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Technically, it’s referenced as “free at the point of care.” Paying for national insurance is a payment — so the resulting healthcare delivery isn’t free.Like most other industrialized countries, the UK is a system of Universal Health Coverage.The U.S. system isn’t comparable to universal health coverage because in the U.S, coverage is tiered by:Age (twice — 26 & 65)Income (Medicaid)Employment (Employer Sponsored Insurance)Military Service (VA)Heritage (Indian Health Services)Individual CoverageNon-ObamacareObamacare PlansGoldSilverBronzeEven after all this “tiering,” we still have about 12% of the population that’s uninsured — meaning they don’t have any health insurance. (Footnote: there’s also millions of Americans that are underinsured because a single major medical expense — say $5,000 — could easily bankrupt them and medical expenses remain the leading cause of personal bankruptcy in the U.S.).Given all that, the closest thing we have to the NHS is our national system of Medicare — which is basically healthcare benefits that are mostly “free at the point of care” to American citizens over the age of 65.In 2015, Medicare provided health insurance for over 55 million—46 million people age 65 and older and 9 million younger people. On average, Medicare covers about half of the health care charges for those enrolled. The enrollees must then cover their remaining costs either with supplemental insurance, separate insurance, or out-of-pocket. Out-of-pocket costs can vary depending on the amount of health care a Medicare enrollee needs. They might include the costs of uncovered services—such as for long-term, dental, hearing, and vision care—and supplemental insurance premiums.Medicare and Medicaid are the two government sponsored medical insurance schemes in the United States. Medicare is further divided into parts A and B - Medicare Part A covers hospital and hospice services; Part B covers outpatient services. Part D covers self-administered prescription drugs. Part C is alternative to the other parts intended to allow experimentation with differently structured plans in an effort to reduce costs to government and allow patients to choose plans with more benefits. [1]One key distinction, however, between U.S. Medicare and the NHS is that the delivery mechanism in the U.K. is principally through government owned and operated facilities. Medicare/Medicaid in the U.S. is the payment mechanism — but delivery of healthcare services is actually through commercial (for-profit and non-profit) facilities and providers.The U.S. system of Medicaid is a close second because it’s designed to provide health benefits to those with lower incomes. The reason it’s different, is that there are eligibility and application requirements and these vary from state to state. Medicaid and CHIP (the program for children in low income households) provides health benefits to about 74 million Americans.[1] Medicare (United States) - Wikipedia

It depends on the type of pain the patient has. I am only familiar with pain from failed back surgeries with no viable surgical options left, pain from severe chronic osteoarthritis/osteoporosis, and pain associated with rheumatoid arthritis. That being said, I want to as briefly as I am able discuss the matter of opiate tolerance and dependence first.What would you say if I told you there was a medication available that has been proven to halt opiate tolerance in research trials? What if I told you this medication had very few, if any side effects, when taken at the low dosage needed to affect opiate tolerance? How about if I mention that it will work effectively at low doses and that it is very affordable? You would probably think I am pulling your leg, yanking your proverbial chain, or perhaps just a pathological liar. And I wouldn't blame you, for this would seem like a pipe dream of sorts. Perhaps I am a con-artist with a sick sense of humor? …and I wouldn't blame you if you thought these things either. But I am telling the truth.To top it all off, what if I told you this medication would not only halt opiate tolerance, but has been proven to actually REVERSE IT? The truth is, there IS such a medicine that was approved by the FDA for medical use in the United States in 2003. And a 30 day supply would have cost about $5.50 in 2019.There is one slight problem. The medication I am referring to has not been approved by the FDA to use for opiate tolerance. It is currently being used as such in different parts of the world, including some of Europe, but to use it in the Untied States would be an "off-label" use and frowned upon by insurance companies and probably Medicare.The medication is currently only approved to be used in the United States in treating moderate to severe Alzheimer's disease, something it is fairly effective in treating for about a year, then loses its' efficacy. Subsequent administration of the medication has proven to be ineffective and the medication has not been helpful in modifying the disease.I recently read that it can now cost between two and three BILLION DOLLARS to get a new drug approved by the FDA. Thankfully older ones can run needed clinical trials for a cost of about 20 Million dollars to add another application for their drug, but this is only if the drug is intended to be used for another aspect of the same illness it is already approved for (at least this is my understanding).But if the drug is to be re-purposed for an entirely new area of treatment, I imagine the cost is going to be a lot higher than 20 million dollars, just how much, I haven't looked into. So when all is said and done, with costs being exhorbadant to get a new drug to market, there has to be a whole lot of potential "upside" to spending the massive amounts of money required on the part of the drug manufacturer if they are going to invest in a drug's market potential. Reasonable, rational, common sense would tell most of us that while there needs to be safeguards in place, requiring a drug company to possibly have to spend billions of dollars to get a product to market is simply ludicrous, at least in my opinion.I am getting to the name of the medication, I just wanted to add some perspective and background to the issue.For those of us who rightfully feel ignored and abandoned by our short-sighted, tunnel visioned government, including the fanatical enforcement agencies that are hell-bent on demonizing opiate medications, we have, for all practical purposes, been abandoned. We now find ourselves in situations without any viable choices. Take Tylenol some of the supposedly educated physicians tell us…. At this point I would like to "take Tylenol" and shove it up their arse!We played by the rules, danced to their tune, took our medication exactly as it was prescribed, yet, in an orchestrated "smear campaign" against opiates that is so misguided that only our government could ever manage to perpetrate such an atrocity, they deemed that prescription opiates were at their heart of the problem. And so, primarily because we were the easiest target that would show the most gain, they took aim and fired. The number of the "so-called" facts that supported this myopic theory were cherry-picked so carefully that they managed to leave out parts of equations that did not fit their desired outcome.Chronically ill patients in pain couldn't sneak under the radar like the heroin addict, who has never had it so easy locating heroin to shoot up. The drug cartels have thwarted every attempt by the DEA to put a dent in the amount of illicit drugs being shipped into our country. They have made fools of the agency time and time again. The government and its agencies, losing their "war on drugs" desperately needed a win. And so they targeted prescription opiates. I am not saying there weren't people obtaining these medications illegally, they obviously were, but they were NOT GETTING THEM from those of us living in chronic pain.Of all the opiate deaths that the government has attributed to opiate prescription medications, has anyone ever wondered how many of them were from a drug overdose of prescription medications all by themselves, with no other drug, legal or illegal, in their system? Every data sheet I could find regarding this indicated that this number was well under one percent, 1%! One report concluded that the number was .08%. That's less than a tenth of one percent. Meanwhile the heroin addict is enjoying a reduced cost for their drug of choice, while four to seven million people in this country are suffering, often in excruciating pain, and needlessly…. And all so our government and its' agencies can "appear" to have a "win". ARE YOU KIDDING ME?Statistics were tossed out that would make any reasonable person scratch their head, but the feeding frenzy of the fanatics was running full steam by the time Opioimania hit the main stream. "Little things" were conveniently "left out" when reporting about opiates ::::sarcasm dripping from that statement:::::. Prescription opiate medications were found to be the cause of death in drug overdoses because they were found in the deceased system….while somehow, inexplicably, the methamphetamines and heroin laced with fentanyl also in the deceased system were not indicated as probably cause. Where are these prescription opiates coming from then? It is logical to presume that if there are the gazillions of opiate medications being distributed in the black market, that somewhere in the supply chain there has been, and probably still is, a major slight of hand happening. Who, what, how, why it is happening, I have no idea, all I know is that the percentage coming from people in horrible is very very low.dOne thing I know for sure. Where ever they are coming from, they are NOT MY OPIATES! You couldn't take them from me back before this debacle took place. That is NOT ADDICTION. That is a patient depending on a medication to help provide a life with some pain relief. The opiates gave me a decent, acceptable amount of relief from the pain was in and without them, life was agony. I still lived in pain every day of my life, but it was MANAGEABLE PAIN. So, give them away or sell them? Are you serious? Hell no!! These miracle medication allowed me to live as close to a normal life as was possible. I could still run a corporation effectively, make sales calls and deliver equipment when necessary. I could sit long enough to play music on the weekends and enjoy it. I could partake in outdoor activities with my family, go camping, even water ski for a reasonable length of time. I was able to visit my father once a month, 325 miles away.I depend(ed) on my pain medication to provide enough relief from blinding pain that I could maintain a quasi-normal life. Has everyone forgotten what addiction really is? I KNOW first hand what frigging addiction is: I am a recovering alcoholic with nearly 36 YEARS of unbroken sobriety. Alcohol is my drug of choice, but at 31 years of age, it almost killed me. Addiction is what an alcoholic has when actively drinking.. They begin drinking and have no idea when they will stop, nor do they have any idea when they start drinking, how much alcohol they will drink. They keep drinking and drinking until they are so I drunk they have no idea where they are, how they got there, and why they even went there in the first place. They simply have no control over the drug, alcohol, because it rules their every waking thought. They wake up in the morning wondering where their car keys are, and shortly thereafter, realize they have NO IDEA where their car is. Did they park it someplace, was it stolen, did they have a wreck and total it? That morning, they have a deafening hangover, their stomach churns with acid, their head pounds while their eyes feel like they are going to pop out of their head! They feel like death eating a cracker…. but two hours later, they are having their first drink of the day, and the cycle repeats itself. THAT, is addiction. People that take their medication exactly how it is prescribed ARE NOT ADDICTS. Addiction involves loss of control and unpredictability. I am not sure how this concept got twisted around, but it certainly seems to have happened. Just because someone is legitimately prescribed opiate pain medication does not immediately make them an addict. An addict would get their monthly prescriptions filled and within a few days, have taken all of it. They would spend the rest of the month trying to find enough money, to steal it if they have to, to buy illegal drugs from a dealer, who has no problem supplying them because they are flowing into the country like Niagara Falls. The word addiction is used all the time now when there is discussion about opioid medication. I wait for someone in power, somewhere in this country, to "wake the F*** up" and scream, "hold on people, we have this all wrong!!" I am still waiting. Addiction my ass!I am sure there were patients eight years or so ago that were able to con their doctor into believing they were in pain all the time and needed the stronger pain medications, but the VAST MAJORITY of those of us who need these medications for chronic, unrelenting, intractable, pain, aren't bamboozling anyone. We have real, excruciating pain, that is unbearable most of the time. Even before the pharmacists that knew me well began sneering at me each month when I picked up my prescribed pain medication, disdain in every word when they give their required overview of the medication. I was/am extremely careful with all of my medications. I didn't change anything I was doing, public perception was changed, and because I took opiate pain medications, people could look down on me, at times "put me down", try to lecture me…. Trying to defend myself became futile… and depressing beyond measure…. Many patients in chronic pain have had their daily dosage slashed to the point the medications are almost totally ineffectual.The government has allowed this to be done in their fanatical fervor to reduce "deaths from opiates". And they have done it using contrived and misleading statistics that ARE NOT REPRESENTATIVE OF CHRONIC PAIN PATIENTS ON OPIATE BASED MEDICATIONS. Chronic pain patients, as a whole, take their medication as prescribed, and do not misuse it, abuse it, give it away or sell it. Why would they? Of course there is always a tiny percentage of people who will abuse the privilege of being prescribed such medications, but isn't that the case with all things "restricted"? It is obscene to single out those of us that depend on these medications to achieve something resembling a normal life, or in many cases, "try" and get as close to one as possible within acceptable reason. But for justifications that are short-sided, ultimately cruel and torturous, we ARE singled out and for reasons that do not even start to come close to justifying the supposed "means".Looking at what has happened, I find our government's actions far beyond pathetic, absolutely unjustified, and according to our Supreme Courts' statutes, in many cases, criminal, especially when it pertains to the disabled, the aged, and those people on Medicare. As a group, we have been singled out to serve a purpose that statistically (using actual statistics) just is not true. Scarily, frighteningly, those of us in true chronic pain are being unjustly punished for this fiasco, and it seems clear to me, that our representatives and their associated agencies are deeming us "an acceptable amount of civilian casualties" in their "war on drugs". There are FOUR TO SEVEN MILLION PEOPLE paying for the "win" the government so badly needed to appear efficacious in the eyes of the public…. Our pain and agony, our lives that their actions have carelessly and thoughtlessly devastated, apparently are of no consequence to them. At this point, it appears that four to seven million Americans are an "acceptable amount of civilian casualties".Little to nothing is mentioned in the media about the growing number of suicides being committed by those of us in such indescribable pain that they simply can not take it anymore. These poor souls get to a point that death seems like a better alternative than to live in the pain they now endure with little to no relief. They know that tomorrow, the next day, and next week, and the months ahead are going to see their unrelenting pain get even worse… with the thought of this unbearable, that they choose death. In my mind, as one of the "forgotten", I view this as nothing less than "murder" on the part of our government, sworn to serve and protect us. They have condemned us to a slow, agonizing death. Shame on them…. Shame on them all…In a move that is breathtakingly ignorant, the government and its' agencies associated with enforcing laws as they pertains to drugs, are enforcing a CAP on daily dosages of opiate based medications, something the FDA had never done in all the years it has been in charge of opiate based prescription medications. If opiates are the demonic scourge of mankind, why hasn't the FDA already put something into effect? The FDA has had a suggested CAP on other medications like Tylenol, Adderall, Wellbutrin, Ibuprofen, and well, just about every other medication. So why did they not put a CAP on opiate pain medications?There was no CAP put on opiate medications because of the known tolerance issues for sure, but partly because moderate to severe pain is highly subjective and the FDA has always trusted the highly trained medical community to be in charge of what dosages should be used in each individual instance. The FDA did not suggest the new CAP that somehow became the new mandate, the CDC did, a government agency that no jurisdiction over any medication whatsoever.Some pain specialists have had the courage to speak out publicly. They are openly declaring that the governments' intervention, regulation, and restriction of opiate medications is the greatest medical tragedy in our history. If you are suffering from chronic intractable pain that once was effectively treated with opiate medications, I am sure your opinion debacle is similar.I think there is another fact that the government hopes no one will find if they look into this fiasco logically, something I alluded to a bit earlier. Decades ago, the Supreme Court of the United States of America specifically prohibited ANY GOVERNMENT AGENCY whatsoever to be involved with any aspect of medicine when it came to Medicare, the disabled, and the aged. There is a specific statue drafted and enacted that made it illegal for anyone in any part of the Federal Government to interfere with the practice of medicine in any way, shape, or form. It is explicit and non-debatable. I am not sure how and where the Statute may cross apply to other members of our population, but at 67 1/2 years of age, I am having my rights violated to the extreme in my opinion. Not only my rights, but the rights of the doctors that treat me, the surgeons who have performed recent surgeries on me, the hospitals, and any other institution involved with my medical care. It is pathetic on a level ISorry about that, I tend to get side-tracked when discussing this topic. So, I'll get back to the medication that researchers have proven to be extremely effective against opiate tolerance. I thought it was profound when I finally discovered the medication along with the associated research supporting what i am writing. If those of us who have been on long-term opiate therapy had a medication we could use that would stop and potentially reverse our tolerance to pain medications, I believe many of us could have, and would have, reduced our daily dosage long ago, taking it down to the level when it first started working. This would save a lot of money for us each of us. But then, that is irrelevant to the big drug companies who would try and block the approval of this medication if at all possible, Why would they support something that would reduce the need for as much of their medicine, no matter how positively it affected a chronic pain sufferer's life? It would cut into their profits substantially.Nearly all of us started on fairly low daily dosages of opiate medications only to find them less effective over a short period of time due to tolerance, a well-known, well-documented issue with long term opiate usage. Our doctors were well aware of this and slowly increased our daily dosage in order to keep the medicine at a level necessary to provide the pain relief we needed. There was a point in time where it was decided, with open and honest communication between ourselves and the physician treating us, that the dosage we finally arrived at and stopped increasing was the best we would be able to do using opiate pain medications for our chronic pain. It was far from ideal, but there are simply no viable alternatives to the quandary.The medication I have been alluding to is marketed as Namenda, Azura, Ebixa, as well as other brand names. The actual drug is called Memantine, or Memantine HCL. As it is only approved for moderate to severe Alzheimer's Disease, a chronic pain patient's doctor would need to prescribe it for off-label use. I have known about Memantine for about five years but have been unable to have the pain specialists I see express any interest in looking into the possibilities this medication has for reducing tolerance. Perhaps they are afraid of the DEA's intervention; they might send in a fully armedtactical squad dressed in full body armor. Regardless, if there was even a remote possibility this might work for their patient who is now suffering from drastically increased daily pain do the government mandated slash of a patient's allowable daily ration of opiate pain medication… one would think they would be open to giving it a try.I recently read that the government has decided to "throw" TWO BILLION DOLLARS at the current SARS-COVID-19 coronavirus pandemic. If they insist on keeping their unfounded CAP on daily opiate dosages in place, would it be too much to ask that our government, sworn to serve and protect us, provide some us a small measure of relief from the torture they have knowingly induced with their CAP?? They could provide could provide the badly needed assistance with our drastically increased pain levels by funding the required studies that will undoubtedly prove to everyone's satisfaction that Memantine IS effective against opiate tolerance. Once proven, this would allow Menantine to be approved by the FDA for opiate tolerance. In my opinion, it is the very least they could do at this juncture.Opiate medications have been the "Gold Standard" for years when it comes to treating intractable chronic paIn. As such, I spent a lot of time researching various supplements that were shown to help with opiate tolerance in some individuals, working as an adjunct to opiate medications although efficacy varied greatly amongst those using them.. There are different suggestions one can find by searching the internet creatively. Some supplements and vitamins work well with tolerance in some people but not so much or others. I found the only way to figure out what seemed to help me was to go through the suggestions I found and take them on a "trial and error basis", making note of the changes I noticed over a period of time. None of the supplements I mention below worked miracles overnight. They had to be taken for several weeks to a month for me to realize any tangible results and at best, seemed to slow tolerance down to a place I noticed a difference.These are the supplements that I found that had a noticeable effect on opiate tolerance:L-Tyrosine - An amino acidDLPA - D & L forms of phenylalanineMagnesium - I used chelated magnesium which is more bio-available form of magnesium.Vitamin B6 -Vitamin B12 -Dextromethorphan - a cough suppressant that has been shown to slow or halt opiate tolerance.I will add to this list as I recall some of the other supplements not listed. I have some notes "someplace" that I will dig up and use to assist my memory. I hope some of this helps.Peace, Doug

Q. Are there graduates of medical schools (MDs and comparable) who are unable to get into a residency program? If so, what happens to them?A. A few articles of interest:Understand Your Odds of Getting into ResidencyShortage of residency slots may have chilling effect on next generation of physiciansOptions Exist for Med Students Without Residency Matches (usnews.com)Medical Students Match Day (statnews.com)Unmatched Graduate: “Med Schools to Blame”Foreign medical graduates get a raw deal. Here's why.Understand Your Odds of Getting into ResidencyMARCH 08, 2017 Heidi Moawad, MDIn recent years, we have all been hearing more and more in the medical community about doctors who are not able to successfully get into a residency training program in the United States. Physicians in this predicament are in a difficult jam, unable to proceed with a career they have spent so much time and money working toward, while at the same time, unable to get work in most other desirable professions, which also require years of specialized education and internships.Many aspiring physicians wonder about the numbers behind this bleak situation and what it means for them. If you have been unable to match so far – or if you are apprehensive that you may have a low chance of matching – the statistics behind this problem can help you gain some insight into your chances of getting into an accredited residency program.MATCH PROGRAM FACTSThe National Residency Matching Program (NRMP) itself, which is the organization that matches physician applicants to U.S. residency training programs, provides a uniform process for all applicants, with consistent application deadlines and scheduled announcements of match results.According to the most recent NRMP results from 2016, there were more than 35,000 applicants for approximately 27,000 PGY1 positions. The gap between applicants and positions is the reason that there are so many medical school graduates who are not able to work as doctors. Of these applicants, about 20,000 are graduates of U.S. medical schools, and the remainder of physician applicants are International Medical School graduates.While there are certainly a substantial number of physicians who do not match in a residency spot, there were more available positions for PGY1 spots this past year than ever before. But, the number of applicants for the 2016 match reached an all-time high. The number of U.S. allopathic medical school and osteopathic medical school applicants was only about 20,000, which is substantially fewer than the number of residency positions available. And, it turns out that most (more than 95 percent) U.S. graduates did match in a residency program.However, there are hundreds of U.S. medical school graduates who do not match each year. U.S. medical students who were not recent graduates had a significantly lower match rate than recent graduates, for various reasons. And American students who graduated from international medical schools did not fare as well as American students who graduated from U.S. medical schools, with a slightly higher match rate than non-U.S. citizen International Medical School graduates, which was little more than 50 percent in 2016.LARGER NUMBER OF APPLICANTSThere has been a larger number of applicants than ever before because most of the applicant groups are growing. There are slightly more U.S. allopathic medical school graduates, more U.S. citizen International Medical School graduates and more Osteopathic medical school graduates, which adds up to more applicants. And, there are more non-U.S. International Medical School graduates applying for residency spots as well. Despite all of the negativity about the medical field, there are still huge numbers of people who want to work as physicians, particularly in the United States, where most doctors perceive the system to be relatively fair, uncorrupt and of high quality.Interestingly, there are also many non-U.S. International Medical School graduates who do not even apply for the match because they have not passed USMLE tests, have scored low on the examinations or have other concerns that make it impractical to apply. And a large number of non-U.S. International Medical School graduates apply for residency, but receive no interviews, and thus do not have the option to proceed with ranking programs in the match.DO YOU HAVE TO MATCH TO WORK AS A DOCTOR?While you can take USMLE parts 1 and 2, and there are special circumstances that allow for you to take USMLE part 3, each state has its own requirements for medical licensing. At least one to two years of residency or internship training is typically required in order to obtain a medical license. If you want to work as a clinical physician, it is best to try to get a position through the match, or shortly after the match during the so-called scrambling period if you do not match. In fact, there are even instances in which physicians become ill or leave training programs, opening unexpected slots that need to be urgently filled at any time during the year.Physicians who want non-clinical work can succeed without residency training, but residency training even helps open the non-clinical route to better options. Therefore it is worthwhile to continue in the process, even accepting a position in a less desirable specialty, whether your aspiration is patient care or non-clinical work.There are options for doctors who do not have residency training, however. To get the most updated information, visit Careers for Physicians Without Residency, which is regularly updated with more opportunities.Shortage of residency slots may have chilling effect on next generation of physiciansBY BRUCE KOEPPEN, M.D. — 01/22/16 11:00 AM ESTMost people are aware of America's looming physician shortage, but the shortage of residency slots for medical school graduates has received less attention.In order to practice medicine in this country, graduates of allopathic (MD) and osteopathic (DO) medical schools must complete a residency training program. In recent years the number of MD and DO graduates has increased by more than 23 percent in an effort by schools to address the country's growing physician shortage, which the American Association of Medical Colleges estimates will approach 90,000 too few physicians by 2025.While the number of medical school graduates is increasing, the number of residency training positions has not kept pace. If this imbalance is not addressed, the number of American MD and DO graduates will exceed the number of first-year residency positions, which by some estimates could occur as soon as 2017. When this happens, young physicians-who dedicated years to the pursuit of a medical education and incurred significant debt doing so-will not be able to practice medicine, and the physician shortage will persist.Part of the problem stems from the funding mechanism for Graduate Medical Education (GME). Medicare covers the majority of the cost teaching hospitals spend on training medical residents, but the Balanced Budget Act of 1997 capped the number of residency slots the federal government would fund. The shortfall-what is not covered by the Federal government-is paid for by the hospitals where residents train. While it is possible to increase the number of residents they train, to do so, hospitals must fund the entire cost of those training positions.Though patient care has shifted its emphasis to wellness and prevention, the current reimbursement system has not yet caught up. It is still based on the number of procedures performed, incentivizing hospitals to fund additional residencies in revenue-producing specialties instead of primary care.Adding to the problem, are for-profit schools that pay hospitals for medical student residency training spots-an incentive for some cash-strapped hospitals-something that is a growing concern among medical school deans. Residency slots that are taken by trainees from non-accredited schools reduce the number of slots available to trainees from accredited allopathic and osteopathic schools.Some of these non-accredited for-profit schools train as many as 1000 students a year without clinical facilities or full time faculty. According to a 2013 Bloomberg Markets investigation, many students who attend these schools incur tremendous debt and fail to complete the programs; many of those who complete the programs are unable to find a residency.The shortage of residency slots is also affecting graduates of accredited programs. Last year, more than 500 graduates from US allopathic medical schools were unable to obtain a residency training position. As more students graduate from medical school in the coming years, this number will only increase.We need to find ways to address the shortfall. There are several solutions being considered.The Foreign Medical School Accountability Fairness Act, a bi-partisan bill from the House and the Senate that would protect taxpayers and students, eliminates an exemption that entitles certain foreign medical schools to US Department of Education Title IV funding without meeting minimum requirements. The bill would ensure that 60 percent of enrollees in medical schools outside the US and Canada must be non-US citizens or permanent residents and have at least a 75 percent pass rate on the US Medical Licensing Exam.Other pending legislation includes the Training Tomorrow's Doctors Today Act, which would add 15,000 new residency training positions over the next five years; and the Resident Physicians Shortage Reduction Act of 2015, which aims to protect against the rapid shortfall of primary care physicians.The Affordable Care Act's $230 million Teaching Health Center Graduate Medical Education Program is designed to train primary care physicians mostly in non-hospital settings, which is exactly where the majority of primary medicine is practiced. Moreover, many of these new training programs serve underserved communities. These residency programs do not rely on Medicare funding, but must be self-supporting by 2017.These efforts all have merit, but the wheels are turning slowly and the clock is ticking. Training physicians doesn't happen overnight. Our lawmakers need to move quickly for the sake of patients and the physicians who have invested so much time and effort into learning how to care for them.Koeppen is founding dean of the Frank H. Netter School of Medicine at Quinnipiac University.Options Exist for Med Students Without Residency Matches (usnews.com)Few days are as important as Match Day for a medical school student.Dozens of videos on YouTube show students crying tears of joy and hugging classmates as they finally learn, this year on March 15, where they will spend the next three to seven years doing their residency. This day marks the unofficial end of medical school and the beginning of a career as a doctor.[Learn about recent changes in the matching process for residents.]On the Monday of Match Week, students learn if they were matched with a residency program. This year there were approximately 40,000 registrants. Unmatched students – this month, 963 registrants were unmatched, according to the National Resident Matching Program – are automatically entered into the Supplemental Offer and Acceptance Program, a one-week process that allows them to apply for unfilled residency positions.Residency offers through SOAP "continue through Friday of Match Week, and that process has been very efficient," says Hal Jenson, president-designate of the National Resident Matching Program.Before SOAP was created, students went through a similar process called "the scramble." But even with coordinated, last-minute efforts to place students, some still find themselves without a residency.After not matching in anesthesiology in 2010 and then failing to find a residency program through the scramble, one aspiring physician spent a year teaching anatomy, physiology and microbiology at a technical school until the next match."I still wanted to do anesthesiology, but I left it open to other fields as well. It sort of becomes a you-take-what-you-get type of deal," says the now second-year resident, who asked not to be identified. He settled for internal medicine."Initially you are disheartened, but what can you do about it? Either you sulk, or you fix it and figure out another situation," he says.[Find out how medical residency work hours can vary.]Experts say there are typically two reasons students don't match. They apply for highly competitive residencies, such as dermatology or radiology, even though their medical school performance makes them unlikely candidates for those slots, or they place too few schools on their ranking list, which they give to the National Resident Matching Program.While unmatched students can take alternative routes to residency, many in the medical field agree it's best to avoid the situation outright. One way is to rank several residency programs at which a student has interviewed."I tell medical students they should always put at least five places," says Stephen Klasko, dean of the University of South Florida Health's Morsani College of Medicine. He encourages students, particularly those who didn't initially match, to expand the number of hospitals they are willing to go within their chosen specialty, or consider choosing a different specialty.Lynn Buckvar-Keltz, associate dean for student affairs at the NYU School of Medicine, says grades and exam scores matter when applying for residency, but those aren't the only factors."Being an engaged, enthusiastic member of the clinical teams during the clinical clerkship is an important part of the student's medical school experience and therefore their residency application as well."[Follow a day in the life of a medical intern.]If an aspiring physician is unmatched, there are a few options.Students can contact their medical school and ask for a transitional slot, which mimics the fourth year of school, or seek a research fellowship."If they do a transitional year or a research fellowship, they can then become more competitive in one of those specialties or they can decide to match in family medicine or general internal medicine where it's easier to get a slot," says Klasko.Obtaining another degree could also increase a student's chances of matching in the next cycle, Klasko says."Now all of a sudden I'm a pretty cool candidate," he says. "It doesn't look like I'm somebody who failed. I'm somebody who decided to get a master's in public health or an MBA. Now I'm a differentiated candidate."Searching for a medical school? Get our complete rankings of Best Medical Schools.Corrected 4/10/13: A previous version of this article misstated the name of the National Resident Matching Program.Tags: doctors, education, graduate schools, medical school, studentsDelece Smith-Barrow is an education reporter at U.S. News, covering college admissions; she previously wrote about graduate schools.POLITICSMedical Students Match Day (statnews.com)Looming question for medical students: Will they be shut out of advanced training? By MELISSA BAILEY MARCH 17, 2016Dr. Heidi Schmidt looks on while a nurse takes the vitals of a patient in a medical clinic at the St. Vincent de Paul food pantry in Indianapolis.They’re about to graduate from medical school with an MD to their names, but hundreds of students across the US learned this week that they haven’t advanced to the next step of training — and will not be allowed to practice medicine.Most medical students found out Friday where they’re headed for their residency, where they’ll work alongside licensed doctors, gradually gaining more responsibility. But each year, a sizable group learns shortly before the official “Match Day” that they’ve been shut out of this training.This year, for instance, more than 29,000 applicants got placed in a first-year residency through the main matching process. But 8,640 did not — a number that includes international applicants and aspiring physicians who graduated from medical schools in recent years, as well as current fourth-year students.That mismatch has prompted a policy debate: Should the rural and urban clinics that struggle to find doctors be allowed to scoop up unmatched graduates so their talents don’t go to waste? Or would it be dangerous to put them in front of patients without a traditional residency, which typically lasts at least three years?Missouri, Kansas, and Arkansas have passed laws to allow unmatched graduates to work in medically underserved areas without doing a residency.Otherwise, “a lot end up wasting all of their education, because there is no place for them in the health care delivery system without having a residency,” said Dr. Edmond Cabbabe, a plastic surgeon in St. Louis who conceived of the Missouri law.Passed in 2014, but not yet implemented, the law will create an “assistant physician” license for these newly minted doctors, who will work with a collaborating physician. That physician will have to directly supervise the new doctors for at least a month before they can see patients on their own. One impetus for the law: Nearly all of Missouri’s 101 rural counties face a shortage of primary care providers.Arkansas this year approved new rules allowing recent medical school graduates with ties to the state to work as a “graduate registered physician” before residency. Kansas, too, created a special license; it’s restricted to graduates of the University of Kansas School of Medicine who strike out in the match process, and it allows them to work, under supervision, for just two years. At that point, they’re expected to move on to a residency.Related Story:Medical students demand an end to pricey exam testing patient care skillsWhile supporters hail such laws as a groundbreaking solution, the medical establishment has frowned on them.The Association of American Medical Colleges “is concerned by efforts that would bypass the experiences necessary for physicians to provide safe and effective patient care independently,” said Tannaz Rasouli, AAMC’s senior director of government relations.The American Medical Association also came out against such programs. Instead, it has called on government, insurance payers, and foundations to pitch in money to create more residency spots.So far, no one is practicing medicine under any of those new regulations.But they could help MDs like Dr. Heidi Schmidt, a Juilliard-trained opera singer and entrepreneur who graduated from American University of the Caribbean School of Medicine on the island of St. Maarten. She received honors in clinical coursework, but struggled with standardized tests and had to make multiple attempts to pass two national board exams.Residency programs often see multiple board exam attempts and degrees from foreign medical schools as red flags when evaluating candidates.Schmidt, who also has master’s degrees in public health, music, and pharmaceutical science, has the title “doctor,” but her options are limited. Without at least one year of postgraduate residency, she can’t practice medicine in the United States. To work as a nurse or a physician assistant, she’d have to go back to school and get a different degree.To stay in medicine, she volunteers in Indianapolis at Gennesaret Free Clinics for the homeless and working poor. She sees patients, but she said a licensed physician must sign off on all her work. Schmidt said she can’t get paid until she becomes a licensed physician. And she longs to treat patients on her own.“My dream has always been to be a physician for the poor,” she said.Dr. Heidi Schmidt at the St. Vincent de Paul food pantry in Indianapolis, Ind. After not being matched with a residency, Schmidt’s plans of becoming a licensed doctor are on hold, so she volunteers at a medical clinic there.LUCAS CARTER FOR STATSeniors in traditional (non-osteopathic) US medical schools have better odds than those from foreign schools: Their match rate has hovered around 94 percent. But that still means 1,130 didn’t get a residency in the main match this year.That news can be a shock. As a senior at the University of Virginia medical school last year, Dr. Daniel Harris applied to 67 general surgery residencies and landed eight interviews at residency programs. On the Monday before Match Day, he got an email letting him know that none had accepted him.Harris said he was in disbelief, but he didn’t have time to process that feeling. He had just two hours to decide which programs he would apply to through the Supplemental Offer and Acceptance Program, or SOAP, which helps unmatched applicants find open spots.Harris picked 20 programs and hit “submit.”“I maybe started crying at that point,” he said. “There was nothing more I could do.”Harris got lucky: He was one of 599 US medical school seniors who scooped up unfilled spots through SOAP last year. Other types of applicants — for instance, those from foreign schools — grabbed another 400-plus spots.That still left hundreds of seniors at US medical schools, and thousands from international schools, halted in their quest to practice medicine in the United States.Were they weeded out for good reason? That’s open for debate. Surely, some were ill-prepared. Others may have been unlucky or just played their cards wrong when picking which residencies to apply for.The most common reason for not matching is poor scores on national board exams, according to a 2005 survey by the AAMC. Other reasons include: applying to a specialty that’s too competitive for the applicant’s academic standing; poor interviewing or interpersonal skills; and having to take a board exam multiple times to pass.Some people in this situation, like Dr. Nick Milligan, decide not to pursue a medical license. Milligan graduated from St. George’s University School of Medicine, on the Caribbean island of Grenada, in 2014. He said he was disappointed not to match with a residency, but he ended up happily employed at Coachella Valley Volunteers in Medicine in California, where he has used his medical training to build a diabetes education program.Medical school grads face a staggering $183,000 in debt, on median, but they can seek relief, as Milligan does, from federal programs that limit monthly loan payments to 10 percent of income.Most graduates of US medical schools don’t give up on becoming a licensed doctor if they don’t match, said Geoffrey Young, AAMC’s senior director for student affairs and programs. They often spend a year doing research, or complete a fifth year of medical school, then apply to the match the following year.Related Story:An urgent call for diversity in medicine, ‘the profession I love’More than 99 percent of US medical school graduates do end up practicing medicine within six years of graduation, Young and coauthors found in a study published in JAMA.The new state laws might offer some of the unmatched students another route to a medical career.Missouri is expected to open enrollment for its assistant physician license this fall. Because it has the least restrictive rules, it may face a flood of applicants from around the country.Schmidt could be one of them.If Missouri opens the door for her to treat patients, she said, “I’d pack up and move in a second.”Update: The story has been updated to include statistics about the matching program for this year.Unmatched Graduate: “Med Schools to Blame”by SkepticalScalpel | Oct 17, 2016 | 30 commentsSkeptial Scalpel (click to view)The following was submitted as a series of comments on my Physician’s Weekly post about Missouri’s new law allowing medical school graduates who did not match into residency positions to work under supervision. The comments have been edited for length and clarity:I am a 38-year-old US medical graduate who has attempted to match 3 times with no success. I decided not to throw the money away again this cycle. I have half a million dollars in educational loans. I would exchange my situation with any non-US-IMG because they probably don’t have massive loans. I have seen kids coming fresh from India with no loans who match in their first attempts because they score high enough on USMLE to separate themselves from people like me.Based on USMLE scores, the matching system is fair to a lot of us. What fails US grads is the educational loan structure that allows us to borrow without any accountability of medical schools that are benefiting most. If medical schools are going to produce doctors who cannot match after genuine attempts, the schools should be blamed. They have standards that require students to pass each course in order to graduate. If they believe a student is not good enough to become a doctor, they shouldn’t graduate the student. Students would benefit more if the medical schools could determine which med students won’t be good doctors earlier on and dismiss them. Then the students will not pile up so much debt.Some graduates find that their training is not good enough to become a physician. It’s a scam. Why do medical schools get a free ride on this? Everyone who has completed medical school successfully with passing scores on USMLE Step 1 and 2 should be allowed to use that acquired knowledge. Why not let those who have demonstrated they can work under supervision get job?What fails US grads is the educational loan structure that allows us to borrow without any accountability of medical schools that are benefiting most.When I try to get a nonclinical job, they read my resume and tell me I am overqualified for the position. I have tried to hide my MD degree and use only my Bachelor of Science degree (biology) in order to get a job. But they tell me I don’t have experience, and the big gap between my undergrad education and my current situation cannot be explained. Some employers have asked me if I spent the time in jail.I applied to PA schools last year and had no success. Some of my rejection letters said as a medical doctor, I am not a good fit for PA career. Some PA programs wanted me to go back to college again to take pre-med courses.Besides medicine I have no other skills I can use to make a living. I am broke. I refuse to become homeless. Last month I applied and qualified for food stamps. Next week I am starting a $10.15/hour job as a UPS package handler while I am looking for other better opportunities.Each year about 5% of US graduates do not match to a residency and have nowhere to go. There are many reasons we did not match—most commonly because of academics. If I were a program director, I would interview the best applicants and rank them accordingly. I just believe unmatched doctors must be given other opportunities to make use of their acquired knowledge instead wasting it in a warehouse or a grocery store.If fresh college grads with 2 years in PA school can become providers under a licensed physician why can’t someone who made it through med school in 4 years function at the same level? Having an MD degree without a residency is like having a felony record. No one will give you a job. Having an MD degree without a residency dooms you to struggle in life. I wish I didn’t have the heavy weight of the MD degree on my back.I hope marginal pre-med students will read my story and make a rational decision before applying to medical school. Med schools want to fill their classes because they know the more students they have, the more money they will make. As they collect your tuition, they will tell you they are nonprofit institutions.No med schools will tell pre-med students the drawbacks such as the scarcity of postgraduate training as med school class sizes increased 30% since 2000. Most schools only publish lists of students who matched successfully and fail to mention those who don’t match. Pre-med students should be told what happens to all graduates of each med school.My story may not be relevant to pre-meds who have demonstrated great potential in medicine (GPA, MCAT, and motivation). The problem is some med schools can’t fill their classes with 100% smart kids. What they do instead is lower their standards to get more students to fill the class. Why? Because they want to make money and are not held accountable.If they can’t recruit students who can become licensed physicians in the US, the classes should be left unfilled. What is point of educating someone and giving him a piece of paper that can’t be used? These institutions should be held accountable for tuition and fees if a medical graduate attempts to match to complete his training but failed. This will force them to dismiss academically or professionally unfit students from medical schools before they accrue massive loans.I don’t see how the schools could ever be forced to do what the writer wants.Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last six years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 2,500,000 page views, and he has over 15,500 followers on Twitter.Foreign medical graduates get a raw deal. Here's why.ERIC BEAM, MD | EDUCATION | MAY 23, 2016On my recent tour of residency programs, I had the pleasure of meeting many foreign medical graduates (a.k.a. FMGs; not to be confused with international medical graduates, who are U.S. citizens who go abroad for medical school).Almost uniformly, they struck me as confident, mature and articulate. Many were older than me, some by as much as 10 or 15 years. Most had extensive research experience, and a few had even completed residency already in another country and were here to take a shot at becoming a U.S.-licensed physician, which would require them to do it all over again. To an outsider, they would appear as competitive candidates for programs that aspire to produce first-class doctors. But I did not envy their plight. In our conversations, one thing became clear: Whereas I was hoping to match into one of my top-choice programs, they were hoping to match, period. And, in 2016, only 50 percent did.FMGs get a raw deal. With the exception of Canada, we don’t recognize international medical training as meeting our quality standards; thus, doctors licensed to practice in their home countries must start at square one if they want to work here. Before they even apply to residency, FMGs need a stamp of approval from the Educational Commission for Foreign Medical Graduates (ECFMG). Only about half succeed in getting certified.One major hurdle, apart from the written exams, is the USMLE Step 2 Clinical Skills test, which requires a high-stakes demonstration of English proficiency and a costly trip to one of the five U.S. cities where it’s offered. (Interestingly, from 1998 to 2004 this test was called the Clinical Skills Assessment, and only FMGs were required to take it.) It’s virtually impossible for a FMG to start residency directly after finishing medical school. They’re often encouraged to do a few years of research to pad their résumé, or to do a rotation or two at a U.S. hospital. This adds up to a lot of time, money and effort spent on an endeavor that is far from a sure thing.All of this is not to say that we shouldn’t have a rigorous screening process for who we allow to train and practice here. We should, and we do. But we must acknowledge that the deck is stacked firmly against FMGs. Imagine you’re a program director comparing two applicants side-by-side, one a U.S. medical graduate and the other a FMG. If, on paper, the two appear to have equivalent qualifications, there’s a good chance the FMG worked harder and sacrificed more to get there. That is an achievement worthy of recognition.But these days it’s become something of a badge of honor for residency programs to exclude FMGs from their rosters, and historically they have served as “fillers” for residency spots that remain vacant after U.S. students have matched. In 1995, the Council on Graduate Medical Education, an advisory body tasked with making recommendations to the Department of Health and Human Services, singled out FMGs in their annual report and proposed cutting federal funding for their training by 75 percent in an effort to reverse course on an impending “physician surplus” (oh, the irony). They walked back this recommendation in a subsequent report due to anticipated “legal complexities,” but even their less controversial plan carried the same aim: to severely restrict FMGs from entering the physician workforce.I have heard two arguments for keeping FMGs out. The first is that their training is substandard. While I’m sure this applies to some cases, it is certainly not a universal truth. Is it really so hard to believe that a student whose education happens outside of a glittering first-world multi-million-dollar medical complex could learn the same principles of biomedical sciences as a student in this country? Is that student not examined as rigorously, mentored as thoughtfully, challenged as intensively, as one of ours?The second argument against FMGs is the so-called “brain drain” theory; that taking FMGs will siphon much-needed talent from poorer countries where doctors are scarce. I take particular issue with this one. All people, no matter their provenance, should be allowed to use their gifts to better their own lives, especially if that means escaping poverty or conflict.And let’s be honest: When a program director rejects a FMG, is he really thinking about the physician supply in Pakistan? What if we applied the same logic within our borders? If a medical student in physician-poor Arkansas graduates at the top of her class, with all the attendant publications and honors to her name, and wants to train at Massachusetts General Hospital, we don’t say, “No, you have to stay, Arkansas needs you.” We let her go as far as her talent and ambition will take her. Will Arkansas suffer? Minimally, perhaps, but they’ll be OK.The U.S. prides itself on having the best doctors in the world, so why not bolster our ranks by welcoming some of the best students the world has to offer? It’s curious that diversity is championed in medical school and residency admissions, just not this kind of diversity. Our knee-jerk aversion to FMGs seems to be the last true sanctioned form of admissions discrimination. First, we must ask ourselves if we want our admissions process to be truly merit-based. If the answer is yes, then it’s time to start recognizing merit even when it comes from outside our borders.Eric Beam is an internal medicine resident who blogs at the Long White Coat.Image credit: Shutterstock.com