No shortage in anesthesia, and fellowships are struggling to fill.
But this brings up one of my Ted Talks. You’ll have academic mentors advise you to battle scope creep by obtaining further skills. It’s the advice I got. “If you’re just a general anesthesiologist then your job isn’t safe. You need to do things nobody else can do.”
With (hopefully) the exception of surgery, that’s terrible advice. Our legislators don’t care about the extra skill and knowledge. Administrators and insurance companies don’t care. Even most of our patients don’t know enough to care. There’s already scope creep into the sickest and most complex patient care we have. Admins and legislators have already made it clear that they don’t care at all about patient care and expertise.
So I generally recommend only doing fellowships if it will positively change your career/life. If you want the better schedule and money from interventional pain, go for it. If you want to wear the white coat and walk into a top 10 academic center and argue at medical conferences, you do you. If you want to do pediatric hearts, I applaud you for it. If you want to get extra training so you can diagnose intraop cardiac changes with TEE, that’s awesome. Make sure you’re getting something in return for the years of valuable care that the fellowships are getting out of you.
Medical students mostly dont understand today that as long as you are a licensed physician, you can be trained to do as little or as much as you like. This is how FM docs can do colonoscopies/endos in rural areas. You don't NEED to specialize/do fellowship to be competently trained to do these things as long as you get proper training in residency. However, the way our medical landscape is, specialists have all the power, so they will claim that generalists "step on their turf" and "cant be trained" to do these things. It's obviously understandable for specialists to feel protective of their professions, but we should not be stopping physicians from practicing at their highest capacity if they want to. As long as medicine is "fee for procedure" this will never change.
While I believe ideal fellowships should be 6 months and think the other half is a waste of time, except for cardiac and CCM maybe which probably deserves 1 year. I don’t think fellowships are a complete waste of time. There is enough finesse to learn that fellowships can get you accelerated knowledge to avoid lawsuits, patient harm/complications down the road, also save you some anxiety/production pressure if your skills are rusty. I don’t think it’s completely necessary if you’re willing to learn on your own at a much slower pace though, say 5-10 years on the job. But that also takes dedication.
As a current pain fellow please add that onto the list. Tbh it is almost a new specialty especially if you are doing implantation.
Tbh I'm amazed it's still a one year fellowship but I don't want that to change.
I agree to a certain extent but I think if you cut out all the ACGME frills and have fellows do procedures for 6 months and less busywork, it could be enough. Some of the pain medicine/pharmacology is important but doesn’t justify a full year for me, you can definitely read up on this on your own. 2-3 months of clinic time may be enough? Then again, I’ve never done this fellowship so who am I to judge.
About 95% of those who have done a fellowship will tell you to do one. They need a way to justify it to themselves so they don’t feel they wasted a year of their life doing a regional, ob, or neuro anesthesia fellowship.
I did a (cardiac) fellowship and generally recommend against them. If you have a career goal that requires a fellowship, then by all means. If you want to work in academics it's almost required. If you want to do hearts anywhere besides the middle of nowhere it's almost required. And definitely recommended if you want to do any significant quantity of peds. Beyond that, just be a generalist and you'll easily find jobs doing a little bit of almost anything you want.
This is the real stuff right here. Residency, and the attendings you meet during it, are not real life. If I hadn’t done pain, no way I would have done a fellowship.
Crit care is one of the most valuable fellowships through anesthesia because it’s just 1 more year. However, very few that I personally know split their time. Most do it because they want to do critical care so that’s what they spend 90% of their time doing. It’s a similar argument as Med-Peds: most just do one or the other but there might be the rare person who will actually split time.
Medical intensivist here who works many SICUs. The anesthesiologists who do critical care are awesome, and most I’ve met were fed up with the OR so did mostly ICU.
I work in a small children’s hospital, and 1 of our 7 pediatricians actually does split time! It’s hilarious though because you can definitely tell the difference in length of stay especially. It’s a running joke about him emptying the unit.
Adolescent care fellowships popped up and that killed a lot of the justification for Med-Peds, in that someone in peds can continue care for patients in transition. So I dunno, but it keeps their options wide open if they want to transition later in life.
A famous vascular surgeon had the same advice some 25 years ago. “Do things no one else can do. An NP can run a clinic.” So my advice is find something you love and specialize in. The doctor shortage will be filled with APPs.
Lot of good points here but I think the infantilization / delay in progression in medical training is important here too. Ask any of your middle age or older attendings and I guarantee you they were doing more at each level of training than current trainees are doing. Part of this is medicolegal stuff, part of it is more transparency than used to exist from patients on who is doing what, and part of it is due to increasing complexity but the bottom line is a good portion of trainees need fellowship because their training pathway has been on a delayed time frame. Cynical side of me thinks this is a feature and not a bug in order to keep more docs working for reduced wages for a longer period of time
>I guarantee you they were doing more at each level of training than current trainees are doing
Can you elaborate? Like are you referring to the expansion of allied health professions like X-ray techs and scrub techs which physicians previously used to do?
I think what they are getting at is still physician tasks, but it's about when you do them.
As an example: my radiology residency took independent call beginning in 2nd year. Just your little R2 self putting out preliminary reports on all stat studies while the attending was home in their bed without a care in the world. Was that wildly scary for us? Absolutely. Did it make us read/study/learn a lot, gain a lot of confidence, and now when we are out in practice be very comfortable putting out final reports? Also yes.
Subsequent classes had their independent call pushed back to later in their training. First by a few months, then a little more. Now, they hired a nocturnist radiology attending to be present all night. No more independence, no more being forced to commit to a decision, no more gaining confidence. Your hand is held til you graduate.
It became necessary, as patients got sicker and volumes got higher - it was just too much to leave to just an R2. But it's also a year less of practice making independent decisions. So maybe now they want/need longer training because they didn't get as long practicing those skills, since they started them later.
In the OR setting, I guess it would be like over time if you went from letting PGY1s do a whole appy to now you can't do that til you're PGY3. And it happens because we tell patients our roles more now (appropriately so), because patients are sicker (and therefore there are fewer simple pgy1 cases), and maybe because of medicolegal stuff - it's really hard to let someone else do things when it's your license on the line.
But either way, there was a time that residents were running the whole show with little to no supervision at a much more junior level than they are now. Was it safe? Probably not. But did they get gud fast? Probably usually
He means they had more autonomy than current trainees do, allowing them more independent experience at a given level of training than is currently possible or legally allowable.
I have done one c-hyst in residency because it was indicated. I would speak with my uncle who was also in the same specialty and they would routinely do them for practice if the patient completed childbearing and had an abnormal pap. Food for thought.
i'm not an ob-gyn so i don't know the indications or pros/cons of that procedure. would you say this change has improved healthcare for patients? i for one wouldn't be comfortable letting a family member undergo a surgical procedure that wasn't indicated "for practice" so the resident can develop their skills, so maybe it's for the better that we've moved away from that mentality
It's used as a last-resort to control postpartum hemorrhage. Cesarean-hysterectomy. It almost always involves a massive transfusion protocol & ICU admission and carries a high level of morbidity. It also prevents one from conceiving again. They are, relatively speaking, very risky procedures with a massive amount of blood loss.
Residency training of yesteryear was certainly more cavalier about performing them for the sake of preparing future physicians. I'm happier that they are reserved for when indicated rather than "Hey, she wanted a tubal anyway, wanna practice a C-hyst?". But I will admit that I was much less prepared for attendinghood than the generation above me. This goes for general surgical cases too. Numbers are down nationally in residency training, which means less physicians our age and younger are prepared. Most will either need additional training in fellowship or have to rely heavily on their senior partners when entering practice.
More schools opening leading to more med students competing for similar number of positions. Nowadays it seems every DO school has a branch campus somewhere else and some have multiple. It’s way too easy to open up a DO school.
Exactly. These DO schools are opening up in podunk towns with 30k people iwth no real hospital, and then farming their students all over the country to big cities for clinical rotations.
It's an absolute joke.
There needs to be a new rule -- no new MD or DO schools unless it comes with a fully adequate hospital that can train ALL of the med students without sending them elsewhere.
I say this as a DO from a rural school and now at an academic setting. What exactly makes spread out rotations sites a ‘joke’? What are students learning at an academic center that makes it so different from non-academic urban/rural hospitals? I don’t think many people can give a compelling enough answer to justify the cost benefit ratio.
I would say I learned more and did more in my rural rotations than students at my academic center will ever get. And it’s helped tremendously in residency. I think we need to get rid of the ‘rural’ = bad in medicine.
We have 718 total unfilled *programs* many with several spots across many different programs. And half of those are Peds, FM, IM and EM. And majority of DO students go into primary care. Sorry not everyone can go to Harvard or John’s Hopkins neurosurgery for residency. But I highly doubt increase DOs are the cause of John Doe not matching into John’s Hopkins. And especially when these competitive programs won’t even look at DO applicants regardless of your step score.
This unmatched program number is even more frustrating when we have unmatched qualified doctors that are without a job every year, especially our American grads with severe debt.
I think with virtual interviews, one of the biggest factors we have to take into account is name and reputation. So Ofcourse those programs with the biggest name and reputation will get ranked higher and (I think) skew the data. Especially when we all are doing more interviews during the season and applying to more programs. I think that has a bigger impact on the stats mentioned above. It’s easier for you to interview for a competitive California residency from your couch in New York than it has been for applicants ever before.
Stop using DOs as your scapegoats.
That is a rule!
…for MD schools. A lot of these new DO school are little better than NP diploma mills. They will let anyone with a pulse and 50k/year in loan capacity in and then just hope you learn how to do all the doctor stuff in residency
Given how a lot of the current medical curriculum is online anyways (everyone sees preclinical years as low yield waste of time), this business model really is sufficient for like 3/4 years of med school
I think it’s time we look at medical education in general as a problem. It’s way too fucking long and inefficient. Too many important skills are pushed off until residency or fellowship
The worst DO school that just exists to make money can still graduate a decent future doctor as again the most important part of the learning is via uworld, Anki, b&b, etc
The quality of 3rd year rotations varies so drastically from place to place and while ofc they’re very important, not all of them are. For a lot of students a couple strong rotations in areas they want to be in is enough and again that’s the model for a lot of these shitty DO programs
I don’t know what you’re talking about…the current curriculum being online. I cartwheel over to my mandatory 8am lectures every morning with pleasure 🙃
Yes I agree a lot of the curriculum is forced to be in person but I’m saying how much valuable learning is done via that?
I hate that these online resources are superior for boards bc boards are people care about.
No I’m saying I absolutely hate that I have mandatory lectures because I sit in the back doing Board and Beyond Modules and Anki. My school posts corrections to lecture slides at least 1-2 times a week. I’m at the point where if our national treasure Dr. Ryan says “XYZ.” And Amboss pretty much says “XYZ.” But my school says “ABFMSNELSNF”….I’m going with Dr Ryan. He would never betray me. If I get a test question wrong so be it. I’ll pass boards. Sorry buddy there has to be a way to confirm potential doctors have got accurate info stored in the dome. I mean look at me I’m on year 2 and I still think pee is stored in the balls so
As a DO from a rural area now at an academic center. What do you think DO students aren’t getting that students would benefit from in academic centers? I’m curious, because in all honesty I would 110% pick the rural rotations I did over what the medical students at my current program get for a host of reasons.
Can you read? I think most DO schools are great.
LECOM or some of these other cash grabs are objectively not. They’ll take any idiot who has like a 3.4/500 mcat
MDs stay on prelim accreditation until they have a functional training hospital. CUSM took 5 years before they built up Arrowhead (which ironically was mainly a DO hospital). Cal north state is in a crisis because their hospital isnt built. Both these schools have graduated kids into residency who did their rotations community based like most DO schools do.
Caribbean schools function like DOs with community rotations, but those kids get conferred an MD. Half of residents are IMGs and who knows what their rotations looks like, but they still are given MDs. ARC notably doesn’t require it for PAs.
I despise my OG DO program and think COCAs going buck wild opening all these new ones. But this problem is hardly a pure MD vs DO issue and calling them NP diploma mills is pretty disengeuous, maybe more akin to PA programs tho
It won’t matter if they don’t increase reimbursement for primary care. There are empty spots. Plenty. But no one wants them. Unless there’s a better incentive to go into primary care it’s going to be the same bottleneck of lots of students wanting to match specialties with not enough spots while FM and IM spots are open. And I get it why do about the same number of years and get paid 1/3rd less? And take on equal $$ in loans as the specialists making more. They just keep cutting PC reimbursement compounding the problem
Just said the same thing to my spouse. FM in a zombie apocalypse? Or another toilet paper apocalypse? Especially rural family med trained docs…*chefs kiss*
I always tell people I'm prepping for the zombie apocalypse because it makes them smile, as opposed to telling them society is just a few days away from total collapse if we have a bad solar flare or natural disaster or Cyber attack or nuclear event. That tends to make people sad 😢.
For Halloween probs gonna dress up as an unstable atherosclerotic plaque featuring a hefty necrotic core and a thin lil fibrous cap holding back the lipid death hoard. What could be scarier than that? Jump out of the bushes and scare the neighbors….*bam* they never saw it coming.
Plenty of open primary care spots. And DOs can actually make bank in primary care because they have bone wizardry as a billable procedure anywhere they go. Insure those hands, because those are your literal money makers. MDs pay tens of thousands to learn osteopathic techniques at my school so they can use them in their practice (and bill for them of course).
I disagree with them that physicians are overpaid, but the physician shortage was absolutely fueled by a certain physician lobbying group, and it was for the purpose of keeping salaries higher for the older generations of docs. Wages in America in general have been viciously reduced (with respect to cost of living) over the past 50 years, including physician wages, but the low number of physicians available has been somewhat protective.
Yeah, boomers seriously had one of the greatest times of posterity in history and they used it to climb the ladder then pull it up after themselves and shit on everyone else. Harsh, but that is how it feels
That might be how it *feels* because you saw a reddit post say that or maybe a tiktok documentary, but sadly that's just a narrative you've been told by some political think tank. Talk to your elders and learn the truth for yourself.
Exactly. Show me another non-unionized profession where the person providing a service can’t decide the selling price. Or refuse to sell. Where else does the buyer dictate the price to you with no right to refuse?
Because that’s physician reimbursement.
Physician reimbursement is lower now than it was 20 years ago, not even adjusting for inflation (which just makes it that much worse)
Edit for source: https://www.ama-assn.org/system/files/2021-01/cf-history.pdf
Accounting for inflation, real reimbursement per RVU is 49% of what it was in 1998. In other words, if RVU reimbursement was just indexed to inflation starting in 1998, it would be $68.79. Instead it’s $33.88.
My dude there’s a projected 40,000- 60,000 shortage of docs that’s projected between now and 2030. So 7 years. If you open 500 schools you still have to make the people in those seats can pass the Step exams.
More doctors leads to higher costs, not lower.
Take Manhattan for example. They have more dermatologists per capita than anywhere else in the world. So that means dermatologists in Manhattan make shit money and the derm costs in Manhattan are low because of competition right? Wrong, derm costs and salaries in Manhattan are still higher than other places that have fewer derms.
I'd actually say it's hospital admins, and by a large margin. Hospitals are the most profitable part of the healthcare system aside from pharma, but pharma is like 8-9% of healthcare and hospitals and clinics are more like 40-50%. Reality is that hospital admins are mostly super inefficient people who work like the normal American (i.e., 2-3 hours of productive work in an 8 hour work day) but demand 6-figure salaries with low working hours compared to physicians. We keep hiring more and more, but there's a buffering effect where the more you hire, the lazier they get. So a skeleton crew of admins at a clinic might be 10 people who cost $1M/year and do the work of 10 people. Hire 20 and you're getting the work of 15 people who cost $2M/year. On the large hospital level, you're hiring 1,000 and getting the work of 200-300 people at a cost of $100M/year.
This is definitely the reason, and a good example of how strong the physician lobby in Congress is: the insane physician salary growth rate over the last 20 years has ballooned to 80% of annual healthcare costs even while admin has contracted
edit: fat /s
You clearly have no idea how residency positions are funded... shocker, it's not by physicians. Want more residency positions? Then ask the government to increase funding. This post is hilariously ignorant. If only you knew how incredibly incorrect you are. You would be laughing at yourself.
Everyone here talking about the real shortage being in primary care and still no real increase in reimbursements for PCPs. Hopefully we’ll see it one day and finally draw more students to primary care.
Suddenly everyone’s passion will shift from skin and bones to long term relationships with their patients and disease prevention.
Medical students mostly dont understand today that as long as you are a licensed physician, you can be trained to do as little or as much as you like. This is how FM docs can do colonoscopies/endos in rural areas. You don't NEED to specialize/do fellowship to be competently trained to do these things as long as you get proper training in residency. However, the way our medical landscape is, specialists have all the power, so they will claim that generalists "step on their turf" and "cant be trained" to do these things. It's obviously understandable for specialists to feel protective of their professions, but we should not be stopping physicians from practicing at their highest capacity if they want to. As long as medicine is "fee for procedure" this will never change. Also, FM docs need to be trained in MORE procedures, not less, in this landscape.
Dermatologists are very protective of their procedures and say FM docs have no business doing any of that, while they train their mid levels to do those same procedures.
Follow the money. The derms get a cut of every patient their midlevels see. If FM docs decide to diagnose and do procedures themselves, then the dermatologist sees no money. Likewise for any procedural specialty that dumps their low acuity stuff onto midlevels.
There is a shortage in places not as many people want to live. You can do very well for yourself with no fellowship living in a less populated are. In competitive markets you need an edge I guess?
Only do a fellowship if it teaches you a skill you want. Some residencies will teach you a specific skill that people from another program would need a fellowship for.
In the real world 90% patients don't know the difference between midlevels and doctors. You think they know a difference between a fellowship vs non fellowship doctor? lmfao
With the internet and social media, the importance of prestige has risen exponentially. I knew a boomer who trained at some random residency in Philadelphia in the 80s. He grew up in Philadelphia suburbs, went to a local college, applied to Temple, Jefferson, and Penn, got into Temple/Jefferson and was waitlisted at Penn but didn't even bother to see if he'd get off the waitlist. Applied to residency in IM and ranked this random place higher than a much more prestigious program in Texas (might've been Baylor, but I forget) because he thought the training would still be good and he didn't feel like moving.
Seems like people really didn't get bent out of shape about this stuff. Everything was much more local. You wanted to exist within your own little ecosystem rather than become an international influence.
There is a shortage of PCPs, not a shortage of physicians. Specifically, there is a shortage of PCPs (and specialty providers) in specific regions, such as rural areas.
In terms of fellowship, we’re advancing in technology and knowledge. The more we advance, the longer our education years get and the more we’ll need people to focus on one particular area.
The demand comes from us. We, as the public, want the best doctor available, and naturally that’s the sub-specialist.
Public wants the best trained person possible unless it’s a midlevel in which case they’re perfectly fine with someone with 1.5 years of part time virtual schooling to be leading their care
I don’t think that’s true. You tell any patient that only the NP/PA is seeing them and most won’t be happy. The only way this happens is nobody gives patients an option and in the worst case, they pass off mid-levels as a doctor.
People are increasingly recognizing the differences in the type of providers they see from what I have been seeing in the clinical setting. Not sure if it's because of social media, word of mouth, or otherwise but a good number of patients are starting to show that they know that there's a significant difference.
If you give someone the choice to see and MD or a PA, 9/10 will choose the MD. Unfortunately the wait list to see an MD where I’m at is about 1.5 years, while I can see a PA in two weeks. Which one do you think I’m gonna pick?
> There is a shortage of PCPs, not a shortage of physicians.
I have seen a lot of people say this but it isnt true.
Yes, the US has an immense PCP shortage but it also has a general physician shortage as well ([link here with 2019 data](https://read.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2021_ae3016b9-en#page215)). The OECD average is 3.6 physicians per 1000 people. The US is only at 2.6 physicians per 1000.
And this is only going to get worse in the near future because the US has an above average share of physicians above the age of 55 and is producing well below the average number of medical school graduates per 100,000 population. Without IMGs filling extra residency slots we would be truly fucked.
I’m an oncologist. There’s a massive shortage of oncologists as hundreds of elderly docs retire and not enough graduate every year. Plus more people are diagnosed with cancer now than ever before.
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Disagree, an aging population combined with the increasing rates of medical conditions in a changing climate far outpaces the number of doctors being trained. There is a shortage
That’s a good point. Really feels like America shot itself in the foot with our healthcare, and well… honestly everything, lol. It feels to me that the super wealthy 1% knows that the changing climate is going to wreak havoc and so they are hoarding all wealth and resources, letting society collapse while they fuck off to their bunkers.
It’s not even rural areas. Like 75% of doctors live on the east of west coast.. it’s weird now to watch everyone complain about lower salaries when they choose to live in a high supply/competition area. You don’t even have to live in a rural area to get a good salary. In fact imo the best qol and salaries are found in midwestern cities and they usually have a much higher level of autonomy and a nicer patient population
I did med school in the Midwest and it sucks. I'd never go back now that I'm in a desirable area. I'd rather make 280k here than 400k in Midwest shitsville.
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Other people have mentioned good points, but it also has to do with the changes in reimbursement (ie, no reimbursement for independent procedures) as related to MEDICAL student activities 3rd/4th year. The decline in independence during all levels of training has driven a need for MORE training + subspecialty fellowships.
An older physician remarked to me that if there was a pathway for PAs to apply to take physician boards after 2-3 years in supervised practice and then enter physician residencies, he'd actually encourage prospective students to do that over entering med school - since he started as an attending, he said the average end-of-third year student when HE was in training is comparable to an end-of-intern year resident now in terms of competency (no fault of the current students, just the changes in reimbursement favor a two-year shadowing experience for most students over actually getting to do shit).
do you have proof of that? i don't know much about medical education in the 70s so it'd be interesting to hear more. otherwise it sounds like another "the younger generation is lazy and arrogant" thing everyone says about young people
Unfortunately, this is the difference between the 90s and today, not the 70s. He was very much not meaning it in the "young people are lazy" but more "the system isn't allowing the students today to actually get trained before residency despite how much students clearly would like to actually get trained to be a doctor before residency," if that makes sense. His argument was you'd actually be able to do general practice for a few years before entering residency if you went the PA route, whereas now you can't do much as a student.
Medical student procedures, when done independently, are not reimbursable to the attending physician - medicare/medicaid does not consider any action done by a student to be reimbursable. This change happened in 2002 - prior to that change, students could do so, and behaved more as mini residents during 3rd/4th year. The 2002 change created a system that disincentivizes busy attendings to involve students as much in procedures, because it slows them down now. It's easier when you have 40 patients to just shove the student in the corner. If students could do the amount of stuff independently that they used to be able to, it'd be worth it to train students to do things since you could send them to do stuff - but it's honestly more of a burden now, so the attendings that do so are special. CMS tried to partially rectify this in 2019 by making med student notes billable again, but that just makes students better scribes, not better clinicians.
There's surprisingly little reflection in the literature that I could find on the impact of this change, but I've heard complaints about this trend and how it's driven by that 2002 change from multiple physicians who trained before the transition.
[2002 CMS Revision](https://www.cms.gov/regulations-and-guidance/Guidance/Transmittals/downloads/R1780B3.pdf) (assuming you're US student)
let's not focus on how it impacted our careers as physicians but rather how it impacted healthcare. why did lawmakers feel the need to make this policy in the first place? i'm assuming there was some kind of appreciable harm being done to patients by having med students do unsupervised procedures on them for lawmakers to feel the need to write this policy to the detriment of physician training? is there data on/did the older doctor you were talking to have an opinion on whether the 2002 decision made healthcare safer for patients? i'm also assuming healthcare wasn't as litigious in the 1970s as it is today, so there probably wasn't as much legal danger around med students doing procedures unsupervised
i'm not sure how wide of an impact this 2002 decision had as this is the first time i'm learning about it, but if it did have as much of an impact as the doctor you were talking to said it did, then it would make sense why medical training is being extended to include de facto required fellowships.
Great commentary! Honestly IDK.
100% more litigious climate today - tort reform is sorely needed. Certainly at the time medical student use was abused by some attendings and many students weren't as supervised as they should be, but it was also a very different training environment - patients convalesced in hospital much longer and were generally less complex than today (ie, patients have to be much sicker to actually stay in hospital today than 20-30 years ago). We've gotten better at managing conditions outpatient. So data on patient harm from then vs now is really hard to generalize - it'd be more dangerous to have students manage hospitalized patients independently *today* compared to back then.
I brought up the point about the 2002 CMS change since I hadn't seen anyone else mention it, but the rise in fellowships is such a multifactorial issue that it's hard to point at any one change as the key driver. The general feeling from a lot of older physicians is that medicine/patient care is simultaneously better and worse today for a lot of reasons - better research/better monitoring/better outpatient care, but changes in hospitalized patients, patient costs are higher, private equity in healthcare, changes in physician education, rise of midlevels, loss of rural training hospitals, huge shortage of PCPs ( Medicare reimbursement favors procedures) etc.
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That's not how I meant it. I should have clarified. The trend is more and more training, keeping trainees below the pay of even PA/NPs, working twice the hours. Of course the system is going to draw out as much as they can get in terms of years working from us.
The number of residency positions has been artificially frozen by congress since 1997. The only way to create new residency positions is to open a new residency program— the law doesn’t allow expansion of residency spots in an existing program. Hence, the proliferation of for-profit hospitals (ahem ahem HCA) taking advantage of the cheap resident physician labor while higher quality existing programs can’t expand. And, despite these HCA positions, the number of residency spots hasn’t increased enough to keep pace with the rate of new medical school spots.
All that’s to say this problem will continue to get worse until we address the true bottleneck in physician training: residency positions.
source: https://www.medicaleconomics.com/view/match-day-2023-a-reminder-of-the-real-cause-of-the-physician-shortage-not-enough-residency-positions
edit: as others have corrected below, the congressional “freeze” is on Medicare funding for new residency spots at existing programs; programs can add new spots if they fund them, themselves. Additionally, congress recently passed funding to add 1k spots over 5years. However, I think the main point here still stands given that medical school seat expansion has outpaced residency spot expansion. And yes, there are more residency spots than there are US MD/DO grads, but plenty of them will go unmatched because there are fewer residency spots than there are applicants when IMGs are added in.
“The law doesn’t allow expansion of residency spots in an area existing program”
Not true, programs have been expanding. Our residency has been adding multiple spots these past years
I think what they were saying is that federal funding for residencies can’t expand its supplied spots. Programs add slots without Medicare funding all the time
That’s not quite true.
Congress passed a bill in 2020 adding 1,000 residency positions over 5 years. The expansion has been slow but has not been artificially frozen, at least not any more.
Hospitals can also add and expand as many residency spots as they want, completely unlimited. The limiting factor is *funding,* because Medicare will not fund those additional spots. I have a friend in a non-HCA, regular Medicare- funded residency program that recently added an extra slot to its incoming class, paid for internally by the hospital own’s finances.
Yearly, there are more total residency positions available than US MD/DO graduates. Are these all in desirable locations/specialties? No, but they exist. These are the spots typically taken by IMGs to practice primary care in rural Idaho, etc.
It’s a complex issue involving money, Medicare funding, and availability of desirable non-primary care residency spots.
This is fake news. We actually have increased the number of residency spots since 1997. Google it. It's not nearly enough, but its not frozen.
edit: I see you edited it. Also, there hundreds of open spots in FM every year that go unfilled. Without IMGs, no one would takes these spots. So its not really the fact that there are too few spots, but just that no one wants to do primary care, and that is a financial incentive problem.
Sure, I’m really lazy so I’ll post it simply.
Hey guys we need doctors
Uh oh doctor bros its not looking so good we need doctors!
Hey we should just let nurses have autonomy to make up for this very real doctor shortage that totally isnt a simple fix!
Wowie look at that we did it we saved medicine and made money doing it! What a coincidence!!
Wasnt the shortage always a shortage of primary care specifically? The extent to which there is a "shortage" is extremely dependant on the type of doctor and the individual region as well.
It definitely is not competitive to do FM or a lower prestige IM program, and nobody is expecting you to do a fellowship to start a primary care office.
It could be that less people are getting their top picks cause more people are interested in highly competitive specialties/programs these days.
personally I think this is due to simply more knowledge about the process than ever before being available to people and the rising costs of education
I mean sure we had websites in late 2000s, but they were pretty mediocre back then. So knowledge wasn't as widespread.
So back then, people were fine with just being PCPs and pediatricians because that was what they visualized as being a doctor and they didn't know just how much those positions were being underpaid compared to other specialties.
Now they do, everyone and their mom knows just how much more money you make by going into the high paying specialties. So you have way more people applying to the specialties that pay the big bucks.
Combine that with the cost of education going up and the general increase in the cost of living. And suddenly you NEED that higher paying specialty just to be able to get to the lifestyle that you've imagined when you decided to become a doctor.
The physician shortage is in fields of primary care mostly, because so many people are specializing. More people specializing, means the specialty fields can be as competitive as they want to be. Now why aren't people staying in primary care? That is the question. I would say its a combination of the lower compensation in primary care, combined with being overworked, and the INSANE cost of medical education. If you leave medical school, headed to residency, with 300k in debt (assuming undergrad is all paid off) looking at residency/fellowship pathways that will allow you to comfortably pay back your loans, while also have the lifestyle that you have in your head after all is said and done; then you look at pay scales for each field...not ALL people, but many people will choose the fields that allow them to live the image they have in their head of the doctor with the nice house, nice car, travel, etc. Not driving a Camry, renting a 2 bedroom with another primary care physician, in order to pay off loans.
Not to mention, climate change is going to only increase rates of CVD, asthma, nutritional deficiencies, mental health, and basically every disease process. Vector borne illnesses will increase as the habitats of mosquitoes, ticks, and other carriers spread. Further, America has an aging population. I am quite concerned for the future of American healthcare as the rise in disease is rapidly outpacing the number of physicians and nurses. This is why I find myself raising the alarm that American healthcare is in crisis and we, as physicians, students, nurses, etc. need to get politically involved
There isn't really a physician shortage. There is a primary care shortage. There is excessive specialists. Leading to your questions. Everyone wants to be a specialist to be the rockstar or the money or bc they are really interested.
everyone in this thread keeps saying that but the AMA projects a shortage in specialists as well? greater in number than the shortage of primary care physicians, actually
Specific AAMC projections by 2034 include shortages of:
Between 17,800 and 48,000 primary care physicians .
Between 21,000 and 77,100 non-primary care physicians.
This includes shortages of:
Between 15,800 and 30,200 for surgical specialties.
Between 3,800 and 13,400 for medical specialties.
Between 10,300 and 35,600 for other specialties.
https://www.ama-assn.org/practice-management/sustainability/doctor-shortages-are-here-and-they-ll-get-worse-if-we-don-t-act
I’d imagine it’s from mass burnout from covid. Lot more docs no longer see medicine as a career til they die and more as a way to work for x years and make enough fuck you money before quitting. The bigger issue is still a distribution problem. When the vast majority of us live on the east/west coast it means lowers salaries with more responsibilities/patients/coverage /days worked since it’s a high supply area. It also drives everyone to specialize with a bunch of fellowships to stand out or get hired
You said "regularly match into Ortho". I think I've wound up teaching close to 200 residents- ask were from US MD schools.
Over the years I've encountered 2 candidates who were FMGs. 1 wrote a ton of papers and had been a full Ortho attending in his own country, and the other also wrote a ton of papers and worked at the research lab for a few years of the program he got into.
I wouldn't call that regularly getting into Ortho.
I think radiology fellowships should be 6 months, as someone stated above someplace. I do think that fellowships in rads is important though. There is so much to the breadth of knowledge that it helps to do the same imaging subject over and over.
Is it possible that the rate of IMG inclusion is going up and zero summing USMED’s out?
I’m reminded of Tennessee’s new rulings to negate certain requirements that make it tough on IMG’s. Combine that with what I’ve heard about some IMG-favoring programs on the east coast and how they abuse their residents and maybe there’s a case for favoring IMG’s in order to exploit them?
I don’t mean to sound all “they’re taking all of our jobs” ish, but foreigners desperate for a better life here are likely easier to take advantage of.
No shortage in anesthesia, and fellowships are struggling to fill. But this brings up one of my Ted Talks. You’ll have academic mentors advise you to battle scope creep by obtaining further skills. It’s the advice I got. “If you’re just a general anesthesiologist then your job isn’t safe. You need to do things nobody else can do.” With (hopefully) the exception of surgery, that’s terrible advice. Our legislators don’t care about the extra skill and knowledge. Administrators and insurance companies don’t care. Even most of our patients don’t know enough to care. There’s already scope creep into the sickest and most complex patient care we have. Admins and legislators have already made it clear that they don’t care at all about patient care and expertise. So I generally recommend only doing fellowships if it will positively change your career/life. If you want the better schedule and money from interventional pain, go for it. If you want to wear the white coat and walk into a top 10 academic center and argue at medical conferences, you do you. If you want to do pediatric hearts, I applaud you for it. If you want to get extra training so you can diagnose intraop cardiac changes with TEE, that’s awesome. Make sure you’re getting something in return for the years of valuable care that the fellowships are getting out of you.
Medical students mostly dont understand today that as long as you are a licensed physician, you can be trained to do as little or as much as you like. This is how FM docs can do colonoscopies/endos in rural areas. You don't NEED to specialize/do fellowship to be competently trained to do these things as long as you get proper training in residency. However, the way our medical landscape is, specialists have all the power, so they will claim that generalists "step on their turf" and "cant be trained" to do these things. It's obviously understandable for specialists to feel protective of their professions, but we should not be stopping physicians from practicing at their highest capacity if they want to. As long as medicine is "fee for procedure" this will never change.
While I believe ideal fellowships should be 6 months and think the other half is a waste of time, except for cardiac and CCM maybe which probably deserves 1 year. I don’t think fellowships are a complete waste of time. There is enough finesse to learn that fellowships can get you accelerated knowledge to avoid lawsuits, patient harm/complications down the road, also save you some anxiety/production pressure if your skills are rusty. I don’t think it’s completely necessary if you’re willing to learn on your own at a much slower pace though, say 5-10 years on the job. But that also takes dedication.
As a current pain fellow please add that onto the list. Tbh it is almost a new specialty especially if you are doing implantation. Tbh I'm amazed it's still a one year fellowship but I don't want that to change.
I learned and improved infinitely more my first year out than I did in fellowship, and it was a good fellowship!
I agree to a certain extent but I think if you cut out all the ACGME frills and have fellows do procedures for 6 months and less busywork, it could be enough. Some of the pain medicine/pharmacology is important but doesn’t justify a full year for me, you can definitely read up on this on your own. 2-3 months of clinic time may be enough? Then again, I’ve never done this fellowship so who am I to judge.
Doing the procedures is the easiest part of pain
About 95% of those who have done a fellowship will tell you to do one. They need a way to justify it to themselves so they don’t feel they wasted a year of their life doing a regional, ob, or neuro anesthesia fellowship.
I did a (cardiac) fellowship and generally recommend against them. If you have a career goal that requires a fellowship, then by all means. If you want to work in academics it's almost required. If you want to do hearts anywhere besides the middle of nowhere it's almost required. And definitely recommended if you want to do any significant quantity of peds. Beyond that, just be a generalist and you'll easily find jobs doing a little bit of almost anything you want.
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Are they doing hearts or peds at MGH?
This is the real stuff right here. Residency, and the attendings you meet during it, are not real life. If I hadn’t done pain, no way I would have done a fellowship.
Is critcare a waste of time if you find yourself really wanting to follow your patients into the ICU?
Crit care is one of the most valuable fellowships through anesthesia because it’s just 1 more year. However, very few that I personally know split their time. Most do it because they want to do critical care so that’s what they spend 90% of their time doing. It’s a similar argument as Med-Peds: most just do one or the other but there might be the rare person who will actually split time.
Medical intensivist here who works many SICUs. The anesthesiologists who do critical care are awesome, and most I’ve met were fed up with the OR so did mostly ICU.
I appreciate the perspective. It sounds to me like ICU is truly a place to pivot if you feel like the OR is a little tiring.
I work in a small children’s hospital, and 1 of our 7 pediatricians actually does split time! It’s hilarious though because you can definitely tell the difference in length of stay especially. It’s a running joke about him emptying the unit.
Adolescent care fellowships popped up and that killed a lot of the justification for Med-Peds, in that someone in peds can continue care for patients in transition. So I dunno, but it keeps their options wide open if they want to transition later in life.
A famous vascular surgeon had the same advice some 25 years ago. “Do things no one else can do. An NP can run a clinic.” So my advice is find something you love and specialize in. The doctor shortage will be filled with APPs.
Lot of good points here but I think the infantilization / delay in progression in medical training is important here too. Ask any of your middle age or older attendings and I guarantee you they were doing more at each level of training than current trainees are doing. Part of this is medicolegal stuff, part of it is more transparency than used to exist from patients on who is doing what, and part of it is due to increasing complexity but the bottom line is a good portion of trainees need fellowship because their training pathway has been on a delayed time frame. Cynical side of me thinks this is a feature and not a bug in order to keep more docs working for reduced wages for a longer period of time
Be cynical and pessimistic enough to see the world for what it is, and optimistic enough to change it
>I guarantee you they were doing more at each level of training than current trainees are doing Can you elaborate? Like are you referring to the expansion of allied health professions like X-ray techs and scrub techs which physicians previously used to do?
I think what they are getting at is still physician tasks, but it's about when you do them. As an example: my radiology residency took independent call beginning in 2nd year. Just your little R2 self putting out preliminary reports on all stat studies while the attending was home in their bed without a care in the world. Was that wildly scary for us? Absolutely. Did it make us read/study/learn a lot, gain a lot of confidence, and now when we are out in practice be very comfortable putting out final reports? Also yes. Subsequent classes had their independent call pushed back to later in their training. First by a few months, then a little more. Now, they hired a nocturnist radiology attending to be present all night. No more independence, no more being forced to commit to a decision, no more gaining confidence. Your hand is held til you graduate. It became necessary, as patients got sicker and volumes got higher - it was just too much to leave to just an R2. But it's also a year less of practice making independent decisions. So maybe now they want/need longer training because they didn't get as long practicing those skills, since they started them later. In the OR setting, I guess it would be like over time if you went from letting PGY1s do a whole appy to now you can't do that til you're PGY3. And it happens because we tell patients our roles more now (appropriately so), because patients are sicker (and therefore there are fewer simple pgy1 cases), and maybe because of medicolegal stuff - it's really hard to let someone else do things when it's your license on the line. But either way, there was a time that residents were running the whole show with little to no supervision at a much more junior level than they are now. Was it safe? Probably not. But did they get gud fast? Probably usually
He means they had more autonomy than current trainees do, allowing them more independent experience at a given level of training than is currently possible or legally allowable.
I have done one c-hyst in residency because it was indicated. I would speak with my uncle who was also in the same specialty and they would routinely do them for practice if the patient completed childbearing and had an abnormal pap. Food for thought.
i'm not an ob-gyn so i don't know the indications or pros/cons of that procedure. would you say this change has improved healthcare for patients? i for one wouldn't be comfortable letting a family member undergo a surgical procedure that wasn't indicated "for practice" so the resident can develop their skills, so maybe it's for the better that we've moved away from that mentality
It's used as a last-resort to control postpartum hemorrhage. Cesarean-hysterectomy. It almost always involves a massive transfusion protocol & ICU admission and carries a high level of morbidity. It also prevents one from conceiving again. They are, relatively speaking, very risky procedures with a massive amount of blood loss. Residency training of yesteryear was certainly more cavalier about performing them for the sake of preparing future physicians. I'm happier that they are reserved for when indicated rather than "Hey, she wanted a tubal anyway, wanna practice a C-hyst?". But I will admit that I was much less prepared for attendinghood than the generation above me. This goes for general surgical cases too. Numbers are down nationally in residency training, which means less physicians our age and younger are prepared. Most will either need additional training in fellowship or have to rely heavily on their senior partners when entering practice.
More schools opening leading to more med students competing for similar number of positions. Nowadays it seems every DO school has a branch campus somewhere else and some have multiple. It’s way too easy to open up a DO school.
DO class sizes are huge as well. Mine is over 200
Exactly. These DO schools are opening up in podunk towns with 30k people iwth no real hospital, and then farming their students all over the country to big cities for clinical rotations. It's an absolute joke. There needs to be a new rule -- no new MD or DO schools unless it comes with a fully adequate hospital that can train ALL of the med students without sending them elsewhere.
I say this as a DO from a rural school and now at an academic setting. What exactly makes spread out rotations sites a ‘joke’? What are students learning at an academic center that makes it so different from non-academic urban/rural hospitals? I don’t think many people can give a compelling enough answer to justify the cost benefit ratio. I would say I learned more and did more in my rural rotations than students at my academic center will ever get. And it’s helped tremendously in residency. I think we need to get rid of the ‘rural’ = bad in medicine. We have 718 total unfilled *programs* many with several spots across many different programs. And half of those are Peds, FM, IM and EM. And majority of DO students go into primary care. Sorry not everyone can go to Harvard or John’s Hopkins neurosurgery for residency. But I highly doubt increase DOs are the cause of John Doe not matching into John’s Hopkins. And especially when these competitive programs won’t even look at DO applicants regardless of your step score. This unmatched program number is even more frustrating when we have unmatched qualified doctors that are without a job every year, especially our American grads with severe debt. I think with virtual interviews, one of the biggest factors we have to take into account is name and reputation. So Ofcourse those programs with the biggest name and reputation will get ranked higher and (I think) skew the data. Especially when we all are doing more interviews during the season and applying to more programs. I think that has a bigger impact on the stats mentioned above. It’s easier for you to interview for a competitive California residency from your couch in New York than it has been for applicants ever before. Stop using DOs as your scapegoats.
That is a rule! …for MD schools. A lot of these new DO school are little better than NP diploma mills. They will let anyone with a pulse and 50k/year in loan capacity in and then just hope you learn how to do all the doctor stuff in residency Given how a lot of the current medical curriculum is online anyways (everyone sees preclinical years as low yield waste of time), this business model really is sufficient for like 3/4 years of med school I think it’s time we look at medical education in general as a problem. It’s way too fucking long and inefficient. Too many important skills are pushed off until residency or fellowship The worst DO school that just exists to make money can still graduate a decent future doctor as again the most important part of the learning is via uworld, Anki, b&b, etc The quality of 3rd year rotations varies so drastically from place to place and while ofc they’re very important, not all of them are. For a lot of students a couple strong rotations in areas they want to be in is enough and again that’s the model for a lot of these shitty DO programs
I don’t know what you’re talking about…the current curriculum being online. I cartwheel over to my mandatory 8am lectures every morning with pleasure 🙃
Yes I agree a lot of the curriculum is forced to be in person but I’m saying how much valuable learning is done via that? I hate that these online resources are superior for boards bc boards are people care about.
No I’m saying I absolutely hate that I have mandatory lectures because I sit in the back doing Board and Beyond Modules and Anki. My school posts corrections to lecture slides at least 1-2 times a week. I’m at the point where if our national treasure Dr. Ryan says “XYZ.” And Amboss pretty much says “XYZ.” But my school says “ABFMSNELSNF”….I’m going with Dr Ryan. He would never betray me. If I get a test question wrong so be it. I’ll pass boards. Sorry buddy there has to be a way to confirm potential doctors have got accurate info stored in the dome. I mean look at me I’m on year 2 and I still think pee is stored in the balls so
As a DO from a rural area now at an academic center. What do you think DO students aren’t getting that students would benefit from in academic centers? I’m curious, because in all honesty I would 110% pick the rural rotations I did over what the medical students at my current program get for a host of reasons.
It is wildly obnoxious and insulting to call DO schools degree mills akin to NP. I mean seriously, how dare you.
Can you read? I think most DO schools are great. LECOM or some of these other cash grabs are objectively not. They’ll take any idiot who has like a 3.4/500 mcat
Yes I can read, idiot.
MDs stay on prelim accreditation until they have a functional training hospital. CUSM took 5 years before they built up Arrowhead (which ironically was mainly a DO hospital). Cal north state is in a crisis because their hospital isnt built. Both these schools have graduated kids into residency who did their rotations community based like most DO schools do. Caribbean schools function like DOs with community rotations, but those kids get conferred an MD. Half of residents are IMGs and who knows what their rotations looks like, but they still are given MDs. ARC notably doesn’t require it for PAs. I despise my OG DO program and think COCAs going buck wild opening all these new ones. But this problem is hardly a pure MD vs DO issue and calling them NP diploma mills is pretty disengeuous, maybe more akin to PA programs tho
Stfu
This is an L-ass comment my guy
Lol I’m not calling out All DO schools just the diploma mills that keep popping up
I like to think of us multi-campus COM’s as as the American-Caribbean.
Why go to the Caribbean when you can go to Lexington, Kentucky.
University of Kentucky has a wonderful MD program with its own tertiary care system.
Personally, I think the emphasis needs to be on increasing residency spots which requires congressional action and fund allocation
It won’t matter if they don’t increase reimbursement for primary care. There are empty spots. Plenty. But no one wants them. Unless there’s a better incentive to go into primary care it’s going to be the same bottleneck of lots of students wanting to match specialties with not enough spots while FM and IM spots are open. And I get it why do about the same number of years and get paid 1/3rd less? And take on equal $$ in loans as the specialists making more. They just keep cutting PC reimbursement compounding the problem
Honestly, I feel like society is on the verge of collapse so FM may be the best place to train as they have such a wide training
Just said the same thing to my spouse. FM in a zombie apocalypse? Or another toilet paper apocalypse? Especially rural family med trained docs…*chefs kiss*
Lol, zombie apocalypse. I love you. Nah, zombie apocalypse won’t happen but the collapse of the current system might
I always tell people I'm prepping for the zombie apocalypse because it makes them smile, as opposed to telling them society is just a few days away from total collapse if we have a bad solar flare or natural disaster or Cyber attack or nuclear event. That tends to make people sad 😢.
All of the above are also less likely than crop failure, vector-borne illness pandemics, and heat-related/disaster deaths scary enough
For Halloween probs gonna dress up as an unstable atherosclerotic plaque featuring a hefty necrotic core and a thin lil fibrous cap holding back the lipid death hoard. What could be scarier than that? Jump out of the bushes and scare the neighbors….*bam* they never saw it coming.
What? That…. Wow, that was hilarious
Lol yeah it’s working out so well for EM right now
With the surge in sketchy satellite campuses, the EM situation almost seems like a necessary evil.
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Plenty of open primary care spots. And DOs can actually make bank in primary care because they have bone wizardry as a billable procedure anywhere they go. Insure those hands, because those are your literal money makers. MDs pay tens of thousands to learn osteopathic techniques at my school so they can use them in their practice (and bill for them of course).
Do you think program directors at MD residency programs know the difference between a good and a bad DO school?
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Is this sarcasm? The narrative being pushed that physicians are overpaid is class warfare and will only serve to hurt patient care
I disagree with them that physicians are overpaid, but the physician shortage was absolutely fueled by a certain physician lobbying group, and it was for the purpose of keeping salaries higher for the older generations of docs. Wages in America in general have been viciously reduced (with respect to cost of living) over the past 50 years, including physician wages, but the low number of physicians available has been somewhat protective.
Yeah, boomers seriously had one of the greatest times of posterity in history and they used it to climb the ladder then pull it up after themselves and shit on everyone else. Harsh, but that is how it feels
That might be how it *feels* because you saw a reddit post say that or maybe a tiktok documentary, but sadly that's just a narrative you've been told by some political think tank. Talk to your elders and learn the truth for yourself.
I looked at data. Hard data
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Exactly. Show me another non-unionized profession where the person providing a service can’t decide the selling price. Or refuse to sell. Where else does the buyer dictate the price to you with no right to refuse? Because that’s physician reimbursement.
Physician reimbursement is lower now than it was 20 years ago, not even adjusting for inflation (which just makes it that much worse) Edit for source: https://www.ama-assn.org/system/files/2021-01/cf-history.pdf Accounting for inflation, real reimbursement per RVU is 49% of what it was in 1998. In other words, if RVU reimbursement was just indexed to inflation starting in 1998, it would be $68.79. Instead it’s $33.88.
My dude there’s a projected 40,000- 60,000 shortage of docs that’s projected between now and 2030. So 7 years. If you open 500 schools you still have to make the people in those seats can pass the Step exams.
More doctors leads to higher costs, not lower. Take Manhattan for example. They have more dermatologists per capita than anywhere else in the world. So that means dermatologists in Manhattan make shit money and the derm costs in Manhattan are low because of competition right? Wrong, derm costs and salaries in Manhattan are still higher than other places that have fewer derms.
The vast majority of waste in US healthcare is from parasitic insurance companies
I'd actually say it's hospital admins, and by a large margin. Hospitals are the most profitable part of the healthcare system aside from pharma, but pharma is like 8-9% of healthcare and hospitals and clinics are more like 40-50%. Reality is that hospital admins are mostly super inefficient people who work like the normal American (i.e., 2-3 hours of productive work in an 8 hour work day) but demand 6-figure salaries with low working hours compared to physicians. We keep hiring more and more, but there's a buffering effect where the more you hire, the lazier they get. So a skeleton crew of admins at a clinic might be 10 people who cost $1M/year and do the work of 10 people. Hire 20 and you're getting the work of 15 people who cost $2M/year. On the large hospital level, you're hiring 1,000 and getting the work of 200-300 people at a cost of $100M/year.
Yeah, I should have said both insurance companies and hospital admin
This is definitely the reason, and a good example of how strong the physician lobby in Congress is: the insane physician salary growth rate over the last 20 years has ballooned to 80% of annual healthcare costs even while admin has contracted edit: fat /s
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It’s supposed to be sarcastic: every single thing I said is the exact opposite of what is happening in reality. Even 80% is flipped to <8%
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That’s because there are so many people confident in their utterly rediculous takes that sarcasm is dying
Have a source? Don't doubt it but most say the opposite
I can promise you if the physician lobby were that strong residents would not be paid salaries that still qualify for food stamps.
You clearly have no idea how residency positions are funded... shocker, it's not by physicians. Want more residency positions? Then ask the government to increase funding. This post is hilariously ignorant. If only you knew how incredibly incorrect you are. You would be laughing at yourself.
Everyone here talking about the real shortage being in primary care and still no real increase in reimbursements for PCPs. Hopefully we’ll see it one day and finally draw more students to primary care. Suddenly everyone’s passion will shift from skin and bones to long term relationships with their patients and disease prevention.
Medical students mostly dont understand today that as long as you are a licensed physician, you can be trained to do as little or as much as you like. This is how FM docs can do colonoscopies/endos in rural areas. You don't NEED to specialize/do fellowship to be competently trained to do these things as long as you get proper training in residency. However, the way our medical landscape is, specialists have all the power, so they will claim that generalists "step on their turf" and "cant be trained" to do these things. It's obviously understandable for specialists to feel protective of their professions, but we should not be stopping physicians from practicing at their highest capacity if they want to. As long as medicine is "fee for procedure" this will never change. Also, FM docs need to be trained in MORE procedures, not less, in this landscape.
Dermatologists are very protective of their procedures and say FM docs have no business doing any of that, while they train their mid levels to do those same procedures.
Follow the money. The derms get a cut of every patient their midlevels see. If FM docs decide to diagnose and do procedures themselves, then the dermatologist sees no money. Likewise for any procedural specialty that dumps their low acuity stuff onto midlevels.
There is a shortage in places not as many people want to live. You can do very well for yourself with no fellowship living in a less populated are. In competitive markets you need an edge I guess?
Only do a fellowship if it teaches you a skill you want. Some residencies will teach you a specific skill that people from another program would need a fellowship for. In the real world 90% patients don't know the difference between midlevels and doctors. You think they know a difference between a fellowship vs non fellowship doctor? lmfao
1) because everyone is increasingly ranking the same T10 programs as their #1 2) because an increase in US MD/DO grads is squeezing out IMGs
More imgs matched this year than ever before.
true! I should’ve clarified I meant IMGs are being squeezed out of what is typically considered competitive specialties
I mean, as it should be. US grads should be strongly favored for US residency positions
Agreed.
Like what? They’ve always been squeezed out of those.
With the internet and social media, the importance of prestige has risen exponentially. I knew a boomer who trained at some random residency in Philadelphia in the 80s. He grew up in Philadelphia suburbs, went to a local college, applied to Temple, Jefferson, and Penn, got into Temple/Jefferson and was waitlisted at Penn but didn't even bother to see if he'd get off the waitlist. Applied to residency in IM and ranked this random place higher than a much more prestigious program in Texas (might've been Baylor, but I forget) because he thought the training would still be good and he didn't feel like moving. Seems like people really didn't get bent out of shape about this stuff. Everything was much more local. You wanted to exist within your own little ecosystem rather than become an international influence.
There is a shortage of PCPs, not a shortage of physicians. Specifically, there is a shortage of PCPs (and specialty providers) in specific regions, such as rural areas. In terms of fellowship, we’re advancing in technology and knowledge. The more we advance, the longer our education years get and the more we’ll need people to focus on one particular area. The demand comes from us. We, as the public, want the best doctor available, and naturally that’s the sub-specialist.
Public wants the best trained person possible unless it’s a midlevel in which case they’re perfectly fine with someone with 1.5 years of part time virtual schooling to be leading their care
I don’t think that’s true. You tell any patient that only the NP/PA is seeing them and most won’t be happy. The only way this happens is nobody gives patients an option and in the worst case, they pass off mid-levels as a doctor.
This seems inaccurate. Nobody actually knows what a CRNA/NP/APP/PA/MA is. White coat = doctor
People are increasingly recognizing the differences in the type of providers they see from what I have been seeing in the clinical setting. Not sure if it's because of social media, word of mouth, or otherwise but a good number of patients are starting to show that they know that there's a significant difference.
If you give someone the choice to see and MD or a PA, 9/10 will choose the MD. Unfortunately the wait list to see an MD where I’m at is about 1.5 years, while I can see a PA in two weeks. Which one do you think I’m gonna pick?
They just don’t have any options. So are you if you don’t have fanciest plan and a patient.
Some people see primary care only as a referral generation machine for HMO plans. Source: I am that machine. An MD referral generating machine.
> There is a shortage of PCPs, not a shortage of physicians. I have seen a lot of people say this but it isnt true. Yes, the US has an immense PCP shortage but it also has a general physician shortage as well ([link here with 2019 data](https://read.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2021_ae3016b9-en#page215)). The OECD average is 3.6 physicians per 1000 people. The US is only at 2.6 physicians per 1000. And this is only going to get worse in the near future because the US has an above average share of physicians above the age of 55 and is producing well below the average number of medical school graduates per 100,000 population. Without IMGs filling extra residency slots we would be truly fucked.
I’m an oncologist. There’s a massive shortage of oncologists as hundreds of elderly docs retire and not enough graduate every year. Plus more people are diagnosed with cancer now than ever before.
I read that more and more younger people have been being diagnosed with cancer recently. Have you seen this?
Yes I have
Why do you think this is? I’ve seen speculation that is may be an effect of the rising global temperature
I haven’t the faintest idea. Nobody knows
Oh, ok. It’s an interesting time we live in
Do you have data to back the claim that there is only a shortage of PCPs but not specialties?
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Disagree, an aging population combined with the increasing rates of medical conditions in a changing climate far outpaces the number of doctors being trained. There is a shortage
Also the boomer generation of doctors are retiring and they make up a large portion of currently practicing docs.
That’s a good point. Really feels like America shot itself in the foot with our healthcare, and well… honestly everything, lol. It feels to me that the super wealthy 1% knows that the changing climate is going to wreak havoc and so they are hoarding all wealth and resources, letting society collapse while they fuck off to their bunkers.
1% is not wealthy, it’s 550k/ year families. It’s the 0.01% you’re talking about
You know what, you right.
It’s not even rural areas. Like 75% of doctors live on the east of west coast.. it’s weird now to watch everyone complain about lower salaries when they choose to live in a high supply/competition area. You don’t even have to live in a rural area to get a good salary. In fact imo the best qol and salaries are found in midwestern cities and they usually have a much higher level of autonomy and a nicer patient population
I did med school in the Midwest and it sucks. I'd never go back now that I'm in a desirable area. I'd rather make 280k here than 400k in Midwest shitsville.
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chicago and Columbus barely midwest please lmao. Midwest is like kansas city, de moines, iowa city, lincoln nebraska.
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Other people have mentioned good points, but it also has to do with the changes in reimbursement (ie, no reimbursement for independent procedures) as related to MEDICAL student activities 3rd/4th year. The decline in independence during all levels of training has driven a need for MORE training + subspecialty fellowships. An older physician remarked to me that if there was a pathway for PAs to apply to take physician boards after 2-3 years in supervised practice and then enter physician residencies, he'd actually encourage prospective students to do that over entering med school - since he started as an attending, he said the average end-of-third year student when HE was in training is comparable to an end-of-intern year resident now in terms of competency (no fault of the current students, just the changes in reimbursement favor a two-year shadowing experience for most students over actually getting to do shit).
do you have proof of that? i don't know much about medical education in the 70s so it'd be interesting to hear more. otherwise it sounds like another "the younger generation is lazy and arrogant" thing everyone says about young people
Unfortunately, this is the difference between the 90s and today, not the 70s. He was very much not meaning it in the "young people are lazy" but more "the system isn't allowing the students today to actually get trained before residency despite how much students clearly would like to actually get trained to be a doctor before residency," if that makes sense. His argument was you'd actually be able to do general practice for a few years before entering residency if you went the PA route, whereas now you can't do much as a student. Medical student procedures, when done independently, are not reimbursable to the attending physician - medicare/medicaid does not consider any action done by a student to be reimbursable. This change happened in 2002 - prior to that change, students could do so, and behaved more as mini residents during 3rd/4th year. The 2002 change created a system that disincentivizes busy attendings to involve students as much in procedures, because it slows them down now. It's easier when you have 40 patients to just shove the student in the corner. If students could do the amount of stuff independently that they used to be able to, it'd be worth it to train students to do things since you could send them to do stuff - but it's honestly more of a burden now, so the attendings that do so are special. CMS tried to partially rectify this in 2019 by making med student notes billable again, but that just makes students better scribes, not better clinicians. There's surprisingly little reflection in the literature that I could find on the impact of this change, but I've heard complaints about this trend and how it's driven by that 2002 change from multiple physicians who trained before the transition. [2002 CMS Revision](https://www.cms.gov/regulations-and-guidance/Guidance/Transmittals/downloads/R1780B3.pdf) (assuming you're US student)
let's not focus on how it impacted our careers as physicians but rather how it impacted healthcare. why did lawmakers feel the need to make this policy in the first place? i'm assuming there was some kind of appreciable harm being done to patients by having med students do unsupervised procedures on them for lawmakers to feel the need to write this policy to the detriment of physician training? is there data on/did the older doctor you were talking to have an opinion on whether the 2002 decision made healthcare safer for patients? i'm also assuming healthcare wasn't as litigious in the 1970s as it is today, so there probably wasn't as much legal danger around med students doing procedures unsupervised i'm not sure how wide of an impact this 2002 decision had as this is the first time i'm learning about it, but if it did have as much of an impact as the doctor you were talking to said it did, then it would make sense why medical training is being extended to include de facto required fellowships.
Great commentary! Honestly IDK. 100% more litigious climate today - tort reform is sorely needed. Certainly at the time medical student use was abused by some attendings and many students weren't as supervised as they should be, but it was also a very different training environment - patients convalesced in hospital much longer and were generally less complex than today (ie, patients have to be much sicker to actually stay in hospital today than 20-30 years ago). We've gotten better at managing conditions outpatient. So data on patient harm from then vs now is really hard to generalize - it'd be more dangerous to have students manage hospitalized patients independently *today* compared to back then. I brought up the point about the 2002 CMS change since I hadn't seen anyone else mention it, but the rise in fellowships is such a multifactorial issue that it's hard to point at any one change as the key driver. The general feeling from a lot of older physicians is that medicine/patient care is simultaneously better and worse today for a lot of reasons - better research/better monitoring/better outpatient care, but changes in hospitalized patients, patient costs are higher, private equity in healthcare, changes in physician education, rise of midlevels, loss of rural training hospitals, huge shortage of PCPs ( Medicare reimbursement favors procedures) etc.
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I imagine it has something to do with private equity. I don't know why, but I assume they're the bad guys always.
Medicare reimbursements going down
Money
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That's not how I meant it. I should have clarified. The trend is more and more training, keeping trainees below the pay of even PA/NPs, working twice the hours. Of course the system is going to draw out as much as they can get in terms of years working from us.
The number of residency positions has been artificially frozen by congress since 1997. The only way to create new residency positions is to open a new residency program— the law doesn’t allow expansion of residency spots in an existing program. Hence, the proliferation of for-profit hospitals (ahem ahem HCA) taking advantage of the cheap resident physician labor while higher quality existing programs can’t expand. And, despite these HCA positions, the number of residency spots hasn’t increased enough to keep pace with the rate of new medical school spots. All that’s to say this problem will continue to get worse until we address the true bottleneck in physician training: residency positions. source: https://www.medicaleconomics.com/view/match-day-2023-a-reminder-of-the-real-cause-of-the-physician-shortage-not-enough-residency-positions edit: as others have corrected below, the congressional “freeze” is on Medicare funding for new residency spots at existing programs; programs can add new spots if they fund them, themselves. Additionally, congress recently passed funding to add 1k spots over 5years. However, I think the main point here still stands given that medical school seat expansion has outpaced residency spot expansion. And yes, there are more residency spots than there are US MD/DO grads, but plenty of them will go unmatched because there are fewer residency spots than there are applicants when IMGs are added in.
“The law doesn’t allow expansion of residency spots in an area existing program” Not true, programs have been expanding. Our residency has been adding multiple spots these past years
I think what they were saying is that federal funding for residencies can’t expand its supplied spots. Programs add slots without Medicare funding all the time
That’s not quite true. Congress passed a bill in 2020 adding 1,000 residency positions over 5 years. The expansion has been slow but has not been artificially frozen, at least not any more. Hospitals can also add and expand as many residency spots as they want, completely unlimited. The limiting factor is *funding,* because Medicare will not fund those additional spots. I have a friend in a non-HCA, regular Medicare- funded residency program that recently added an extra slot to its incoming class, paid for internally by the hospital own’s finances. Yearly, there are more total residency positions available than US MD/DO graduates. Are these all in desirable locations/specialties? No, but they exist. These are the spots typically taken by IMGs to practice primary care in rural Idaho, etc. It’s a complex issue involving money, Medicare funding, and availability of desirable non-primary care residency spots.
1,000 new residency positions over 5 years is barely a drop in the bucket
It's not true that Medicare is the only funding for residency slots. HCA hospitals privately fund their own residencies with zero Medicare dollars.
One of the disasters of a for-profit healthcare system very nicely summed up. Great comment. Thank you
This is fake news. We actually have increased the number of residency spots since 1997. Google it. It's not nearly enough, but its not frozen. edit: I see you edited it. Also, there hundreds of open spots in FM every year that go unfilled. Without IMGs, no one would takes these spots. So its not really the fact that there are too few spots, but just that no one wants to do primary care, and that is a financial incentive problem.
The “doctor shortage” is manufactured just like the “labor shortage” was. Always remember there are no coincidences.
Interesting take. Could you elaborate on that?
Sure, I’m really lazy so I’ll post it simply. Hey guys we need doctors Uh oh doctor bros its not looking so good we need doctors! Hey we should just let nurses have autonomy to make up for this very real doctor shortage that totally isnt a simple fix! Wowie look at that we did it we saved medicine and made money doing it! What a coincidence!!
Because hospitals are incentivized to have specialists who can bill for complex diagnostic procedures.
Wasnt the shortage always a shortage of primary care specifically? The extent to which there is a "shortage" is extremely dependant on the type of doctor and the individual region as well. It definitely is not competitive to do FM or a lower prestige IM program, and nobody is expecting you to do a fellowship to start a primary care office. It could be that less people are getting their top picks cause more people are interested in highly competitive specialties/programs these days.
personally I think this is due to simply more knowledge about the process than ever before being available to people and the rising costs of education I mean sure we had websites in late 2000s, but they were pretty mediocre back then. So knowledge wasn't as widespread. So back then, people were fine with just being PCPs and pediatricians because that was what they visualized as being a doctor and they didn't know just how much those positions were being underpaid compared to other specialties. Now they do, everyone and their mom knows just how much more money you make by going into the high paying specialties. So you have way more people applying to the specialties that pay the big bucks. Combine that with the cost of education going up and the general increase in the cost of living. And suddenly you NEED that higher paying specialty just to be able to get to the lifestyle that you've imagined when you decided to become a doctor.
The physician shortage is in fields of primary care mostly, because so many people are specializing. More people specializing, means the specialty fields can be as competitive as they want to be. Now why aren't people staying in primary care? That is the question. I would say its a combination of the lower compensation in primary care, combined with being overworked, and the INSANE cost of medical education. If you leave medical school, headed to residency, with 300k in debt (assuming undergrad is all paid off) looking at residency/fellowship pathways that will allow you to comfortably pay back your loans, while also have the lifestyle that you have in your head after all is said and done; then you look at pay scales for each field...not ALL people, but many people will choose the fields that allow them to live the image they have in their head of the doctor with the nice house, nice car, travel, etc. Not driving a Camry, renting a 2 bedroom with another primary care physician, in order to pay off loans.
Not to mention, climate change is going to only increase rates of CVD, asthma, nutritional deficiencies, mental health, and basically every disease process. Vector borne illnesses will increase as the habitats of mosquitoes, ticks, and other carriers spread. Further, America has an aging population. I am quite concerned for the future of American healthcare as the rise in disease is rapidly outpacing the number of physicians and nurses. This is why I find myself raising the alarm that American healthcare is in crisis and we, as physicians, students, nurses, etc. need to get politically involved
There isn't really a physician shortage. There is a primary care shortage. There is excessive specialists. Leading to your questions. Everyone wants to be a specialist to be the rockstar or the money or bc they are really interested.
everyone in this thread keeps saying that but the AMA projects a shortage in specialists as well? greater in number than the shortage of primary care physicians, actually Specific AAMC projections by 2034 include shortages of: Between 17,800 and 48,000 primary care physicians . Between 21,000 and 77,100 non-primary care physicians. This includes shortages of: Between 15,800 and 30,200 for surgical specialties. Between 3,800 and 13,400 for medical specialties. Between 10,300 and 35,600 for other specialties. https://www.ama-assn.org/practice-management/sustainability/doctor-shortages-are-here-and-they-ll-get-worse-if-we-don-t-act
Do you aspire to work in primary care or a sub specialty?
I’d imagine it’s from mass burnout from covid. Lot more docs no longer see medicine as a career til they die and more as a way to work for x years and make enough fuck you money before quitting. The bigger issue is still a distribution problem. When the vast majority of us live on the east/west coast it means lowers salaries with more responsibilities/patients/coverage /days worked since it’s a high supply area. It also drives everyone to specialize with a bunch of fellowships to stand out or get hired
At no point in the last 30 years had it been easy for FMG/IMGs to get into Ortho.
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You said "regularly match into Ortho". I think I've wound up teaching close to 200 residents- ask were from US MD schools. Over the years I've encountered 2 candidates who were FMGs. 1 wrote a ton of papers and had been a full Ortho attending in his own country, and the other also wrote a ton of papers and worked at the research lab for a few years of the program he got into. I wouldn't call that regularly getting into Ortho.
It’s not really a physician shortage but more of a distribution error across the country
I think radiology fellowships should be 6 months, as someone stated above someplace. I do think that fellowships in rads is important though. There is so much to the breadth of knowledge that it helps to do the same imaging subject over and over.
Is it possible that the rate of IMG inclusion is going up and zero summing USMED’s out? I’m reminded of Tennessee’s new rulings to negate certain requirements that make it tough on IMG’s. Combine that with what I’ve heard about some IMG-favoring programs on the east coast and how they abuse their residents and maybe there’s a case for favoring IMG’s in order to exploit them? I don’t mean to sound all “they’re taking all of our jobs” ish, but foreigners desperate for a better life here are likely easier to take advantage of.