of education and training after undergraduate college. This post will examine the most recent physician compensation report and what it indicates about the relationship between income and the years of training required for each specialty.

Determining average physician incomes by specialty turns out to be a lot more difficult that it would seem. There are many physician compensation surveys and each of them reports compensation a bit differently with the result that it is difficult to accurately know how much the average specialist actually earns per year. Some of the most common surveys include:

  1. AAMC – American Association of Medical Colleges. This annual survey reports physician compensation from 153 U.S. medical schools and > 400 teaching hospitals that serve 124,000 physicians.
  2. MGMA – Medical Group Management Association. This annual reports surveys 3,400 U.S. medical practice administrators that serve 142,000 physicians and advanced practice providers. These group practices are largely mid-sized groups (typically 6 – 50 physicians).
  3. AGMA – American Group Medical Association. This survey represents 380 medical groups from large-sized groups (with > 100 physicians).
  4. Doximity. This survey is of self-reported total compensation from 31,000 full-time U.S. physicians.
  5. Medscape. This survey is of self-reported total compensation from 13,000 U.S. physicians.
  6. Various physician search firms and consultation firms. These are typically of small numbers of physicians and often limited to compensation reports of individual physicians that they have helped with job placement and physician groups that they have consulted with.

I tend to rely mostly on the AAMC and MGMA reports because they sample the largest number of physicians and have stricter methodology regarding what is (and is not) included in total compensation. For academic physicians, the AAMC survey is more comprehensive and generally reports higher incomes for academic physicians than the MGMA survey. For non-academic physicians, the MGMA report provides comprehensive data. For this post, I will use the 2022 MGMA physician compensation report. Total compensation is defined as salary and bonuses as well as physician contributions to retirement plans, health insurance, and life insurance. Notably, the reported compensation does not include employer contributions to retirement plans, health insurance, life insurance, or malpractice insurance.

This is particularly important when comparing academic from non-academic physician compensation since most academic jobs come with lucrative employer contributions. As an example, the Ohio State University contributes about $25,000 per year to their physician faculty member’s State Teacher’s Retirement Plan, life insurance, disability insurance, and health insurance. OSU also pays for medical malpractice insurance – the U.S. national average cost for a critical care physician’s malpractice premium is $20,215 per year. In other words, a typical OSU physician has a total of about $45,000 per year in fringe benefits as an academic physician that they would otherwise likely not have had if they were in a private medical practice. One of the reasons that the MGMA reports that academic physician compensation is much lower than private practice physician compensation is because these employer contributions provided by academic institutions are not included in the total compensation listed in the MGMA reports. If you were to factor in these employer contributions into total compensation, academic physicians’ compensation is closer to that of non-academic physicians.

The MGMA breaks reported compensation into mean, median, 25th percentile, and 75th percentile. For academic physicians, the MGMA additionally breaks down compensation by academic rank: instructor, assistant professor, associate professor, and professor. Other metrics of compensation and productivity are also included such as average total RVUs, average work RVUs, and total compensation per RVU for each specialty. Caution must be exercised when interpreting these data. For example, the mean compensation will include all non-academic physicians in a specialty, regardless of seniority. Physicians in their first years of practice after completion of training are less efficient, less productive, and less highly compensated than physicians in practice for 10, 20, or 30 years. Therefore, a newly-trained physician should not expect to earn the mean or median compensation for a specialty. Conversely, experienced physicians with many years of practice generally earn more than the mean or median. However, for simplicity purposes, this post will focus on the mean total compensation for various specialities for non-academic and academic physicians. The total compensations are summarized in the tables below:

Non-Academic Physician Compensation

This graph illustrates the mean total compensation for non-academic physicians reported by the MGMA in 2022, similar to the table above (to enlarge this graph, click on it to open it in a new window and then click on it again to enlarge). The most highly-compensated specialties were neurosurgery ($947,030), cardiovascular surgery ($829,072), cardiology electrophysiology ($747,947), orthopedic surgery ($715,399), and interventional cardiology ($702,019). At the low end of the compensation spectrum were pediatric specialties: pediatric hospitalist ($237,530), pediatric endocrinology ($239,072), general pediatrics ($252,575), and pediatric infectious disease ($256,364). In fact, of the 9 lowest compensated specialties, all but one (geriatrics) was a pediatric specialty.

Academic Physician Compensation

This graph illustrates the mean total compensation for academic physicians reported by the MGMA in 2022. The most highly-compensated specialties were cardiovascular surgery ($718,802), neurosurgery ($694,605), pediatric surgery ($588,934), thoracic surgery ($581,387), and plastic surgery ($525,215). At the other end of the compensation spectrum were again pediatric specialties: pediatric endocrinology ($184,479), general pediatrics ($189,178), pediatric infectious disease ($201,607), and pediatric hospitalist ($204,661).

In every specialty, academic physician total compensation was lower than non-academic physicians (academic pediatric-internal medicine compensation was not reported). The specialties with the greatest difference between non-academic and academic compensation were cardiology electrophysiology ($293,318), neurosurgery ($252,425), gastroenterology ($244,091), hematology/oncology ($237,720), and orthopedic surgery ($231,973). The large difference between academic and non-academic incomes explains why it has been so difficult for medical schools to keep gastroenterologists and oncologists since they can earn a quarter of a million dollars more per year in private practice. The lure of that much money is just too much for even the most noble of academic teachers and researchers. Specialties with the least difference between non-academic and academic compensation were pediatric hospitalist ($32,869), pediatric nephrology ($44,281), pediatric critical care ($47,283), and pediatric hematology/oncology ($53,152).

Compensation per work RVU

Physician work effort is often measured by the number of RVUs (relative value units) produced. Every physician service and procedure is assigned an RVU value by Medicare and then Medicare pays the physician based on the number of RVUs billed. Currently, Medicare pays $33.89 per RVU. Commercial insurance companies generally pay a higher amount per RVU and Medicaid pays a lower amount per RVU. The RVU is composed of three subunits, the work RVU (wRVU), practice expense RVU, and malpractice RVU. Of these subunits, the wRVU is most commonly used to measure physician productivity. Note that anesthesiology does not use RVUs and anesthesiologist productivity is instead measured by anesthesia units (1 unit = 15 minutes of time).

Physicians who earn a high dollar amount of compensation per wRVU generally require subsidization from hospitals.This is typically done either when the physician performs procedures that are highly lucrative for the hospitals (such as open heart surgery) or when the physician performs a lot of non-compensated work essential to the function of the hospital (such as hospitalists who take night-call). On the other hand, physicians earning a low dollar amount of compensation per wRVU have less (or no) hospital subsidization. These are usually outpatient specialties whose physicians are less often employed by a hospital.

Non-academic physicians with the highest compensation per wRVU are pediatric surgeons ($148/wRVU), pediatric hospitalists ($138/wRVU), pediatric infectious disease ($123/wRVU), neurosurgeons ($113/wRVU), and pediatric hematology/oncology ($112/wRVU). Those specialties with the lowest compensation per wRVU are pediatric/internal medicine ($54/wRVU), endocrinology ($59/wRVU), ophthalmology ($59/wRVU), family medicine ($62/wRVU), and general pediatrics ($62/wRVU).

For academic physicians, the specialties with the highest compensation per wRVU are pediatric hospitalist ($179/wRVU), pediatric surgery ($133/wRVU), internal medicine hospitalist ($123/wRVU), hematology/oncology ($117/wRVU), and infectious disease ($114/wRVU). The high compensation per wRVU for academic infectious disease physicians may reflect the impact of the COVID-19 pandemic when academic infectious disease specialists were called on to perform a great deal of administrative duties (subsidized by hospitals) in addition to their regular clinical duties. Academic physician specialties with the lowest compensation per wRVU are dermatology ($48/wRVU), neonatology ($50/wRVU), pathology ($51/wRVU), radiology ($55/wRVU), and interventional radiology ($55/wRVU). The MGMA survey did not report data for academic pediatric/internal medicine or for pediatric infectious disease.

Compensation per year of residency & fellowship training

Residency and fellowship can be viewed as an investment in a physician’s career. In theory, the longer the period of training, the greater the knowledge and skill of a physician in any given specialty. Residents and fellows do get paid but the average annual income is modest, starting at $61,000 for a first year resident (i.e., an intern) and that amount increases by about $2,500 for each additional year of residency and fellowship. During this time, residents and fellows are also required to start paying back student loans (payments averaging $4,000 per year during residency). As a consequence of residency and fellowship training years, most physicians finally enter the workforce when they are in their 30’s. The total duration of residency varies from the shortest at 3 years (internal medicine, pediatrics, and family medicine) to the longest at 7 years (neurosurgery, pediatric surgery, and interventional radiology). Fellowship training after residency further extends the total duration of training, for example, cardiology electrophysiology requires 8 years of training (3 years internal medicine residency, 3 years cardiology fellowship, and then 2 years cardiac electrophysiology fellowship). Longer residency/fellowship durations also equate to a shorter working career. The general internist with a 3-year residency will typically work 35 years before retiring at age 65 whereas the cardiology electrophysiologist will only work 30 years before retirement at age 65. Thus, the cardiology electrophysiologist sacrifices 5 of their lifetime income-earning years to do fellowship training after their internal medicine residency.

Do more years of residency/fellowship translate to higher incomes? One way to answer that question is to express physician compensation per number of years of training required for that specialty. In a completely free labor market, there would be a direct relationship between income and duration of training: every additional year of training for any given specialty would result in a predictable increase in annual income. In other words, the return on investment in terms of years of training should be constant across all specialties. This turns out to not be the case in reality.

For non-academic physicians, there is a wide variation in compensation per year of training. The specialties with the largest amount of total compensation per year of residency/fellowship are orthopedic surgery ($143,080 per training year), dermatology ($140,439 per training year), cardiovascular surgery ($138,179 per training year), neurosurgery ($135,290 per training year), and emergency medicine ($124,239 per training year). These specialties have a very high return on their investment of training time. At the low end are pediatric endocrinology ($39,845 per training year), pediatric infectious disease ($42,727 per training year), pediatric hematology/oncology ($43,808 per training year), pediatric nephrology ($44,756 per training year), and pediatric hospitalist ($47,506 per training year). These specialties have a low return on investment of training time.

The spread of total compensation per number of years of residency/fellowship training for academic physicians was similar. Specialities with a high compensation per year of training were cardiovascular surgery ($119,800 per training year), emergency medicine ($102,326 per training year), anesthesiology ($101,900 per training year), neurosurgery ($99,229 per training year), and thoracic surgery ($96,898 per training year). Once again, the least compensated per year of training for academic physicians were all pediatric specialties: pediatric endocrinology ($30,747 per training year), pediatric infectious disease ($33,601 per training year), pediatric hematology/oncology ($34,950 per training year), pediatric pulmonary ($35,946 per training year), and pediatric nephrology ($37,376 per training year). The MGMA survey did not report on pediatrics/internal medicine.

Several subspecialties were particularly noteworthy because their total compensation was less than their parent specialties. For example, pediatric hospitalists require 2 additional years of fellowship after completion of a pediatric residency and pediatric endocrinologists require 3 years of fellowship after pediatric residency. However, both non-academic pediatric hospitalists and non-academic pediatric endocrinologists make less money than non-academic general pediatricians who only completed the 3-year pediatric residency. Similarly, to specialize in geriatrics or endocrinology, a physician must first complete a 3-year internal medicine residency followed by a 1-year (geriatrics) or 2-year (endocrinology) fellowship. However, non-academic physicians specializing in geriatrics or endocrinology make less money than non-academic general internists who only completed the 3-year internal medicine residency.

In academic practices, there are even more specialities where subspecialty fellowship results in lower total compensation than the parent specialty. Academic pediatric endocrinologists make less than academic general pediatricians. Academic geriatric, rheumatology, endocrinology, and infectious disease specialists all make less than academic general internists. In these subspecialties, not only does the additional years of fellowship training not result in greater income, but the those physicians are actually financially penalized for their additional years of training by making less money than if they had just stopped after their pediatric or internal medicine residency.

It is noteworthy that there are more factors to consider than just years of training when comparing total compensation between different specialties. Some of the specialties with the highest compensation per year of training are also those with the most grueling on-call schedules, such as cardiovascular surgery, anesthesiology, emergency medicine, and neurosurgery. It is entirely appropriate that the neurosurgeon who has to take trauma call every 4th night for his/her entire life makes a high income. In addition, the cost of medical malpractice insurance premiums varies significantly. The average general internist pays $16,000 per year in malpractice premiums but the average neurosurgeon pays $92,000 per year for malpractice coverage. Once again, it is entirely appropriate that the neurosurgeon has a high income in order to cover the high overhead malpractice insurance expense inherent in that specialty.

What is the solution to these compensation disparities?

In a free labor market, a worker’s income is determined by the supply of workers and the demand for that worker’s services. So, on the surface, it would appear that there is a shortage of heart surgeons and neurosurgeons whereas there is a overabundance of general pediatricians and pediatric endocrinologists. However, American medicine is not a simple free market economy. Hospitals make the most money from procedures and surgeries: the financial margin on a surgery is much greater than the margin on a medical admission. That margin is highest for inpatient surgeries such as cardiovascular surgeries and neurosurgeries. Because of this, hospitals are incentivized to subsidize specialists who perform these high-margin procedures. Furthermore, many of these surgical subspecialists have much more rigorous on-call schedules – a neurosurgeon or interventional cardiologist is much more likely to be called into the hospital in the middle of the night to manage a patient with head trauma or with a myocardial infarction than an endocrinologist or rheumatologist whose practice is largely outpatient and limited to Mondays through Fridays during the daytime. Therefore, in order to provide 24-hour trauma or cardiac care, hospitals must pay these subspecialists substantial on-call pay.

A central problem with physician reimbursement is that it has not kept up with inflation and has, in fact, fallen over the past decades. In 1998, Medicare reimbursement per RVU was $36.69 and 25 years later, in 2023, the reimbursement per RVU had fallen to $33.89. By contrast, if the RVU reimbursement had merely kept up with inflation, then the $36.69 rate in 1998 should be $70.45 today! Physicians have made up for the reduced payments per RVU somewhat by spending less time with each patient in order to see more patients per day but that alone has been insufficient to maintain a constant income. The solution has frequently been for physicians to become employed by hospitals with the hospitals subsidizing their income. This has resulted in physician income becoming untethered from physician work productivity. The effect has been that physician income is increasingly determined by the value of the physician’s specialty to the hospital’s finances more than the physician’s actual patient care work effort.

It has been proposed that the solution would be to pay low-compensation subspecialists more. This would work in a pure free market economy but would not work in our current system of physician reimbursement. Physician services are categorized by CPT codes and then reimbursed by the number of RVUs associated with each of those CPT codes. Non-procedural specialties all use the same CPT codes for the evaluation and management services that they provide. Thus, the endocrinologist or geriatrician bills the exact same CPT codes as the general internist and gets reimbursed the exact same amount per RVU as the general internist. Because of this, the “cognitive” subspecialties of pediatrics and internal medicine (i.e., those without associated procedures) have no chance of generating more RVUs than the general pediatrician or internist. Indeed, the amount of time and effort to see a 10-year old with uncontrolled type 1 diabetes in the pediatric endocrinology office is considerably more than that required to see an otherwise healthy 10-year old with an ear infection in the general pediatrics office, even though the payment is the same for both patients. As a result, for many of these subspecialties, the reward for more years of training is a lower income. Because these pediatric and internal medicine subspecialties do not generate significant margins for hospitals, there is little incentive for hospitals to subsidize them.

It is notable that pediatric subspecialties dominate the low compensation specialties. One of the driving reasons for this is Medicare/Medicaid. Nearly every American over age 65 qualifies for Medicare so older adults are by and large all insured. Children are not eligible for Medicare but are instead covered by CHIP and Medicaid programs (or have no insurance at all!). In most states, Medicaid pays considerably less than Medicare (in Ohio, Medicaid payments for primary care services are only 57% of the Medicare amounts). Consequently, pediatricians of all subspecialties have an inherently worse payer mix than physicians who care for adults. Similarly, pediatric hospitals also have a worse payer mix than hospitals caring for adults.

So, how do we fix this? There are several tactics that can be considered:

  • Increase residency positions in some specialties. This will work only for those highly compensated specialties where there is truly an insufficient supply of physicians for current demands.
  • Re-align RVUs assigned to different procedures and services. The current RVU assignments have been affected by intense lobbying from subspecialty physician organizations and in many cases, the most RVUs have been given to the loudest lobbyists.
  • Increase physician reimbursement for Medicaid and CHIP patients. In an ideal world, a physician would get paid the same for a patient with Medicare, Medicaid, or CHIP. This would help correct the low compensation for pediatric specialties.
  • Increase the RVU conversion factor. The current conversion factor of $33.89 per RVU is too low for the vast majority of physicians to earn a living from professional billings alone with the result that most physicians require hospital subsidization. This has eroded free market effects on physician compensation.
  • Normalize the relation between years of training and income. It is entirely appropriate that the interventional cardiologist who trains for 7 years has a higher income than the general internist who trains for 3 years. But it makes absolutely no sense that the endocrinologist who trains for 5 years makes less than the internist who trains for 3 years.
  • Strategic expansion of advance practice provider utilization. We have to face the reality that income disparities in some specialties will eventually result in fewer physicians entering those specialties. Hospitals should start training nurse practitioners, physician assistants, and pharmacists to perform some of the work done by these specialists. For example, advance practice providers can often effectively replace most of the daily inpatient diabetes management currently done by endocrinologists.
  • Embrace AI. The heart surgeon will not do a coronary artery bypass surgery faster using artificial intelligence but AI may allow the general internist to more efficiently evaluate a patient with chest pain. Similarly, AI may speed up the time required for an infectious disease specialist to come up with a diagnosis based on a patient’s presenting history and lab findings. It can help the endocrinologist select the most effective diabetes treatment based on a patient’s co-morbidities. It can shorten note and order-writing time for patients performing E&M (evaluation and management) services. Artificial intelligence has the greatest potential to improve productivity of physicians in cognitive specialities, which are also the specialties that are the most under-compensated.

The forces that affect physician incomes are complex. But if we do not begin to take corrective action soon, we will find ourselves without endocrinologists, geriatricians, and pediatric endocrinologists in the near future. Because of the structure of American healthcare, we cannot rely on free market forces alone to solve this problem.

April 9, 2023