A Comprehensive Solution to the Problem of Unmatched Medical Graduates

Today, Friday 3/18/2022, is Match Day.  This week tens of thousands of graduates of US MD and DO schools will find out what residency program they matched to.  And many tens of thousands will find themselves having not matched to any position at all.

These situations are always tragic- medical students have worked hard for 8 years (4 years undergrad, 4 years medical school), are often hundreds of thousands of dollars in debt, and find themselves with no clear path to making enough money to clear that terrible burden. Especially combined with projected future physician shortages AND the reality of current lack of access to care.  Many will declare that we need more residency spots to train more doctors. And we do. But the situation is more complex than it first appears, and reflexively increasing residency spots actually won't help anyone.

Instead, I propose these four steps, which will address the root causes of the problem, and create enduring change.

1. Funding for more residency spots, accompanied by a national healthcare workforce commission empowered by congress to conduct and analyze research into future workforce needs, and allocate (and re-allocate) GME funding for MD and DO residencies accordingly
2. A multi-step match. 1st step: US MD and DO grads. 2nd step (1 month later), unmatched US MD and DO grads along with Foreign Medical Graduates (FMGs) and US citizen graduates of international medical schools (IMGs).  This should be accompanied by a repeal of the NRMP provision requiring programs to offer all of their positions in the match.  Meaning if they want to specially recruit an FMG due to research or other relationships, they can still do so.
3. For all US MD and DO graduates, IMGs, and FMGs who pass Steps 1, 2, and 3: guaranteed entry into special Physician-Assistant Qualification pathways, which would be 6 months long and allow them to gain licenses as PAs.
4. Forgiveness of all educational debt for any US MD or DO graduate AND any US IMG who does not match 2 years in a row, and who does not qualify for a pathway to practice as a PA
5. If we retain preliminary residencies, then for all graduates who successfully complete a 1 year preliminary or transitional year residency (which do not lead to board certification and consequent allowance of independent practice), we fund and establish guaranteed reserve family medicine 2 year residencies.  These "completion" residencies would ONLY be open to such graduates, and would have to go unfilled otherwise.

I support affirmative action. I support holistic review. I do not support holistic review used to achieve affirmative action.

The world of medicine has been roiled recently by an article published in the Journal of the American Heart Association.  The author, Dr. Norman Wang, MD (since fired from his job as an cardiac electrophysiology fellowship program director) argued against affirmative action in medicine, believing that individuals with "weaker" academic credentials shouldn't be accepted into medicine programs.  It was subsequently condemned as racist and retracted.

President Trump is Ignoring America’s Trump Card in the Conflict with China

President Trump recently announced a series of harsh measures against China, including the suspension of entry of all graduate and post-graduate students into the United States.  I can understand the desire to protect American intellectual property by preventing students from learning skills and intellectual property and then returning to China and making use of them without royalties.  But a blanket ban on the entry of Chinese students ignores how the fields of medicine, science, and engineering really work and is likely to backfire spectacularly.

The Rule of Law is Dead in Medicine

The United States is a nation of laws, not of men's dictates.  The rule of law is what keeps (most) drivers from routinely running red lights, police officers from demanding bribes, and our civil servants and elected officials largely honest.  There of course will be violators of this code, as there are in any society, but nonetheless compared to many other nations in the US most citizens and state officials believe the laws are legitimate, and by and large obey them.  One of the most bitter criticisms of President Trump and proximate cause for his impeachment proceedings is that he is breaking down a critical part of the rule of law.  By using tools of state commonly felt to be apolitical (foreign policy, the justice department) to go after his political opponents; issuing executive orders that seem to punish certain religious or ethnic groups, thereby legitimizing white supremacy; and attacking institutions respected by all such as the FBI, intelligence agencies, and the judicial branch- he is accused of slowly diminishing respect for those institutions and the sense that the institutions of the state serve all citizens fairly and equally.  This then threatens to breakdown the trust that all Americans have in our nation, which is critical to its continued existence.

Governor Northam's Comments about Abortion, Explained, and a Proposal for Compromise

Democrats in Virgina made a massive own goal this week- and that was before Governor Northam, a renowned pediatric neurologist, was possibly found to have done blackface OR dressed up in a KKK outfit 30 years ago at a Halloween party.

Disclosing Conflicts of Interest on Twitter is Security Theater at its Finest

Conflicts of interest (COIs) have been in the news lately, with the resignations and public mea culpas of several prominent figures over undisclosed conflicts of interest in journal articles.  Memorial Sloan Kettering is one of the two top cancer hospitals in the United States: unequaled by anyone other than MD Anderson in it's advanced, cutting edge care. The Chief Medical Officer of that institution spectacularly resigned after failing to note millions of dollars in payments by pharmaceutical companies he had worked with in journal articles which he wrote.

Now I will disclose here that I am a Baylor College of Medicine General Surgery resident who will rotate at MD Anderson.

CNN vs. the Mayo Clinic: Did an American Hospital Imprison a Patient?

In an astonishing story, CNN claims that the famed Mayo clinic imprisoned an adult patient there against her will.  In an unusual move, the patient's family signed a consent form for the hospital to respond without concern for HIPAA privacy protections, and even more unusually Mayo released a statement so scorching that it all but accused CNN of committing blood libel.  CNN stood by it's story and claimed multiple Mayo spokespeople were shown to have no grasp on the details of the case, and spent an inordinate amount of time accusing Mayo of significant shadiness with whether a meeting was "on-the-record".  But, as with so many problems in medicine, this situation too boils down to a failure to communicate on Mayo's part, and a failure to understand medicine on the part of CNN.

The strange saga of Dr. Eugene Gu- #Resistance hero to accused Rapist

To many active on social media the saga of Dr. Eugene Gu, from #Resistance figure to accused rapist, is a long and strange one that holds some lessons for many physicians in the social media age.

Alfie Evans: A Reasonable Economic Decision Disguised as a Horrific Moral Determination

The tragic case of Alfie Evans has roiled Great Britain and the world. Alfie was a 2 year old child in the United Kingdom with an unknown degenerative brain disease who eventually deteriorated to the point that he required life support- his brain had become mostly liquid, and he could not see, speak, or hear. Alder Hey hospital decided his condition was terminal and irreversible, and wanted to stop further treatment. His parents disagreed, and wanted to transfer care to another hospital in Italy which was willing to accept him. Alder Hey went to court, arguing that it was better that the child be allowed to die because keeping him alive was cruel and harmful. They ultimately won, and Alfie Evans passed away. This has sparked a great outcry, particularly among the pro-life movement in the US. And indeed, the idea that the state can literally declare that death is better than life for anyone should be horrifying to everyone.

But the decision to take Alfie off life support was a reasonable and ethical one- if it was justified as being fair to all patients. It is even a reasonable one for individual doctors to conclude that further treating a patient in front of them is harmful and not ethical. But when court decided it had the right to decide that the child should die rather than live, it became an abomination.

The Resident: Learn the Lessons, Laugh at Everything Else

A new medical TV show, The Resident, made a big splash in the social media- largely for a perceived negative portrayal of physicians.  One EM physician even published a long editorial on NBC news condemning it as reducing trust in the entire medical profession.  The creator of the show, Amy Holden Jones, has been viciously attacked on twitter for the show, and even accused of causing patient deaths by decreasing trust in the medical establishment.

The LA Times's crucifixion of Dr. Puliafito is not appropriate, and has left the most important question unanswered

Two weeks ago the LA Times broke a story that Dr. Carmen Puliafito, former Dean of the Keck School of Medicine of USC, had been abusing drugs and keeping company with a group of younger individuals who engaged in drug use and illicit activity.  Much of this activity occurred while he was Dean, and it is a shocking story- a 66 year-old titan of the field of ophthalmology, renowned for inventing a device that revolutionized the field and forging both the 1st and 2nd ranked programs in the country (University of Miami's Bascom-Palmer and previously USC's Doheny before its split)- found partying with a prostitute and her friends while taking methamphetamine and other drugs.

As an Intern, I Support the ACGME's Increased Duty Hour Limits

Last month, the ACGME formally increased its work-hour limits for resident physicians, a change that was widely covered in the press.

This decision has also been significantly mis-reported.  While it may seem like all residents will now work for longer hours, in reality, only first year interns will be allowed to work longer 24 hour shifts, where the previous maximum was 16- a limit adopted in 2011.  2nd year and up, the restrictions will not change: 24 hour shifts, no more often than every 3rd day, with an 80 hour per week average which were the restrictions adopted in 2003.

A Response to the Volume Pledge

Dr. Pronovost is a leading figure in the patient safety movement, and is someone I greatly admire.  His work with surgical checklists is touted by Dr. Atul Gawande as having saved more lives than any researcher in the past decade.  However, I disagree with his latest initiative- to get hospitals who perform certain procedures at very low rates to stop performing them altogether.

On the surface, it seems like a perfect idea- hospitals that perform few surgeries of a certain type usually have worse outcomes and higher patient mortality than hospitals that perform many of them, a fact that has been known for decades.  However, the issue is more complex than it first appears.

How Much is a Human Life Worth: A Question we Need to Answer

With the election of Donald Trump, there has been much speculation about his plans for the ACA- speculation that rose again after the announcement that Dr. Tom Price, MD, is to be appointed as his Secretary of Health and Human Services.  But the reality is that any health plan in the United States- Trumpcare, Pricecare, Obamacare, Hillarycare, and someday perhaps Warrencare or Bidencare will not work because of our collective failure as a society to answer a question that every foreign health system has answered in some way:

When will the Medical Bureaucracy learn that Performance Metrics in Healthcare can be Lethal?

Yet another scandal regarding performance incentives in healthcare has surfaced.  This time, the area is transplant medicine.  It was reported that the demands by the Center for Medicare and Medicaid (CMS) for extremely low complication and death rates (with the threat of loss of accreditation and shutting down of the program) has led to thousands of kidneys and livers being discarded while tens of thousands languish in waiting lists, desperate to escape the living hell that is dialysis.

Questions to ask When Picking a Medical School if You Want to be a Good Doctor

I graduated medical school this May from the Keck School of Medicine of USC.  And only now can I speak about what I should have cared about when picking a medical school in the first place.  Originally, I had picked USC for a unique medical engineering program called Health, Technology, and Engineering, and because I heard colloquially that it had good clinical training since it had a major county hospital.  I was extremely fortunate that I did so.

Is the FDA's "Ban" on Gay Men Donating their Blood Discriminatory?

In the wake of the horrific Orlando shootings, there has been renewed attention given to the US Food and Drug Administration's (FDA) so-called ban on blood donations from Gay men.  A congressman called the ban discriminatory, and demanded it's repeal- a call joined by the American Medical Student Association and many others.

Politics and Medicine: Hillary Clinton's Health Risks

This presidential campaign has been alternately amusing and terrifying, courtesy of the antics of Donald Trump.  The prospect of someone who feels the need to boast about the size of his penis during a presidential debate having his small, small hands on the button to launch our nuclear arsenal does not inspire feelings of security.

He is looking increasingly likely to be nominated by the Republican Party.  Many however console themselves by thinking, "Well, now Hillary Clinton will definitely win!", given her increasing likelihood of winning the Democratic nomination.

Unfortunately, Secretary Clinton's health records reveal some cause for concern.

Penile Discharge Deja Vu

Yesterday was groundhog day-

About 2 months ago, I was volunteering at one of USC's free student-run clinics, located in a homeless shelter.  The last patient of the day was a guy with penile discharge and burning. After treating him, we went out for ramen in Little Tokyo afterwards, since there isn't too much else to do in LA at 9pm on a weekday.  We had a great time eating and chatting late into the night.  It would be the last time I'd ever speak normally.

Residency Work-Hour Restrictions Ought to be Individualized

There's been a bit of kerfuffle over resident duty hours lately.

For those unfamiliar with the topic, physicians in training in the United States have traditionally lived in the hospital- hence why they were called residents- and available to patients 24/7.  Over time, concerns about patient safety led to limits on how many hours could be worked consecutively in the hospital.  In 2003, the maximum number of hours worked per week was restricted to 80 hours.  In 2011, the maximum work day for first year residents was restricted to 16 hours- for second year residents and above the limit was set at 24 hours of work plus 6 hours for handing off patient care.