President's Page

President's Page
June 2007

Forever Changed:

Graduate Medical Education, part 1

by James T. Norwood, MD
2007 DCMS President

July 1 is coming soon. Until you graduated from medical school, all that meant was getting ready for the Fourth of July holiday with its picnics and fireworks. But after you graduated from medical school, July 1 symbolized a transition. It marked the beginning of your residency. Since that fateful day, I doubt a July 1 has passed that you haven’t thought about your first day as an intern or resident. I still have a pair of scrubs from that day. At least I call it a pair of scrubs; my wife, Cecilia, refers to them as a couple of rags.

On that day you were changed forever. You no longer needed someone to countersign your orders or progress notes. You could write prescriptions. You could see a patient and truly say, “Hello, I’m Dr. _____.” Sure, you continued to read and study just like in medical school, but the knowledge you gained was applied to patients rather than to quizzes. The impact of your knowledge and skill had a greater and often lifetime impact. Quizzes don’t bleed or cry out for help. Until then you weren’t much different from a law student or graduate student—a lot of knowledge and some practical skills. After that day you were forever changed as you embarked on the transition from gaining knowledge, to independent thinking, then to independent action, and finally to autonomy with compassion that is required of a physician.

Speaking of interns and residents, for the 2007 match, the National Resident Matching Program had a record 21,845 positions for which 27,944 applicants competed. This is the highest number of positions and applicants in the program’s 55-year history. Ninety-four percent of US medical school seniors and 45% of foreign applicants successfully matched. The NRMP highlighted four interesting findings:

Family Practice—There were 100 fewer positions in family practice compared to 2006 and 500 fewer than were available in the 2000 match. There now are only 2603 positions in family practice available in the United States. Only 88 percent of the available family practice slots were filled—42 percent by US medical school seniors and the remaining slots by international applicants.

Internal Medicine—More than 98 percent of available internal medicine residency slots were filled, continuing a three-year increase. Of the total, US medical school seniors filled 56 percent of the positions.

General Surgery—This continues to be a highly competitive specialty. All but two of the 1057 available slots were filled. US graduates filled 78% of those positions.

Obstetrics and Gynecology—Interest in this specialty has been increasing over the past several years and 99.5% of the slots were filled. US graduates claimed 73% of those positions.

I separate US graduates from international applicants because surveys have shown that programs tend to prefer to fill their positions with US graduates. US programs have more knowledge of US medical schools, and visa problems are nonexistent. Canada is an exception because its medical schools are under the same accreditation organization as are US schools. I refer to the international pool as applicants rather than students because so many of them have completed postgraduate training in another country.

Although this news may give you a warm feeling of nostalgia while remembering call nights with your fellow interns, and a positive feeling about graduate medical education in general, several items in the full NRMP report are revealing and concerning. Five specialties have more US seniors applying than positions available. These are plastic surgery, general surgery, dermatology, orthopedic surgery, and radiation oncology. These are highly competitive and sought-after specialties. Internal medicine/pediatrics (a combined program) and family practice have more positions available than all applicants combined (US and international). If you don’t consider applicants interested in specialty training in general internal medicine and general pediatrics, they, too, have more positions than all applicants combined.

Does this indicate that family practice, internal medicine, and pediatrics have built too many residency positions? I doubt it. Considering the cost of funding a position for a resident and the scrutiny from the ACGME, it probably reflects a declining interest in these fields of medicine. Many of my colleagues argue that increasing the number of primary care positions will help with this decline. I contend that that is like building a bigger stadium when you know the same number of people will show up for the game.

Our medical students have less and less interest in the specialties that form the heart and soul of primary care. We don’t need more programs yet; we need more interest in these specialties. Our medical students know these are exciting fields of medicine, but they see the realities of lifestyle and reimbursement. We need to increase their interest by working on these issues. A group practice can help a lot with the lifestyle issues, but that may not be an option for rural one- or two-physician practices. There needs to be a way to help them take a break to spend time with their families and enjoy life. Reimbursement is a big issue. There seems to be a direct link between interest in primary care and reimbursement. Working harder to make less money or being reimbursed just 50% of what it took you to provide the service does not sustain a practice or generate enthusiasm. The state of Texas needs to address this or else the state of primary care will be forever changed.

Next month I will cover the GME situation in Texas and what is being done (and not done) for primary care in our state. In the meantime I hope you enjoy your picnic and fireworks. The complete report from the National Resident Matching Program is on its website at www.nrmp.org.

List of Past President Pages

Copyright © 1997-2004, Dallas County Medical Society. Information contained in this site does not constitute legal or medical advice.
Links are provided within this site as an added benefit to our visitors. The content of other sites is not monitored by DCMS.