June 2022 President’s Message

June 2022 President’s Message

Many medical school graduates are not matching

by E. Jeanne Kroeker, MD

How do you define a “New Year?”

Obviously, standard Western convention and most purchased calendars define the first day of the new year as Jan. 1. Corporations often define their fiscal year as starting Oct. 1. Some religions use a solar calendar and others use a lunar calendar to define the start of their year. When I was growing up on the East Coast, my school year always started after Labor Day, so the beginning of September still feels like the start of a new year for me.

What about July 1? Every physician trained in the United States recognizes this as a unique new year anniversary. July 1 is the fairly universal, traditional start day for residency, forever ingrained in our memories as the start of our employment as physicians.

Some of you were probably pretty confident on July 1, eagerly scribbling your name on orders (or choosing your name from a drop-down list) with “MD” trailing after your signature for the first time. Some of you might have been a little terrified, realizing that your orders actually would be followed, unchecked, and you no longer had the protection of signing “MS3” or “MS4” and waiting for an MD to follow after to make it official. On July 1 of some year, most of us started to be paid to work as a doctor.

Unfortunately, in this country, there are many medical school graduates who do not have the opportunity to start signing “MD” on orders on July 1. In 2021, there were 42,508 active MD appli­cants for residencies but only 35,194 first-year positions. In 2022, 42,549 allopathic medical students applied to U.S. residencies, hoping to match into one of the 36,277 first-year residency spots. In 2022, 7,303 osteopathic medical students participated in the match, and only 6,666 matched to first-year positions.

Each year, the gap between graduates and potential residen­cies remains devastatingly broad for those who don’t match. Thousands of medical students have a degree that cost hundreds of thousands of dollars to earn, and no ability to practice medicine.

In 1965, the Medicare and Medicaid Act specified that resi­dency positions would be primarily funded by the Medicare and Medicaid programs. The actual funding structure was somewhat vague. In 1983, Medicare made changes to hospital reimburse­ment calculations for residency positions, with the dollar amount of residency training funds to be equal to a percentage of the hospital’s care expenditures and the hospital’s Medicare patient volume.

As a consequence of this change, hospitals prioritizing primary care in rural areas inevitably received less funding. That led to fewer residency spots in rural and suburban hospitals compared to urban hospitals with many patients and many complex, expen­sive procedures. Residencies became less focused on clinic visits and outpatient care and much more hospital focused. This shift has persisted for the past three decades. Most of us spent 70% to 90% of our residency hours in a hospital with only 10% to 30% of the time in clinics, largely due to residency funding methods.

In 1997, the Balanced Budget Act capped the number of residency spots funded by Medicare, and capped the number of residents each hospital could have, at 1996 levels. This restriction was not lifted until 2010 – 14 years later as part of the Affordable Care Act.

In 2020, a federal budget bill provided for 1,000 new Medicare-funded residency spots in the U.S., but these spots would only be added over five years. With an annual residency deficit of more than 5,000 spots for U.S. medical school graduates, this is not nearly enough. Some hospitals have managed to work around this, funding additional residency spots though donations from private insurance funds, but these are usually available only at hospitals with “prestigious programs” and market power. And there is, of course, a question of conflicts of interest when a physician’s training is funded by an insurance corporation.

So, as July 1 rolls around and a new batch of residents move into the PGY1 positions in our many local residency programs, welcome them, help them and empathize with them. But also remember those whose dream of becoming a practicing physician has been deferred by a training demand that exceeds our supply.

Perhaps, in the near future, we might be able to ensure that every medical school graduate who wants to become a licensed doctor will be able to do so.