Residency under pressure

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MYRNA BROWN, HOST: Today is Thursday, November 20th.

Thank you for turning to WORLD Radio to help start your day.

Good morning. I’m Myrna Brown.

MARY REICHARD, HOST: And I’m Mary Reichard.

Coming next on The World and Everything in It: Residency.

It’s what turns a medical school graduate into a licensed, practicing physician. Each year some 50,000 new doctors begin residency training in hospitals and healthcare centers across the country.

BROWN: The system connects residents to particular programs, from primary care to neurosurgery. It’s been in place since the 1950s. But some think it’s time for a change. WORLD Senior Writer Kim Henderson brings us this report.

KIM HENDERSON: Medical students from all over the United States anticipate— and agonize over— Match Day.

STUDENT: I’m right hanging over the edge and I can see the drop…

It’s the day they find out where they’ll spend the next 3 to 7 years of their lives while they train as residents.

MONTAGE: Definitely emotional but all good feelings, all good feelings. My heart’s pounding, my palms’ a little sweaty, I matched neurosurgery at Emory! I’m going to Duke! [cheers]

Olivia Orndorff is with the National Resident Matching Program. It’s a non-profit that helps U.S. med students land the residencies they want by using a mathematical algorithm.

ORNDORFF: In this country, you can decide if you want to be an orthopedic surgeon, if you want to be an internal medicine or if you want to go into emergency medicine…

The only way a match happens is if it's on both of the rank order lists: the med student’s list and the residency program’s list.

ORNDORFF: Applicants will come in, and they'll rank the programs they want. Programs will rank the applicants that they want.

The matching process is designed to be a fair way to distribute residents across different specialties and hospitals. Its founders even won a 2012 Nobel Prize for the system.

But these days, it’s getting some pushback. But it’s a system that comes with a cost to the students. And even Congress is taking note.

AUDIO: [Sound of gavel]

Earlier this year, the U.S. House Judiciary Committee’s antitrust panel launched an investigation into the medical residency matching system. The big concern is Congress’ 2004 decision to shield the “Match” from antitrust laws.

CHAIRMAN: As a result, there's no competition now, and it decides the fate of more than 50,000 residents and fellows each year. Applicants cannot negotiate pay. They must accept whatever slot the logarithm hands them or whatever terms they are given.

That’s U.S. Rep. Scott Fitzgerald. He gave hard numbers at a subcommittee hearing to show why fair pay for residents is an issue—especially in the midst of a growing doctor shortage.

CHAIRMAN: Last year the average first-year resident earned just $66,000. That's roughly $60,000 less than a physician assistant or $100,000 less than a nurse practitioner despite working long hours and holding more advanced credentials.

And it’s not just the pay. An 80-hour workweek is the norm in graduate medical training programs around the country.

Residency is tough, and once a match is made, there’s no negotiating.

Recent research shows that residencies are often too hard on the trainees' own health. And programs are responding. There’s a new focus on resident well-being and the training environment as a whole.

NUTHALAPATY: There's a lot of education now that we're required to do with our residents along this vein, helping them to recognize indicators of poor well-being, a lack of energy, a lack of sleep, stress . . .

Dr. Francis Nuthalapaty is an expert in medical education. He says residency programs should emphasize a good environment and a good work experience. They should offer spaces for sleep when needed. Have ample food on site. Provide transportation for residents too exhausted to drive safely.

NUTHALAPATY: So these are all things that I would say previously were not emphasized at all. You are just kind of there to work, and it is what it is, all of us have to go through the gauntlet. Versus now where we recognize those issues. We educate them and try to create a more healthy work environment.

Nuthalapaty believes there’s more to residency than medical training, though. It’s a time of professional identity formation.

NUTHALAPATY: As medical students, they're learning a lot, but they haven't really grasped what it is to be a doctor. That's what happens during residency training.

He believes that’s critical. Lack of identity formation could be a factor contributing to the doctor shortage America is experiencing.

NUTHALAPATY: Especially since the COVID era, is this concept of moral injury, where it’s really a loss of this idea of calling and mission in terms of the practice of medicine, and a shift towards really more of a profit based motive. And really a loss of physician identity. So I think that has driven a lot of attrition from the field of medicine as a whole.

Could changing the residency matching system affect this shift? Maybe. More flexibility for graduates could lead to better residency experiences. And longer careers of service to patients.

Nuthalapaty says he can remember when it was common for his senior colleagues to work well into their 70s.

NUTHALAPATY: They loved it. It was who they were. It was their identity. I would say now, it's a rarity to see people practicing medicine that long, and I think it's just a sign of how much just the whole field of medicine has changed, in this country especially.

Reporting for WORLD, I’m Kim Henderson.

REICHARD: To read the full print feature story on the doctor shortage, look for the December issue of WORLD Magazine...and we’ll post a link to the digital version of the story in the transcript of this episode. 

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