The BRI Blog

As the noise about single-payer amplifies in the U.S., a Canadian opinion writer, Neil Macdonald, warns that his country’s health plan is, well, sclerotic. Read the article.

Have you ever wondered why it’s so difficult to talk to a liberal about health care? Or why there is such a passionate desire on the left to remake everyone’s health insurance, even though 80% of Americans (according to Gallup) rate their health coverage as “excellent” or “good”?

Most of what the left has to say about health policy makes no logical sense. That’s mainly because they don’t understand health economics. And that’s because they tend to reject the economic way of thinking as such.

John Goodman, President of the Goodman Institute for Public Policy Research, a Senior Fellow at the Independent Institute and author of the widely acclaimed book, Priceless, in a recent post for Forbes explained all this in detail. [Read More]

You might find interesting a recent general but brief commentary about Direct Primary Care by John Carlson, Wall Street Journal contributor, of the Washington Policy Center. [READ THE ARTICLE]

Though it’s no longer front-page news, the opioid crisis continues to plague the medical profession, the healthcare system, state budgets, and federal government agencies tasked to keep up with the epidemic. Investigative reporter Sara Carter recently produced a documentary about the crisis, “Not In Vein.” The focus of Ms. Carter’s documentary is largely on the scope and human impact of the epidemic, she also lightly delves into the impact on physicians and the healthcare system and the toxicology of opioids. [Watch Now]

A question that students commonly wrestle with is “How will BRI involvement affect my MATCH experience?” I wrestled with this question myself. With the MATCH growing increasingly competitive, none of us want to add additional barriers to our dream program or specialty. After successfully going through the MATCH for psychiatry, however, I can confidently say that my BRI experiences were highlights, rather than detriments, on the interview trail! Before I elaborate about my experience, this is my first key point:

BRI can certainly help you build a competitive application, so go forward with boldness!

The key word in that first point is “can.” BRI can help, but simply being a passive member won’t necessarily generate talking points on the interview trail. My involvement in BRI was helpful because I was blessed to take advantage of leadership, internship, and fellowship opportunities. Consequently, here is my second key point: If you are a member, be active! Organize meetings, attend conferences, write blogs, host debates! Many programs asked about the single payer debate we hosted and about the BRI podcast I helped create. Some even asked, with sincere curiosity, for my opinions about the future of American healthcare! Thanks to my experiences in BRI, I had meaningful things to share with my interviewers.

Now for a little more about the statistics of my experience. When preparing for the interview trail, I narrowed my search based on the most consistent piece of advice I heard: Choose a program where you’ll be happy! Since I was recently married and expecting a baby, happiness meant staying close to family in St. Louis. Fortunately, there are a handful of great programs in this area! However, based on the “2018 Charting Outcomes” (https://mk0nrmpcikgb8jxyd19h.kinstacdn.com/wp-content/uploads/2018/06/Charting-Outcomes-in-the-Match-2018-Seniors.pdf) MATCH document, my advisor recommended I apply to about 25 programs just to be safe.

The MATCH document also provided a terrifying statistic: The no-match rate into psychiatry for US seniors was 16%! For reference, the no-match rates for orthopedic surgery and radiology were 17% and 11%, respectively! Those who did NOT match only interviewed and ranked an average of 5.8 programs. So, I decided to aim for 9 interviews and ranks, giving me about a 90% chance of matching. When it was all said and done, I interviewed at all the regional programs I had hoped for, as well as two prestigious schools that were a flight away. I ended up turning down two interviews and officially ranked 7 programs. Thankfully, I was ultimately accepted by my top pick in the St. Louis area — Saint Louis University!

Overall, I was very pleased with how my application was received. I was interviewed by what I consider to be 2 top programs, 3 strong programs, and 2 safety programs. The impression I received was that the strength of my application was in work and leadership experiences. Many of these experiences, of course, I credited to BRI! My interviewers seemed genuinely impressed that I had committed so much time to studying the economic, political, and philosophical issues within medicine during medical school. It reminded me of the physicians I had met at BRI conferences who often said, “I wish I would have started learning about these issues as a medical student!” That seemed to be a common sentiment on the interview trail as well. These conversations confirmed the importance of these issues to current physicians, and I truly believe that engaging with these ideas as students gives us a dramatic advantage as we prepare for our practice!

The issues we learn about with the help of BRI have a major impact on the quality of life for working physicians! Unfortunately, it seems that many physicians feel stuck or already burned out with medicine. It’s our responsibility as students and residents to add to the road that has been paved for us. We have an opportunity to improve the systems that have taught us everything we know about medicine.
And so, my third key point is really a call to action: Keep learning and build something better! Whether you continue the debate of ideas in academics or participate in disruptive innovation in the private sector, there are so many ways to add value! It really is up to us to improve healthcare affordability, accessibility, and quality. We’ll never achieve those goals, though, if there are no physicians to care for patients. Consequently, it’s also up to us to restore and protect the fulfilling patient-doctor relationship. So for your sake and for the sake of your future patients, build something better! John Flo, MD, St. Louis University School of Medicine, 2019, Resident Doctor SSM Health Saint Louis University Hospital

The Problem
The American population under age 18 is projected to grow by only 3%, while the population aged 65 and over is projected to grow by 50% by 2030. It is estimated that the shortage of physicians will be around 100,000 by 2030. This puts enormous burden on the medical training system to train highly competent and invested physicians [1].

Previously, the burden of meeting the demand for physicians was on medical schools. They were responsible to admit a sufficient number of students to satisfy the ever-increasing demand for healthcare services. Medical schools have already taken it upon themselves to help solve the projected physician shortage problem. They have opened up 29.2% more seats since 2003 [2]. Now the bottleneck has shifted up to residency programs, which have not expanded their number of residency positions at the same rate that medical schools have expanded seats in their medical schools. There are a number of reasons for this.

One, residencies aren’t profitable. They do not generate enough revenue to cover their cost, which includes not only salary, but academicians and administrators to manage training.

Two, medical schools can scale where residencies cannot. Schools are using technological innovations, like recorded lectures, to meet the needs of teaching medical students the basic sciences. Residency programs do not have the luxury of adopting these methods, as their training is hands-on and does not lend itself well to scalable teaching technologies.

Because of these two reasons, residencies must procure funding from outside of the budget-conscious hospital or clinic. Typically, residencies receive the funds to operate from federal sources, specifically Medicare and Medicaid. However, federal funding for residencies has not increased in more than 20 years [3]. Indeed, it would be financially catastrophic for academic and community hospitals to expand to rapidly meet the future demand for healthcare without rapidly expanding the funding from external sources. The model of training a resident must change. Here, I will present my theory of how to expand residency training positions from a grassroots level independent of relying on our federal congress.

The Plan
I believe that the additional residency training positions should come from local and community funding efforts. Indeed, within our current model, residents are no more tied to the community in which they train than they are tied to their undergraduate institution, even though residents spend 3 to 6 years of their life in residencies and perform untold numbers of life-saving interventions in those communities. Often, residents have very little interest in the communities in which they train. They are there to become competent doctors. This is because our current model of training does not incentivize residents to remain in the community in which they train.

Theoretically, if provider-hungry communities wish to have more physicians in their communities, they would support a program designed to keep trainees practicing in their communities well into their careers, not just the years of training. Therefore, I suggest that we create new residency positions that not only incentivize residents to remain in the communities in which they train, but hold residents accountable to serve their communities better during their training.

Example in practice: the Dell School of Medicine

A good model for this is the recently-opened Dell School of Medicine in Austin, Texas. It is the first and only medical school to open with a vote from community members, allowing the entire community to become stakeholders in the medical school. The goal of the medical school is to improve the health of Austin as a whole. The medical students at the Dell School of Medicine are accountable to the community to be innovators, leaders, and servants to the community, and the community shows reciprocal trust in the mission of the students with continued funding for the school through increased taxation. Much of the money for the medical school comes from local sources and remains in local hands. Benefits are confined to the community. The small-scale funding operation is effective as it keeps those receiving benefits very close to those who are responsible for giving the benefits. This is a stark contrast to funding from the large mechanism of the federal government, which distances the beneficiary and payer. The same could and should be done with new residency positions. If residents are accountable to the community members, they will theoretically be much more invested in the health and overall well-being of that community.

Action Items for Implementation
I have three suggestions for community-funded residency programs.

One, that community-funded residency positions outcompete other residencies’ salary. The more competitive the resident pay, the more likely the smaller, community-based program is to attract not only the best and brightest individuals, but the ones most suited to the community.

Two, that residency directors be democratically elected positions. This ensures that the community in question has a voice not only in whether it receives residents, but in who selects those residents.

Three, that communities offer loan forgiveness in exchange for long-term commitment to a community. Loans forgiveness is a major draw for many students with mounting student loans.

A Unique Roadmap to Prosperity
You may ask, then, how this is different from programs like the National Health Service Corps. For one, the funding for the residency positions are collected from, invested in, remain with, and exclusively benefit communities. This means that communities may be more flexible, creative, and autonomous in directly negotiating with residents. Second, cities that are not strictly defined as “underserved” may participate. Lastly, unlike NHSC and other federal government-funded scholarship programs, the new residency programs would be open to all specialties, as our critical shortage of physicians extends far beyond primary care.

It will take a Herculean effort to close the gap of the projected physician shortage. But, with innovative and creative solutions like grassroots, community-funded residency programs, we will begin to chip away at the problem.  Rufus Sweeney, M1 from University of Wisconsin School of Medicine and Public Health

1. http://1. https://news.aamc.org/press-releases/article/2019-workforce-projections-update/
2. http://2. https://www.aamc.org/newsroom/newsreleases/431036/20150430.html
3. http://3. https://aamc-black.global.ssl.fastly.net/production/media/filer_public/98/7b/987b00be-2ca9-4466-89cd-0892d233f63d/gme_training_tomorrows_physician_workforce.pdf