Why Underfunding Residency May Create Competitive and Broken Physicians

It is no secret the U.S. healthcare system is deeply flawed. Among these flaws is the broken medical education system. What is seldom mentioned is the fact that the number of medical school positions in the U.S. continues to outpace the number of available residency positions as a result of underfunding residency.

Many training hospitals receive federal funding to support resident salaries, but that funding has not kept up over the years. CMS finally increased funding for resident salaries in December of 2021, but only to provide funding for a total of 1,000 new resident spots to be added in 200 position increments over the next five years.

That marked the first federal funding increase in residency positions since 1996, marking 25 years of almost no growth in the number of residency spots in the US. According to data from the AAMC, between 2002 and 2019 the number of medical school admissions (DO and MD) increased by 53%. However, in the same time frame, the number of residency spots only increased by 40%.

Looking at the 2022 Match results reported by the NRMP, there were a total of 47,675 applicants for residency program in the US (including foreign medical graduates) but only 36,277 available residency positions. At then end of the Match cycle, 93.9% of all available residency positions were filled.

Underfunding Residency Drives Competition

Alright, so the shortage of residency positions creates a bottleneck. You have more medical students graduating from medical school than available residency positions. This issue is further compounded when you consider the number U.S. citizens graduating from Caribbean medical schools or international medical graduates who are also applying for residency training in the U.S.

Who does this burden fall onto? Certainly not the hospitals. The hospitals have more applicants to their residency programs than they know what to do with. The burden falls onto the medical students. The average medical school debt in the U.S. is approximately $200,000.

In order to become board certified and begin making a six figure salary to help pay off their debt burden over the next 10 years, medical students must compete with one another to get into residency. More emphasis is placed on achieving higher and higher test scores, padding one’s resume with extracurriculars, and publishing scientific or clinical research.

But how do you turn off the need to compete when it has been programmed into you throughout medical school and even in college? Arguably, this sense of competition directly impacts a resident’s ability to work as a team player with other healthcare professionals, trainees, and patients. How could it not?

Underfunding Residency Drives Exploitation

It also predisposes residents to being abused and exploited by their programs. Because a greater emphasis is placed on physicians needing to be board certified in their specialty, which only occurs after completing a residency program, the resident is in a very vulnerable position.

The residency programs can force residents to take on dangerously high patient loads with insufficient supervision, pressure residents into working more than 80 hours a week and downplaying their hour logs, and manipulate the curriculum to better serve the needs of the hospital rather than the learning needs of the residents. Residents are very unlikely to speak up about such abuse and exploitation because they fear retaliation.

Even though the Accreditation Council for Graduate Medical Education exists in theory to protect the educational and work experience of residents, residency program faculty can falsely accuse residents of not meeting subjective competencies such as communication and professionalism. What this means is that if residents try to speak up against the way they are treated, they can be placed on remediation and ultimately fired on the whim of their program faculty.

It is incredibly challenging for residents who are fired or have a record of remediation to finish their training at another program. Hence the reason why the majority of residents remain silent about the mistreatment they and their peers face.

Competition + Exploitation = Broken Doctors

What kind of physicians do we create in this educational environment of competition, silent mistreatment, and abuse? How can these residents become well-adjusted, compassionate physicians under these circumstances? I argue believe that many cannot, which is why we see such high rates of burnout, substance abuse, and mental illness in healthcare providers.

In summary, the U.S. healthcare system is deeply flawed, in part due to underfunding residency programs. A shortage of residency positions drives up competition and leads to the silent exploitation, abuse, and mistreatment of medical students and residents. If we want a better healthcare system, we must be willing to advocate for better medical education.