“Main Residency Match” Post-Game

March 17, 2013 in Residency Training, Workforce Development | Tags: National Residency Match Program

The latest Main Residency Match (registered Trade Mark) results are in. Officially it is an impartial venue for matching applicants’ preferences for residency positions with program directors’ preferences for applicants. Unofficially it reflects a lot more, as I have discussed before (found here). For those of you living in towns with medical schools, it is the day that the hometown paperbloggythingy is filled with pictures of medical students crying because they are so happy to be leaving their current God-forsaken burg for one of better value (in Mobile, typically one several states away). To make a long story short, without successfully working in a residency position for several years, a young physician will never be allowed to practice medicine in the United States (how much time in residency is required varies by state).

There has been discussion on e-mail by my colleagues about the Early Results (term not trademarked, results found here). The good news for family medicine is that of the 3037 positions offered, 2914 were filled (about 95%). That bodes well for primary care, say some, and thus the glass is half full. The bad news for Family Medicine is that out of the 17, 487 graduates of traditional US (allopathic) medical schools, only 1356 chose Family Medicine, filling only 44% of our positions and comprising only 7% of the graduates of these schools. 1097 graduates of these schools did not match into any program and though there were Family Medicine positions available, did not apparently want these either. They have chosen, I presume, to sit out a year and try for the specialty of their choice again rather than seek three years of training to make a nice living (over $200,000 a year after completion) as a family physician. Looking at it that way, the glass is half empty.

Our society needs physicians practicing primary care, and graduates of family medicine residencies are the most likely to practice this kind of medicine. Graduates of traditional medical schools tend to seek the “ROAD to success” (Radiology, Ophthalmology, Anesthesia, Dermatology) specialties, so named because the average work week is less than 40 hours and the mean pay is over $400,000. So, where do we look?

One place is Osteopathic schools. The students who attend these schools tend to have a lower MCAT (24, average for most allopathic schools 30-31) and lower GPA but more life experience. (MCAT and GPA beyond a threshold value have been found to only predict success on the first of three standardized tests and have no bearing on clinical ability.) The students are typically committed to a distributed education model and often chosen for interest in primary care practice. Previously, osteopathic schools were seen by some as the domain of those not “smart enough” to be admitted into allopathic medical school. For those interviewing with us this year, it was decidedly not the case. In our experience, osteopathic candidates for our residency resemble allopathic students in their knowledge base. Their clinical skill set is a little different than the allopathic students’ but different can be better. In our experience they are bright and committed to going back to their community to practice (often an underserved community). There were 2677 total applicants in the Main Residency Match and 2019 got a position. How many went into family medicine is unknown.

Another place is the Caribbean. Medical schools there have exploded in the past 10 years. This seems to be at the expense of the old 5th pathway program (US citizens going to Mexican medical schools a la Bad Medicine) and non-US citizens looking to come to America (the J-1 programs, as seen here). It used to be that applicants with a marginal application (relatively low grade, MCAT, or both) would have a application with the following pattern: apply to allopathic school with a marginal MCAT/grades, get wait-listed, “make your application look better” by retaking the MCAT and bumping it up two points, work as a hospital orderly, reapply, repeat until accepted or life passes you by. This is dead. Many students give US schools one shot then apply to a Caribbean school.

Coincidentally, many of these students with marginal applications also have a strong interest in primary care. Many of them have parents who are in primary care and who did not go to US schools. Their children are not looking for prestigious medical school but for training that allows them to qualify to take the ECFMG test. Passing this test allows them to give residency training a shot, often in family medicine. In 2009 there were 3390 applicants from these schools and only 1600 matched. This year there were 5095 and 3601 matched. That is 15% of the matched pool. For these schools the standardization of testing for graduates of non-US schools (ECFMG, NBME, and clinical skills evaluation) has been the great levelers. These graduates are a large part of our current workforce and have filled our training programs for the past 10 years.

Can we look to traditional medical schools to supply a larger percentage of the primary care workforce? Allopathic schools expanded their classes by 10% several years back to fill a “need.” That 10% was supposed to be selected to correspond to the needs of the “community.” The additional allopathic students, unfortunately, tend to look like the other 90%, overwhelmingly white, overwhelmingly privileged, overwhelmingly looking for a ride on the “ROAD.” Telling to me were the results for the 1487 allopathic graduates who did not get a position last year. I am assuming they have not been working as a physician for the past year (because they can’t). They applied for positions in this year’s match. 758 of them were unmatched for a second time. This means that rather than “settle” for a primary care residency that will net them $200,000 a year at the end of 3 years, they are going to sit out another year, presumably looking to get on the ROAD.

So, in our class we have 2 osteopathic physicians, 2 physicians who are from a Caribbean school, one traditional resident, and one resident who did not match last year and elected to apply in family this year. We are excited about training them and, since 60% of residency graduates tend to stay within 100 miles of where they are trained, I’m happy to welcome them to the community.

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March 17, 2013 at 11:34 pm

Robert C. Bowman, M.D.

After 32 class years, still just 3000 FM graduates grace the US design. The one specialty with multiple times more primary care during a career, multiple times more primary care where needed, multiple times more geriatric care, multiple times more economic impact where needed, the pediatric source for the children long left behind, and the specialty with least training cost for the primary care delivery yield over a career.

FM is the only efficient, effective, affordable primary care recovery source. NP and PA are up to 6 grads to deliver the same primary care as a single FM resident an will soon by up to 7 or 8 as more disappear to more non-primary care specialties with more in each specialty.

There is nothing wrong with FM. What is wrong is what the US designers have done for decades – driving medical students away from permanent primary care and primary care where needed. They want to be flexible and they do not want to go to 30,000 zip codes where 200 million Americans are found – and need local or adjacent care. They want to pile into a small % of the land area where physicians are not needed and do care that drives up the cost without doing much else.

As before, FM in the match attracts a mixed group of those committed, those rating FM lower as a backup but not getting their first choices, and grads with few choices other than IM or FM due to lower rated schools and scores, etc.

This does not mean FM is marginal in anything, as I have full confidence that the FM residency will be a good start and 6 – 8 years of practice as an FM doc will provide appropriate training, orientation, and more. (4 years of formal FM GME is a huge mistake for the match and will not boost training).

The major advance required for med ed in the next decade is understanding that patient situations shape health care. Patients and situations also shape FM docs patient by patient – before, during, and after training. Normal Americans shape FM docs into what FM docs should be.

FM training should be more before, during, and after FM training. Clinician specific training is required for choice of FM, and more than the minimal 3 months we offer in med school. Why would we think that preparation by research and hospital experiences, subspecialty focus, dysfunctional primary care training (Keirns, Academic Medicine), or longer training would work for FM? Shorter prep and medical school training, more specific preparation and training, and training with practicing FM docs await implementation for primary care recovery focus by design.

FM choice in US Seniors is a measure of the horrid policies for primary care support that have continued for 32 years with the exception of 1994 – 1998 when FM peaked with a sudden and brief reversal of policy. (Five Periods of Health Policy and FM choice) 7% choice is still a measure indicating horrid policies.

FM from 1965 to 1980 reflects US policies aligned all the right ways – primary care and FM focused, FM funding from state and federal sources focused on more FM grads, new primary care schools favoring FM, more primary care dollars, more primary care dollars where needed – all of the 12 principles for health access recovery were followed – since then almost none of the 12 have been followed.

Why have we had more positions filled? Well we have insufficient GME positions. Lower ranking MD schools and graduates, DO schools and graduates, and Caribbean graduates tend to choose IM, FM, psych. Non-citizens choice IM. Those choosing IM fail for primary care and primary care where needed, leaving the FM importance for any real primary care recovery. PD expansions have also failed for primary care increase. PA expansions have also failed and NP appears to have failed also due to employed family practice result cut in half.

In short, we have a design that does everything wrong for primary care and health access and primary care where needed – all those things that family medicine has been, is, and will remain.

Note to those celebrating their Dermatology match – good luck finding a job! The average derm PA generates over $600,000 or about as much as a derm doc (JAAPA March 2013). The derm PA costs less than half as much for salary and benefits. Who do you think is going to hire a physician derm doc when they can generate 1.5 million in revenue for the same cost?

Other non-primary care situations will be moving this way as NP and PA will generate 18000 new competitors 2013, in 2014, in 2015, and each year for decades. Established subspecialists will benefit while the new kids in town will face more problems. You may see dollar signs, but you might consider job security – especially with all that debt and no hope of loan repayment, etc.

March 17, 2013 at 11:38 pm

Robert C. Bowman, M.D.

Osteopathic schools are not a haven for lower MCAT. Note to applicants not really DO interested – Please do us a favor and avoid going to an osteopathic school if you do not want to learn to diagnose and treat with your hands. Note to applicants – if you do not want to lay hands upon other students of all types – don’t do osteopathic or our school. And if you actually want to combine good clinical skills training with OMM, SOMA is your place.

DO is not a primary care recovery solution as it has been influenced by US policy away from primary care. DO grads are twice as likely to be in primary care, but the % has declined. Osteopathic primary care is predominantly FM as IM and PD are few. The doubling and redoubling of osteopathic graduates has resulted in no primary care increase because the FM % was cut in half 1970 to 1995 (70% to 35%) and again 1995 to 2010 (35% to 18%) – with a slight increase in the last 2 years. PA has doubled annual grads also with no gain.

Ross U in the Caribbean is the number 1 US source of FM and therefore US primary care with 26% FM and 45% IM from 700 annual grads in recent years (not data from this year, but last few year average will be the same). Of course only 25% of the IM grads will do primary care much at all. Ross profits off of many things, especially tuition dollars. It also buys rotations at 1200 to 1400 dollars per month using the tuition dollars – pinching US MD and DO even more.

What will happen with generic GME position expansion? More graduates can bypass FM resulting in declines in FM choice. Graduates listing FM as a backup are more likely to get their first choice. The peak FM choice was seen with GME contraction – losses of hospital based positions in the 1990s due to the managed care threat – that was quickly killed off by the designers.

What will work for primary care recovery? Pure FM only expansion, FM schools bypassing traditional medical schools, rural medical schools offering career choice but obligated for 6 – 8 years of instate rural practice, PA or NP forced to be permanent family practice employed workforce (not less than 25% and falling, little chance of this happening).

What has worked? Duluth and a few DO schools with long term high FM %, the first 25 years of the 1970s created primary care MD schools (before Flexnerian impact and US policy influences reversed their course), the 6 osteopathic public schools (but some lagging), and admissions that is more representative of normal Americans.

We are still moving the wrong way in admissions and in training.

The bad news is a new study demonstrates 78% of about 240 top colleges are top quartile income in origin. This is up quite a bit from 74% of the top 146 schools. Normal kids have little chance – those more likely to choose FM and distribute where needed.

Narrower in origin, preparation, training, career choice, and practice location does not work. Narrower in health care spending to just a few zip codes, to subspecialty, to academic, to largest systems – does not work.

Broader in origin and training, broader in distribution, permanent in broadest generalist – work for most Americans in need of care.

March 18, 2013 at 11:20 am

Dr P