A debate has been brewing in the physician community about how to handle a seemingly intractable problem — what to do with thousands of medical students nationwide who don’t match for residency.
Typically these physicians-in-training have few options. Many go into medical research, get another degree in a related field such as public health, or simply hope another residency slot opens for them. If that doesn’t happen, they go on to other careers.
Until recently, the only long-term solution has been to push to create more residency positions, the path the Texas Medical Association continues to support.
But in 2014, Missouri created a new career path. It allows medical students who graduate and pass key medical exams — but do not match for residency — to become “assistant physicians.” (See “States With Licensing Programs For Physicians Without Residency,” page 24.)
The debate over assistant physicians and similar positions reached the TMA’s Annual Meeting, TexMed, in May in San Antonio. The House of Delegates’ Reference Committee on Medical Education and Health Care Quality considered a contentious proposal that would create a program in Texas similar to the one in Missouri and four other states.
Introduced by TMA’s International Medical Graduate (IMG) Section, the proposal was designed to reverse current TMA policy stating “TMA opposes the creation of special licensing pathways for physicians who have not completed a year of residency training.”
Instead, the new measure called for TMA to draft legislation for the 2019 session of the Texas Legislature that would “establish a licensing program for qualified U.S. medical school graduates and [Educational Commission for Foreign Medical Graduates]-certified international medical graduates with specific U.S. legal status who have not entered residency training due to a shortage of residency positions.” Anyone licensed this way would be under the supervision of a physician in a specialty for which there is a physician shortage.
Sejal S. Mehta, MD, chair of the IMG Section, told Texas Medicine before the conference that the goal of the measure was two-fold: to help alleviate Texas’ chronic shortage of physicians and to employ highly educated medical school graduates.
In Texas, only a few dozen medical students fail to match for a residency each year. There were 36 unmatched fourth-year Texas students in 2018.
However, Dr. Mehta pointed out that the problem nationwide is much larger. In recent years, thousands of physicians have been unable to match to residency positions. In the 2018 National Resident Matching Program, only 1,171 positions were offered in the Post-Match process for 8,063 applicants who did not match during the Main Residency Match. Those applicants looking for a second chance included 1,078 U.S. medical school seniors and 5,280 IMGs (not including American Osteopathic Association DO match statistics).
Each of those students represents at least 15,000 hours of medical education that could be put to use taking care of patients, Dr. Mehta said. On the other hand, nurse practitioners have only about 620 to 1,000 hours of training.
“Here you are allowing people [nurse practitioners] with 700 hours of training to function under the supervision of a physician, and I supervise nurse practitioners,” said Dr. Mehta, a psychiatrist from Plano. “So if I feel comfortable supervising someone with 700 hours of training, why wouldn’t I feel comfortable supervising someone with 12,000 hours of training?”
Marina George, MD, an internist from the Houston area, spoke in favor of the resolution at the reference committee. She said efforts to fund more residency slots will take years, and it is important to find immediate ways to help those graduates get to work. She also said the program could be structured in ways to avoid creating two tiers of medical care.
“We are not trying to create — and I want to make this very clear — we are not creating two tiers for physicians,” she said. “We are trying to create an increased number of physicians.”
But the proposal met with impassioned opposition.
Steven R. Hays, MD, outgoing chair of the TMA Council on Medical Education, testified that the council strongly opposed the resolution. He noted this would likely hurt TMA’s ability to advocate for the state’s continued support in expanding graduate medical education capacity and hamper TMA in scope-of-practice battles. He also argued that it would, in fact, create two tiers of medical education, redefining what it means to be a physician, and that it could, for regulatory purposes, put physicians on the same level as nurse practitioners and physician assistants.
“This would give the mid-levels the goal of equality that they have been after for a very long time,” Dr. Hays testified.
The move to equate these untrained physicians with mid-levels is apparently gaining traction in Missouri. The April 2018 newsletter of the Missouri State Medical Association, which supported the creation of assistant physician positions, says the new law may be amended this year in “an effort to align assistant physician oversight restrictions with those of other mid-level practitioners.”
TMA Board of Trustees member Patrick D. Crowley, a medical student at the University of North Texas Health Science Center at Fort Worth Texas College of Osteopathic Medicine, testified on behalf of the board in opposition to the measure.
“We wanted to emphasize that the Board of Trustees is acutely interested in this issue, and we recognize [the] striking trouble, particularly being an international medical graduate, [for] a student who fails to match,” he said. “But we want to reemphasize that the issue is not the need for a separate licensure path. The issue is residency spots, and we need to remain focused on this.”
After even more debate on the floor, the House of Delegates ultimately voted for TMA to study further the issue of unmatched candidates for U.S. residency programs and to report back in 2019.
Tex Med. 2018;114(7):22-26
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