I couldn鈥檛 help but compare and see the analogy with physicians who become the best at their craft, becoming a doctor鈥檚 doctor. Having trained and taught at many top tier USA and Canadian medical schools, both allopathic and osteopathic, I have learned that many of the physicians who went on to become a 鈥渄octor鈥檚 doctor鈥� did not graduate from ivy league schools, nor in the top ten percent of their class. Most did not have a privileged pedigree, come from wealth or score in the stratosphere on standardized exams such as MCAT or USMLE/COMLEX. Yet, they went on to become a trusted 鈥渄octor鈥檚 doctor.鈥�
My response, the title of a lecture I deliver yearly is 鈥渋t鈥檚 the doctor in you.鈥� Seth Godin, American Author has stated, 鈥渙ur credential-obsessed society teaches high achievers to equate success with approval from an external authority. Unfortunately, this outlook undermines your ability to trust yourself.
It is a convenient place to hide from our own potential. Godin goes on to question, the fact that you have a degree doesn鈥檛 mean you have insight, experience, or concern. You鈥檝e acquired a piece of paper, but that doesn鈥檛 mean you care.鈥�
More significantly, are you willing to persevere and do you have compassion. 鈥淚t鈥檚 the doctor in you,鈥�
that will instill a desire, a drive to continue to learn, long after medical school is completed.
This brings to mind the adage, 鈥淲hat do you call the person who graduated last in your medical school class?鈥� Doctor. Medical students and doctors early in their career do not need to be trapped in their past. As TIM Denning states. 鈥淭he past in your default program.鈥� And to beat the default program, you have to change.
Being a doctors鈥� doctor has been an enormous privilege and honor. Bearing witness to the relentless and pernicious stigma in the house of medicine and how that ravages the minds and souls of our brothers and sisters in medicine has been a driving force. Through my teaching and mentorship, I know that there are many young and early-career physicians taking up the reins and making a commitment to physician health.

Being a doctors鈥� doctor can be a worthwhile experience, however it can be a daunting encounter for some. Caring for doctors may for some manifest feelings of inferior professional competence and feel pressured, strained and insecure. There are some doctors who prefer and choose to avoid such encounters. Other qualities of a doctor鈥檚 doctor is the ability to listen and be a good communicator.

鈥淟isten to your patient; he is telling you the diagnosis.鈥� Sir William Osler
But what it does mean is that the patient will provide doctors with enough clues to make the diagnosis, sometimes even before we examine them. For years I have taught my medical students when exiting a patient鈥檚 room after taking a history, if you are left in a quandary as to what could be possibly wrong with the patient, you need to return to the patient鈥檚 bedside and explore the history further, as 80% of the diagnosis is discoverable in the history.
Dr. Lisa Sanders an internist and author stated:鈥� in an interview on NPR about her book, 鈥淓very Patient Tells a Story,鈥� she aptly points out that there are two conversations going on at once. One is with the person telling the doctor about their problem. The second is a simultaneous conversation going on in the doctor鈥檚 head when they are thinking, 鈥渨hat does it mean and what do I ask next?鈥� This second conversation frequently fogs the patient鈥檚 message and leads to the doctor interrupting the patient.鈥�
Over 30 years ago a landmark study published in the Annals of Internal Medicine (Nov. 1984) reported that on average, physicians interrupted their patients after only 18 seconds. It should be noted that not all interruptions are verbal, a knock on the door, beeper interruptions, and computer use all interfered with communication, and increased frequency of interruptions are associated with less favorable patient perceptions of the office visit.鈥�
A more recent study published in the Journal of General Internal Medicine (online, July 2, 2018) assessed 112 doctor-patient interactions between 2008 and 2015. This study reported that the clinician interrupted the patient after a medial of 11 seconds. The authors of this study concluded:
鈥淭he medical interview is a pillar of medicine. It allows patients and clinicians to build a relationship. Ideally, this process is inherently therapeutic, allowing the clinician to convey compassion, and be responsive to the needs of each patient. Eliciting and understanding the patient鈥檚 agenda enhances and facilitates patient-clinician communication.鈥�
鈥淭he good physician treats the disease; the great physician treats the patient with the disease.鈥�
Sir William Osler
Osler鈥檚 19th-century admonitions have enduring relevance even today. Osler鈥檚 maxim has been proposed to reflect the realities of modern healthcare:
鈥淓ngage the patient; she is not only telling you the diagnosis but is integral to all aspects of her health and healthcare.鈥�

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Dr. Penny’s thoughts for students seeking paths to overcome the obstacles’ faced during their medical education

“The Comeback is Greater than the Setback”

People enjoy a comeback story because it gives them hope that one day they can rise above an obstacle in their own personal struggles.  There is an overwhelming desire deep down that most people want to see redemption, a second chance.  Comebacks are possible and they happen all the time.  Life is full of setbacks, and many times it may seem impossible for you to emerge victoriously.  At one time or another, all people will experience some form of adversity, hardship, or a tough experience. How do people deal with these types of events that change their lives? The death of a loved one, a harrowing combat event, a loss of a job, serious illness, terrorist attacks and other traumatic events: these are all examples of very challenging life experiences

One of the greatest comebacks of all time is the career of Muhammad Ali.  After winning the gold medal in the 1960 Rome Olympic games for light heavyweight boxing, Ali went on to defeat Sonny Liston in February 1964.  Ali after having an initial streak of success was then struck with multiple setbacks.  In April 1967 he was found guilty of draft evasion and stripped of his title.  However, in June 1971 four years after being convicted and sentenced to five years in prison and stripped of his heavyweight championship by the boxing commission, the Supreme Court decided that Ali was improperly drafted in their first place.  This was not Ali鈥檚 only comeback, Ali lost his heavy weight championship fight to Joe Frazier in the 鈥渇ight of the century鈥� at Madison Square Garden in 1971. Once again, Ali overcame his setback and defeated Joe Frazier in January 1974.  After that, Muhammad Ali went on to beat George Foreman in the 鈥淩umble in the Jungle鈥� and finally Joe Frazier once again in 1975 in the 鈥淭hrilla in Manilla.鈥�

The message gleaned from this story, you can overcome the obstacles you face, and those created currently by the pandemic.    Personal setbacks including financial, health, loss of loved ones, divorce and academic to name only a few.  With respect to the effects of the pandemic on medical education, it has caused an unprecedented disruption in medical education and healthcare systems worldwide. The disease can cause life-threatening conditions and it presents challenges for medical education, as instructors must deliver lectures safely, while ensuring the integrity and continuity of the medical education process.

As Provost and Dean of Clinical Affairs at the American University of Integrative Sciences, I have witnessed similar disruptions in the delivery of medical education of our students.  I have also communicated with many potential students interested in pursuing a medical education, yet reticent in making the commitment to apply.  My personal discussions with these students have identified many students who have had setbacks academically, past failures forced withdrawals and financial struggles to name a few.

My message to those students who are hesitant, a comeback will always begin with change.  91福利 is a medical school that will allow you the chance for a Comeback.  A need to be willing to do things differently from what you have done in the past.  Change will always happen when you choose to be committed, this will result in a change of your future.  With proper personal mentoring, small class size and a successful track record,  91福利 can turn it around and put you on the road to future success.

鈥淚 did the best I could at the time with what I knew鈥�

The resilience of the human spirit speaks to the character of those who have been setback, it demonstrates their determination, creativity, and vigor.  At a basic level it resorts to what you want to achieve.  Many who have been successful have a strong belief in possibilities; Simon Sinek is one example who has stated:

鈥淢y goal is to live in a world where the vast majority of people wake up every single morning inspired to go to work and fulfilled by the work that they do.鈥�

For those of you procrastinating on making the commitment to go to medical school, the time is right, and our next class will begin January 2022.  91福利 is accepting students currently and the class is not yet complete.  If further information is required, our admissions officers are available to discuss options.

鈥淲e can鈥檛 undo, but we can rebuild.鈥� Chaitanya Charon

The American University of Integrative Sciences is proud of our record in training physicians, including those that have been unsuccessful in the past and allowed a second chance.  Come join us and become the comeback that overcame your personal setback!  We would love to share this with you.

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Dr. Agnihotri and I are currently planning to make available a CS equivalent exam in February 2021 to meet ECFMG requirements. This exam does not replace the necessity that our graduating students preparing to enter residency, will still be required to take the USMLE Step 2 CS exam once testing has recommenced. The details of the exam and the optional preparatory course will be announced in mid-December. In order to fulfill ECFMG requirements, the 91福利 exam will closely resemble the actual CS exam, with multiple patient encounters, employment of standardized patients, video recordings, and SOAP note preparation and grading of equal scrutiny to the CS exam. The difficulty in firmly announcing the date and format is the fact that COVID infections are continuing to increase along with hospitalizations and deaths. It is anticipated that a further 鈥渓ockdown鈥� will be announced by the federal government, which will ban all public gatherings?

Thomas Oppong posed the question in a recent article; 鈥淚n our chaotic world, What鈥檚 the best way to live? How can I stay calm in turbulent times? What should I do to build resilience? How should I manage my emotions? 鈥淭he one message I want to emphasize,鈥� you are not alone.鈥� As a professor at two other Stateside medical schools, I can share with you that medical students throughout the US and Canada are experiencing the same mental and emotional burden of uncertainty as to our own 91福利 students. The positives are that hopefully you and your family are healthy and have not been hospitalized? You may have gathered that a number of our administrative faculty, me included have recovered from COVID.

Just as in past pandemics, conflict in the world, world wars, tornadoes, and hurricanes we as a nation have survived and, in the end, have more resolve, compassion, and tenacity. When you think of the personal hurdles you have overcome, to be where you are; you will prevail and will emerge stronger. Remember, 鈥渨hy you started.鈥� The dream has not died, just delayed by a virus unknown to man that has created an unprecedented quagmire in which we will not only survive but will emerge more pertinacious as a society.

Seneca stated: 鈥淭he greatest obstacle to living is expectancy, which hangs upon tomorrow, and loses today.鈥� Fortunately, with advanced technology, and the ability to improvise; 91福利 has been able to continue to offer medical education via a distant learning format. As a result, our pedagogical methods have transformed to meet the needs of 91福利 undergraduate medical education and remain COVID compliant with State and Federal guidelines.

I encourage you in this period of reflection and thanksgiving, to appreciate the loved ones in your life, to reach out to those less fortunate with kindness and compassion, and to treasure your own health and remember 鈥淲hy you Started.鈥�

Don W. Penney MD.MSC.FACEP.FAAEM.
Neurological Surgeon
Provost, Dean Clinical Affairs. 91福利
School of Medicine.

The post Thanksgiving Day Message, 2020 appeared first on 91福利 | Caribbean Medical School.

The July 7th issue of Jama published a viewpoint article titled:鈥� Potential Implications of COVID 19 for the 2020-2021 Residency Application Cycle.鈥�   91福利 students who have access to the journal, I strongly recommend they take time to review the article.  I have taken the liberty to summarize some of the key points made by its author, May M Hammound. 

It is expected that in the 2020-2021 academic year, more than 40,000 medical students and physicians will apply for residency positions in the United States. As a result of the COVID 19 pandemic, the process of applying will be 鈥渄istinctly different鈥� from previous years.  The pandemic will certainly stress an already stressful process, the author also suggested that this was an opportunity for change and possibly 鈥渟ystemic improvements.鈥�

     鈥淪ometimes the object in the path, becomes the path鈥�

Prior to the COVID 19 pandemic, many have recommended reform in the residency selection process.  A topic that I have addressed in previous updates.   In the past, applicants for residency programs in the 2019-20 cycle applied to an average of 65 programs, and international medical graduates (IMGs) applied to an average of 137 programs. This number of applications does not improve match rates and results in significant cost burden to applicants as well as volume overload for program directors.  Hammound queries whether COVID 19 may spur an increase in the number of applications?  As a result of USMLE testing centers being closed, fulfilling the requirement for IMGs to pass Step 2 CK to obtain certification from the Educational Commission for Foreign Medical Graduates (ECFMG) to apply to a US residency program becomes problematic.  Added to this conundrum, is the fact that many medical schools have shortened clerkships, shifted to virtual rotations, canceled rotations, and electives resulting in a reduction of student opportunities to obtain faculty evaluations, letters of recommendation, and communicate their interest in respective programs. 

Additionally, program directors will have potential difficulty in determining which applicants to interview without the use of traditional screening metrics.  Considering other logistic difficulties include travel disruptions, social distancing requirements and with recent increases in the infection rate, possible social isolation maybe implemented?

Temporary solutions have been proposed, including:

• Virtual interviews
• Waiving requirements for USMLE scores and letters of recommendation

Hammound points out that the number of interviews an applicant attends has in the past been limited by 鈥渢ime and travel expense.鈥�  Many programs are known to overinvite the same pool of highly qualified applicants with just 7-21% of the applicant pool filling half of all interview slots in some specialties. (Lee et. Al. Laryngoscope 2019; 129 (3).

91福利 students should be aware that despite the challenges, suggestions have been made to improve the process and may ultimately improve a much need overhaul of an antiquated system.  The following is a list of some of the proposals, I encourage our student body to review the article to further these suggestions in detail:

• Adjust the residency application timeline (allowing students more time of complete application requirements.)
• Modify Application requirements. ( Consider applications unable to receive USMLE Step 2 CK scores)
• Encourage holistic review (Consider applicant鈥檚 attributes, aptitudes, experiences?)
• Limit the number of applications (holistic only possible if applicants limit the number of applications)
• Improve the quality of information programs receive (standardizing the MSPE to address applicant鈥檚 integrity, reliability, motivation, professionalism)
• Temporarily make exceptions to the NRMP all-in-policy (consider accepting students outside of the match)
• Cap the number of interviews a student can accept (limiting the number of interviews a student can accept, preventing over interviewing and limiting the number of interview slots available for others.)
• Implement preference-signaling mechanisms (allow applicants to designate preferred programs could improve the process)

We the faculty and administration of 91福利, strongly support our student body, stay current with frequent updates, and share in our graduating student鈥檚 consternation regarding the match.  As provost, and previous member of both neurological surgery and emergency medicine residency selection committee鈥檚, will monitor recommendations and changes in this evolving situation.

Don W. Penney MD.MSC.FACEP.

Neurological Surgeon

Provost/Dean of Clinical Affairs, 91福利.

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A recent airline emergency at 30,000 feet, prompted the airline crew to request the assistance of any doctor on board. I have had this experience once in the past, in 1993 while traveling from Phoenix, AZ to Chicago, IL. I was traveling with my wife and family of two young toddler children. After ringing the call bell, the flight attendant questioned my background, including having to provide proof of state medical licenses, American Board of Emergency Medicine Certification, and employment status. After satisfying their scrutiny, I was allowed to spend the remainder of the flight on the floor with an elderly female who was suffering from a hypoglycemic episode.

The medical kit that was provided to me was scant. At that time there was no AED, there were an oxygen cylinder and face mask, an AMBU bag, some over the counter medications; Tylenol, Advil, a sphygmomanometer, a stethoscope, I.V. administration set: 1 tubing with 2 Y-site connectors, 2 alcohol-soaked sponges, a roll of 1-inch-wide adhesive tape, 1 pair of tape scissors, and 1 tourniquet.
Protective nonpermeable gloves or equivalent, 1 pair, 50% dextrose, epinephrine injection 1mg/ml, diphenhydramine injection and nitroglycerin tablets.
The Federal Aviation Administration (FAA) has required since 2004 an automated external defibrillator (AED) be present on board.
The FAA has also proposed a list of minimum contents for emergency medical kits to be included on all flights in 2001. Should be noted that these kits are much improved over what was provided to me in 1993.
It should also be recognized that medical professionals who volunteer to provide in-flight assistance, need to be qualified, active, licensed and sober. A recent publication noted that 鈥渕ore than 4 billion passengers are expected to fly in 2019, and more than 60,000 medical emergencies are anticipated.鈥�
The current contents of an FAA Approved Emergency Medical Kit includes:
Sphygmomanometer
Stethoscope
Airways, oropharyngeal: 1 pediatric, 1 small adult, and 1 large adult or equivalent
Self-inflating manual resuscitation device with 1 pediatric mask, 1 small adult mask, and 1 large adult or equivalent mask
Cardiopulmonary resuscitation masks: 1 pediatric, 1 small adult, and 1 large adult or equivalent
V. administration set: 1 tubing with 2 Y-site connectors, 2 alcohol-soaked sponges, 1 standard roll of 1-inch-wide adhesive tape, 1 pair of tape scissors, and 1 tourniquet
Protective nonpermeable gloves or equivalent, 1 pair
Needles: 2 18 gauge, 2 20 gauge, and 2 22 gauge; or 6 needles in sizes necessary to administer required medications
Syringes: 1 5 cc and 2 10 cc; or 4 syringes in sizes necessary to administer required medications
Analgesic, nonnarcotic, 325-mg tablets, 4
Antihistamine, 25-mg tablets, 4
Antihistamine injection, 50-mg single-dose ampule or equivalent, 2
Atropine injection, 0.5-mg single-dose 5-mL ampule or equivalent, 2
Aspirin, 325-mg tablets, 4
Bronchodilator, metered-dose inhaler or equivalent
50% Dextrose injection, single-dose 50-mL ampule or equivalent
Epinephrine injection, 1:1000 (1 mg/mL) single-dose 1-mL ampule or equivalent, 2
Epinephrine injection, 1:10,000 (0.1 mg/mL) single-dose 2*-mL ampule or equivalent, 2
Lidocaine injection, 20-mg/mL single-dose 5-mL ampule or equivalent, 2
Nitroglycerin, 0.4-mg tablets, 10
9% Sodium chloride injection, 500 mL
Basic instructions for use of the drugs in the kit

One would ponder are there legal ramifications of providing medical assistance during a flight? Nable et al. reported in the New England Journal of Medicine,鈥� that providing care creates a doctor-patient relationship with its attendant obligations and liability risk. Liability is usually determined under the law of the country in which the aircraft is registered. 鈥淣able goes on to state;鈥� U.S. health care providers traveling on registered U.S. airlines have no legal obligation to assist in the event of a medical emergency, ethical obligations often prevail. Some countries including Australia and other European countries impose a legal obligation to assist.

Congress passed the Aviation Medical Assistance Act (AMAA) in 1998. This provides protection to providers who assist in in-flight medical emergencies from liability. Although a number of caveats are important to recognize. The AMAA does allow liability of providers if the provider was grossly negligent or flagrantly disregarded the patient鈥檚 health safety.
It is recommended that the provider provide written documentation of the care provided.

The most common in-flight emergencies include chest pain, syncope, asthma attack, head injury secondary to overhead luggage falling from storage bins, psychiatric problems (anxiety/phobias), abdominal illnesses such as diarrhea and pain, diabetic-related emergencies, allergic reactions, obstetric and gynecological emergencies. Although not all doctors are trained to treat all possible emergencies, however, a good rule of thumb keeps in mind 鈥減rimum non nocere.鈥�

For our Canadian students in training, 鈥渢here were 133.4 million airline passengers in 2015, a 27.3% increase from 2009.鈥� Kodama ET. Al. In addition to the increase in passenger traffic, there has been a significant increase in the number of passengers taking longer flights, subjecting patients to physiologic stressors, relative hypoxia and lower humidity. Delaney et al. recently reported that respiratory viruses are not spread through recirculated air on commercial flights, only approximately 50% of the air is recirculated and that all air is HEPA filtered. (EM Practice 09/19)

Ground-based medical consulting companies exist and are often contracted by major airlines to provide consultation when needed. Their primary role is to assist in medical decision-making and advising. Estimates as high as $100,000 is the potential cost to an airline that is diverted because of an ill passenger. In addition, to the logistics of re-routing new flights for passengers, possible hotel and meal accommodation can be arduous.

For me, after spending almost 3 hours on the floor with my ill patient, who did well and was transported to hospital after arriving in Chicago. I was met at the door by the flight attendant when departing, and 鈥渨as thanked for the help.鈥� My wife who I abandoned with our two small children, was left to attend to their needs on her own.

Don W. Penney MD.MSC.FACEP.FAAEM.

The post Musings on Assisting with Air Travel Medical Emergencies – March 2020 appeared first on 91福利 | Caribbean Medical School.

 The article titled: 鈥淭he Great Big Lie That Will Destroy Your Career Success鈥�

Was especially relevant considering my familiarity with the topic with reference to my role as provost for 91福利 School of Medicine?

We all indulge in 鈥渟elf-talk;鈥� the internal dialogue influenced by our subconscious mind, revealing our thoughts, beliefs, questions, and ideas.  Self-talk can be both negative and positive. It can be encouraging and it can be depressing, it also can be truthful and it can take the form of a lie.  As the provost, I have interviewed students considering a career in medicine that have been victims of their own self-sabotage.  Those who are victims of deluding themselves, chipping away at their self-confidence.  Many who desire a different life or career success are doomed by their negative self-talk.  Students have confided in me that they don鈥檛 have choices and unable to fulfill life-long goals.  It is easier to continue to believe they have no choices, rather than believe they are afraid to make the change. 

Many students blame their career failures on a lack of choices or options in life.  Unfortunately, they remain in jobs and careers because they don鈥檛 like the choices they have; more as a result of the potential cost to them, forcing them to leave their 鈥渃omfort zone.鈥�  As a result, the status quo holds and they never experience their dreams and career success. 

The post The Great Big Lie That Will Destroy Your Career Success – March 4, 2020 appeared first on 91福利 | Caribbean Medical School.

鈥淣o Matter what religion we follow, what politics we support what family we were born into, or where we鈥檝e placed our roots, we all deal with universal problems. Regardless of our differences, we all live our lives around the same questions. How we answer them dictates the choices we鈥檒l make and what kind of person we鈥檒l be from moment to moment. Some answers actually breathe when we inflate them and try to find a pulse, Others seem implausible and yet make a world of sense when we step inside them and wrap them around our circumstances.

And others still can feel absolute for what seems like an eternity until life cross-examines them and reminds us how fragile most answers are.鈥�

As provost and Dean of Clinical Affairs, of the American University Integrative Sciences, I have had the opportunity over the last four years to teach and direct the Advanced Clinical Medicine course, three to four times a year.  This one-month intensive course is designed to prepare students for their clinical clerkships and USMLE STEP 2 CS exam. Students that have completed their pre-clinical basic sciences courses taught at 91福利 on the island of Barbados return to Atlanta to begin their clinical clerkships.  In addition, students from other medical schools that are transferring to 91福利 attend the course in preparation for a clerkship.  

This year, the November 2019 course was completed the week of Thanksgiving.  Each year the Hosea Williams 鈥淔eed the Hungry鈥� foundation held at the Georgia World Congress Center sponsors a dinner for the homeless.  In addition, attendees have access to clothing, medical check-ups, showers and barber services. Yearly I have witnessed the most frequent station utilized in this event is the 鈥渇oot washing鈥� station.  Many of the homeless have no shoes and at best worn-out shoes. Their feet are often infected, with open sores and dirty reflecting their life on the street. Volunteers from all walks of life, assist in one or more stations.

This year, I had the occasion to have two of our own 91福利 medical students attend the event.  Nitya Chitravanshi and Swati Patel, both were keen to treat medically attendees requiring medical assistance.  During a lull in the patient count, one of our students, Nitya Chitravanshi dawned a plastic apron and gloves and assisted at the foot-washing station. (see video).   The other 91福利 student Swati, along with medical and pharmacy students from the Morehouse School of Medicine, Emory, and the Philadelphia College of Osteopathic Medicine; addressed the medical needs of participants.

 In contemplating a career in medicine, I would encourage any student anticipating applying to medical school to strongly consider 91福利 as a strong consideration.

Based on years of reflection in academia, I ruminate as to what type of student 91福利 attracts? Those that put service to others before themselves.    I believe most physicians are drawn to medicine for the human connection. A basic belief/tenant of life is to improve the condition of others. I have come to learn, that behind every patient lies a story, whether hidden or shared.  Physicians have the honor of examining patients not only with their eyes but also with their hearts.

Desmond Tutu echoed this in his quotation; 鈥淒o your little bit of good where you are.  It鈥檚 those little bits of good put together that overwhelm the world.鈥�

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In a follow-up to my most recent post, I wanted to bring to the attention of our student body the on-going dialogue and consideration of converting the USMLE exam to a pass/fail score.

As noted in the accompanying viewpoint/opinion article from JAMA: July 19, 2019, 鈥渢he official purpose of the examination is to assist state authorities in granting medical licenses, but it also reassures various groups 鈥�.. that licensed physicians have attained a minimum standard of medical knowledge.鈥�

Currently, these examinations (Step 1, Step2 Clinical Knowledge, and Step 3) are reported in a 3 digit format.  As Swalis et al. reports: 鈥淭he federation of State Medical Boards and National Board of Medical Examiners has released joint preliminary recommendations, which suggest consideration of a move to pass-fail score reporting.鈥�

Of particular importance to our 91福利 student body, the article states: 鈥淎pplication inflation is especially prominent for programs evaluating international medical graduates, who fill approximately 20% of position in US residency programs.  To manage this volume, program directors use filters in the Electronic Residency Application Service.  Filters exclude application below a requested standard, leaving fewer to be evaluated. 

Interestingly enough, Swalis states:鈥� the narrow differences in examination scores used by some program to exclude many applicants are arbitrary with neither clinical, nor statistical meaning.鈥�

Changing the USMLE exam to a pass-fail score would require residency program directors to utilize other criteria to adequately assess a student鈥檚 candidacy for residency?  Swalis rightfully points out, 鈥減rograms might identify outstanding applicants who would have been overlooked based on a numerical cutoff鈥�

It is well known, that medical students seeking residencies in much sought-after high demand programs are selected based on higher USMLE scores.  In particular, neurosurgery, plastic surgery, dermatology, radiology, and emergency medicine are very difficult to match- in because of their popularity.

Of particular concern, Swalis states: 鈥渟olitary test preparation, which is inconsistent with the important skill of collaborative patient care, can replace class attendance.  Some students become isolated from each other and potential faculty mentors. They may focus exclusively on testable material. The stakes could be higher for international medical graduates, who may not match in US-based residency programs without exceptional scores.鈥�

As many of our 91福利 students come from backgrounds that are already underrepresented in medicine, potentially resulting in a significant lack of diversity in competitive postgraduate specialties.  As reported by Swalis: 鈥漞vidence suggests the USMLE may exhibit bias against racial/ethnic minority students, emphasis on USMLE scores during resident selection may contribute to this phenomenon and affect the specialty decisions of medical students from backgrounds that are underrepresented in medicine.鈥�

91福利 students are encouraged to follow the on-going dialogue and be familiar with residency match requirements.  In addition, in choosing a residency students should be realistic in their choice selection; based on USMLE scores, GPA, letters of reference, and clerkship performance.  

Don W. Penney MD.MSC.FACEP.

Provost, Dean of Clinical Affairs, 

91福利 School of Medicine.

The post Letter from Provost – 08/20/2019 appeared first on 91福利 | Caribbean Medical School.

Student Body at 91福利, I recently came across an article published by UNDARK, titled:

&苍产蝉辫;鈥淎 Doctor Shortage is Looming, and a Clinton-Era Policy is partly to Blame.鈥� Authored by Kunal Sindu; dated July 25, 2019.

This essay reminded me of the annual anxiety-provoking event that most senior medical students are facing each year on Match day.  Various publications have once again detailed the anticipated doctor shortage by the year 2032.  Estimates ranging from 46,000 to 121,900 physicians was quoted by Sindu.  The predicted doctor shortage is not the result of the lack of physicians being trained and graduating from medical school; but the limited number of residency positions available to obtain postgraduate training in the U.S.   There has been a dramatic increase in the number of osteopathic medical schools opening in the US, a report in US News detailed that a 162% increase in first year enrollment at osteopathic schools is expected between the 2002 and 2020.  MD Granting schools anticipate a 29% increase within that same period.   Additionally, international foreign medical graduates are also competing for coveted residency positions.  To put the numbers into perspective, in 2019 there were 38,376 applicants for 32,194 first year residency positions.  There were 5,080 US international medical school graduates (IMG) who entered the match, with 2,997 successfully obtaining a residency match, a rate of 59%.  There were 6,869 non-US citizen IMG鈥檚 entering the match of which 4,028 matched at a rate of 58.6%.  Make note that the 91福利 2018 match rate was 74.2%, out pacing the international school performance rate.  Considering all international medical graduates including both US and nonUS citizens; their respective match rate was the highest since 1990 and 1991. 

(Source: The Match. National Registry Match Program)

The disproportionate number of doctors graduating from medical school and the limited number of residency positions is the result of a law that was passed by Congress in 1997.  The Balanced Budget Act which was revised in 1999 limited Medicare reimbursements to postgraduate institutions, capping the number of medical school graduates training as resident in the U.S. teaching hospitals.  The American Medical Association in 1997, prior to the Balanced Budget Act being enacted, supported the reduction of the number of U.S. residency positions by approximately 25 percent. The reasoning, 鈥渢he United States is on the verge of a serious oversupply of physicians.鈥� 

Well known to matriculating medial students, the fact that a medical student can successfully acquire their medical degree, however without a residency; they cannot be licensed to practice medicine within the United States.    Unfortunately, each year thousands of residency applicants fail to secure a residency slot. Although the number of residency positions has increased, the number of available residency slots has not paralleled the number of graduating physicians and the need for more physicians to meet U.S. health care needs. 

The anticipated doctor shortage is compounded by the fact that the age distribution of physicians has shifted, especially in rural America.    The total number of rural physicians from the years 2000 to 2017, grew only 3%, the number of physicians under 50 years of age living in rural areas decreased by 25%.  As reported by Skinner et. Al. NEJM. 381;4 July 25, 2019;

 鈥淏y 2017 more than half of the rural physicians were at least 50 years old, and more than a quarter were at least 60. Twenty percent of the country鈥檚 population lives in a rural area, and the ratio of physicians to patients is 1 to 2,500, which means that 60 million people are dealing with the impact of this shortage.鈥�

Historically, rural areas in the United States suffer disproportionately from inadequate access to health care. In 2018, according to the Health Resources and Services Administration (HRSA), 66% of Health Professional Shortage Areas for primary care and 62% of those for mental health were located in rural or partially rural areas of the country. Although there is disagreement about the adequacy of the overall physician supply, there is little disagreement that the uneven distribution of physicians presents serious access problems in many rural areas. Limited access to physicians can reduce access to preventive care and exacerbate unmet health needs, leading to costly hospitalizations and poor health status.

Despite decades of private – public-sector initiatives aimed at increasing physician supply in rural areas, these projections of the rural physician supply are troubling. In 2030, residents of rural areas will have access to one third as many physicians per capita as their suburban and urban counterparts will. Yet rural residents are likely to be older, poorer, and in worse health than city dwellers, with a lower life expectancy, and they are more likely to be uninsured.

Until major changes have been implemented, and as a result of the match being so competitive, students are encouraged to focus on performing well on their USMLE exams, grade point average, performance reviews on clinical rotations and references.  In addition, satisfactorily completing the thirteen Entrustable professional activities prior to residency commencement is expected by residency directors. 

Don Penney MD.MSC.FACEP.

Source material gathered from:

A Doctor Shortage Is Looming, and a Clinton-Era Policy Is Partly to Blame, – 

And Disparity Rural Physician Workforce NEJM

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