Interesting article from STAT News by Melissa Bailey:


Looming question for medical students: Will they be shut out of advanced training?

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Dr. Heidi Schmidt looks on while a nurse takes the vitals of a patient in a medical clinic at the St. Vincent de Paul food pantry in Indianapolis.

They’re about to graduate from medical school with an MD to their names, but hundreds of students across the US learned this week that they haven’t advanced to the next step of training — and will not be allowed to practice medicine.

Most medical students found out Friday where they’re headed for their residency, where they’ll work alongside licensed doctors, gradually gaining more responsibility. But each year, a sizable group learns shortly before the official “Match Day” that they’ve been shut out of this training.

This year, for instance, more than 29,000 applicants got placed in a first-year residency through the main matching process. But 8,640 did not — a number that includes international applicants and aspiring physicians who graduated from medical schools in recent years, as well as current fourth-year students.

That mismatch has prompted a policy debate: Should the rural and urban clinics that struggle to find doctors be allowed to scoop up unmatched graduates so their talents don’t go to waste? Or would it be dangerous to put them in front of patients without a traditional residency, which typically lasts at least three years?
Missouri, Kansas, and Arkansas have passed laws to allow unmatched graduates to work in medically underserved areas without doing a residency.

Otherwise, “a lot end up wasting all of their education, because there is no place for them in the health care delivery system without having a residency,” said Dr. Edmond Cabbabe, a plastic surgeon in St. Louis who conceived of the Missouri law.

Passed in 2014, but not yet implemented, the law will create an “assistant physician” license for these newly minted doctors, who will work with a collaborating physician. That physician will have to directly supervise the new doctors for at least a month before they can see patients on their own. One impetus for the law: Nearly all of Missouri’s 101 rural counties face a shortage of primary care providers.

Arkansas this year approved new rules allowing recent medical school graduates with ties to the state to work as a “graduate registered physician” before residency. Kansas, too, created a special license; it’s restricted to graduates of the University of Kansas School of Medicine who strike out in the match process, and it allows them to work, under supervision, for just two years. At that point, they’re expected to move on to a residency.

While supporters hail such laws as a groundbreaking solution, the medical establishment has frowned on them.
The Association of American Medical Colleges “is concerned by efforts that would bypass the experiences necessary for physicians to provide safe and effective patient care independently,” said Tannaz Rasouli, AAMC’s senior director of government relations.

The American Medical Association also came out against such programs. Instead, it has called on government, insurance payers, and foundations to pitch in money to create more residency spots.

So far, no one is practicing medicine under any of those new regulations.

But they could help MDs like Dr. Heidi Schmidt, a Juilliard-trained opera singer and entrepreneur who graduated from American University of the Caribbean School of Medicine on the island of St. Maarten. She received honors in clinical coursework, but struggled with standardized tests and had to make multiple attempts to pass two national board exams.

Residency programs often see multiple board exam attempts and degrees from foreign medical schools as red flags when evaluating candidates.

Schmidt, who also has master’s degrees in public health, music, and pharmaceutical science, has the title “doctor,” but her options are limited. Without at least one year of postgraduate residency, she can’t practice medicine in the United States. To work as a nurse or a physician assistant, she’d have to go back to school and get a different degree.

To stay in medicine, she volunteers in Indianapolis at Gennesaret Free Clinics for the homeless and working poor. She sees patients, but she said a licensed physician must sign off on all her work. Schmidt said she can’t get paid until she becomes a licensed physician. And she longs to treat patients on her own.

“My dream has always been to be a physician for the poor,” she said.

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Dr. Heidi Schmidt at the St. Vincent de Paul food pantry in Indianapolis, Ind. After not being matched with a residency, Schmidt’s plans of becoming a licensed doctor are on hold, so she volunteers at a medical clinic there.

Seniors in traditional (non-osteopathic) US medical schools have better odds than those from foreign schools: Their match rate has hovered around 94 percent. But that still means 1.130 didn’t get a residency in the main match this year.

That news can be a shock. As a senior at the University of Virginia medical school last year, Dr. Daniel Harris applied to 67 general surgery residencies and landed eight interviews at residency programs. On the Monday before Match Day, he got an email letting him know that none had accepted him.

Harris said he was in disbelief, but he didn’t have time to process that feeling. He had just two hours to decide which programs he would apply to through the Supplemental Offer and Acceptance Program, or SOAP, which helps unmatched applicants find open spots.

Harris picked 20 programs and hit “submit.”

“I maybe started crying at that point,” he said. “There was nothing more I could do.”

Harris got lucky: He was one of 599 US medical school seniors who scooped up unfilled spots through SOAP last year. Other types of applicants — for instance, those from foreign schools — grabbed another 400-plus spots.
That still left hundreds of seniors at US medical schools, and thousands from international schools, halted in their quest to practice medicine in the United States.

Were they weeded out for good reason? That’s open for debate. Surely, some were ill-prepared. Others may have been unlucky or just played their cards wrong when picking which residencies to apply for.

The most common reason for not matching is poor scores on national board exams, according to a 2005 survey by the AAMC. Other reasons include: applying to a specialty that’s too competitive for the applicant’s academic standing; poor interviewing or interpersonal skills; and having to take a board exam multiple times to pass.

Some people in this situation, like Dr. Nick Milligan, decide not to pursue a medical license. Milligan graduated from St. George’s University School of Medicine, on the Caribbean island of Grenada, in 2014. He said he was disappointed not to match with a residency, but he ended up happily employed at Coachella Valley Volunteers in Medicine in California, where he has used his medical training to build a diabetes education program.

Medical school grads face a staggering $183,000 in debt, on median, but they can seek relief, as Milligan does, from federal programs that limit monthly loan payments to 10 percent of income.

Most graduates of US medical schools don’t give up on becoming a licensed doctor if they don’t match, said Geoffrey Young, AAMC’s senior director for student affairs and programs. They often spend a year doing research, or complete a fifth year of medical school, then apply to the match the following year.

More than 99 percent of US medical school graduates do end up practicing medicine within six years of graduation, Young and coauthors found in a study published in JAMA.

The new state laws might offer some of the unmatched students another route to a medical career.
Missouri is expected to open enrollment for its assistant physician license this fall. Because it has the least restrictive rules, it may face a flood of applicants from around the country.

Schmidt could be one of them.

If Missouri opens the door for her to treat patients, she said, “I’d pack up and move in a second.”

Update: The story has been updated to include statistics about the matching program for this year.

MARCH 17, 2016

Melissa Bailey can be reached at melissa.bailey
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