Thursday, November 16, 2017

The great plan

Draft proposal

DRAFT Outline 11/11/2017
Plan to start Primary Care internships in the USA
Purpose: To fill the need for primary care physicians in rural and suburban areas and in Critical areas of need across the USA.
Introduction: Currently the United States has a shortage of primary care physicians in many areas of the country. The Accreditation Council for Graduate Medical Education (ACGME) has been unable to provide enough training spots for the growing number of qualified medical school graduates both domestic and foreign. In 2017 alone over 8,000 medical graduates living in the US were unable to match and that number is doubled if foreign medical graduates (FMG) are counted. Times have changed and so should the current system of training.
ACGME has not always been the accreditation body for US residencies. ACGME was formed in 1981 to restructure the old system of residencies. To be qualified for a medical residency one must graduate medical school, pass United States Licensing Exam (USMLE) steps one, two and Clinical Skills (CS) within 6 attempts each.  This standard has not been followed due to the current competitiveness caused by the shortage of spots to train. Currently a medical school graduate is expected to have passed the USMLE in first attempts with high score and graduated less than 3 years to be interviewed and possibly accepted into residencies. This limitation leaves many without training despite being qualified. Many FMGs have practiced in their home countries for years gaining knowledge and experience, yet at disadvantage due to year of graduation.  Some who did not pass the USMLE the first attempt, studied rigorously and learned from mistakes and now successfully passed.  
Some US states, such as Missouri, have enacted an Assistant Physician law, allowing medical school graduates to be limited licensed without residency and passage of steps one and two.  Other places such as the US territory Puerto Rico have both ACGME residencies and one year internships that both could lead to licensure after one year as a General Practice Physician.
Proposal: We propose a system of one year internships to be created in each state. These internships would be less costly than ACGME residencies and commit the graduates to practicing in their states for a period of time after the internship as General Practitioners.  ACGME has been insufficient to provide the needed Primary care physicians. These Internships thus would be accredited by each state and overseen by the state boards of medicine. Currently in Puerto Rico the State Medical Board accredits the one year internships so this has been successfully done within the US.
The one year program would consist of:
1. 2 months of Emergency medicine
2. 3 months of Internal medicine including ICU
3. 2 months of Pediatrics
4. 1 month of Obstetrics
5. 1 month of Surgery
6. 3 months of clinic based rotation FM ( preferably at an FQHC)
Total 12 months 2 weeks’ vacation cannot be taken during 1 month rotations

Cost: Currently ACGME programs average 130,000 usd per resident. We believe this cost can be easily cut in half maybe less since the new program is accredited by the state.

1. Pay could be lower than current average in ACGME, proposal of 25,000 to 35,000 for the year with housing allowances for the residents. (Lowest paid ACGME residency is in Puerto Rico at about 37,000 year 1)
2. Faculty can be both paid and non-paid.
3. Subsidies from HRSA could be sought in form of grants.
4. If FQHC based then Malpractice is a much lower in cost.
5. No research requirement ( this alone cuts the cost considerably)
6. Other funds from private sources.
Advantages to the state:
1. Residents sign a commitment to practice within the state for a period of three years post residency once licensed.
2. Increased resident physicians to help with the underserved volume of patients during training.
3. An avenue to tap into the hundreds of thousands of qualified US and Foreign physicians ready to practice but cannot due to limited to no training opportunities.

Path to employment:
Currently General Practice Physicians exist in the US with this training and experience. They successfully practice in hospitals and clinics in the US territory of Puerto Rico with an unrestricted license to practice medicine. They practice all over the main land US working for the US Federal Government, VA, Indian Health services, in Florida and Texas in areas of need.  The states should change the current licensing laws to include General Practice medicine. They could expand to the rural practice areas of need more freely than currently. The license should be unrestricted as in Puerto Rico.

A path to in state fully trained board certified Family Medicine Physicians:
Create a new pathway accepted by the American Board of Medical Specialties (ABMS) or American Board of Physician Specialties (ABPS) for Family medicine Board certification. This pathway would be for the graduated General Practitioners from any state or territory program to be accepted after one year of work into a 3 to 5 year fellowship. The would then spend part time studying, testing and fulfilling requirements to be Board eligible in Family Medicine. Completion of the fellowship would also make them eligible for Full Licensure if the general practice is limited licensure in the state.

William Hudson MD

Friday, July 21, 2017

Most days plus call


Most days during Internal Medicine start with arriving at 7:50am and doing "mini rounds" checking charts census on medical and both ICU floors, then if I have time a quick breakfast. Labs are ready around nine to review and chart, review new patients and start progress notes then go assess patients, attendings on this rotation come in between 12 and 4, mine 3:30 to 4.
If this is a call day, get notes written 100% because call is ER duty plus house officer.
Call starts at 4pm and its not unusual to see more than 10 patients in the ER over night. 4p-8a rarely we get to sleep 2-3 hours.

This is an internado, full Residency experience but no pay during, licensed after if all steps are passed.

Buenos días