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.