• Fixing the doctor shortage – my two cents

    I want to add a quick note to Sarah Kliff’s coverage of Alex Wayne’s piece on the doctor shortage. Specifically this (emphasis mine):

    Medical schools are holding back on further expansion because the number of applicants for residencies already exceeds the available positions, according to the National Resident Matching Program, a 60-year-old Washington-based nonprofit that oversees the program.

    While it is true that the overall number of applicants exceeds the available positions, there are a number of things hidden in there worth noting.

    First of all, this is less true in some specialties than others. If you’re going for a very competitive specialty (think dermatology), then yes, there are many more people than spots. But in less competitive specialties (think pediatrics), that’s not necessarily the case. And, yes, I’m a pediatrician.

    Second, there are also sometimes fewer American applicants than there are positions. Many foreign-educated students apply for residency positions in the US, and get them. I’m not saying this is a bad thing, but we sometimes have fewer medical students in the US than you’d think, too.

    Moreover, there are unfilled residency spots almost every year. That’s because while lots and lots of people may be willing to train in NYC, far fewer students may be willing to train in Indiana. And, yes, I live in Indiana. Complaining that we don’t have enough residency spots in the US when there are open slots available is like complaining you can’t go to college because you only applied to top tier schools and didn’t get in. There were 1100 unfilled first year residency slots in the US in 2012.

    I actually still agree that we likely need to train more physicians, and will need more slots. But the issue is more nuanced than many think.

    Actual data here: http://www.nrmp.org/data/resultsanddata2012.pdf


    • Are any types of incentives offered to get students to take up the less-popular specialties?

    • Who then is responsible for working conditions not equilibriating between pediatricians and dermatologists?

      Docs who determine standard treatment fees?

      Docs who determine the number of residency slots, maintain relative scarcity, and above equilibrium outcomes?

      Governments for some particular regulation?

      Governments for allowing docs to write their own rules.

    • With Medicare pay for residencies going away, one way or another, I wonder how residencies survive? Training them is a lot of work, time and hassle and many of us doing so dont get paid anything for it.


    • The current residency system is an anachronistic throwback. The system needs to be scrapped.

    • There may have been 1100 positions unfilled in the Match, but that doesn’t mean they stayed unfilled. Many applicants who didn’t match, including some who didn’t even try to match, sought and found positions after the Match.

    • Does anyone have thoughts on using something like a human capital contract to pay for resident training? This is a concept that’s been applied to some extent to college students and it seems like it could potentially be used to fund residencies, particularly since physicians who complete a residency program are very likely to earn a substantial income compared to your average unpredictable undergrad.

      Now I can see some potential drawbacks to this too. An obvious one: investors are more likely to fund high-income residencies like dermatology and radiology than the shortage areas like family medicine so this could even exacerbate the market influence on doctor specialties. As the Boston Globe article notes there are risks of income hiding and adverse selection too.

      If Congress and the American people are serious about refusing to directly subsidize any more residencies, maybe this is a “market solution” though.

      Here’s a couple of articles about human capital contracts:

      • And of course this adds MORE debt to starting doctors (although possibly structured differently) which could exacerbate other problems. How you see that probably depends on what you think of student loans and their issues.

    • A few little points –

      The 1100 number is a bit of double counting as it includes 440 unfilled PGY-1 preliminary surgery spots and 123 prelim medicine spots. The surgery ones don’t count in any meaningful sense, since whoever is in them still needs to match into something for the years following, and there are not many post-surgery PGY-2 programs with open slots. Somewhat similar for the medicine ones, though there are empty categorical medicine and family medicine spots. Still double counting though.

      If US medical schools expanded, they would probably find residencies for their students (I gather that residencies prefer US students), but that wouldn’t increase the number of US-trained doctors.