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Hell Yes! I mean REALLY!As a Senior (MS 4) student, during my Clinical Externship(s) I elected to do a Pediatric Hospital Rotation, just to see what all the fuss was about.They also had a required Ambulatory / Walk-In Center, as part of the rotation, and was just across from the ER.During one of the early week’s, I was assigned to a Community Well-Child program, that screened infants to children.One AM, I was to do an exam on a new Toddler that was about 16/18 months old.He was so happy and excited as I walked in and introduced myself to the young mother. I ran thru the history, forms to fill out, some Q&A’s, etc, etc … and then moved on to the exam.Just as I picked him … He squealed in delight … and then as I was lifting and just about to place him on the table, with his mom besides him … He Kicked his legs & little boots … with a perfect shot right INTO my Nuggets …It was a delayed reaction, but I managed to have the mom hold him … to give me some time to “recover” … so Yes some Tearing took place … and the Mom was at first shocked because she saw it happen … got embarrassed, but amusingly shocked and kept asking me if I needed any help (I mean exactly WHAT could she have done?), or to call a Nurse.The LAST THING, I needed was a Nurse, as I would NEVER hear “The End of It” …I’ll never forget just How little, big Cody “Re-freshed my memory” that sunny, fresh Morning … to ‘Protect Yourself At All Times’ …Of course, my GF at the time, was very caring and supportive … and it did get me off the hook for other household duties and on-demand responsibilities, but, only for 72 hours …Later, of course, it was FUNNY AS HELL … when I shared my “Ped’s Combat Story” with other Med students & Staff …Those were “The Day’s Of Our Lives” … Chapter 1 - Ped’s.TBC …

Q. What is something that is painful to see?A. Imagine you are a radiologist reading films from the Emergency Department of young children suffering from minor trauma and you see these xrays of the chest, skeleton, CT scan images of the brain and of the abdomen and MRI of the brain.RibsFemursKneeCT Brain (blood is white)CT Brain (2nd patient, died)CT SkullMRI Brain - white new blood, grey old bloodCT Abdomen (arrow to liver)CT Abdomen (arrow to pancreas)You go examine the patients.4 million children abused, 2,000 deaths/year.Shaken infant syndrome classic pattern of injuries. Child held around the chest and violently shaken back and forth, causing the extremities and the head to flail back and forth in a whiplash movement.Intracranial injury occurs as a result of severe angular acceleration, deceleration and direct impact as the head strikes a solid object.The chest is compressed resulting in rib fractures.Arms and legs move about in a whiplash movement resulting in the typical 'corner' or 'bucket-handle'-fractures in the metaphyseal region. 10% under age 5 brought to ER with alleged accidents actually abused. Wide range of findings can mimic other disease. Further injury if delayed in diagnosis.Radiologist can suggest diagnosis when studies are performed for other reasons. High degree of suspicion, inability to explain the degree of injury or a reported mechanism of injury that is inconsistent with the physical findings.Skeletal InjuryForces needed to break a bone in an infant or young child are enormous.Any fracture in this age group indicates a major traumatic event, not just a fall from a low height.Fractures with a high specificity for child abuse:Metaphyseal corner or bucket handle fracture.Rib fractures children less than 2 year.Fractures of the acromion, sternum and spinous processes.Occipital impression and other skull fractures occur when the head strikes a solid object.Corner fractureSmall piece of bone is avulsed due to shearing forces on the fragile growth plate. Can be subtle, hence skeletal surveys for suspected infant abuse must be good quality.Bucket handle fracturesEssentially same as corner fractures, but avulsed bone fragment is larger and seen 'en face' as a disc or bucket handle. Most common in the tibia, distal femora and proximal humeri. Frequently bilateral.Rib fracturesIn violent shaking, the child is held very tightly around the chest and squeezed while being shaken. This compresses the ribs front to back and tends to break them next to their attachment to vertebrae, and laterally where they are being literally almost folded in half. Therefore, lateral and posterior rib fractures are highly specific for abuse. CPR does not cause such fractures.(Found incidentally on chest X-rays for other reasons such as pneumonia.)Bone Scan: Each hot spot in the skeleton is a fracture (besides growth plates)Skull fracturesSkull fractures are common child abuse injuries, but they are also common in accidental trauma.Patterns of skull fracture that suggest child abuse are:- Multiple 'eggshell' fractures- Occipital impression fractures- Fractures crossing suturesThe infant's skull is very resistant to trauma, so any fracture that is inconsistent with the history should raise the question of non-accidental injury.LEFT: eggshell fractures in a child who died of cerebral injury after being thrown of a height. RIGHT: skull fracture crossing suture in abused childDiaphyseal fracturesDiaphyseal (long bone) fractures are non-specific as they do occur in both accidental and non-accidental injury. However, in these cases the age of the child and the history become very important. A fall out of a bed will usually not produce a diaphyseal fracture. In order to break a femur you have to fold it with enormous power. Spiral fractures are a result of twisting forces which are uncommon in accidents in young children, but more common in adults. So a simple fall does not produce a spiral fracture in a child.Two infants with a femur fracture. Child abuse was suspected because of the age of the child and an inconsistent history given by the parents.Fracture healingCallus in long bone fractures generally forms no earlier than 5 days after a fracture, but will usually form by 14 days. A child that fell out of bed the day before cannot have a fracture with callus formation.Diaphyseal femur fracture with a lot of callus is at least 2 weeks old.CNS (Central Nervous System) InjuryCNS injury related to nonaccidental injury is a leading cause of morbidity and mortality in infants and children. 80% deaths under age 2. A baby's neck muscles are very weak and its head is large and heavy in proportion to the rest of its body. When a baby is shaken, the neck snaps back and forth, like whiplash injury, causing the brain to hit the front and back of the skull. This can damage the brain and cause it to bruise, bleed and swell.CT Brain: Subdural hematomas arise from disruption of delicate bridging veins extending from the cortex to the dural sinuses. Blood to extend into the posterior interhemispheric fissure.Child died of CNS injuries. Further examination also revealed rib fractures. CT: hematoma in the interhemispheric region.MR Brain: more sensitive in detecting subdural hematomas.T1WI shows bilateral fluid collections as a result of chronic bilateral subdural hematomas and new subdural hematomas in the right frontal and posterior interhemispheric region.Other injuriesVisceral injuryVisceral injury is seen at autopsy of young infants, 2-10% of all abdominal injury results from child abuse. Mean age of 2 years, more common in boys, mortality rate is 50% due to 'patients and doctors delay'. These children are brought to the hospital days after the injury, when a perforation already has resulted in peritonitis and sepsis.The history given by the abusers usually does not correlate with the symptoms, which makes these cases very difficult to evaluate for the clinician.Common abdominal injuries in abused children are liver laceration, duodenal hematoma and pancreatic laceration.The most common non-accidental abdominal injuries are:- visceral perforation or hematoma- liver- and pancreatic laceration- adrenal bleedingSurprisingly the most common abdominal accidental injuries, which are laceration or subcapsular bleeding of the spleen and the kidney, are unusual in these children.Pancreatic laceration in child abuseLiver laceration in child abuse. These abdominal injuries are non specific and could also be attributed to accidental injury. History does not correlate well with the injuries.Liver laceration in child abuseImaging and reporting considerations for suspected physical abuse (non-accidental injury) in infants and young children (clinicalradiologyonline.net)Foster Son Starves While Mom And Daughter Eat, Then A Customer Interrupts And Does Something Amazing | SmartiedRadiological Imaging in Infant Non-Accidental InjuryIn the UK, seven percent of children will have experienced serious physical abuse from their primary carers at some point during their childhood. Appropriate and effective imaging techniques can drastically improve diagnosis of resultant non-accidental injury (NAI) from child abuse. This includes suitable imaging modality choice and techniques set out by expert opinion and clinical guidelines, such as the standards for radiological investigations of suspected non-accidental injury produced by the Royal College of Radiologists (RCR) in collaboration with the Royal College of Paediatrics and Child Health (RCPCH). There are certain markers that are almost diagnostic of NAI, for example classic metaphyseal lesions or subdural and retinal haemorrhage with encephalopathy. Effective evaluation of these findings by a capable radiologist will lead to accurate and efficient diagnosis and management. Furthermore, an awareness of potential radiological mimics of NAI is vital for appropriate diagnosis. If this is achieved successfully, radiologists and other members of the multidisciplinary healthcare team can have a direct, positive impact on effective management of these sensitive cases.Abusive head trauma - WikipediaNever EVER Shake a Baby - A NYT Article Every New Parent Should ReadShaken Baby Syndrome: A Diagnosis That Divides the Medical WorldPerhaps no crime staggers the mind, or turns the stomach, more than the murder of a baby, and so it is not a surprise when law enforcement comes down hard on the presumed killers. Often enough, these are men and women accused of having succumbed to sudden rage or simmering frustration and literally shaken the life out of a helpless infant who would not stop crying or would not fall asleep.Shaken baby syndrome has been a recognized diagnosis for several decades, though many medical professionals now prefer the term abusive head trauma. It is defined by a constellation of symptoms known as the triad: brain swelling, bleeding on the surface of the brain and bleeding behind the eyes. For years, those three symptoms by themselves were uniformly accepted as evidence that a crime had been committed, even in the absence of bruises, broken bones or other signs of abuse. While many doctors, maybe most, still swear by the diagnosis, a growing number have lost faith. Not that they doubt that some babies have been abused. But these skeptics assert that factors other than shaking, and having nothing to do with criminal behavior, may sometimes explain the triad.Has the syndrome been diagnosed too liberally? Are some innocent parents and other caretakers being wrongly sent to prison? Those questions, at the complex intersection of medicine and the law, can stir strong emotions among doctors, parents and prosecutors. They shape this first installment in a new series of Retro Report, video documentaries that explore major news stories of the past and their enduring consequences.The video’s starting point is a Massachusetts criminal case that introduced the concept of shaken baby syndrome to many Americans: the 1997 murder trial of Louise Woodward, an 18-year-old British au pair accused of having shaken an 8-month-old boy, Matthew Eappen, so aggressively that he died. Matthew also had injuries that may have predated Ms. Woodward’s joining the Eappen family in Newton, outside Boston. The focus, however, was on the triad of symptoms. To prosecution witnesses, they proved that the baby had been shaken violently, his head hitting some hard surface.The Anatomy of a Murder CaseThe anatomy of a shaken baby case from the perspective of defense attorney Adele Bernhard. Published On Sept. 13, 2015Throughout, Ms. Woodward insisted on her innocence. But a jury in state court found her guilty of second-degree murder, and she was sentenced to a prison term of 15 years to life. Within days, though, the trial judge called the murder conviction an injustice. He knocked down the charge to involuntary manslaughter, reducing the young woman’s sentence to time already served, 279 days. Many in Massachusetts and beyond were outraged. Nonetheless, Ms. Woodward was free to return to England.The “nanny murder trial,” as headline writers called it, had an unfortunate subplot. In some quarters of public opinion, Matthew’s mother, Deborah Eappen, stood figuratively in the dock as well. A doctor — like her husband, Sunil Eappen — she found herself under the sort of attack many working women face to this day. The case, a New York Times article said in 1997, “put a spotlight on the backlash against working mothers who consign their children to the care of others.”But the dominant issue was child abuse. Shaken baby syndrome is but one aspect of this phenomenon. It is a topic in which statistics can be elusive because reported episodes may not reflect the full extent of the problem. That said, a report issued in April by a division of the Department of Health and Human Services estimated that in 2013, more than 1,500 children in the United States, or four a day, died from various forms of abuse or neglect. Nearly three-fourths of the victims were under the age of 3. (Various studies over the years have suggested that a serious threat to a small child’s well-being is the presence of the mother’s live-in boyfriend.)In the Woodward trial, a key prosecution witness was Dr. Patrick Barnes, a neuroradiologist then at Children’s Hospital in Boston, now at Stanford University. “I was adamant that it had to be child abuse, shaken baby syndrome,” Dr. Barnes told Retro Report.But after the trial, he rethought his testimony and in effect became a penitent. He is now convinced that the diagnosis has been invoked too readily in criminal cases and that other causes might explain any bleeding and brain swelling. They include infections, earlier injuries from accidental falls and even strokes that occurred in utero. Other doctors who share his outlook question whether just shaking an infant, without resorting to other forms of violence, could in fact produce the triad’s telltale signs. Testing that thesis, though, may verge on the impossible: Who in the name of responsible science is about to shake a roomful of babies to see what happens?Discovering Shaken Baby SyndromeWithout question, Dr. Barnes said, abuse exists, “and we have to do our duty to protect children.” But families need protection, too, he said, and in some criminal cases, “there is no doubt that errors have been made and injustices have resulted.” Were he able to testify again in the Woodward trial, he said, he would say that the medical findings do not confirm abuse and that the baby’s injuries “could have been accidental.”One of the more exhaustive studies of shaken baby syndrome’s legal ramifications was conducted by The Washington Post and journalists from the Medill Justice Project at Northwestern University. In March, they published their analysis of about 1,800 abuse cases across the country that had reached resolution since 2001. Far more often than not — 1,600 cases — the result was a conviction. But the researchers found that in 200 cases, a substantial number, charges were dropped or dismissed, defendants were acquitted or convictions were overturned. The Retro Report video examines one such instance, involving Quentin Stone, a California man whom a jury last year cleared of charges that he had violently shaken his 3-month-old son to death.Not that the medical establishment is starting to line up on Dr. Barnes’s side. Far from it. Dr. Robert W. Block, a former president of the American Academy of Pediatrics, stands firmly by the diagnosis, telling Retro Report that abusive head trauma is supported by decades of observation.The divisions within the medical world run so deep that they pain a towering figure on this issue: Dr. A. Norman Guthkelch, a British doctor who in 1971 found a connection between baby-shaking and brain injury. “There are cases where people on both sides, both of whom I admire equally, are barely able to speak to one another, and that’s a shame,” Dr. Guthkelch, who turned 100 this month, told NPR in 2011. Yet he, too, has come to believe that the syndrome is applied too loosely in some criminal cases.As the debate continues, Louise Woodward has carved out a new life in Shropshire, in central England, where she teaches dance. Married, she has a baby of her own now, a girl born 20 months ago. Even before her pregnancy, she was quoted as telling The Daily Mail: “I know there are some people waiting for me to have a baby so they can say nasty things. It upsets me, but that is not going to stop me leading my life. I am innocent. I have done nothing wrong.”The videos with this article are part of a documentary series presented by The New York Times.A look back: Notorious au pair convicted in baby's death (Wcbv.com)Physical Abuse of Children | NEJMChild Abuse and Neglect (clinicalgate.com)Stephen LudwigPhysical AbusePhysical abuse is defined as nonaccidental physical injury to a child by parental acts or omissions. There has been an alarming increase in reported cases of child abuse throughout the United States in the past 3 decades. In all states, health professionals are now legally required to report their suspicions of abuse to their state’s child protection services (CPS) or police.Clinical PresentationDetermination of suspected abuse is based on compilation of information from five data sources: (1) history, (2) physical examination, (3) laboratory and radiographic information, (4) observation of parental–child interaction, and (5) a detailed family social history.When examining any child with an injury, the clinician should be suspicious of abuse if the history reveals an unusual delay in seeking medical care, the parents’ explanation of the injury is not compatible with the physical findings, the cause of the injury is unknown or “magical,” or there is a history of similar or repeated episodes. Parents may be reluctant to give information or their reaction may be inappropriate to the seriousness of the injuries. Other worrisome signs are a lack of primary care (no immunizations, no source of health care), a history of parental mental illness or substance abuse, and high levels of family stress.While examining the child, maintain a high index of suspicion for abuse or neglect if the child’s weight is below the third percentile for age and there is poor personal hygiene, lack of adequate clothing, behavioral disturbance (especially undue compliance with the examiner), or an abnormal interaction between the parent and child (unwarranted roughness or extreme aloofness). But realize that abuse may occur by parents of any socioeconomic or educational level.Remove all of the child’s clothing and examine the skin carefully for contusions, abrasions, burns, and lacerations in various stages of resolution. Any bruise on a child who is not yet cruising or walking is unusual. Certain skin lesions are typical for specific types of abuse; such as circular cigarette burns; human bite marks; J-shaped curvilinear or loop-shaped marks from a wire, cord, or belt; circumferential rope burns; “grid” marks from an electric heater; and symmetrical scald burns on the buttocks or extremities (Figure 12-1). Other dermatologic manifestations include cutaneous signs of malnutrition (decreased subcutaneous fat, increased creases), scalp hematomas, signs of trauma to the genital area, and signs of injuries at different stages of healing (Figure 12-2).Figure 12-1 Child abuse injury patterns.Figure 12-2 Signs of neglect and staging of injuries.Fractures are suggested by refusal to bear weight or move an extremity, gross deformity, or soft tissue swelling and point tenderness over an extremity. However, most metaphyseal chip fractures are not associated with deformity (Figure 12-3). Neurologic manifestations may include retinal hemorrhages, unexplainable irritability, coma, or convulsions (see Figure 12-3). Finally, an acute abdomen, poisoning, or any traumatic injury that cannot be explained may in fact represent forms of child abuse.Figure 12-3 Fractures and head injuries in child abuse.The differential diagnosis of the abused child includes conditions with skeletal involvement: accidental trauma, osteogenesis imperfecta, Caffey’s disease, scurvy, rickets, birth trauma, and congenital infection. Diseases with dermatologic manifestations include bleeding disorders (idiopathic thrombocytopenic purpura, leukemia, hemophilia, von Willebrand’s disease), recurrent pyodermas, and scalded skin syndrome. Sudden infant death syndrome and accidental poisonings may be mistaken for child abuse. The most common clinical problem is the differentiation between accidental and nonaccidental trauma.Evaluation and ManagementIf there is any fracture or other suggestion of any form of abuse in a child younger than 2 years of age, obtain a complete skeletal survey for trauma. For older patients, if the physical examination suggests a fracture, obtain specific radiographs. Order other radiologic studies, such as a head computed tomography or magnetic resonance imaging scan, as indicated by the nature of the injuries. Ophthalmologic consultation may be needed to identify retinal hemorrhage.In 1997, a young British nanny charged with murder brought shaken baby syndrome into the national spotlight, and raised a scientific debate that continues to shape child abuse cases today. Published On Sept. 13, 2015If the parents deny any knowledge of the cause of skin bruises, obtain a complete blood count with differential, platelet count, prothrombin time, partial thromboplastin time, and a bleeding time. The differential diagnosis and other possible laboratory studies are shown in Table 12-1.NOW YOU ARE READY TO BECOME AN EMERGENCY DEPARTMENT RADIOLOGIST.

Original Question: Is it possible to train skilled, competent doctors without the use of extreme sleep deprivation? If so, why don't we do it?Absolutely! The only question is: are you/we willing to actually do so—and if so, what are you/we willing to give up in exchange?Pop quiz time!How many new physicians does the United States—a country with more than 300 million residents—license in a given year? Let’s use 2020, just as an example. To be clear, I’m asking about new licenses—not physicians who come out of retirement, or academics and researchers who go back into practice, or anything like that.How many newly licensed physicians were trained and obtained a medical license in 2020? Write your guess down in the comments below, if you feel like playing.Ready?You sure?You still have time to change your answer.Going once, going twice…going three times…Okay…pencils down!The correct answer is: 35,185.That’s it. That is how many new “doctors”—spread out across all medical specialties, in all 50 states—got licensed to practice medicine. In the entirety of the United States of America, in the Year of Our Lord 2020, only 35,185 physicians were “added” to the ranks of white coat-clad clinicians. What’s more, that figure is an all-time record for the US, and represents the most new doctors ever licensed in a single year, in the history of the National Resident Matching Program.You see, for better or for worse, the medical licensing process in the United States is integrally tied to the completion of (and/or admission to) a postgraduate residency training program. And, for better or for worse, the number of new “post graduate year 1 (PGY-1)” training slots is hard-capped, and fixed for every residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME)—which is the only accreditation council in America that can accredit postgraduate medical residency programs. For the 2020 application cycle, which ended this past March, that cap was fixed at 35,185, representing the sum-total of all residency training slots for all specialties and in all 50 states, including psychiatry, pediatrics, internal medicine, cardiothoracic surgery and otorhinolaryngology. In fact, you can actually peruse the 2020 Main Residency Match Data and Reports at their website, to figure out exactly how many “new doctors”—or “PGY-1 residents” there were in every specialty for that year, and just about any other.For example, in 2020 the United States added precisely 31 new dermatologists[1] to its ranks of dermatologists. That same year, it also added 232 new neurosurgeons.[2] Thoracic surgeons? 38.[3] Interventional radiologists? Also 38.[4] And so on down the list.So what is the relevance to this question, you might ask?Here in the United States, there is virtually no way to be licensed to practice medicine as a physician without completing at least one year of postgraduate residency training. Even if you were the deputy minister of health in the United Kingdom—or developed the cure for eastern equine encephalitis as your high school science fair project—without at least one year of residency under your belt your medical degree isn’t worth the vellum it is printed on. And even if you graduated from a US medical school summa cum laude, without a year of residency training your credentials aren’t worth the horse spit you used to test the vaccine that helped you to win your Nobel Prize.Worse still, given that there are only 35K or so 1st year residency training slots, that means that there can only be 35K or so new “doctors” in the pipeline at any given time. Which is a problem, because although the number of new doctors in America is finite and fixed by force of law—or rather, by force of the written policies of a private, independent (i.e. non-governmental) tax-exempt not-for-profit advisory council, which in this case is basically the same thing—the number of new patients in America obeys no such restrictions, and adheres to no such regulatory policy.This means that not only may the needs of society vastly (and rapidly) outweigh the capacity for the medical system to accommodate them, but the very act of trying to expand capacity to meet those increased demands faces a serious (and institutionalized) lag time, measured on the order of years, if not decades.Even if you are facing a rapidly aging population cohort.[5]Even if you are facing a generally sicker and less healthy demographic.[6]Even if you are facing a major global pandemic.[7]Even if you were facing a critical shortage of doctors to begin with.[8][9][10][11](Or, in the present case, all of the above).Thus, even as patient populations grow, the fixed and finite number of doctors actually being trained to deal with them is left to lag behind—and has been allowed to lag behind for decades—the inevitable result of which is a dangerous combination of too many patients and not enough physicians. This, in turn, inevitably results in long hours and sleepless nights[12][13]—even if you’re not a doctor, and just a family member watching them slowly grind themselves down to the bone.[14][15]So, how do we reduce the fatigue and sleep deprivation of physicians in training?Step 1: We have to want to.Right now, physician fatigue and physician burnout is treated more or less the same way that American society has treated other problems of societal and mental health: a hearty handshake, and a pat on the back, with some “Buck up, kiddo!” can-do attitude.Which is, to be fair, a significant improvement of our old method of dealing with problems of societal and mental health, specifically: denial, repression, victim-blaming, and a healthy dose of “c’est la vie” shoulder-shrugging.But what we really need is not more “mindfulness” training and meditation and relaxation retreats—we need bodies in lab coats, pressing stethoscopes into chests. We don’t need more nap pods or yoga mats or motivational posters. We don’t even need to throw more money into physician salaries or benefits—although I’d be lying if I said I was opposed to the notion.What we need is to recognize that we actually have a problem—and that problem is not enough doctors. The doctors themselves are doing the same thing they’ve done since the days of Galen and Hippocrates; that is, “the best they can, for as many people as they can, with the best tools that they’ve been left with.”Step 2: We should focus on the problem we actually have, and not the problem we wish we had.Right now, we actually have a lot of doctors—at least if you define them as “people with medical degrees, who have graduated from medical school.” Medical schools, both here in the United States, and elsewhere around the world, have actually grown their class sizes considerably since the 1990s; far more (and far faster) than the number of postgraduate residency programs the ACGME has deigned to accredit and certify. Because of this, more people apply for ACGME positions than there are positions themselves, meaning that competition is fierce—and the applicants supernumerary. On the face of it, this might seem like a good thing—after all, the United States gets to have their “pick of the litter” in terms of not just US medical graduates, but medical graduates from around the country. So, one might assume that this is actually a good thing.The problem is, that “qualifications” are not a major consideration, and never have been. The United States doesn’t have a lack of qualified applicants—and never has. Most if not all of the applicants to ACGME-accredited programs are qualified, by definition, because a precondition of even applying for consideration to a residency program is being qualified for licensure in the state that program is located in—often in the form of taking and passing at least some part of the United States Medical Licensing Examination, the nominal purpose of which is to gauge the skills and competency of physician candidates before, during and after they graduate medical school.(Note: There are actually four “steps” to the USMLE, despite the fact that it is nominally a “single” exam.The USMLE Step 1, taken between the second and third year of medical school (MS-2/MS-3)The USMLE Step 2 Clinical Knowledge, taken after the third year of medical school.The USMLE Step 2 Clinical Skills, taken during the 4th year of medical schoolUPDATE: As of January 26, 2021, the USMLE Step 2 CS has officially been terminated indefinitely,[16] for a couple of reasons:It was pointless, expensive, and totally unnecessary.COVID-19 made it much, much harder to pretend that it wasn’t.The USMLE Step 3, taken the year after graduation of medical school, regardless of whether the applicant gets a residency.This also doesn’t count the Medical College Admission Test (MCAT), which is required for entry into an accredited medical school.)And yet, because there are more USMLE-passing physicians than there are ACGME slots, ACGME programs have taken to using the USMLE not as a “criteria for licensure”—which is, again, its primary, sole, and originally intended function—but as a “objective selection criteria,” to weigh/weed out applicants, in much the same way that American colleges might use the SAT or the ACT. Because of this, and because of the cut-throat competition for the finite number of residency slots, many qualified medical graduates (especially those that graduated from foreign countries) are forced to be “strategic” in their residency applications—often spending hundreds if not thousands of dollars on applications fees, in addition to the travel expenses of the “interview trail” required for residency applications—and many others simply decide not to try.This is because the nightmare scenario for a aspiring physician is to go through all of the above steps, and yet remain “unmatched,” meaning they are either unable to obtain a residency at all, or must go through several rounds of applications before they are able to obtain one. If that happens, they will not be able to practice medicine in the United States until they obtain a residency slot, all while the debts from their student loans are compounding (and capitalizing).(Note: Student visas for medical students are only valid while an applicant is enrolled in school. Once an international student graduates from medical school—regardless of whether they “match” into residency or not—their visa will expire, requiring them to leave the country. They may be able to obtain a temporary visa to return for the “interview trail” in subsequent application cycles—but the interview and application process is expensive, even for US medical graduates who already live in the US.)Because of this, and because of the fact that the average (US) medical student graduates with more than $200,000 in debt, many would-be physicians are discouraged from even applying to medical school, and those who do (but remain unmatched) are instead forced to abandon their medical studies and move into “less risky” professions like nursing or pharmacy schools—neither of which have postgraduate “gatekeepers” that could potentially derail their career prospects simply because they lost at the “computer algorithm lottery.”(Oh yes, I forgot to mention it before. That’s how medical residency positions are filled—with a Nobel Prize-winning “ranked choice” computer algorithm[17]).Step 3: We need to stop pretending that we’re “still looking” for solutions.We know what needs to be done. We’ve known what needs to be done for decades. And we will still know it in the next decade, even if we insist on pretending otherwise.Sure, “independent oversight” bodies like the ACGME, the LCME, the AMA, and their affiliates will undoubtedly wring their hands and fret about “falling standards” or “lack of oversight” or “loosening restrictions” or whatever variation of “We’re afraid of losing power but we can’t say it that way without looking like prats” that their PR and image consultants have come up with. And there is, certainly, a valid point to be made with respect to maintaining high standards of practice and training. But at the end of the day, the problem today is the same as it was in the 1990s and early 2000s, just as it was when researchers first began warning about critical shortages of healthcare personnel: we have too many people to take care of, and not enough people to take care of them. And whether we like it or not, there are really only two solutions to that problem:We can stop making people—or simply stop caring for them.We can train more people to take care of them—and actually let them do so.Everything else is just dancing around the issue and trying to patch holes in periphery of the margins. Can we expand the role of mid-level practitioners? Sure! But that’s still just trying to evade—excuse me, “mitigate”—the larger problem of physician supply. Don’t get me wrong, NPs and PAs are highly qualified and skilled professionals, and they do a lot of really good and important work. But they’re not physicians, nor are they adequate replacements for them. A PA will not (and cannot) replace a surgeon. An NP will not (and cannot) take the place of a psychiatrist. And a nurse midwife will not (and cannot) perform an emergency cesarean, complicated by a uterine rupture.For those things, you need someone with the letters MD (or DO) after their name.(UPDATE 02/19/2021): Apparently, this issue is starting to get some much-needed attention in the news.‘I Am Worth It’: Why Thousands of Doctors in America Can’t Get a JobFootnotes[1] https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2020/06/MM_Results_and-Data_2020-1.pdf[2] https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2020/06/MM_Results_and-Data_2020-1.pdf[3] https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2020/06/MM_Results_and-Data_2020-1.pdf[4] https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2020/06/MM_Results_and-Data_2020-1.pdf[5] Older People Projected to Outnumber Children[6] American seniors are sicker than global peers[7] COVID-19 Is Making the Physician Shortage Worse, Groups Say[8] U.S. physician shortage growing[9] The US is on the verge of a devastating, but avoidable doctor shortage[10] New Findings Confirm Predictions on Physician Shortage[11] We're Devastatingly Short on Doctors. Why Doesn't the US Just Make More?[12] No Doctor Should Work 30 Straight Hours Without Sleep[13] Residents are sleep deprived. So what’s new?[14] https://www.medscape.com/slideshow/2020-lifestyle-burnout-6012460[15] Physician Burnout: Its Origin, Symptoms, and Five Main Causes[16] USMLE Step 2 CS canceled: What it means for medical students[17] Nobel Prize - The Match, National Resident Matching Program