Today is Match Day, a long-anticipated event by countless medical students across the nation.
Since 1952, the National Resident Matching Program has coordinated the process by which medical school graduates and the directors of medical residency programs can declare their preferences and be matched with each other in an objective and non-political way.
The third Friday of March is anticipated almost as much as graduation by future physicians. It is truly the beginning of their career.
Medical schools have seen consistent growth since 2002 when the Association of American Medical Colleges (AAMC) called for an expansion of enrollment to meet the growing physician shortage.
Enrollment expanded over 30% in the decades that followed, rising from 16,488 first-year students in 2002-03 to 21,869 in 2019-20.
While this has been great for medical schools, it might not reduce the growing physician shortage because these wide-eyed, eager students might not have anywhere to go after graduation.
In a 2019 study sponsored by the AAMC, researchers reported that of the 154 schools surveyed, 44% reported concerns about the inability of incoming students to ultimately be placed in a residency program after graduation.
The problem is that the development of medical residency programs has not kept pace with the expansion of medical degree programs.
While it is very prestigious to have earned an MD or DO, the degree alone does not mean you are licensed to practice medicine.
All physicians are required to participate in some kind of internship/residency program after earning a degree in order to obtain licensure.
Some specialties require years in a fellowship program prior to practicing independently. Once out of medical school, physicians will spend 2-7 years in clinical training.
While a few states allow a physician to practice with only an internship, this is the exception. Plus, board certification requires an extensive residency.
In June 2020, the AAMC reported that by 2033 the U.S. will face a physician shortfall of between 54,100 and 139,000.
Currently, we face a bottle neck in our physician pipeline that has been created by the Balanced Budget Act of 1997 (BBA), which placed caps on the number of residency positions that a teaching hospital could use to receive Medicare funding.
Most taxpayers are unaware that when Congress created Medicare in 1965, it set up subsidies for medical residency programs.
By the 1980’s, Medicare was reimbursing hospitals for a large portion of the physician trainee’s salary, benefits and cost of instruction. Hospitals could also claim an additional reimbursement to compensate the medical center for indirect cost of supporting a residency program.
This generous program encouraged the expansion of residency programs, which created fear that the market would be saturated with new physicians and that the extra payments were not financially sustainable by Medicare.
Therefore, Congress passed the BBA, capping the number of new positions.
Today, Medicare provides $10.1 billion annuals for these programs. That comes out to about $112,000 per medical resident.
Since 1997, there have been additional resident slots added to the pool, but these were one-time additions or based on special programs.
In order to add more resident slots, Representatives Terri Sewell (D-AL) and John Katko (R-NY) have proposed H.R. 1763, while Senators Robert Menendez (D-NJ), John Boozman (R-AR) and Charles Schumer (D-NY) S. 348.
Together, these bills form The Resident Physician Shortage Reduction Act of 2019, which would increase the total number of residency slots from 12,000 to 15,000 over the next five years.
If the bill were passed into law, it would help alleviate part of the shortage, but more would need to be done.
Our current situation has created two moral issues that need to be addressed.
The first is stated above.
There needs to be a serious and frank discussion between this country’s medical schools, insurance companies, hospitals and policy makers in order to develop cost-effective plans not only to address the growing physician shortage but also the cost containment of physician education and training.
Further, the distributions of physicians, and especially physician residents, is not equitable. The Northeast has the lion share of medical residents.
In 2019, New York State had over 85 Medicare-supported medical residents per 100,000 people. By comparison, the median rate was 29.9 nationally, with some states, like Idaho, Montana or Wyoming, having less than 10 per 100,000.
This unfair distribution does two things.
First, it drives up the cost of physician residency programs.
The cost of living in the Northeast is significantly more than in, say, Arkansas or Mississippi. Depending on the comparison, costs can almost double.
A more balanced distribution is necessary to make residency programs more affordable.
Second, the future distribution of physicians becomes skewed.
The national median is 263.3 physicians per 100,000, with the largest shares again going to the Northeast. Massachusetts has almost 450 physicians per 100,000, while Midwestern and Southern states have well below 250 per 100,000.
Medical residents have a tendency to settle in the state where they do their training. This is unfortunate, since southern states are already facing physician shortages and suffer from a higher percentage of chronic diseases.
The second moral issue is the injustice done to students enrolling in our medical schools.
Medical school is not cheap, and it is four more years of school. It can cost between $150,000-250,000 alone, not including the cost of an undergraduate degree.
These are huge numbers. Historically, these expenses have been worth it since physicians, on average, make well over $200,000 annually, with some specialties coming in at over $500,000 a year.
A shortage of physician training programs potentially leaves graduates out in the cold. Earning an MD or DO does not ensure work as a physician or a salary that can help pay off $200,000 in student loans.
Because of the nature of physician education, not being able to match in a residency program leaves a graduate with a crushing debt that they cannot hope to ever pay.
If prospective medical students believe that the financial risks are too high, then they will not even enroll. As a result, the nation’s physician shortage will increase.
Therefore, it is time we look at how we train our future health care providers.
Our leaders need to work together to revise the system so that it is cost effective, efficient and takes into account the risk our future physicians take in order to follow their dreams.
Senior Staff Chaplain and Clinical Ethicist at the Baptist Health Medical Center in Little Rock, Arkansas.
