Category: Medical Education

The annual residency match is an event like nothing else in the United States. Each year, 4th year medical students spend the fall and winter applying to and interviewing with residency programs. In February, they submit their ranked list of the programs that they would like to attend next year to the National Resident Matching Program. Simultaneously, all of the residency programs submit their ranked list of the medical students they would like to hire next year. The National Resident Matching Program then pairs the medical students with the residency programs using an algorithm that assigns the students to residency programs by matching the two rank lists. Although it sounds a bit impersonal, it actually is the fairest way to ensure that students get into the residency programs that they want while simultaneously ensuring that the residency programs get the students that they want.

The results of the match were released on Match Day, March 19th, and all across the country, 4th year medical students found out which hospital in which city they will be spending the next 3-5 years at starting in late June. If you drill into the Advance Data Table from this year’s match results, there are some interesting take-away points.

Some specialties are more competitive than others

There are 4 groups of students applying to residency: MD students, DO students, U.S. students attending foreign medical schools, and foreign students attending foreign medical schools. The most competitive specialties are those that fill most of their positions with U.S. medical graduates, and in particular, those graduating with MD degrees.

From this graph, it is apparent that surgical subspecialties are the most competitive residencies. Thoracic surgery, plastic surgery, otolaryngology, and neurosurgery all filled greater than 85% of their available positions with graduates from U.S. medical schools (MD). On the other hand, specialties that filled fewer than 50% of their positions with graduates from U.S. medical schools included radiation oncology, internal medicine, family medicine, and pathology.

The number of osteopathic graduates is growing

The number of applicants from U.S. allopathic (MD) medical schools has been rising slowly over the past 5 years. Combining the number of 4th year medical students applying for residency plus the number of applicants applying who previously graduated from allopathic medical schools, the total number has increased from 18,639 in 2017 to 21,538 in 2021, a 16% increase over 5 years. However, the number of applicants from U.S. osteopathic (DO) schools has increased from 3,590 to 7,710 over the same 5-year period, a 115% increase. Applicants from U.S. medical schools (MD) still have the best chance of getting into a residency with 92.8% of senior MD medical students matching. Seniors from osteopathic (DO) schools were a close second with 89.1% matching. U.S. citizens attending foreign medical schools fair less well with only 59.5% matching into a residency program. Foreign citizens attending foreign medical schools continued to be the least successful in getting a residency with only 54.8% matching. Over the past 5 years, despite the significant increase in numbers of senior students from osteopathic schools applying to residency, osteopathic students have been also been increasingly successful in obtaining residency with their match rate increasing from 85% in 2017 to 89.1% in 2021.

Competitive residencies require lots of ranks

In order to get into a residency program, a 4th year medical student must first apply to that program, then get accepted to interview at that program, then travel to the city where that residency is located to interview, then list that residency program on student’s rank list. In order to increase the chances of getting into a residency somewhere, you need to interview at and then rank several programs. In the past, that meant a lot of expensive travel across the country and a lot of time away from medical school to do those on-site interviews. This year, interviewing became a bit easier and less expensive since COVID-19 resulted in all interviews being done virtually, by video. Overall, the average senior student at an allopathic (MD) medical school ranked 9.4 residency programs. However, that number varied considerably. Not surprisingly, the average number of programs ranked per student correlated with how competitive the specialty is.Vascular surgery led with 20.5 programs ranked per applicant, followed by neurosurgery with 18.2, thoracic surgery with 18.1, and otolaryngology with 15.3. At the other end of the spectrum, students applying to pathology residencies ranked the fewest residency programs per student at 4.4, followed by family medicine at 4.9, and internal medicine at 5.7.

More students go into internal medicine

As in the past, the largest number of positions available is in internal medicine. Medical subspecialties such as cardiology, gastroenterology, pulmonary, and oncology first require an internal medicine residency so many of the students applying to internal medicine have long-term aspirations of subspecializing. Nonetheless, there are twice as many residency positions available for internal medicine (3,523) than are available for the next closest specialty, emergency medicine (1,765). Not included in these numbers are students seeking a preliminary or transitional year of internal medicine which is a pre-requisite before specialties such as neurology, dermatology, and ophthalmology. Of note, ophthalmology is unique in that the ophthalmology match occurs earlier in the year and does not participate in the regular residency match.

Your future doctor is less likely to be an MD

In the past, most U.S. physicians were graduates of U.S. allopathic medical schools and had an “M.D.” after their name. That is changing and with the current trends, this may be the last year that U.S. MD graduates comprise the majority of future physicians.

For the past 5 years, the number of available residency positions in the United States has been increasing. In 2017, there were 27,688 residency positions and this grew to 33,353 in 2021. Although the absolute numbers of applicants from each of the four types of students applying to residency has increased, the numbers of students from osteopathic schools, U.S. students attending foreign medical schools, and foreign students attending foreign medical schools has increased faster than the number of students from U.S. medical schools (MD). As a result, the percentage of students matching to residency from U.S. medical schools has fallen from 65.6% in 2017 to 50.7% in 2021. At this rate, the percentage will likely be < 50% next year. A total of 31% of students who matched this year trained at a foreign medical school, either as a U.S. citizen abroad or as a foreign citizen. That is up from 24% in 2017 and at this rate, in the near future, more U.S. physicians will have trained at a foreign medical school than at a U.S. medical school.

What happens to the students who don’t match?

Unmatched applicants included 1,431 U.S. medical school seniors, 866 U.S. medical school previous graduates, 774 osteopathic seniors, 339, osteopathic previous graduates, 2,143 U.S. citizens attending foreign medical schools, and 3,587 foreign citizens attending foreign medical schools. Combined, this is a total of 9,140 students who did not get into a residency. This is a mixed bag of students. Some will land a residency position in the “scramble” when unmatched students call program directors of residency programs that did not fill in hopes of getting a residency position after the match. Some will take a year or two off to get an MBA or other masters degree. Some will decide not to pursue medicine altogether and switch to another career. Some will take a year off to do research or work in another field and then try again next year.

Those unmatched students who apply to the match a second time face lower chances of obtaining a residency position. Of senior medical students applying to residency for the first time, 92.8% matched; however, of graduates of medical schools applying later, only 48.2% matched. The same trend exists for osteopathic students: 89.1% of senior students applying for the first time matched but only 44.3% of graduates applying later matched.

The results of the National Resident Matching Program tell us a lot about which specialties are hot and which specialties are not. But by looking more closely at the results, we can also forecast who our doctors are going to be in the future.

March 23, 2021

Fourth year medical students are facing challenges that no previous group of medical students have faced. The COVID-19 outbreak resulted in a loss of approximately 1/3 of their clinical rotation time during their third year of medical school as students were removed from our teaching hospitals in order to protect their own health. The re-direction from in-person to telemedicine outpatient visits was largely engineered to ensure continuity of patient care and physician income preservation – medical student education was left out of telemedicine. Students wanting to explore different hospitals or specialties not available at their own medical institution have seen clinical  “away rotations” eliminated due to travel restrictions. And now, the long-standing tradition of the residency interview has been radically changed with the replacement of on-site interviews with virtual interviews performed over the internet.

Residency Interviews are Expensive

In some ways, the virtual interview process brings benefits. Travel costs for medical students average $250 – $500 per interview and with students ranking an average of 12.5 residency programs in last year’s National Resident Matching Program, the typical medical student incurs about $5,000 in interview costs in order to apply to residency programs. There is a time cost as well, with one study finding that the average medical student spends 26 days traveling to interviews. Travel time and costs are the major factors that limit the number of programs a student can interview with.  The probability of matching to a residency program is dependent on both the number of programs a student ranks on their match list as well as the type of specialty that they have chosen. For example, 90% of U.S. medical students applying to pediatric residencies matched in their top 3 rank selections whereas 90% of internal medicine residency applicants  matched in their top 4 selections. Orthopedic surgery is considerably more competitive with 90% of applicants matching in their top 11 selections.

Last month, I attended the American College of Chest Physicians annual meeting. At one of the sessions, I realized I could hear the men talking but I had a hard time hearing the women despite the fact that they were all standing in front of the same lectern and all speaking in what seemed to be normal conversational speech. I realized that there can be implicit gender bias in lecture acoustics and that women need to be aware of some of these sources of acoustic bias in order to be effective speakers. There are several sources of acoustic gender bias. In this post, at the risk of being a male talking about female gender bias, I’ll explore several of these.

Gender differences in vocal frequency

Male and female voices occupy different sound frequencies. A typical male voice extends from 150 Hz to 6,000 Hz and a typical female voice extends from 350 to 8,000 Hz. However, in normal voiced speech, a male voice is 85 – 180 Hz and a female voice is 165 – 255 Hz. Certain vocal sounds occur at higher frequencies than others. For example, the sound of “J”, “M”, or “Z” occurs at a low frequency whereas the sound of “K”, “F”, or S” occurs at a much higher frequency.

Humans are wired to associate lower frequency voices with authority. In a study of male CEOs, the size of the company that a CEO ran correlated with the frequency of his voice – a lower voice pitch was associated with running a larger company and correlated with a higher salary. Interestingly, the average frequency of adult women’s voices has fallen by 23 Hz since 1960 which may reflect evolving societal differences in women in positions of authority. Because children have higher pitched voices than adults, a high-pitched voice can make a person sound young or inexperienced.

Many sound systems are adjusted to make the (often male) CEO sound great and this can put people with higher frequency voices at an inherent disadvantage unless there is someone tending the sound system who can make everyone sound just as great as the CEO.

We lose high frequency hearing with age

As we get older, our ability to hear high frequencies is diminished. Business owners use this to their advantage when they install a Mosquito alarm outside their buildings. This device emits an annoying 17,400 Hz noise that loitering teenagers can hear but older people are oblivious to. High frequency hearing loss begins at age 30 and increases with each decade of life.

As a result, many older people have a hard time hearing female voices with their higher frequency pitch. This is not an issue if you are lecturing to a group of college students. However, if you are lecturing to an older group of people or giving a presentation at a board meeting full of older board members, then a higher frequency voice is harder to hear. A woman often needs to speak slightly louder to be heard as well as her male colleague.

Equipment bias

There are two pieces of equipment that can affect how women’s voices project as opposed to men’s voices: the microphone and the equalizer. Each microphone will have a frequency rating that reflects how well it picks up different sound frequencies. A microphone that is better at picking up lower frequencies will tend to make a male voice sound louder and a female voice sound softer.

A second way that the microphone can cause discrimination by the “proximity effect”. This occurs because lower frequencies tend to be lost the further away a person is to the microphone. The average American man is 5 foot 9 inches tall where as the average American woman is 5 foot 4 inches tall, a difference of 5 inches. If a lectern microphone is set to position that microphone for the height of a man’s head, then a woman’s head is going to be 5 inches further away from that microphone with the effect of losing her lower frequency elements of speech. Therefore, simply by being closer to the microphone, you can augment the lower, or base frequencies in your voice. An easy way to demonstrate this is to use the “voice memo” app on your phone and record your voice saying the same thing with the phone 2 inches, 12 inches, and 24 inches away from your mouth. At 2 inches, your voice will have more base elements and will sound deeper and richer.

Microphones come in two general categories, directional and omnidirectional. A directional microphone picks up sounds from one specific direction and should be positioned so that it is pointed toward the source of that sound. An omnidirectional microphone picks up sounds from all directions from the microphone. The microphones on lecture room lecterns are usually directional so that the speaker’s voice is picked up but room noise is minimized. However, even with a directional microphone, as you increase the distance from the microphone, room noises will start to creep into the audio if the audio technician is attempting to maintain your voice at a constant volume. To ensure optimal acoustics, be sure that the directional microphone is pointed at your mouth.

 

Two other effects of the distance to the microphone is on reverberation and “popping noise”. Reverberation, or the echo of one’s voice in a room, becomes more evident when there are non-porous materials in the room (for example, concrete walls) and when one gets further from the microphone that they are speaking into. Those echos can make words harder to hear. If a person gets too close to a microphone, then the microphone can pick up puffs of air that can accompany sounds like the letters “p” or “b” and this can result in a distracting popping sound to one’s speech. Professional musicians overcome this by using a pop-filter composed of a piece of stocking-like material stretched and mounted as a screen between the microphone and the singer’s mouth. Pop-filters are impractical in a typical lecture room. The best distance is usually 6-12 inches between microphone and mouth; this distance is the best compromise between reducing popping sounds at the same time as reducing reverberation and room noise.

In order to account for different frequencies, equalizers are often used by sound engineers. An equalizer allows the engineer to preferentially amplify sounds in different frequency ranges and this can be used to “equalize” voices of different pitches, for example, men versus women. The bass and treble knobs on a radio are the most simple form of an equalizer. An equalizer in a lecture room can have between 5 and 31 sliders with each controlling a range of frequencies. Most lecture rooms don’t come with professional sound engineers, however, and so equalizers in a sound system may be set to a factory default frequency preference or the equalizer may be run by an audio-visual staff member with little idea of acoustic optimization. If you ever go to a small venue concert, the singer will almost always recognize the person running the sound system at the end of the show – how well that person manages the equalizer can make an enormous difference in how the singer sounds. The person running the lecture room sound system is just as important to the effectiveness of the lecturer.

Room bias

The acoustic response of a room if affected by many variables but one of the more important is the degree of absorption of different frequencies. Porous materials in a room, for example, carpet or fabric, can reduce reverberation and echos but will also absorb high frequency sounds. Thus, a person with a high frequency voice may not seem to be as loud as a person with a lower frequency voice. The more porous materials are in a room, the more a woman’s voice can be lost.

The individual’s “voice brand”

There are 5 main features of a person’s individual voice brand: intensity, inflection, rate, frequency, and quality. Adopting different elements of each of these features can significantly impact the effect a voice can have on a listener.

Intensity is the loudness of a voice in decibels. Too soft of a voice can come across as meek and timid but too loud of a voice can come across as if you are shouting or angry.

Inflection is the intonation of voice or the degree to which the pitch varies. An excessively monotone voice has little variation in the frequency of the words spoken and can come across as uninteresting. An excessively up-and-down voice with constant swings in the frequency of words can come across as unintelligent.

Rate is the speed of one’s speech. Too slow comes across as condescending but too fast comes across as being rushed. Varying the rate of speech can be an effective way of emphasizing certain points. A good rate range is 162-175 words per minute.

Frequency is the pitch of the voice, usually measured in hertz (Hz). Too high of a frequency can make one sound young or less intelligent, as discussed above. Too low of a frequency can be authoritative but can also come across as aggressive.

Quality are those characteristics of a voice that can create an “interesting voice”. Two voice qualities to avoid in public speaking are the “glottal fry” and “up-talking”. Glottal fry is when a person takes their voice down to an unnaturally low pitch during part of a phrase resulting in a creaky or graveling timber. A study of voice perception found that people over age 40 believe that speakers using vocal fry sound like they lack authority. Up-taking, or high rising terminal, is when a person increases the frequency of their voice at the end of a sentence. This results in a tone that sounds like a question and can make the speaker come across as unsure of themself or uncomfortable.

So what can women do?

To create an equal acoustic playing field, there are some things that you cannot control. For example, you cannot control the shape of the room, the extent of porous room materials, or the frequency rating of the microphone. However, there are some things that you can control and you can use these to your advantage.

The first thing one can do is to speak louder. As men and women speak in a loud (but not shouting) voice, the differences between the acoustic perception of different frequencies of sound become less apparent. So, if a woman speaks slightly louder than normal, she can eliminate the auditory perception gap that exists between male speech and female speech, particularly in the lower vocal frequencies. This becomes more necessary when a woman is speaking to an audience of mostly older persons.

A second strategy involves speaking with the person running the sound equipment for the lecture room (when such a person exists!). Many times, they will have set the equalizer to a default setting or they will have optimized it for whoever the first speaker is. If that first speaker is a man with a low pitched voice, then the woman who is the second speaker will often be acoustically disadvantaged. Asking the sound technician to be sure to adjust the equalizer when you are giving your presentation will remind that technician that you are aware of the importance of what they do and ensure that he or she optimizes the settings for the unique frequencies of your voice.

A third strategy is to adjust the microphone height. In order to retain the authoritative lower frequency vocal intonations, one has to maintain proximity to the microphone. Sometimes this may mean adjusting the height of a lectern (if it is adjustable) and sometimes this means bending a flexible goose-neck microphone down to an appropriate height. Stand close to the microphone with a goal of your mouth being 6-12 inches away. Be sure that the microphone is pointing directly at your mouth. Lavalier microphones are a great choice because they stay pointed directly at the mouth and they stay a fixed 8 inches from the mouth.

A fourth strategy is to adjust your voice brand. Most of us do not really know how we sound to others. Recording a practice session of your presentation and then listening  to it can help you identify features such as glottal fry and up-talking that may not have much impact on younger audiences but can make you seem less authoritative to older audiences. Ensure that your rate is 162-175 words per minute and that your intonation is neither too monotone nor too up-and-down.

To be successful, it is important to not only be qualified but to also sound qualified.

November 12, 2019

It costs more than $1.1 million to train a doctor in the United States. The societal investment in creating physicians is enormous and has widespread implications for American health care in everything from acceptance of international medical graduates to the future use of non-physician health care providers.

Breaking down the costs

Depending on the specialty, tt takes 11 to 15 years to train a physician when you count college, medical school, residency, and fellowship. At each of these steps there are direct costs and indirect costs. Some of these costs are paid by the physician in training and some of these costs are paid for by society in general (usually through state or federal taxes). Here is a breakdown of the direct and indirect costs at each step along the way:

Undergraduate education. Colleges essentially have 3 sources of income: tuition, endowment, and government funds. For this reason, the total cost to educate an undergraduate is considerably more than what the student actually pays in tuition. It becomes complicated because most colleges not only have to finance the education of students but also have to finance the research activities that professors must perform in order to keep their jobs. Thus, it is hard to separate the costs of education from the costs of research. Public colleges receive state government funds to subsidize their education and research activities and this results in lower tuition for in-state residents than for out-of-state residents. The out-of-state tuition and fees best reflects the cost to teach an undergraduate without the state governmental subsidy. Private colleges and universities generally do not receive state governmental subsidies and have considerably higher tuition costs. For the purpose of this analysis, I used the current cost of attendance for out-of-state freshman at the Ohio State University that includes tuition, fees, books, room, board, and miscellaneous expenses if living on-campus which is $49,556. For four years of college, this would be a total cost of $198,224.

Medical school. Colleges of medicine have the same 3 sources of income as undergraduate colleges so for this analysis, I used the current cost of attendance for an out-of-state medical student at the Ohio State University College of Medicine. Once again, this estimate is for tuition and fees as well as estimated living expenses. Unlike undergraduate college, the cost of medical school varies considerably for each of the four years of training: year one = $80,019, year two = $76,026, year three = $114,442, and year four = $114,542. Totaling all four years, the cost to go to medical school is $385,029.

Residency. There are both direct and indirect costs of resident education. The direct costs are the resident’s salary and benefits. At the Ohio State University Medical Center, these costs are $51,510 for a first year resident (intern) and increases each year so that a fourth year resident cost is $56,636. However, the direct costs are only the tip of the iceberg when it comes to the total cost to train a resident. There is the cost of everything from hospital call rooms, to residency program administrator salaries, to part of the salaries of chairmen and faculty to cover otherwise non-compensated teaching time. Most of these indirect costs are ultimately paid from federal tax dollars- either by Medicare payments to teaching hospitals for graduate medical education or by the higher Medicare payments for clinical services that teaching hospitals get paid (as opposed to non-teaching hospitals). In 2014, the Alliance for Academic Internal Medicine estimated that the total direct and indirect costs to train a resident is $183,416 per year. For the 3 years of residency it takes to become a general internist, pediatrician, family physician, or hospitalist, the cost is $550,248. It takes longer to train other specialists, for example, an obstetrician is 4 years ($733,664), a gastroenterologist is 6 years ($1,100,496), and an interventional cardiologist is 7 years ($1,283,912).

Total costs. Adding all of these together, the total costs to train physicians is astounding. This demonstrates that society has an enormous investment in each physician in the United States.

• $1,133,501 – general internist, family physician, pediatrician
• $1,316,917 – obstetrician, psychiatrist
• $1,500,333 – general surgeon, endocrinologist
• $1,683,749 – gastroenterologist, pulmonary/critical care, general cardiologist
• $1,867,165 – interventional cardiologist, neurosurgeon

Implications for U.S. healthcare

International medical graduates. One of the best ways to reduce the cost of training doctors is to get someone else to pay for it. If you can get another country to cover the costs of college and medical school, then the cost to American society drops. Therefore, the U.S. cost to train a family physician who is an international medical graduate is $583,253 less than a family physician who is a U.S. medical graduate. In other words, the cost to American society of an international medical graduate is about half that of a U.S. medical graduate.

Non-physician providers. Nurse practitioners and physician assistants are far less expensive to train than physicians. The typical NP or PA training consists of 4 years of undergraduate training plus 2 years of NP/PA training. The costs to become an NP or PA is approximately $84,598 after college (tuition and living expenses) and the total cost including college is $282,822. In other words, the cost to train a family practice NP/PA is only one-fourth of the cost of training a family practice physician. Given that NPs and PAs increasingly have a similar scope of practice as physicians, from a societal standpoint, it will be a lot less expensive to train an NP or PA than it is to train a physician to do the same job. The implication is that NPs and PAs will replace many physician jobs in the future.

Repairing broken physicians. In a meeting I was recently attending, a question was asked whether we have different standards for terminating physicians with behavioral problems or substance abuse than we do for terminating other health care workers for the same problems. The reality is that I think we probably do and part of this is because of the enormous societal investment in those physicians. To create an analogy, if you have a broken handle on a screw driver that cost $2, you buy a new screw driver and don’t pay the cost of repairing it. On the other hand, if you have a broken handle on an airplane that costs $1.2 million, you repair the handle rather than throwing out the entire plane. If society invests $1.2 million to create a physician who then develops alcoholism, one can make the argument that hospitals have a societal obligation to first attempt to cure the physician and return him or her to practice when/if safe to do so rather than permanently end that physician’s career. Like it or not, hospitals will often put broken physicians on leave and attempt to rehabilitate them for infractions that would result in an unskilled employee being terminated – it is not necessarily fair but it is an economic reality. On the other hand, if an airplane has a critical mechanical flaw that puts it in continuous danger of crashing, you decommission that airplane – physicians with critical flaws should similarly be decommissioned.

Discussions about the cost of training physicians usually center around the cost to the individual physician and often stop at the average debt of a graduating medical student. But beyond medical student debt, there is a much larger cost that is not paid directly by the doctor but is paid more broadly by the institutions that provide scholarships, by the citizens who pay state and federal taxes, by direct salary costs of residents who cannot bill for their services, and by the indirect costs to hospitals to train residents.

July 11, 2019

Last week, the National Resident Match Program released its annual data report on the most recent fellowship match for positions to begin in July 2019. The fellowship matches take place between May 2018 and January 2019, with different match days for different specialties. The NRMP releases a summary of all of the specialty match results in February each year. By analyzing the data, you can learn a lot about which specialties are attracting new physicians and which ones are not attracting new physicians. And projecting forward, you can predict which specialties are going to have shortages of practitioners in future years. The 2019 year had the most positions ever offered in the U.S. (10,936), the most fellowship programs ever in existence in the U.S. (4,750), and the most residents who matched into a fellowship program in the U.S. (9,378).

Because the hospital I practice in primarily has internal medicine specialists, I am particularly interested in the outcome of the various internal medicine specialty fellowship matches. This table in blue shows the number of internal medicine fellowship positions by specialty. They vary widely from a low of adult congenital heart disease (9) to a high of cardiology (951). Oncology-only fellowships and hematology-only fellowships generally have very small numbers of available positions because most physicians tend to go into combined hematology and oncology fellowships. Similarly, there are few pulmonary-only fellowships because most candidates go into a combined pulmonary and critical care fellowship.

The NRMP also reports the percentage of available positions that fill with U.S. allopathic (MD degree) medical school graduates, as shown in this table in red. Eliminating oncology, hematology, and pulmonary from the analysis because most doctors interested in those fields do a combined fellowship, it becomes clear that the most popular specialties are hematology & oncology, gastroenterology, and palliative medicine (adult congenital heart disease, interventional pulmonary, and cardiac electrophysiology are only done after a doctor has already completed a pulmonary or cardiology fellowship and are thus sub-specialty fellowships). The least popular fellowships are nephrology, geriatrics, and endocrinology.

Next, lets look at the how all of the various specialties filled when including not only U.S. allopathic graduates but also U.S. osteopathic (DO) graduates, U.S. citizens who attended foreign medical schools (most frequently Caribbean medical schools), Canadian medical school graduates, and foreign medical school graduates. Here, in the table in brown, we see that most fellowships eventually filled. However, nephrology and geriatrics are notable exceptions.

So, why are certain specialties so unpopular? One factor may be salary. Using the 2018 Medscape Physician Compensation Survey data, the internal medicine specialties with the highest salaries also had the highest percentage of available fellowship positions filled with U.S. allopathic medical school graduates (cardiology, gastroenterology, and hematology/oncology). Endocrinology is notable because the annual salary of an endocrinologist is less than a general internist, meaning that for the personal cost of doing 2 additional years of fellowship training in endocrinology compared with a general internist, you get to make $18,000 less than a general internist – not surprisingly, relatively few of the endocrinology fellowship positions were filled by U.S. allopathic medical school graduates.

Another way of analyzing salary and work effort is from the annual MGMA Physician Compensation Report. The 2018 report is the most recent and it reflects 2017 data. There are important differences between the MGMA compensation data and the Medscape compensation data. The MGMA report only includes large group practices, is reported by practice managers, and reflects total compensation. The MGMA report has data on private practice physicians (who make more) separate from academic physicians (who make less). On the other hand, the Medscape report includes any physician, is self-reported by the physician, and represents salary (which may not be the same as total compensation). The Medscape report includes both academic and private practice physicians. The MGMA data is probably more accurate but represents a skewed population of doctors. The Medscape data is probably less accurate but in theory is more representative of the average doctor (or at least those who are willing to take the time to fill out the survey). This table reflects just the MGMA private practice data. From the MGMA report, it is apparent that based on median wRVUs, nephrologists work very hard, in fact, harder than any other specialists except cardiologists. However, they make $140,000 less than cardiologists. When the MGMA data is expressed as total compensation per wRVU, it appears that nephrologists make the second lowest amount of money per wRVU compared to other specialists (note that the MGMA total compensation per wRVU is calculated with a complicated equation and that not all practices report both total compensation plus wRVUs so the reported values will be different than if you simply divide the mean total compensation by the median wRVUs for any given specialty).

There is a pretty sharp demarcation between the lowest paid specialties (geriatrics, endocrinology, rheumatology, infectious disease, and nephrology) and the highest paid specialties. The lowest paid specialties had the lowest percentage of fellowship positions filled with U.S. allopathic medical graduates. The one exception to this is palliative medicine but palliative is unique in that palliative physicians make about twice as much income per wRVU at $110.57 than the other specialties.

Another reason why newly trained residents may choose one specialty over another is how happy the physicians are in a given specialty. The 2018 Medscape Physician Compensation Report also has information on job satisfaction of physicians, including a survey question of “Would I choose the same specialty again?”. Once again, there is a relationship between job satisfaction and the percentage of residents who choose that specialty. The least happy internal medicine specialists are nephrologists (in fact, per the Medscape survey, they are the least happy specialty of all physicians, not just internal medicine specialties). Nephrology is also the specialty that filled the least of available positions with U.S. allopathic medical school graduates. So, if you choose to do 2 additional years of training compared to a general internist, you are rewarded by being 30% less happy with your job than a general internist. On the other hand, the three specialties with the most satisfied physicians are also the 3 specialties with the highest percentage of fellowship positions filled with U.S. allopathic medical school graduates (hematology/oncology, cardiology, and gastroenterology).

As we project the results of this year’s fellowship match into the future, we should anticipate future physician shortages in nephrology, geriatrics, infectious disease, and palliative medicine. Additionally, we should anticipate that there will be more nephrologists who are foreign medical school graduates than U.S. allopathic medical school graduates in the future based on the total number of U.S. versus foreign medical school graduates filling fellowship positions this year. Endocrinology and geriatric medicine are not far behind and in the future, your endocrinologist and geriatrician will probably be more likely to be an immigrant from another country than a graduate of a U.S. medical school.

If American medicine was an entirely free market economy, then as the supply of nephrologists, geriatric physicians, infectious disease physicians, and palliative medicine physicians goes down, then their salaries should go up. But physician supply and demand is complex and since it can take many years to train enough physicians to fill a specialty with a physician shortage, we may be looking at a medical economy with too few nephrologists, geriatric physicians, infectious disease physicians, and palliative medicine physicians for years to come.

An alternative explanation is that we have too many fellowship positions open in these specialties and that academic medicine is out of alignment with the needs of American medicine. Academic medical centers tend to create fellowship positions based on the needs of the individual divisions and departments within a given medical center and not necessarily based on the needs of the medical economy as a whole. This can also contribute to a misalignment of specialist supply and demand.

One thing seems certain, however. American nephrologists are less happy with their job, work harder in terms of wRVUs, and are compensated less per wRVU than other physicians. I believe that these are the reasons why so few physicians are entering the nephrology fellowship match and why so few nephrology fellowship positions filled in this year’s fellowship match. To insure that our patients’ medical needs are met in the future, hospitals will need to be sure that their nephrologists are happy and are compensated appropriately for the work that they do. On the other hand, gastroenterologists, hematology/oncologists, and cardiologists are the happiest and most highly compensated and this may explain why these three specialties filled so well in this year’s match.

February 26, 2019

This post falls under the general category of shameless self-promotion. The American Board of Internal Medicine keeps changing the requirements for maintaining board certification. When I completed my internal medicine residency, it was easy – you took a board examination and then you were board certified for life. But after 1989, everything changed and the ABIM required re-taking a board examination every 10 years to maintain board certification. Since I first took pulmonary boards in 1990 and critical care boards in 1991, I was required to do those exams once a decade. Next came the maintenance of certification program that required us to do on-line ABIM MOC learning modules that included “open-book” exams every year plus do the 10-year formal board examination. Most recently, the ABIM has done away with their own MOC modules and now require 100 MOC points to be earned every 5 years (in addition to the every 10-year formal board examination).

This has left physicians scrambling to try to get enough MOC points by December 31st in order to maintain their board certification. Since physicians can no longer go to the ABIM’s website to get those MOC points, they must be earned through other activities, usually coupled with continuing medical education credits. Some of these are pretty easy – for example, I can generally get 18-22 MOC points by just attending the annual American College of Chest Physicians meeting. But attending the ACCP meeting costs me more than $2,000 and it seems like we inevitably come up a few MOC points short by the end of the year.

One way of finding activities that you can do to earn MOC points is by going to the Accreditation Council for Continuing Medical Education’s website that allows you to search for different CME activities. One of these is where the shameless self-promotion comes in:

OSU MedNet

21 years ago, I started moderating a weekly CME television program called OMEN-TV (Ohio Medical Education Network- TV). This was born out of an audio CME program called OMEN that began in 1962. The original OMEN was broadcast from an audio studio on campus at the Ohio State University and went out over a telephone speaker system to hospitals throughout the country that would be pre-mailed 35 mm slide sets. OMEN evolved into OMEN-TV in the 1980’s and was broadcast from a television studio at OSU over a satellite TV system every Friday at noon and was targeted to subscribing hospitals that used the programs as the equivalent of a grand rounds for their medical staff. In 2002, OMEN-TV evolved into a webcast and was renamed OSU MedNet in order to reflect the internet broadcast.

I’m still moderating the program and currently, we produce 40 OSU MedNet programs every year and we leave them up on the internet for 3 years with the result that we have 120 hours of medical education programming available at any given time. Anyone can view the programs for free. To get either CME credits or MOC points, physicians either have to be on the medical staff at a subscribing hospital, be on the faculty of the Ohio State University, or pay at the end to take a post-test to get their credits.

The great thing about using OSU MedNet for your MOC points is that it is simple and you can learn a lot. Here is how you do it:

1. Go to the OSU Center for Continuing Medical Education website and open up an account. Remember, this is all free if you are at a subscribing hospital or if you are employed by Ohio State University.
2. Log into your account and then go to the OSU MedNet website. Click on any of the 120 programs that are relevant to your practice (all programs since September 2016 are approved for MOC points).
3. At the bottom of the webpage for that particular program, click on the “Take Pre-Test” button. This will pull up a short quiz to test your knowledge of the topic before you view the webcast.
4. After you submit your pre-test, view the program over the internet. Each program is 55-60 minutes long (43 minute if you watch at 1.4 speed or 37 minutes if you watch at 1.6 speed). You can also listen to the programs as an audio podcast if you prefer. You can download a PDF file of the PowerPoint slides from the webcast in either 2 slides per page or 4 slides per page format to help you with your learning.
5. After you view the program, click on the “Take Post-Test” button and you will take the same short quiz that you took for the pre-test. If you need to refer back to the materials to help with any of the questions, you can refer to the PDF files of the PowerPoint slides.
6. Once you submit your answers to the post-test and pass the test, you will have an MOC point (and a category 1 CME credit). Your total MOC points will appear on your account. The MOC points are uploaded to the ABIM at the end of each month and you will get an email from the ABIM letting you know how many MOC points you have earned.

With my Amazon Prime account and my Netfix account, I’ve been binging on everything from “Jack Ryan” to “The Great British Baking Show”. Now you can spend your weekend binging on MOC from the comfort of your own home. You don’t need to buy airfare or a hotel room to attend a conference and at $25 per MedNet program ($800 for a 40-program season), it is less expensive than the meeting registration to attend national conferences.

The ABIM is the organization that internists used to love to hate. But you don’t have to hate any longer because with OSU MedNet, keeping up with your MOC points is easier than ever before and you can chose the particular MedNet programs you want to use based on your own unique clinical practice needs.

November 1, 2018

The Accreditation Council for Graduate Medical Education (ACGME) has released new resident duty hour restrictions that will go into effect July 1, 2017. Resident work hour restrictions all started with the case of Libby Zion.

In March 1984, Libby Zion was admitted to New York Hospital with a flu-like illness, fever to 103.5 F, and tremors. She was evaluated by an emergency room physician and then worked up by an intern and a second year internal medicine resident. She had a history of depression and was taking the MAO inhibitor, Nardil. The housestaff discussed her case with Ms. Zion’s attending physician and prescribed Demerol for the tremors. She became agitated during the night, so the intern prescribed Haldol. She then developed higher fever with a body temperature of 107 F followed by a cardiac arrest and died within 8 hours of admission. Tests revealed traces of cocaine. The ultimate conclusion was that the cause of death was serotonin syndrome triggered by the combination of Nardil plus Demerol. Ms. Zion’s father, Sidney Zion, was a trial attorney and contributor to the New York Times who had previously been fired for publicly releasing Daniel Ellsberg’s identity as the source for the Pentagon Papers. Mr. Zion was enraged at the medical system and said that his daughter was murdered by the hospital and the doctors. He focused on the fact that the intern was working a 36-hour shift and attributed his daughter’s death to the over-worked intern. He filed a medical malpractice claim and convinced the district attorney to have a grand jury consider murder charges against the intern and resident – although the grand jury declined to indict them for murder, they did charge them with 38 counts of gross negligence because of the prescription of Demerol. Ultimately, they paid $375,000 to the family for pain and suffering compensation.

Because of this case, the New York State Health Commissioner put together a commission headed by Dr. Bertrand Bell. The “Bell Commission” recommended that residents should not work more than 80 hours per week, no more than 24 consecutive hours, and that the attending physician needed to be physically present in the hospital at all times. In 2003, the ACGME adopted the 80-hour resident work restriction. Of note, Dr. Bell had been a life-long critic of residency training, having coined the mantra: “see one, do one, teach one, kill one” and was later dismissed from his administrative role by the Dean of the Albert Einstein College of Medicine. Later in his life, he acknowledged that he did not arrive at the 80-hour limit by scientific analysis, instead, he and a friend came up with the number during a conversation on his porch one day.

The problem with the Libby Zion case is that her death really had nothing to do with resident work hours, despite the allegations raised by her father. She died of a very rare condition (serotonin syndrome) that was a rare side effects of the Demerol that she was prescribed. Prior to this case, the overwhelming majority of physicians in the United States had never heard of serotonin syndrome resulting from the combination of Nardil and Demerol (I certainly had not) and very few physicians had ever seen a case of serotonin syndrome (I’ve seen 2 cases in the ICU in my 30 years in critical care). The intern would likely have prescribed the Demerol whether it was the middle of the night or whether it was his first hour back after a week-long vacation. Unless you are a savant, it is just not humanly possible to memorize every drug-drug interaction that can occur. If Libby Zion was admitted to a hospital today, she would probably live – not because the interns and residents are better rested, but because we now have electronic medical record order entry that automatically alert physicians when they prescribe medications that can interact with other medications.

So, that brings us to the new ACGME rules that continue to limit residents to less than 80 clinical work and education hours per week but now specify that these work hours not only include time spent in the office, the hospital, and the library,  but also time spent with home-call. This has residency and fellowship programs in a quandary because now they have to have some way of accounting for calls that residents and fellows take at night. Should they use resident self-reported hours? Should they require residents to submit cell phone call logs? Do they audit the amount of time residents spends in the electronic medical record at night?

Although there is abundant sleep medicine literature to support that sleep deprivation impairs cognitive performance, a 2016 study in the New England Journal of Medicine showed that residents who were subject to an 80-hour work restriction did not perform any differently than those who were not subject to duty hour restrictions. Furthermore, attending physicians do have to work more than 80 hours during some weeks and my own personal opinion is that doctors are better prepared to work those occasional very long hours if they have been trained in how to do it. As an attending pulmonary/critical care physician, I do occasionally work more than 80 hours per week, particularly on the weeks that I cover the hospital on weekends (about once a month).

However, given the legal precedent of the Libby Zion case and the ACGME’s strong stance on duty hour restrictions, it is unlikely that future doctors will experience 80 work weeks until after they complete their training. Many older physicians who trained in an era of every-other-night call during internship currently work long days and nights, because it is what they always have done. Tomorrow’s doctors will probably be less willing to work 80-hour weeks because they never did it during training. That means that hospitals will need more physicians to provide the same amount of 7-day per week on-call coverage and this will cost more money. And that means that in the future, physicians will either earn less or consumers health care costs will go up.

80-hour work/education weeks do improve resident satisfaction and may lessen physician burnout. And I think that keeping residents from regularly spending more than 80 hours a week in clinical care and education activities is a good thing. But the genesis of the 80-hour duty restriction was based on anger and zeal, not on scientific evidence. It is one of those “right outcome for the wrong reasons” phenomenon. For me, 90-100 hour work weeks during my internship in 1984 (the same year Libby Zion died) allowed me to succeed – my greatest strength was not my IQ but my endurance and in that era, endurance was a trait that made a good doctor a better doctor. Success in anything is a match between the unique characteristics of an individual and the unique demands of the environment at a unique time. And in the future, endurance will no longer be a trait that makes one a better doctor and someone like me will less likely to be successful in medicine.

For now, it looks like residents are going to have to start logging those calls they take at night from patients who need medication refills and text pages they get from hospital nurses letting them know they have a consult for the next morning.

May 23, 2017