Bryan Carmody
@jbcarmody
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The Sheriff of Sodium | Pediatric nephrologist | Associate professor | APD | Husband | Dad | Virginian | Advocate for medical students and common sense
Hampton Roads, VA
Joined July 2013
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Pinned Tweet
A thread for a few of my more popular or important threads and Tweets.
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I don’t usually brag about our residency program, but today I’m gonna make an exception.
Like other children’s hospitals, we’re managing a surge in respiratory illness.
But unlike most hospitals, we’re gonna pay the residents who work extra overnight/weekend shifts $100/hour.
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Anyone else out there think we’ll be wearing masks for the rest of our careers?
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Most physicians who took USMLE Step 1 over 5 years ago have no clue what’s actually on the exam.
Don’t believe me?
For those of you who’ve forgotten what Step 1 really tests, hop on board for a little refresher.
(thread)
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Last week, Tennessee passed legislation to allow international medical graduates to obtain licensure and practice independently *without* completing a U.S. residency program.
This is BIG news.
So you know what that means.
Time to break it down, Winners & Losers™️ style.
(🧵)
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Last year saw a record number of applicants for the opthalmology match.
Let the AAMC talk about the ‘Fauci effect’ in medical school applications - I’m gonna talk about the
@DGlaucomflecken
effect for ophthalmology residency programs.
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It’s one thing for an insurer to DENY a claim. But why do so many insurers expend such effort to DELAY payment, even for justified claims they know they have to pay?
If you didn’t know already, let me teach you about “float.”
(thread)
I’m trying to think of another industry with record profits that just doesn’t pay its bills.
Anthem, UnitedHealthcare, other major insurers are running billions behind in payments to hospitals, doctors via
@USATODAY
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The average resident physician earns around $60,000/year.
But what is their financial impact on the hospitals that employ them? What are resident physicians worth?
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Good Lord.
Suggestions include attending a tuition-free medical school, “improving financial literacy,” and applying to fewer medical schools.
Why not include “Don’t be poor” while you’re at it?
While the cost of attending medical school is high, it is not insurmountable. Here are 7 ways that can help you reduce medical school debt:
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I am stunned.
USMLE Step 1 will scored pass/fail - potentially as soon as January 2022.
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In 1998, a small residency program in Colorado lost its accreditation.
It wasn’t the kind of thing that you’d expect to change the course of academic medicine.
And yet, it *almost* did.
Earlier, I explained how the Match started. Now, I’ll tell you how it nearly collapsed.
🧵
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WSJ covered resident unions today.
Article dropped 3h ago; 400+ comments already.
My fave is “There was no issue with work-life balance until women became MDs!”
But don’t worry, Stockholm syndrome, the bootstraps brigade, and socialized medicine fearmongering are there, too.
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930
Number of unfilled positions in family medicine and internal medicine in the 2022 Match
-
847
Number of fourth year MD students who failed to match in orthopedics, dermatology, otolaryngology, neurosurgery, and plastic surgery
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If you don’t interview DOs, or applicants who need work visas, or students who failed to match in a previous cycle or whose USMLE scores don’t exceed a certain threshold - just say so. Save yourself some time, and save an applicant $26 on an application that won’t even be read.
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For weeks, I’ve waited patiently for preliminary application data for the 2023-2024 residency application to be released by the AAMC.
And today they dropped.
So you know what that means.
Yup, that’s right.
It’s time to break it down, Winners & Losers style™️.
(🧵)
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Hate to be the bearer of bad news, but…
Yes, medical residents are once again exempted from being paid overtime.
See p. 378 of the final rule PDF:
BREAKING: 4 million workers will now take home more money when they work more than 40 hours a week under a new Labor Dept. rule released today. The changes would make it so salaried workers earning less than about $59k annually would automatically be due overtime pay.
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I always said this would never happen.
I guess even I’m wrong... every now and again.
USMLE STEP 2 CS IS CANCELLED FOREVER!!!!!
No more USMLE Step 2 CS!!!
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If you survey medical students right after Match Day, the happiest and most satisfied ones are those who matched higher on their rank order list.
But ask them again 3 months into intern year, and everyone is indistinguishable.
From:
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This is shameful.
If you want to give bonuses to frontline workers, why would you specifically exclude the resident physicians?
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@DGlaucomflecken
The man is telling the truth.
ERAS has become the AAMC’s cash cow, with revenue (and revenue growth) that far outpaces their other programs.
In 2019, ERAS took in $94 million in revenue - more than doubling its revenue from a decade before.
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Lemme just say, I honestly *can’t wait* to celebrate with all 24 of you later this week - and work with each of you in July.
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Percentage of pediatric and internal medicine specialty programs that filled in this week’s NRMP fellowship match.
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Preliminary data from ERAS are out… looks like another record-setting year.
The average number of applications received by residency programs is up in most specialties - in some cases, by 30-40% versus 2019.
#ApplicationFever
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In 2019, the University of New Mexico’s neurosurgery residency program lost its accreditation.
It took 23 NPs/PAs to replace the work of 8 residents… at ~5x the cost for the institution.
My latest video:
How Much Are Resident Physicians Worth?
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Yes, it’s true:
The reason a physician in graduate medical education training is called a “resident” is because back in the day, they *literally* lived in the hospital.
(a short thread)
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RESEARCHERS: Black, Hispanic, and Native American internal medicine residents receive lower scores from their faculty on the ACGME competencies. Maybe it’s structural racism?
FORMER IVY LEAGUE MEDICAL SCHOOL DEAN: Maybe they’re just not as good!
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Today is Match Day for internal medicine and pediatric subspecialties.
Here’s how things shook out for programs.
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Well, the envelopes have been opened. Tears (hopefully of joy) have been shed. And just like that, another Match Day is in the books.
And you know what that means.
Time to break it down, Winners & Losers™️ style.
(🧵)
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This weekend, the AMA House of Delegates adopted a resolution citing antitrust concerns with the NRMP Match, and calling upon the AMA to study alternatives to the residency match that would be less restrictive on free market competition.
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I’d like to talk about the finances - and potential financial conflict of interest - at the National Board of Medical Examiners.
This is gonna be a long one - but thanks for hearing me out.
(Thread)
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Well, all it took was a pandemic - but USMLE Step 2 CS is over.
(at least temporarily)
Official word should be coming from the USMLE later today.
#EndStep2CS
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A medical school applicant who was denied admission to medical schools in Texas has sued, alleging discrimination based on his status as a white male.
(🧵)
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If you were a med school dean who was so concerned about your reputation that you’d sue a former student for defamation - just to force an apology that got 2 likes - you might think you’d try harder not to express racist views on Twitter where God and everybody can see them.
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The research arms race for U.S. medical students
The average *unmatched* applicant in 2020 had more abstracts, presentations, and publications than the average *matched* applicant did in 2009.
(Data from
@TheNRMP
Charting Outcomes in the Match)
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How much do hospitals receive from the government to train residents?
It depends. There are multiple funding streams and the formulae are complicated.
But here, a consulting firm did the math...
…and estimated that, in 2019, the average Medicare subsidy was $145,435/resident.
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Show me a program that rejects an application in 15 minutes, and I’ll show you a program that needs to be honest with applicants about their ERAS filters.
I got a rejection 15 minutes into the season at 9:15 AM, probably an automatic reply to filtered out applications but that was fast.
#ERAS2023
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UPDATE:
Last week, a Nepali doctor filed a class action lawsuit against the National Board of Medical Examiners, alleging discrimination based upon national origin and requesting that invalidated USMLE scores be restored while examinees appeal.
Today, the NBME responded.
(🧵)
A brief update on the USMLE cheating scandal:
This week, a Nepali doctor and Match applicant whose Step 1, Step 2 CK, and Step 3 scores were all invalidated has sued the NBME.
The NBME will respond by February 19, and the court will render a decision by February 21.
(🧵)
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Hang around
#MedTwitter
for a while, and you’ll find someone claiming that there aren’t enough residency positions for U.S. medical students, or that residency positions aren’t growing at the same rate as medical school graduates.
Trouble is, neither is true.
(a 🧵)
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As we countdown to Match Day, I want you to meet Dr. Kevin Jon Williams.
For nearly 20 years, he fought for - and eventually won - a student-optimal matching algorithm.
It’s one of the great stories of advocacy in Match history… and the NRMP refuses to acknowledge it.
(a 🧵)
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Interesting statistic from the AAMC:
47% of matriculating medical students were admitted to exactly *one* medical school
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Today, I reviewed course feedback for a second-year medical school course. In response to a request for areas for improvement, one student wrote this.
The sentiment is extremely common, but rarely have I seen it stated so succinctly.
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Preliminary data for this year’s residency application cycle are now available.
These figures won’t surprise anyone familiar with the contemporary application process… but if you’ve been out of the game for a while, some of the numbers will be eye-popping.
#ApplicationFever
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Back when I was an intern, I was chatting with the grandmother of one of my patients.
Her granddaughter was about to begin 9th grade, and she recalled how excited she’d been to start high school herself - but the school was closed.
I was puzzled. I didn’t know what she meant.
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Emergency Medicine has 555 unfilled positions up for grabs in the SOAP.
Of course, you heard it here back in October…
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Big news from the NRMP:
Starting in 2026, there will be *public* reporting of match outcomes for medical schools and applicant demographic data for programs.
(🧵)
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This is a student’s worst nightmare.
You take
@TheUSMLE
… but somehow,
@PrometricGlobal
doesn’t record your test responses.
Some shameful stuff right here. A refund is necessary, but not sufficient.
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ATTENTION PROGRAM DIRECTORS:
If you can reject an applicant within 43 minutes of ERAS opening, then you need to be more transparent about your filters.
(Save yourself some trouble; save the applicant $26.)
@JazmynShaw1
@DAndreaCeasar21
And for the record, this did happen today to a friend who’s applying to OBGYN.
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Well, it’s (all but) official:
The AAMC has recommended that residency programs offer only virtual interviews for the upcoming season.
Who wins, and who loses? Let’s find out!
(thread)
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Survey: Hey program directors, how do you feel about pass/fail Step 1?
PDs: Oh, it’s *TERRIBLE*
Survey: I see - so does using Step 1 scores actually help you find successful residents?
PDs: Nah, not really
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Thought of the day:
The current interest rate on federal student loans is 6.8%.
The average medical student graduates with around $200,000 of debt.
In real terms, for the average medical graduate, their student loan balance is increasing by $1.55 per HOUR.
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With Match Day over, we can now enjoy self-congratulatory press releases from medical schools claiming 100% “match rates” for their students.
For instance, *every single DO school except one* claims to have a match rate of 98-100% - even though the national average is ~91%.
🧵
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Does more research in medical school *really* lead to better doctors?
Or does it simply encourage quantity over quality; erect barriers for low SES/URiM applicants; calcify prestige hierarchies; and incentivize shoddy research?
(Sounds like a good research question to me.)
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A brief update on USMLE score creep:
In 1994, the mean USMLE Step 2 CK score was 200.
By 2008, it was 226.
And in 2023, it’s 248.
(Over that time frame, the USMLE has increased the minimum passing score threshold nine times, from 167 to 214.)
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Paying residents fairly is NOT incompatible with high-quality education.
I'm old & trained in a community hospital in a better era. Residency is a SHORT timeframe. You'll have access to the BEST education possible IF you know HOW. THAT'S your GOAL. MONEY comes LATER. Find the best MENTORS to TEACH you what you need to know to gain KNOWLEDGE & RESPECT.
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In 2021, the average first-year resident earned a salary of $57,500.
Adjusted for inflation, that’s $49,824 in 2012 dollars - which means that, in real dollars, resident salaries have increased only $5000 over the past 40 years.
(a short 🧵)
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ERAS remains the AAMC’s cash cow, taking in revenue of $116.7 million in fiscal year 2021 - and with revenue growth that continues to outpace the AAMC’s other programs.
(a 🧵)
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I’m still hearing from applicants who got an interview invitation; responded within a few minutes; and were unable to schedule an interview because all the spots were taken.
Just a reminder that, as of this year, this is a Match Violation for programs:
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If you want to become a pediatric subspecialist, you’ve gotta do a fellowship.
For most subspecialties, that fellowship lasts 3 years.
But most of that time isn’t spent learning clinical medicine. It’s spent doing research.
Ever wondered why these fellowships last so long?
🧵
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This year, 10 Columbia medical students applied in orthopedic surgery.
Collectively, they applied to 125 programs *without* signaling.
So how many interview offers did this elite group of applicants receive from their non-signaled applications?
-🥁-
-🥁-
-🥁-
One.
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A brief update on the USMLE cheating scandal:
This week, a Nepali doctor and Match applicant whose Step 1, Step 2 CK, and Step 3 scores were all invalidated has sued the NBME.
The NBME will respond by February 19, and the court will render a decision by February 21.
(🧵)
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The most - to least - desired medical specialties in the 2022 Match, ranked by ratio of applicants to positions.
(These data include only an applicant’s preferred specialty - i.e., the specialty they ranked number 1 - so multiple specialty applicants count only once.)
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“Why were there so many unfilled positions in EM this year?”
Well…
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I’ve gotten DMs asking “How could the USMLE prove they cheated? High scores alone don’t prove that!”
-and-
“How do I know my high score won’t be flagged as evidence of cheating just because of where I took the test?”
Lemme explain how I think these cheaters were caught.
(🧵)
Over the past few months I heard from two separate groups with concerns about USMLE cheating in Nepal.
Glad to see the USMLE taking action.
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Fifty years ago, the New England Journal of Medicine published an study showing that sleep-deprived interns had “transient psychopathology” and impaired cognitive performance.
Whew! Good thing we got that fixed, huh?
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@DGlaucomflecken
Seems like a good place to leave this.
Today’s test-taker who scores at the median on USMLE Step 2 CK would have been in the 98th percentile if they’d taken the test 30 years ago.
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TODAY IS MATCH DAY!!!
Time for a quick 🧵 to explore the NRMP preliminary data.
Here’s how the specialties filled (or didn’t), by applicant educational background.
#Match2022
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If you didn’t believe me when I said that the loss of ERAS revenue is an existential threat for the AAMC, take a look at this ‘not for circulation’ e-mail they sent to medical school deans, urging them to keep program directors from switching to another application system.
(🧵)
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Since the announcement that Step 1 will go pass/fail, there’s been a growing false narrative that USMLE scores allowed IMGs to compete on a level playing field with U.S. MDs for competitive residencies.
Here is the uncomfortable truth - and what to do about it.
(thread)
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Total registration fees for NBME exams, then and now:
1920:
$5
2020:
$645 (Step 1)
+ $645 (Step 2 CK)
+ $1300 (Step 2 CS)
+ $895 (Step 3)
__________
$3,485
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In the U.S., hospitals that provide graduate medical education are eligible to receive payments from Medicare to subsidize the costs of training residents.
In 2018, the top 15 hospitals receiving Medicare GME payments received over $100 million apiece.
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Big changes may be coming for internal medicine residency applicants in the 2024-2025 application cycle…
The
@AAIMOnline
is recommending:
-⬆️ preference signals from 7 to 15 (3 gold, 12 silver)
-capping interviews at 15
-no interviews before November 1
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Fun fact:
Residency programs already have their Match lists.
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Yes, it’s just a kidney in a bucket of ice.
But it’s also a chance at a whole new life, and I just think it’s so beautiful.
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HCA is the nation’s largest for-profit hospital chain.
It’s also the
#1
sponsor of residency training programs in the U.S.
And HCA has **QUADRUPLED** the number of residents they train over the past decade.
(But yeah, tell me again how hospitals lose money training residents.)
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ERAS revenue in FY 2019:
$94,153,946
(That’s around $1 million for every minute that ERAS functioned before crashing in the first round of SOAP.)
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This is a surprising statistic:
Only 23% of this year’s Stanford medical school class completed their studies in four years.
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Lemme flesh out the argument here since some respondents and QT’ers seem to be missing the point.
It’s not just “greedy insurance companies are making health care expensive!”
It’s that *we built a system that incentivizes insurers to systematically ⬆️ health care costs.*
(🧵)
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INSURANCE: We denied the prior auth because the patient’s plan doesn’t cover candesartan.
Me: So what does it cover?
INSURANCE: Valsartan and losartan.
Me: You know those have been recalled, right?
INSURANCE: The plan doesn’t include that as a reason for authorization.
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My dad is not a doctor, but he is the smartest man I’ve ever known.
My wife sent him the link to my Medscape profile:
His response, in part:
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Well, here’s the worst idea I’ve heard in a while:
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I’m seeing a lot of Tweets from students who did - or didn’t - get their goal Step 1 or Step 2 CK score.
So whether you’re feeling up - or you’re feeling down - it seems like a good time to remind everyone how imprecise USMLE scores are.
(thread)
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And the 2021 Match is in the books.
Match rates:
MD seniors: 92.8%
DO seniors: 89.1%
Couples: 93.4%
(Each of those figures is down - but just slightly - from previous years.)
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The
@NBMEnow
has a task force to study whether high-stakes exams like the USMLE contribute to student burnout.
It sounds to me like their inclination is just to blame students for their lack of resiliency.
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In 2022, plastic surgery applicants were surveyed regarding the frequency of ‘illegal interview questions’ (e.g., regarding intended ranking, marital status, childbearing plans, etc.).
78% reported being asked these questions
0% made official complaint to NRMP or others
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Over the past few months I heard from two separate groups with concerns about USMLE cheating in Nepal.
Glad to see the USMLE taking action.
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Advocacy works.
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In case you wondered where those ERAS fees go
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Most and least competitive specialties, then and now
(listed in order of lowest-to-highest match rate for graduating U.S. MD students)
Biggest ⬆️: OB-GYN
Biggest ⬇️: Radiation oncology
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I’ll leave you with these wise words from the BMJ nearly 30 years ago:
“We need less research, better research, and research done for the right reasons. Abandoning using the number of publications as a measure of ability would be a start.”
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Succinct summary of what going tuition-free does for medical schools:
⬆️ selectivity
⬆️ U.S. News & World Report ranking
⬇️ % of students going into lower-paying specialties/primary care
“Relieving the burden of student loan repayment does nothing to address the link between wealth and medical school admissions in the United States.”
Read more from me and
@Jared_Boyce
via
@statnews
here:
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And please please please, spare me the argument that students need to learn this because some of them might go on to become basic scientists.
Cause here’s the thing: Step 1 is a licensing exam. Not an “explore different career pathways” exam.
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A fair bit of what we call “mentorship” in academic medicine is actually just exploitation.
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Another Match Week has come and gone.
Time to break it down, Winners & Losers™️ style.
#MatchDay2022
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Do we really need MORE research?
Really???
Will homo sapiens really be better off as a species by having every resident publish a paper?
Or will we just end up with more low quality, irredeemably biased, non-reproducible (or outright fraudulent) peer-reviewed PubMed pollution?
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Here’s a fun fact:
In terms of *relative* performance, an examinee who scored a 219 on USMLE Step 1 in 1993 is equivalent to one who scored a 250 today.
(thread)
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Your move,
@NBOME
.
Today, the USMLE Program is announcing the discontinuation of work to relaunch a modified Step 2 Clinical Skills examination (Step 2 CS). Read the full statement here
#MedTwitter
#MedEd
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The ACGME just released new program requirements for pediatrics - some of which may significantly change the way we train future pediatricians.
So who wins - and who loses - under the new requirements?
You guessed it - it’s time to break it down, Winners & Losers™️ style.
🧵
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Advocacy works.
JUST ANNOUNCED: NBOME indefinitely postpones COMLEX-USA Level 2-PE and announces Special Commission for COMLEX-USA. Learn more here:
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