Category: Medical Education

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:
  • Addiction, Stigmata, & First-Person Language
• 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 American College of Physicians
  • The American Society of Addiction Medicine
  • The American Medical Association
  • The American Society of Anesthesiologists
  • The American Academy of Pediatrics
• 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

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

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

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.

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 disability. Disparity 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

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

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

Today, the results of the 2023 National Residency Match Program were released. Every year, the match determines where medical students in their senior year will be doing their residencies starting in July. There are some important take-away lessons from this year’s match.

The number of applications increased.

There were 48,156 applicants in this year’s match, up from 47,675 applicants last year. This was driven by an increase in foreign medical graduates (707) and U.S. osteopathic school seniors (153). Notably, the number of U.S. medical school seniors applying to the match dropped by 236 this year. Not all applicants certified a rank order list of residencies but of those who did submit a rank list, 81.1% matched to a first-year residency position. There were 1,239 couples (6% of match applicants) in this year’s match and they had a higher match rate of 93%, which has been constant for the past 35 years.

There were a total of 40,375 residency positions available in this year’s match, 3% more than last year. 93.3% of these positions filled in this year’s match. There were a total of 2,658 unfilled residency spots in this year’s match that will be available to unmatched students in the Supplemental Offer and Acceptance Program. This program is currently actively filling open positions so the results of the SOAP are not yet available.

Foreign medical graduates are back.

Until the COVID pandemic, foreign medical graduate applicants in the match had been steadily increasing. In 2022, there was the first-ever fall in the number of foreign medical graduates, primarily due to COVID travel restrictions and fear of the United States’ high COVID prevalence and high COVID death rate. In 2023, the number of foreign medical graduates increased to the highest number on record. Foreign medical graduates continue to have the lowest match rate with only 59.4% matching into a PGY-1 residency.

U.S. MD applicants once again had the highest match rates.

Seniors at U.S. medical schools had the highest match rate at 93.7%. This is similar to the match rate for these students over the past 40 years. Seniors at U.S. osteopathic schools had the next highest match rate at 91.6% which is the highest match rate ever for these students. U.S. citizens attending foreign medical schools were next with a 67.6% match rate and non-U.S. citizens from foreign medical schools had the lowest match rate at 59.4%.

The most popular specialties.

Categorical internal medicine had the most filled positions (9,345) followed by family medicine (4,511), categorical pediatrics (2,900), emergency medicine (2,456), and psychiatry (2,143). Several specialties have the option of either matching into an integrative PGY-1 position or matching into a PGY-2 position after doing a transitional or preliminary residency year. In the graph below, the specialties include the number of applicants matching into both PGY-1 and PGY-2 positions.

The above graph only includes 25 largest specialties and does not include specialties with small numbers of residency positions such as nuclear medicine.

Specialties with the largest growth in number of residency positions offered compared to last year include categorical internal medicine (+335), family medicine (+172), psychiatry (+117), emergency medicine (+79), anesthesiology (+65), neurology (+49), general surgery (+48), and primary care internal medicine (+24),

The most (and least) competitive specialties.

Competitive specialties are those that have the highest rate of filling either by U.S. medical school (MD) senior applicants or by total applicants. The major specialties with the highest percentage of available positions filled by U.S. medical school (MD) applicants were all surgical specialties: plastic surgery (92.3%), neurosurgery (86.8%), thoracic surgery (83.7%), otolaryngology (83.1%, and vascular surgery (80.6%). Ten specialties filled all available positions (100%) when considering all applicants: plastic surgery, thoracic surgery, dermatology, orthopedic surgery, anesthesiology, interventional radiology, radiation oncology, child neurology, physical medicine, and neurology.

Five major specialties filled fewer than 50% of available positions with U.S. medical school (MD)  applicants: emergency medicine (42.3%), pathology (39.5%), categorical internal medicine (36.9%), family medicine (29.2%), and preliminary surgery (21.7%). When considering all applicants, four specialties matched fewer than 90% of available positions: family medicine (88.7%), transitional year (87.8%), emergency medicine (81.6%), and preliminary surgery (51.4%).

The more competitive a specialty is, the larger the number of programs are ranked by each applicant. The largest average number of residency programs ranked by each U.S. medical school (MD) applicant were vascular surgery (19), neurosurgery (18), thoracic surgery (17), plastic surgery (15), and otolaryngology (14). On the other hand, primary care specialties had fewer average rankings per applicant: family medicine (4), internal medicine (5), emergency medicine (7), and pediatrics (8).

Which specialties are in trouble?

Emergency medicine has seen a fall in the total number of filled positions over the last 3 years. In the past, emergency medicine filled >99% of available positions but this dropped to 93% in 2022 and 82% in 2023. This year, emergency medicine had 554 unfilled positions, second only to family medicine (577 unfilled positions). Because of its past competitiveness, emergency medicine residencies have historically accepted relatively few foreign medical graduates. This year was no exception and foreign medical graduates only accounted for 2% of filled emergency medicine residency positions. The number of residency positions offered in emergency medicine has been increasing each year at a faster pace than other specialties. This, combined with the declining interest in emergency medicine by applicants signals that emergency medicine residencies will need to make adjustments in the future to attract more U.S. medical school graduates and U.S. osteopathic school graduates. In addition, emergency medicine residencies need to be more receptive to foreign medical graduate applicants.

The number of filled internal medicine preliminary year positions has also been steadily declining over the past 5 years. However, this decline has been offset by a steady increase in the number of filled transitional year positions, suggesting that applicants are selecting transitional year programs instead of internal medicine preliminary year programs. These two types of 1-year programs are very similar and often both offered by the same departments at teaching hospitals.

These are your future doctors

In 3 1/2 years, the students who matched today will begin completing residency programs and will begin to enter the attending physician workforce. The results suggest a future worsening of the shortage of primary care physicians and emergency medicine physicians. The results also indicate that foreign medical graduates will comprise an increasing percentage of practicing physicians in the United States in the future.

March 17, 2023

ChatGPT is a free artificial intelligence program that can write letters, reports, and research papers using internet information. Recently, it has generated concern by educators that students can use it to write term papers and do homework assignments. I used ChatGPT to write a personal statement for a pulmonary fellowship application that was indistinguishable from the real thing. Our application process now needs to adapt to this new paradigm.

Residency and fellowship application personal statements

Up to now, applying to residency or fellowship programs involved filling out a standard application form that included information such as board examination scores, medical school grades, research publications, and faculty recommendation letters. A central component of these applications has been the personal statement where the applicant tells why he or she has chosen a particular specialty in which to pursue further training. After reviewing these applications, residency and fellowship program directors then select which applicants to invite for a face-to-face interview. Based on the contents of the application, the personal statement, and the interview, program directors then rank all of the applicants to submit to the National Residency Match Program (NRMP). The NRMP then matches the rank list of applicants with the rank list of the residency or fellowship programs to determine where the applicants will do their residency or fellowship training.

Over the past 35 years, I have read thousands of personal statements when grading applications to our internal medicine residency and our pulmonary/critical care fellowship programs. Occasionally, a personal statement would lower my overall grade if it contained misspellings, contained grammar errors, or was just plain weird. Occasionally, a personal statement would stand out as being particularly emotionally moving or show evidence that an applicant had to overcome particularly difficult personal barriers and this could raise my overall grade of their application. Most of the time, however, I viewed the personal statement fairly neutrally and it had relatively little impact on how high I would grade an application. Honestly, most personal statements all sound about the same.

What is ChatGPT?

ChatGPT is an artificial intelligence chatbot that was launched on the internet on November 30, 2022 as a prototype. By January 2023, it had 100 million users, making it the fastest growing consumer application to date. ChatGPT was developed by the company, OpenAI. This was a home run for OpenAI which is now valued at $29 billion.

This morning, I wanted to find out if ChatGPT can be used to write personal statements for residency and fellowship applications. So, I went to the website of OpenAI and opened a ChatGPT account. It is free and took me less than 30 seconds to start my account. I then asked ChatGPT to write a personal statement. I entered the following information: “I am a resident in internal medicine influenced by my intensive care unit attending, write a personal statement for pulmonary fellowship”. That was all the information I included. ChatGPT did not know anything else about me other than my email address, name, and phone number. It took ChatGPT about 15 seconds to write a personal statement and here is what it came up with:

I was pretty amazed… this personal statement was darn good and was easily as good as 75% of the fellowship application personal statements that I have read in the past that were written by actual human beings. There were no misspellings and no grammar errors. The personal statement expressed passion about a career in pulmonary medicine and showed no sign that the applicant possesses some underlying psychopathology. In short, it checked all of the boxes. If I had read this personal statement a year ago, I would have passed the application on as perfectly acceptable.

I’m a baby boomer and I’m not supposed to be very knowledgable about new technology and artificial intelligence. Just think what millennials can do with this. Most 4th year medical students submit their residency applications in September/October so ChatGPT has probably not been used for this year’s residency applications. However, I can almost guarantee that every 3rd year medical student who will be filling out residency applications this summer will at least think about using ChatGPT. The same goes for fellowship applications.

As an attending physician, I have also written hundreds of reference letters and letters of recommendation for students applying to residency and for residents applying to fellowship. These letters take a lot of time to write and it would probably cross my mind to use ChatGPT if I got a request from 20 students for residency recommendation letters tomorrow.

What does this mean for the future?

In just the past 3 months, the value of the personal statement has diminished to the point that it is essentially irrelevant. A personal statement that would have taken me 10 hours to write and re-write as a medical student in 1984 would take me less than a minute to generate using ChatGPT. And the personal statement written by ChatGPT would be every bit as good as anything that I would have written. So, should we eliminate the personal statement from residency and fellowship applications altogether?

I think we should.

Personal statements have always been a bit contrived. Most applicants make multiple revisions and have their personal statements critiqued and edited by friends, family members, and colleagues to the point that they are usually excessively washed, polished, and filtered versions of an applicant’s true motivations for choosing a particular specialty. I believe that most of the information contained in the personal statement can be more effectively evaluated during a live interview. Even a virtual interview done over the internet will have greater value than a ChatGPT-derived personal statement.

The world of medicine just turned on its head

But ChatGPT and other artificial intelligence systems have many more applications than just writing personal statements for residency and fellowship applications. In academic medicine, reference letters, grant applications, research manuscripts, and promotion & tenure dossiers can all be created faster and better using ChatGPT. In clinical medicine, letters to referring physicians, consultant reports, history & physicals, and progress notes can be generated in seconds, thus reducing tedious keyboard entry by clinicians.

As a medical student, I memorized mnemonics for hospital admission orders so that I would never forget about including a patient’s allergies or how frequently vital signs should be performed. How to write comprehensive admission orders was a key part of our medical education. The interns and senior residents evaluated students on the completeness of our hand-written admission orders. When computer electronic order entry was created, the computer automatically generated admission order sets that included all of the components in my mnemonic. This made life easier and better but created a void in the usual medical student education.

As an attending physician, I evaluated the proficiency of the internal medicine interns by their written history and physical examinations… did they include a smoking history? Was there a complete review of systems? Did they list the patient’s medications? When electronic medical records were introduced, the interns no longer had to know how to write an H&P, all then needed was a history and physical exam template in the computer software. At first, I lamented the loss of the time-honored skill of a masterfully written history and physical but then quickly realized that the electronic medical record H&P template was the new reality.

It does not matter what any of us think about ChatGPT and other artificial intelligence writing systems. They are the new reality, whether you like them or not. The personal statement has now gone the way of admission order mnemonics and hand-written history & physicals – shadows of a bygone era in medical education. So, how are we going to assess the motivations and passions of our trainee applicants? I think it just comes down to that most human of all methods… we talk with them.

As an aside, I’ve wondered if ChatGPT will be the beginning of the end of blogging. I suspect that ChatGPT could probably write a post far better and faster than I can. But I write posts for my own gratification and enjoyment. So, rest assured, the words that appear on these pages will always be my own.

February 26, 2023

Overall, union membership in the United States has been steadily declining over the past 60 years. However, one of the consequences of the COVID-19 pandemic has been a resurgence of interest in doctor’s unions, especially among residents and fellows. In the past two months, residents at the Keck School of Medicine of USC, Stanford Health Care, and University of Vermont voted to unionize. Is a union in your hospital’s future?

The Bureau of Labor Statistics recently reported that in 2021, there were 14 million wage and salary workers in the United States who were members of a union. This equates to an overall union membership rate of 10.3%. Overall, union membership has dropped considerably over the past 70 years.

There are tremendous differences in the union membership rates for public sector workers (33.9%) versus private sector workers (6.1%). There are also profound geographic differences in union membership rates ranging from high rates in Hawaii (22.4%) and New York (22.2%) to low rates in South Carolina (1.7%) and North Carolina (2.6%). Physicians are less likely to be unionized than most other professions with approximately 5% of U.S. doctors belonging to a union. Residents and fellows comprise the largest group of physicians who are unionized and their numbers are growing.

The largest union of residents and fellows is the Committee of Interns and Residents (CIR), a part of the Service Employees International Union. In normal years, the CIR reports 1-2 hospitals have union organizing campaigns per year. However, with the COVID pandemic, that number has tripled. Currently, residents at about 60 hospitals nationwide are unionized with an estimated 15% of all U.S. residents belonging to unions.

Fewer attending physicians are unionized. The largest union is the Union of American Physicians and Dentists, an AFL-CIO affiliate. It is estimated that about 10,000 of the 700,000 U.S. attending physicians are unionized, slightly less than 1.5%. Historically, most attending physicians were in private practices, either as solo providers or as part of medical group practices. There was very little reason for these physicians to unionize because they were self-employed. This may change in the future as physicians become increasingly hospital-employed.

The pros and cons of resident unions

The effect of resident unionization has not been well-studied. A 2021 study published in JAMA Network Open of 5,701 U.S. surgery residents found that unionized residents were more likely to have hospital-subsidized housing and more likely to have 4 weeks of vacation per year (as opposed to 2-3 weeks) than non-unionized residents. However, there was no difference in burnout, suicidality, job satisfaction, duty hour violations, mistreatment, salary, or educational environment between residents at unionized and non-unionized programs.

Residents and fellows hold a unique employment status – they are simultaneously trainees and employees of the hospital. They also have time-limited employment, unlike most American union members who can spend their entire employment career as union workers. Because of their unique status, there are advantages and disadvantages to residents unionizing.

The pros of resident unionization

1. Ability to negotiate salary. Residents earn an average of about $64,000 per year. Typically, salaries increase by about $2,000 for each year of residency. Although the precise salary for residents varies from hospital to hospital, most of the variation is related to geographic cost of living differences. Most of the financial support for resident salaries comes from fixed Medicare payments to hospitals for graduate medical education. Overall, the ability of resident unions to impact base salaries is limited. However, supplemental pay for working during disasters and for in-house moonlighting may be more negotiable.
2. Ability to negotiate vacation. Unlike salary, hospitals do have more flexibility in the amount of vacation time offered. The JAMA Network Open article found that unionized residents had more vacation time per year than non-unionized residents.
3. Ability to negotiate fringe benefits. Hospital night call rooms, meals while on-duty, hospital-subsidized housing, and maternity/paternity leave are all on the table when residents are unionized.
4. Ability to negotiate work conditions. Issues such as availability of personal protective equipment and prioritization of hospital employe vaccination became very important to residents during the COVID pandemic. Most healthcare workers experienced stressful working conditions during the pandemic and residents were no exception. Many residents turned toward unions in hope that unionization would reduce these stressful conditions.

The cons of resident unionization

1. Union dues. Currently, annual dues for residents who belong to the CIR are 1.6% of their total salary. This can be an important deterrent to joining a union given that residents do not have high salaries to begin with and that residents are often feeling financial pressures due to student loans and young children at home.
2. Short duration of employment. Internal medicine, pediatrics, and family medicine residencies are 3 years long. Psychiatry residency is 4 years long. Surgery is 5 years long. Many current residents do not want to go through the time and hassle of forming a union since they will personally only experience any benefits of unionization for a short period of time before they become attending physicians.
3. Barriers to going on strike. The most powerful tool of any union is the strike. Some ethicists have opined that it is unethical for physicians to go on strike as a strike could lead to patient abandonment and resultant patient harm. It has been argued that since residents must be supervised by attending physicians, the attending physicians could cover patient care responsibilities if the residents go on strike. However, residents are integral components of health care teams and if they are not present, then there is a risk of team malfunction. There is also a very different public perception of physicians going on strike as opposed to other workers – if your Starbucks barista goes on strike, it is a minor inconvenience but if your doctor goes on strike, your health is threatened. Striking physicians may find little sympathy from the general public and may garner very negative opinions. That being said, last month, Los Angeles residents threatened to go on strike and the strike was averted at the last minute.
4. Soured relation with attending physicians. When residents complete their residencies, they either get a job as an attending physician or continue their training as subspecialty fellows. In either case, they rely on the attending physicians that they trained under during their residency for letters of recommendation. If union activities result in an adversarial relation between the residents and those attending physicians, those letters of recommendations may take on a negative tone. Labor laws prohibit retribution against union members for union activities; however, when it comes to these letters, an average recommendation implies that the resident is actually significantly below average. Therefore, a resident whose union activities antagonized his/her attending physician could receive a lukewarm recommendation letter from that attending. Such a letter could not be proven to be retribution from a legal standpoint but would put that resident at a considerable disadvantage when applying to fellowship positions compared to other resident applicants with glowing letters. Moreover, residents who develop reputations for organizing collective actions against their hospitals on the part of their union may be perceived as troublemakers by fellowship programs at other hospitals, placing those residents at a competitive disadvantage when applying for fellowship positions after completion of their residencies.
5. Lack of credibility. It can be difficult to negotiate for salary and benefits when everyone knows that you are going to have an annual income of hundreds of thousands of dollars in a couple of years.
6. The ACGME already dictates many work conditions. The Accreditation Council for Graduate Medical Education has fairly strict limits on weekly duty hours, call schedules, educational curriculum, resident responsibility for non-clinical activities (such as patient transportation, blood drawing, etc.), and work environment. As such, the ACGME has functioned in a resident advocacy role similar to the advocacy roles played by unions in other occupations. Failure of hospitals to comply with ACGME requirements can result in loss of hospital accreditation which can be a death sentence to the hospital’s residency program.
7. The loudest voices do not always represent the majority of the doctors. Often, the residents who are most opinionated and passionate are the ones who become most vocal in union affairs. This can result in issues that are of no importance to the silent majority of residents becoming the forefront of union demands.
8. Most residents cannot chose to unionize. Senior medical students are assigned the hospital where they will do their residency by the National Residency Match Program. The students create a preference list of the residency programs that they are most interested in and a computer then matches the students with the residency programs based on their degree of mutual interest. Most students will list about 10 programs on their match list but for competitive specialties, such as otolaryngology and ophthalmology, students will typically list 20 or more programs. Unless a residency program is located in a right-to-work state (see below), the students have no say in whether or not they will be in a union. After 3-5 years, all of the residents turn over and those who had originally voted to unionize are replaced by others who may or may not have any interest in belonging to a union.
9. Loss of autonomy. As a breed, doctors tend to be independent. The surgeon in the operating room, the emergency medicine physician in the ED on trauma call, the cardiologist doing an emergent heart catheterization – all of these physicians have to be self-reliant and generally do not want to be told how to do their job. A hospital with a thousand doctors is a hospital with a thousand people who think of themselves as the CEO. Many physicians are inherently distrustful of any organization that tells them what to do and that includes unions.

Right-To-Work states

American unions became empowered by the 1935 National Labor Relations Act (Wagner Act). This allowed workers to organize into closed shops (where union membership was a prerequisite requirement to employment),  union shops (where non-union workers could be hired with the requirement that they join the union within a specified amount of time), agency shops (where workers were not required to join a union but could still be charged union dues), and open shops (where workers were neither required to join a union nor pay dues). In 1947, the Taft-Hartley Act repealed some elements of the Wagner Act – closed shops became illegal and states were individually allowed to decide whether union shops and agency shops would be allowed.

The result of the Taft-Hartley Act was that some states passed legislation or state constitutional amendments to become “right-to-work” states. In these states, union shops and agency shops were not allowed and unions could only exist act open shops. The phrase “right-to-work” in essence means that workers had the right to work without having to join a union. 27 states have have right-to-work laws (red in the map below) and in addition, Delaware allows individual localities to make their own decisions about right-to-work.

The vast majority of unionized residency programs are in non-right to work states, meaning that once the residency is unionized, future residents do not have a choice about whether or not they want to participate in the union or pay union dues.

A new era of physician unionization?

In the 1950’s, about 75% of U.S. physicians belonged to the American Medical Association. Today, that number is only about 17%. The AMA is not a union but it does play an important role in physician advocacy and lobbying. Today’s physicians have not felt that the AMA provides sufficient benefits to warrant membership and attendant annual dues of $450 per year. As a consequence, the AMA has less political and public health influence today than it had in the past. Some medical leaders have called for a new form of unionization for attending physicians to more strongly advocate for issues of importance to physicians such as gun control and vaccinations against communicable disease. Although a laudable idea, it is probably unrealistic.

However, the recent change in physician employment models resulting in most physicians now being hospital-employed rather than in private practice may change the appetite of some physicians to become unionized. As many specialties have had compensation become untethered to professional practice income, physicians in these specialties depend more on the wording of their hospital employment contracts for their salary and work hours. Anesthesiologists, hospitalists, critical care physicians, and emergency medicine physicians are perhaps most notable. For example, tying hospitalist RVU production too tightly to compensation can work counterproductively to hospital goals of patient length of stay, readmission rates, and patient satisfaction scores. For shift work-based physicians, unionization may become appealing if the physicians perceive that their hospital is not responsive to appeals to improve working conditions or pay competitive salaries and benefits.

Physicians whose incomes are more closely tied to their RVU production (such as surgeons, gastroenterologists, and ophthalmologists) are likely to feel less benefit to unionization as they would want to preserve their ability to tie high incomes to work effort. Also, when there are relatively few physicians in a specialty at a hospital, they already command a great deal of power and may not perceive a benefit to unionization. For example, if there are only 2 orthopedic surgeons at a hospital, just one of them threatening to leave to go to another hospital on the other side of town can be enough for the hospital to acquiesce to their demand to contract with a different joint implant vendor.

For the foreseeable future, there is projected to be physician shortages in most specialties. This results in a state of perpetual imbalance between supply and demand for physicians. A hospitalist who is not happy with their salary or required number of shifts per year at one hospital can easily get a job at another hospital within commuting distance. This imbalance gives attending physicians a great deal of power in negotiating salary, benefits, and working conditions with the hospital. In the future, if the supply of physicians catches up with the demand for physicians, then the benefits of unionization may become more appealing to physicians in some specialties.

For now, unionization is likely to be primarily relegated to residents and fellows. The current increased interest in resident unions will likely be transitory as life in the hospital returns to normal with receding COVID-19 cases.

June 16, 2022