Friday, March 31, 2017

Still not a doctor, just an MD

The first year I did not match, I did what every medical graduate thinks they should do and applied for research positions. Without research experience it is very difficult to get these jobs. So, I tried to apply to MPH programs, but the deadline had passed on most programs and the ones still available were exceptionally expensive. I applied for hundreds of positions while caring for my infant son. My husband and I scoured the web looking for any viable solution. All routes were closed. In order to be a medical assistant, I needed to go to medical assistant school. To be a PA, I needed to go to PA school. My nursing license had lapsed in medical school and renewal would be a year-long, expensive process. To have any clinical contact with a patient, I needed to have a degree in that specific field and medical school credits were not transferable. We were completely panicked - my family had sacrificed nearly everything we had to get me through medical school. Unfortunately, this experience is not all that unusual.

There are more than 7000 graduate physicians who do not find a residency position every year, but there is absolutely no information or support for them after graduation. It is a nightmare and a lonely journey. This situation almost broke me. I am compelled to speak up. I wrote my story and posted it everywhere. My posts attracted national attention and I was interviewed for blogs and newspapers about my story. Instead of widespread support from the medical community, criticism about my character was rampant. Many practicing physicians did not believe that an American graduate could not get a residency. They said, “There must be something wrong with you” or “you did not earn the privilege.” 

I then understood the silence. Unlicensed physicians are reluctant to speak up for themselves and are often “bullied” by the medical system. There is a decided ignorance regarding the residency bottleneck, the careers available for unlicensed physicians, and the multiple legislative blocks against alternatives such as supervised practice.  Medical culture can be unforgiving and critical. What is the point of wasting such a large pool of talented physicians? Why are so many MD’s made useless, of no service to anyone? 

The number of medical school graduates is at an all-time high. The increased output of medical school graduates and the paucity of primary care residency programs gives graduate physicians without licenses few options to work in the healthcare industry and no ability to clinically interact with patients.  This is a known national issue but the solution is to hire more mid-level providers. In fact, doctors are being replaced with nurse practitioners or physicians assistants. I appreciate and support the work of Mid-level practitioners (MLPs) but knowledge gaps exist. 

 There is movement happening in medicine to restore the physician's role in primary care. Initially MLPs worked alongside physicians in a team approach to solve the physician shortage. However, as it is now there are 23 states in this country that have passed laws to allow MLPs to practice independently of physician supervision. At the end of my third year medical school I was better prepared to practice than an NP/PA, yet we have thousands of physicians who finish an additional year of direct patient contact care and are not allowed to practice medicine but a NP can. We are ignoring the thousands of doctors who are infinitely better prepared to take care of patients.

Today in Oregon, licensure to practice medicine is granted to physicians with one year of residency training. A bill to allow graduate physicians to practice medicine in the medically underserved areas of the state under a board-certified physician mentorship would not only decrease costs allotted with hiring nurse practitioners but also give medical graduates clinical experience and mentorship. Allowing graduate physicians to practice under mentorship would not dilute the standards for patient care, but enhance access to primary care while providing important post-graduate experience for qualified MD’s and DO’s.

By comparison:

-       After receiving a bachelor’s degree, Naturopathic physicians and Nurse practitioners (NP) are able to practice independently without residency training in the state of Oregon. 

-        Physician assistants (PA) can practice under supervision after 2 years of training.

-       Nurse practitioners (NP) have 2-3 years clinical training, physician assistants (PA) have 2 years, Naturopathic physicians have 4 years, and MD/DOs have 4 years of training as well. MD/DOs are the only degree that require residency training to practice medicine. 

-       The out-of-the-classroom, hands-on patient care portion of medical school training (i.e. two years of clinical rotations) is as rigorous as the clinical rotations for NDs, PAs, or NPs. Medical students spend more time on clinical rotations can rotate with more services, giving allopathic and osteopathic medical students broader exposure to the various specialties and practice environments in medicine. Medical school graduates are as well prepared for clinical practice as an NP or a PA. 

I am a graduate from a US medical school and I earned the right to be called a doctor and to practice clinically. Recently, I requested a bill to be sponsored in Oregon to support medical graduates in a mentorship program. The goal was to get medical graduates into rural and underserved areas to not only offer support in rural areas lacking care, but to give graduates the opportunity to practice medicine under supervision and mentorship. This bill would restore a standard of medical practice that worked quite well through most of our state’s history - the supervised practice of primary care medicine in rural and underserved communities. 

There was much resistance from both the Oregon Medical Board and the Osteopathic Physicians and Surgeons of Oregon (OPSO) organizations that the bill will not be pursued further in this session. I intend to persist and work toward legislation that all organizations can accept. They believe that they only way a physician can practice is through a residency program. However this was not always the route toward licensure. The current system of residency training for physicians was established in the early 1900s and originally was structured such that only unmarried men were allowed to participate because the expectation was that the study and practice of medicine would require all of their time. Physicians at that time were expected to live at their place of work, thus coining the term 'residency'. Since that time significant strides have been made to standardize, maintain quality, and to protect young physicians from fatigue and abuse. However, The system is large, complicated, fraught with politics, unfair biases and barriers to change. The American College of Graduate Medical Education accredits programs for a certain number of residents each year that they are allowed to train. Government funding of medical residency subsidizes the cost to hospitals for this training but is insufficient to allow the expansion of programs to provide more residency positions, even if it were allowed by the ACGME. Mentorship is the underlying principle on which Graduate Medical Education is based. All systems and policies are in place to ensure that occurs within the residency. The system should not be built such that mentorship in other settings is made impossible.  

Some unlicensed doctors go on to do research or possibly public health work, others never enter the medical profession. For most, their hearts remain in patient care and advocacy. These healers can never practice medicine in any form. Their rejection from the medical community is often emotionally challenging and many suffer deep depression.  Our culture accepts abusive tactics such as shaming and ostracization, but these actions defeat the purpose of the medical arts - to listen, understand, and heal everyone who needs our help. 

Most MD organizations will not represent unlicensed physicians - membership is not even an option. These entities encourage the exclusion of unlicensed physicians, which feeds the intolerance of the dominant medical culture. The systemic failure to adequately provide resident training for MD’s has been cast as the personal failure of the individual medical school graduate but a generation ago, this rarely happened. Performance measures, certifications and licensing restrictions have replaced the good judgement of independent doctors and restricted their ability to stand up for qualified candidates that need additional support to thrive. We all must stand up and demand that everyone who graduates in good standing from a qualified medical school be given the opportunity to practice medicine. We must organize and draw attention to this blight on our profession.

I am organizing an association to represent the growing population of unlicensed physicians and I need your support. We have to shift the conversation and bring this issue into the light. I intend to develop a dialogue between unlicensed physicians, bringing support to those in their deepest despair and giving hope for functional change in the graduate medical establishment. Let the silence end now. We need a voice with that supports unlicensed physicians, offering the resources needed to help them live their dream. United, we can press for change and educate our leaders about the depth of this crisis, focusing energy on: legislating for change in supervised licensing; pressuring for additional governmental funds for graduate medical education;  creating efficiencies with current funding to offer more priority positions; compel medical schools to add internship training for unmatched graduates and develop alternative funding sources for much needed rural and primary care path programs.

Wednesday, August 10, 2016

I recently had a local article written about me in the PORTLAND TRIBUNE.

Monday, March 23, 2015


In what is presented as a success, the 2015 Match, where medical students become doctors and find out if they will be accepted for residency, is over. It’s over and I am one of the 1,093 U.S. students that was rejected by every place that I interviewed. This year I packed up my family and we traveled across the U.S. in an annual cross-country pilgrimage to interview at residency programs. We couldn’t afford to fly. My husband, my infant son and I drove in a 15 year old station wagon, breaking our change jars to sleep in roach motels so that I would have a chance to give them a better life. It was an exhausting journey followed by an anxious month-long wait to find out where we would be living for the next three years. Instead of a better life, the National Resident Matching Program, Oregon Health and Sciences University and the American Medical Association have left us on the curb with over $400,000 dollars in debt and no way to pay it back. A doctor without a residency is unable to practice anywhere and although I hold the title, this is probably the end of the line for me. I labored and sacrificed ten years for a change in my life and I feel like a part of me has died.

After being rejected from the Match, I got to participate in the Supplemental Offer and Acceptance Program (SOAP), a mop up for the residency remainders where you can’t call the programs but they’ll call you if they want to and usually they don’t. You have a one in four chance of getting anything in what is an operatic drama where you sit by your computer and click refresh on your browser hundreds of times a day until you just know that no one wants you and it’s over (I’m paraphrasing an anonymous posting off of one of the student doctor forums). But not really. At the end, there is the Post-SOAP scramble, the last push to find a spot anywhere. That is when you go through the list of all of the programs in the U.S. and you try and get ahold of anyone from any of those programs and if they answer it’s usually a curt, “we’re full,” followed by a click and a ringtone. This process can take weeks and it is emotionally draining. But you do it anyway and then you get anyone who has any influence from the rotations that you did as a student that is willing to do the same on your behalf. When you’ve exhausted every opportunity in the U.S. you look abroad as far as you can imagine and justify packing up your family to move to Saipan if they will just answer your calls, which they don’t. And that is it, it’s over and you are done.

This year about 41,000 people applied for a little over 30,000 positions. This is an all-time high for applicants, but nowhere near what we need to reach if the U.S. is to keep enough doctors for people to have fair access to care. Whatever you think about the Patient Protection and Affordable Care Act (otherwise known as Obamacare), none of it matters if you can’t actually see a doctor. According to a recent report by the Association of American Medical Colleges, by 2025 we will suffer a shortage of 91,000 doctors. Many doctors are retiring early or just quitting out of frustration with the current situation. Visits are shorter and the wait to get one longer now than ever before. In Oregon it currently takes an average of 13 to 20 days to see a physician (depending on the specialty). If you were sick when you called for an appointment, you had better be cured by the time you get one. Medical schools have responded by pumping up their numbers but residency spots have not corresponded to demand. Even if, like me, you manage to graduate from a top-ranked program like OHSU, a blemish (we call them deficits) on your record means that you will not go on to serve your community and all of your talents and skills will be wasted. The competition is fierce today with a large pool of qualified candidates. I did my best in interviews and I tried to make them understand that I have a genuine desire to practice Family Medicine and focus on under-privileged communities. Not everyone who goes to medical school has the need for a large bank account and a diminutive sports car. Most of us regard this as a calling, a way to serve those who need healing and care. Hour for hour, when your investment in education and training is considered, a physician’s assistant can make more money than a family doctor. A Nurse Practitioner does pretty good too.  I chose to take this path because I wanted the autonomy to make health care choices for my patients and be responsible for their healing as a doctor.

Oregon is not alone in its shortage of physicians. Some states, like Kansas, have circled their wagons and don’t let anyone from outside of their own schools into these precious residency slots because they want to keep their own doctors in their state when they are done with residency. I was able to interview in Kansas due to my MPH at Kansas State University and encountered only Kansas University Medical School graduates during my interview. In Oregon it doesn’t matter where you went to medical school, as long as you fit their profile you will get a coveted spot in the Pacific Northwest (PNW).  U.S. News and World Report rates OHSU as the fifth most expensive medical school in the world. In the world. With the new campus that went up on the South Waterfront tuition is likely to climb. Yet in my case, despite having the recommendation of a Chief of Surgery from OHSU, after I interviewed for the Preliminary General Surgery program I wasn’t even on their list of possible candidates and they had three spots left open at the end of the Match. I want to do Family Medicine but the Surgery Prelim program interviewed me because of the personal recommendation. I would have really enjoyed working there but OHSU wanted anyone but one of their own to fill what is essentially the bottom of the barrel in residencies.

This is because programs are risk averse. Risk averse is code for everyone wants the same thing - perfect test scores, good teeth, fit and possibly sporty. In Klamath Falls, the OHSU rural track program that I interviewed with, they spent more time asking me about what kind of extreme outdoor adventure activities I was into than actually talking about you know, medicine. As a nearly 40 year old mother of two children with some baggage, I don’t think I fit their mold. Oh, and I bombed the USMLE (a test of tests), until I was diagnosed with ADHD and given testing strategies to sit for eight hours a day in a cramped room with bad fluorescent lights. I knew the answers but I had a hard time sitting through an eight hour computer exam.  I passed the two required USMLE exams to enter residency. I went ahead and passed another USMLE test that I normally wouldn’t have to take until the end of my intern year of residency to show what I could do with a little training. Oh, and I went ahead and got an additional degree in Public Health (MPH) just to sweeten the deal.

Failing a test is a big deal for any program to overlook, but my value as a doctor and a student should not be only based on a test that took less than 24 hours of my life. I’ve got ten years of experience as a nurse. Four top-of-their-field doctors that I worked with wrote me strong recommendations and some of them even got on the phone to help me track down a position. I have skills and I’m still eligible to be a doctor in Oregon, I just won’t receive the chance to do an intern year to prove my worth.

You see, I’m a two-time loser. I failed to find a position last year and the further away you get from your graduation, the less attractive you are as a candidate. Programs would rather choose a person who couldn’t get into a U.S. medical school and spent their education in the Caribbean (we call them IMG’s - International Medical Graduates) than a student with a “hyperkinetic disorder”. They might resent this depiction, but I made it into a U.S. program and I’m proud of that. I’ve known for years that I have to work harder than most people to pass tests, but I usually pass them because I’m persistent and smart. I never got an actual diagnosis for ADHD before I took the USMLE tests because of the stigma attached to the condition… that and the $500 dollars that I simply did not ever seem to have. It’s hard enough to be older, poorer, a single mother and of mixed heritage (for the record, until recently I was a single mom  who had raised a happy and healthy now 20 year old daughter). When OHSU cancelled their student diversity program I was a bit shocked, but not surprised. I never realized much benefit from it anyway. I do wonder if my pregnancy while interviewing last year affected their decision. This year I was nursing and despite having a spot-on husband who wanted to take the role of Mr. Mom, it is possible that the family-in-tow affected my career opportunities. No program could ever legally admit to this, but the question does linger. I made plenty of mistakes in school but I did well on my rotations and got decent grades. I didn't seek out help for my testing issues early enough. I needed guidance and I didn't look for it in time.

How did it come to this? Isn’t OHSU the shining beacon on the hill that represents what is good and forward thinking about health care in our state? Portland is the city that works hard on its reputation for being inclusive. Don’t we take care of our own? Not really, not unless you come from money. If someone would have told me that my chances of getting into and succeeding at medical school were based on what my parents did for a living, I wouldn’t even have applied. The Association of American Medical Colleges is well aware of this problem. The average medical student in the U.S. comes from a family in the top 15% of income earners. I come from a poor family. In my family you become a nurse if you want to aspire to a better life. In fact, I was a nurse for 10 years, a pretty good one. My mom was in the military and a nurse before me. I remember being told that nurses can’t be doctors but I didn’t let that hold me back. I might have been wrong. Since it is impossible to work while you are a medical student at OHSU it was unfeasible to maintain my license. I’m not even a nurse anymore.

What can the 1,000 odd U.S. graduates and the 8,000 plus IMG’s do with an M.D. and no residency? Nothing. Not a thing, seriously. Try googling it and you’ll see suggestions such as - go into pharmaceutical and medical equipment sales, consult with corporations, become an entrepreneur or have you thought about research? With the exception of sales (and if you’ve met me, you know my tolerance for salespeople is not high) these other opportunities don’t exist. You can’t go into research unless you’ve done research before you went to medical school. You can’t be an entrepreneur unless you know the first thing about business (or come from money). Consulting is just another term for “I’m unemployed, but I still have a clean shirt to wear in public” unless you have a substantial network. Most people in this position go on to other fields and leave this depressing chapter behind them to start again. Almost no one talks about failing to match. For people like me who didn’t have anything to begin with, the repercussions of the decision to go to medical school is just beginning.

Have you ever been behind on a student loan? Have you ever been behind on a doctor’s burden of student loans when they know that you will never be a doctor? They own you. I will never qualify to buy a house. It’s likely that I’ll always drive a junk car (I would bike everywhere like I did in med school, but I can no longer afford to live in the heart of Portland). While at OHSU I sold plasma to pay my electricity bill. Not once, but many months. I even joined the military to get help, but they kicked me out when they saw my credit score. That actually happens. I joined the Air Force and despite telling them that I have bad credit and was declaring bankruptcy, they swore me in. This was right around when we were pulling out of Iraq (which could just be a coincidence) but Uncle Sam booted me after basic training and asked for their money back (and not in a nice way). It’s hard to know that you won’t be able to pass on a family anything to your children.

Why the bottleneck? If we need more people like me, then why isn’t OHSU and the rest of the medical community filling the gap? Why build more schools when we just need more residents? We’ve been stuck near the same rate since the 1990’s. The World Health Organization estimates that there is a shortage of 4.3 million physicians and nurses worldwide. The story is the same wherever you look. Canadians come here because they can’t get into their own anemic programs. Australians look to New Zealand and the Irish go to the UK if they can but none of those countries have enough residencies to provide for their own needs anymore. It’s spooky. It is harder to get into any program that reciprocates with the U.S. than it is to get into a residency here. This lack of health care providers is not an abstract phenomena. There are real human costs - people die. According to a study by the U.S. Senate SubCommittee on Primary Health and Aging more than 45,000 people die in the U.S. each year. Based on population, thats 563 people in Oregon who die every year because it took them too long to get a doctor’s appointment. Every day there are almost two preventable deaths in Oregon. Because of our under-served rural population that number is probably much higher. Even with all of the public and private funded residencies not one of those doctors goes further East than Klamath Falls or Hood River. The majority of our state sees no benefits from these programs.

At about $45,000 - $52,000 dollars a year for 80 hours a week of work, Medical Residents are a bargain. If you end up in the emergency room late at night, chances are you are seeing a resident. In a hospital you are more likely to see a resident first. At a free-clinic, probably a resident. The workload is legendary and the stress incredible, but we fight for these positions. Why wouldn’t OHSU and Oregon want as many of these as we can get? We can put up or take down billboards that say “Oregon Cares” but it is the doctors, residents, nurses and staff that do the actual caring. I may have a lot to say about OHSU and its politics, but it is a good school and everyone there is dedicated to quality. There are incredible teachers who took their time and energy to make sure that I had the substantial medical knowledge that I need to save your life. OHSU, for the most part, made a strong and positive impression on me. It is a top-ranked school and they’ve built a shiny new building to prove that.

The problem is - what will OHSU do when there are more and more students like me? Most medical schools are increasing their student load, but residencies still fall far behind in capacity. Would fewer people die if I would have been able to get a spot? I can actually say, yes. I would have saved lives. It is what I was trained to do. With more doctors people will get the care when they need it. Instead, I’m scrambling for a place on a subsidized-housing waitlist near felony flats and applying for a SNAP card (food stamps). We’ve blown most of our resources on this eventful journey. I love my family too much to give up. I'll keep calling and applying and working my connections for any chance out there but I’m also going to use my MPH, not my MD, to find any job I can. Chances are something will open up at a rural county in a public health position where I can make $28,000 and a difference. I’ll maintain my dignity this way but this is probably what my student loans will cost a year. I’ve been through worse. Like most overeducated-underpaid Portlanders, I’ll get by somehow - really, I will. Don’t we always?


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