Facing a physician shortage, can we leave medical school grads on the sidelines?

Dr. Heidi Schmidt cannot practice medicine. The problem is not that she lost her license or was named in too many malpractice lawsuits. To the contrary, she has never held a license to practice medicine. Yet she has earned not only an M.D. but also master’s degrees in public health and pharmacy, passed all the licensing exams required of medical students and devoted countless hours of voluntary service to underserved populations.

And she is not alone – many medical school graduates like her cannot obtain a license. Last year, 52,860 U.S. and international medical graduates applied for residency positions in the U.S., yet only 26,252 actually matched into a program.

The painful irony is that the U.S. now faces a substantial shortage of physicians, which is on track to worsen in the decades to come. Increased demand for physicians is driven by advances in medical science and technology, population growth and an aging population that uses more medical care. A study by the Association of American Medical College predicts that by 2025, the U.S. will face a shortfall of between 46,000 and 90,000 physicians.

The situation is growing worse by the year, because U.S. medical schools have increased enrollments by nearly 30 percent in recent years, while the number of residency positions has increased to a much smaller degree.

Facing a physician shortage, can the U.S. leave so many doctors on the sidelines? To understand how this situation arose, it helps to know more of Heidi’s story.

From music to medicine

Now based in Indianapolis, Heidi grew up in a family of physicians. Her father, brother, aunt and several of her cousins are M.D.’s. But it was apparent at a young age that Heidi was musically gifted, and when she graduated from high school, she studied violin and voice at two of the nation’s top music schools. After graduating, she traveled to Italy to study with one of the world’s top voice coaches before embarking on a successful international career as a voice artist.

She also devoted considerable time and energy to service. She staged a series of concerts to raise funds to preserve New York City’s Central Park band shell, founded an organization in Italy to support underrepresented artists, and cofounded a nonprofit organization that provides tutoring and mentorship to disadvantaged children.

I know Heidi, and she is a talented person who cares about those in need and gets things done. She is not, however, a gifted standardized test taker. Taking multiple-choice tests and taking care of patients may be as different as night and day, but such exams play a huge role in determining which graduating medical students gain admission to residency training. This creates problems for poor test-takers, no matter how well they care for patients.

When Heidi was in her 30’s, she decided to switch from music to medicine. Initially, she did poorly on the medical school admission test and was placed on the wait list. Feeling the pressure of time, she decided to attend a Caribbean medical school. She did well in her course work, but again had difficulty passing the board exam. Eventually, she enrolled in an exam preparation course that taught her an approach to multiple-choice questions. Her score went from just below passing to the student average.

Thinking the problem was solved, she was surprised to discover that her history of exam retakes made residency programs reluctant to “take a chance on her.” If a program accepts a student who performs poorly on the third step of the licensure exam (which is taken during residency training), its funding can be jeopardized. And without at least a year of residency training after medical school, Heidi cannot obtain a license to practice medicine.

Test scores aren’t everything

Exam scores are not the only thing residency programs look at, but they often serve as a first filter. Many graduates with low scores are eliminated before their dossiers get a full look. Yet test scores and the ability to care well for patients are not the same thing, and patients are missing out on the contributions of many talented doctors.

For students like Heidi, the consequences of not obtaining a residency spot can be disastrous. For one thing, the average graduate has accumulated an educational debt of US$180,000. Without a license to practice medicine, a debt of this magnitude can be nearly impossible to repay. Add to this the disappointment of being unable to care for patients – a lifelong dream for many – and the predicament grows even worse.

Yet these figures do not do full justice to the problem, in part because the distribution of physicians across the country is so uneven, leaving many communities without care.

Large metropolitan areas tend to be well-supplied, but smaller rural counties often experience great difficulty recruiting physicians, perhaps in part because they differ so much from the urban environments of most medical schools and residency programs.

The irony is this: such underserved areas are exactly where Heidi and many other unlicensed physicians express enthusiasm for practicing. “I want to work with patients that other physicians typically do not want to serve,” she told me. “For example, if I were licensed, I would move to a sparsely populated rural area and work there for decades, meeting the needs of people who otherwise would not have access to care. I am not in this for the money. I want to help people in need.”

Asked what she would do to change the situation, Heidi suggests a new training program that would allow her and thousands of other unlicensed M.D.’s to train in underserved areas under licensed physicians.

What we are asking for is not a free pass but a chance to prove ourselves. If we could earn our licenses caring for people who currently cannot find a physician, we could make a huge difference, and many of us would commit to continuing to serve needy populations for years to come.

Heidi has been doing this sort of work already, volunteering in a local free clinic for underserved patients. She sees patients, diagnoses their conditions and prescribes medications and other therapies just like other doctors, except that her orders are cosigned by a licensed physician. “Why shouldn’t this kind of work count toward licensure?” she asks. “The physicians who supervise me would happily attest to the fact that I am competent to practice.”

Despite the challenges, Heidi sees cause for hope.

For example, Missouri is experimenting with an assistant physician licensure program, endorsed by the Missouri State Medical Association, which would allow M.D'.s like Heidi to gain supervised experience and qualify for licensure. Part of the rationale for such programs is to help ease physician shortages.

Others states, including Arkansas, Kansas and Oklahoma, are looking to follow suit. Heidi believes they are headed in the right direction. “Many of us share a deep sense of calling to care for patients,” she says. “Given the worsening physician shortage, how can the nation afford to keep us on the sidelines?”