San Francisco Chronicle
More doctors? First, more residencies
On Friday, nearly 40,000 soon-to-be medical school graduates will learn which hospital-based residency program they will be joining as part of the required rite of passage toward becoming a fully licensed independent doctor.
With an aging physician community and rising reports of physician burnout, the country needs these newly minted doctors now more than ever.
But not every doctor who is ready and prepared to embark on this next step in their training will get the opportunity. Why? Because there aren’t enough residency spots.
Last year, 47,675 medical school graduates registered for the Match, the online system that pairs new doctors with hospital training programs. But there were only 36,277 available spots. The process left more than 11,000 new doctors stuck in limbo, unable to treat patients despite being qualified to do so.
Without more residency spots, the number of unmatched doctors will only increase as medical school enrollment rises.
That’s a big problem — not only for the unmatched doctors but for the medical field and the entire country as well.
By 2030, the U.S. will have an estimated physician shortage of up to 104,900 doctors, according to a 2017 study from the Association of American Medical Colleges. Here in California, many have already felt the pinch. Only about half of the state’s primary care needs were met in 2022, according to data from the Kaiser Family Foundation.
Not being able to match affects doctors from even the most prestigious medical schools. Last year, three of my peers went unmatched at Stanford University, where I am finishing my medical and master’s in business administration degrees. After going unmatched, they delayed graduation to reapply. (Our advisers recommend reapplying while you are still enrolled and affiliated with a medical school rather than as a graduate.) One had applied for five specialties. The two others went into venture capital.
For the doctors who do match, the path is not easy. Residency programs are notoriously grueling: Residents in the U.S. spend up to 80 hours a week at the hospital, including shifts that can last 28 hours. As a result, many residents are overworked, underpaid and feel undervalued. In recent years, thousands of residents have begun to unionize, but with ever-increasing demands on our health care system, unions can go only so far. Only by increasing the number of residents can the workload be spread out and ultimately improve working conditions.
So how do we do that?
One way is by pressuring Congress to increase the number of Medicare-funded residency spots. The 1997 Balanced Budget Act capped the number of positions supported by Medicare at the number of residents being trained in each hospital’s existing residency programs in 1996. In 2021, Congress increased the cap, but only by 1,000 positions — nowhere near addressing the country’s immediate and long-term needs.
Another way to increase residency spots is for hospitals to create new residency programs that are eligible for additional Medicare funds. New residency programs have five years to grow before Congress caps their Medicare funding at the number of residents they are training in year five. Stakeholders, such as residency program directors, agree that five years is not enough, especially for under-resourced hospitals. Since residents can only be hired during the annual Match process, these hospitals do not have enough runway to maximize the number of residents they could train.
Finally, hospitals can fund residents from their own pockets. According to the U.S. Government and Accountability office, 70% of U.S. hospitals already fund residency spots beyond their Medicare allocations. That’s estimated to account for 20% of all physicians in training. But this is still not enough.
Hospitals could subsidize enough residency spots to close the gap so that all new doctors can match. Yes, training a resident is expensive. Hospitals receive an average of $171,000 from Medicare per resident to support their salary (an average of $64,000 in 2022), benefits and administrative costs. But residents earn less than doctors, nurses and physician assistants. They also free up time for doctors to bill for more procedures or visits by writing notes, fielding patient calls and messages, and prescribing. The cost of replacing a resident with a more expensive nurse, physician assistant or doctor is higher than the cost to train a resident.
Hiring more residents will not only help address the physician shortage, but it will also reduce physician burnout by dividing the work of patient care among more capable hands and ultimately lead to better patient care.
Congress can reset its 1996 cap and extend the five-year window given to hospitals before capping Medicare funding. This can help under-resourced hospitals, particularly those in rural areas, by increasing the number of residents they can train.
I dropped out of this year’s Match process on March 1, the last day to rank training programs. My mom had just been diagnosed with cancer. The thought of working more than 12 hours a day, six days a week, with little time off while my mom underwent surgery, chemotherapy or radiation unsettled me. So, I withdrew. While the 1,037 other young doctors who applied for a dermatology residency this year may have thanked me, they still had to compete for roughly 500 spots.
At the time of publication, half of these qualified and capable doctors will have gone unmatched in their desired field.
It shouldn’t be this way.