Guest column: Legal barriers create Michigan’s doctor shortage

By Mark D. DuBay

In "Michigan gets med-school boom, doctor bust," the author correctly points out that a doctor may not be fully licensed in this state unless a period of post graduate education, also known as a "residency," is first completed. Under section 333.17031 of the Public Health Code, a doctor is to "complete a period of postgraduate education to attain proficiency in the practice of the profession" before a full license is granted.

The residency requirement was originally intended to give doctors additional experience and training after medical school. It was never intended to limit the number of licensed doctors. Regardless of its original intent, the residency requirement effectively limits the number of doctors licensed in Michigan. If a doctor successfully graduates from medical school and passes all three steps of the United States Medical Licensing Examination (USMLE), the doctor is nonetheless ineligible for a license.

When it was adopted in 1965, Medicare became the primary source of funding residency programs. These funds have been "frozen" since 1996. This has reduced the pool of doctors available to serve Michigan residents. It is unlikely that funds from this source will be increased any time soon. The American Association of Medical Colleges published a report in 2008 indicating that, even if residency programs were funded at a level described as "robust", doctors would still be licensed in numbers insufficient to service the projected need.

The medical profession is unusual, if not unique, in requiring "post graduate education" as a licensing condition. Most other major professions merely require obtaining a professional degree and passing national exams to prove competency. A review of state statutes and the administrative code shows that this is the rule overwhelmingly. Once educated and tested, a license is granted to accountants, dentists, engineers, lawyers, pharmacists, or other licensed professionals without further training.

Fitzhugh Mullan quotes experts criticizing the length of medical education: "To the four years of ‘undergraduate’ medical education that were the norm of the early 20th century have been added three to seven more years of ‘graduate’ medical education (residency), depending on the specialty being pursued. In 1988 Robert Ebert, dean emeritus of the Harvard Medical School, and Columbia University health economist Eli Ginzberg argued that medical education had become unnecessarily lengthy."

Michigan licensing law must be reconsidered. Those doctors who wish to become specialists should have the residencies and become board certified. Those who wish to simply practice medicine as a primary care physician should be allowed "to attain proficiency in the practice of the profession" by working under the supervision of fully licensed doctors.

Michigan is not alone in this problem, and each state controls its own licensing laws and therefore controls solutions. The authority of Physician’s Assistants in Michigan was increased this past November with the adoption of Public Act 210 of 2011. Since doctors who have been educated and tested can do nothing without a residency and residencies for all those eligible are not being provided, medical licensing laws should be revisited, just as they were for Physician’s Assistants.

If a U.S. citizen is a medical school graduate, has passed the United States Medical Licensing Examination and is eligible for licensure if a residency were provided, it is time to license this doctor. In a time of shortage, it makes no sense to waste medical talent. One does not pass the United States Medical Licensing Examination without being competent.

Other pathways to licensure must be created if Michigan’s physician shortage is to be solved. It may be done by working in harmony with the current residency system, which may be used to train specialists, not the general practitioner. If a dean emeritus of the Harvard Medical School thinks medical education is unnecessarily lengthy, perhaps it is time to listen.





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Thu, 08/02/2012 - 9:12am
An engineer has similar requirements in that an Engineer in Training exam is administered usually in the last semester of undergraduate school. This exam covers all fields of engineering, but passing it does not result in the issuance of any license. The engineer must then work four years in his/her field before taking the Professional Engineers exam, an exam that is somewhat limited to a chosen field such as mechanical, civil, or electrical engineering. Passing that will result in the issuance of a PE license. One should also note that most engineers, working for mainly large companies, do not have to have any license to practice their profession, as long as the company assumes responsibility for the engineer's product.
Thu, 08/02/2012 - 9:56am
A Certified Public Accountant in Michigan is required to have one year practical experience in addition to education and examination requirements. To my knowledge there is no other path to any type of accounting license in Michigan.
Thu, 08/02/2012 - 11:11am
As a family physician, I cannot disagree strongly enough with Mr. DuBay. Since every student chooses a specialty and a residency and almost all complete a residency, changing the legal requirement will have little impact on the number of physicians that practice in Michigan. One or two years of post graduate education do not prepare one well enough for practice, especially as a generalist. The three years that a family physician spends in a residency may not be enough, as the American Board of Family Medicine is piloting a four year residency to see it that extra year is needed. And since just about every student completes a residency, other states with lesser requirements than Michigan are not pirating away doctors from our state. Add to this that most insurance companies will not pay physicians who are not board certified/eligible changing our requirements will not increase physician supply. The original Mr. DuBay references was about the expansion of medical schools in our state. But the main problem with that is it will not increase the physician supply unless we expand residency slots, and right now, Medicare (the main finder of residencies) and the state will not expand the funding for more slots. 10% of current residents went to medical school outside the US, and they by and large stay in the US after they finish their training. So more US students, Michigan students will just squeeze out the international students, resulting in no more doctors. And training doctors is expensive, more than $100,000 per resident on average per year. The way to increase the supply of doctors is not to change the licensing requirements, but to expand medical schools AND residency slots.
Beaufort Cranford
Thu, 08/02/2012 - 1:24pm
There is such an obvious gulf of competency between even first- and third-year residents in some specialties that I would hate to see residency made optional or abolished. I'm much more concerned with the quality of care I receive than the quantity of physicians available, even if it means I have to wait for an appt. I'd like to see residency slots expanded and the requirement maintained.
Sat, 08/04/2012 - 9:44am
As noted above, the solution to the problem is to expand residencies to allow those who have been trained as physicians to gain the experience needed to practice their profession. The reality is that is not going to happen given the economic environment in which we find ourselves. The baby boomers are aging and the new healthcare program gives an additional 35 million people access to healthcare. How are we going to accomodate that kind of demand. I am a retired executive from an HMO so I have some experience with problems with access to healthcare. I believe we may be heading for a 'heathcare access sunami'. I am intimately familiar with the quality of care that is rendered by Physician Assistants having worked in a staff model environment. Patients visit them routinely mostly without reservation. Nurse Practicioners have even less training but are also accepted as primary care providers.The idea that somehow a doctorate level provider who studies under the direction of a fully licensed family practitioner for 5 years or longer cannot provide quality care seems a bit unbelieveable. I do respect the attainment of Board Certification as an indicator of accomplishment and it shouldn't be minimized. However, when the need for additional practitioners becomes acute (and it already has in many parts of the country), the proposed change in the law seems viable as a partial solution to the problem. Additionally, schools should not be producing more graduates than there are open residency slots to be filled. For universities to produce more Doctors who cannot practice without a guaranteed residency is ridiculous and somewhat self serving. For graduates who have given 8 years of their life and hundreds of thousands of dollars in cost (and lifetime debt) not to be able to practice for the lack of a residency is just wrong.
Sat, 08/04/2012 - 4:46pm
It does not make any sense. How can all graduate doctors, from Michigan medical schools, not be guaranteed residency slots at hospitals or clinics? And can not the hospitals figure out a way to pay for them?
Tue, 08/07/2012 - 4:47pm
What about those students that do not get residencies? What is happening to the WASTED talent? You can hardly miss the countless headlines on the health care crises, the need for health care reform, the shortage of doctors, the plight of the uninsured, etc. etc.They pop up all the time. It doesn't seem possible that this can be happening at the same time we have a residency shortage. Are we in gridlock? Can we not find a creative solution to utilize talent that is virtually being tossed aside otherwise when a residency spot is not obtained? How did we decide to reduce the number of residencies anyway? Didn't anyone notice the aging of baby boomers, the increase in longevity, the survival rate of victims of accident and illness, on and on. Some of the medical school graduates without residencies are U.S. citizens who have invested huge amounts of time, money, and energy to no avail, at a time when we need them most. Surely we can find a solution.
Fri, 11/02/2012 - 12:12am
I'm a new doctor who will be applying residency next year and im really worried that I may not get a residency slot. I really don't support the idea of allowing doctors without a residency training to practice medicine unsupervised. I think we need a better solution than that. These are my suggestions for the state: 1. since medicare funds are not enough, have the doctors pay for their training 2. Increase residency slots with more medicare money 3. Allow qualified doctors without residency to give physician assistant license exams and become a PA. 4. Allow qualified doctors without residency to give Nurse Practioner exams and become a NP 5. Recognize residencies done outside of U.S then provide one year "prove yourself-training"in a U.S hospital. if they are deemed competent to practice medicine in a unsupervised way then give the license.