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July/ August 2013 First Teach No Harm

The U.S. spends $13 billion a year subsidizing graduate medical education. Yet almost all of this money winds up producing the wrong kinds of doctors in the wrong places, with America’s most elite teaching hospitals being the worst offenders.

By Phillip Longman

docs

Perhaps you’ve noticed their full-page ads in your local newspaper. In late 2012, a new series began showing an anesthetized woman laid out on an operating table. The stark headline reads “BE CAREFUL WHAT YOU CUT.” The ad goes on to explain: “Reducing the deficit is essential. But at a time when our nation faces a critical shortage of doctors, cutting federal support for doctor training will jeopardize access to care and turn back the clock on life-saving cures and medical discoveries.”

These ads are brought to you by the Association of American Medical Colleges and are part of an extensive lobbying and public relations effort. At issue are some $13 billion in government subsidies that flow each year to medical residency programs, such as the kind depicted in the long-running, popular TV series Scrubs.

Under America’s system for educating doctors, medical school graduates may not practice on their own until they have first completed a period of on-the-job training know as residency, which typically last three to five years. Such training usually occurs in so-called “teaching hospitals” or academic medical centers, which offer residency slots in various specialty areas of medicine, such as dermatology or cardiology. If you’ve ever been treated in a teaching hospital, you may well have seen the drill in which a gray-haired attending physician comes to your bedside surrounded by a group of twentysomethings whom he quizzes about the lessons of your case.

Typically, teaching hospitals and other sponsors of residency programs receive subsidies amounting to about $100,000 per year for every resident they enroll, with about half of that going to the residents themselves in the form of stipends. Add in the additional money flowing from state Medicaid programs, and the public cost of residency programs comes to about $500,000 for every physician the hospitals produce.

The AAMC and its allies are very intent that Congress not cut these subsidies, and, indeed, want them raised. Without greater subsidies, the AAMC argues, America will face a shortage of 91,500 doctors by 2020. Just in case you don’t get the intended message, a video produced by the AAMC explains that unless the feds put more money into residency programs, Obamacare will bring “insurance in name only.”

But there is a big problem with this argument. America does indeed face a looming shortage of medical professionals, but because of the way it’s spent, that $13 billion subsidy isn’t helping us fill the gap. The nation’s residency programs are producing too many of the wrong kinds of doctors in the wrong places, while not producing enough of the kinds of doctors we most need to sustain the U.S. health care system.

Specifically, the programs turn out too many specialists who go on to practice in places where such doctors are already in oversupply, and where, according to numerous studies, they often inflate health care spending by engaging in massive amounts of unnecessary surgery and other forms of over-treatment. Meanwhile, residency programs are producing a dwindling number of primary care physicians and other generalists, who are already in chronically short supply in most parts of the country and are desperately needed to implement the kind of reforms to the health care delivery system necessary to improve its quality and efficiency.

Many hospitals and other health care providers are making strides in implementing best practices in medicine. But these reforms can only go so far as long as our system of graduate medical education remains increasingly out of sync with the kind of health care workforce the country actually needs. Unless Congress faces down the demands for more subsidies coming from the AAMC and its allies, and the public starts holding them accountable for the outcomes they produce with taxpayer money, the problem will only get worse.

Overwhelmingly, the greatest shortages of doctors today are primary care physicians and other generalists. According to a recent survey sponsored by the independent congressional agency MedPAC, finding a primary care doctor is highly problematic even for Americans with good health insurance. Among fully insured Americans over the age of fifty who went looking for a primary care doctor last year, fully one out of seven report it was a “big problem.” This is double the percent who report having trouble finding a specialist. Even in affluent parts of the country, finding a primary care doctor who is still taking new patients can require as much scheming as getting your three-year-old into Montessori. In rural and poor inner-city areas, it’s often well nigh impossible. Nearly sixty million Americans—almost one out of five—live in regions or neighborhoods designated by the federal government as primary care shortage areas.

And on current course, these shortages are about to get much more acute. As the Affordable Care Act extends health insurance coverage to thirty-two million more Americans, this alone will increase the need for primary care physicians from 25,000 to an estimated 45,000 by 2020. Meanwhile, studies predict that the aging of the Baby Boom generation will leave the country short another 35,000 to 44,000 primary care doctors. Yet our current residency programs are producing about 40 percent fewer new primary care doctors than are needed even to replace those who are currently practicing as they retire or move to other areas of medicine.

Part of the problem is that, due largely to the political power of specialists, the reimbursement rates paid by Medicare and private insurance are set far higher for specialists than for primary care doctors (for more, see “What the RUC?”). But our system for training doctors is also deeply at fault, with the country’s most elite and deeply subsidized teaching hospitals being by far the worst offenders. In the tables below, we show the nation’s largest residency programs ranked according to the percentage of primary care doctors they produce. At the top of the list are the University of Nevada School of Medicine and the Bronx-Lebanon Hospital Center. Among the residency programs sponsored by these institutions, half or more of their graduates go into primary care. These institutions may not score high on the annual rankings of the most prestigious hospitals put together by the U.S. News & World Report, but they clearly deserve to be celebrated for doing more than their part to reduce the nation’s acute shortage of primary care doctors. At the bottom of the list, by contrast, are some of America’s most prestigious medical institutions. For all the federal subsidies they receive, most are barely in the business of training primary care doctors.

Data from Graham Center and George Washington University. Explore further using their online tool.
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Phillip Longman is senior editor of the Washington Monthly.

Comments

  • Brian Crownover MD on June 21, 2013 12:22 PM:

    Finally, someone is talking about REAL health care reform, not health care ACCESS reform which the ACA addressed. This review should be mandatory reading for every congressman and especially Pres Obama. For clear insight on the need to reform physician payment which directly impacts specialty choice, read about the RUC. http://well.blogs.nytimes.com/2011/09/22/how-one-small-group-sets-doctors-pay/?_r=0
    http://www.medscape.com/viewarticle/779989

  • Henrietta McClellan on June 21, 2013 1:18 PM:

    Great article. Am looking for a link to forward to some of my friends on my email list!

  • Denise Shungu on June 21, 2013 3:03 PM:

    Something you almost completely leave out of this thoughtful article is the student loans from the 4 years of medical school and sometimes of college as well. If you would cancel half of the loans for anyone going into Family medicine or whatever the Primary Care is called, you would have many more students who would take that specialty and residency programs would be forced to change because of increased demand.

    My own son who is doing his residency in Primary Care at Thomas Jefferson was able to able to do this because he received a full tuition scholarship to a medical school. His fiancee who had both college loans and medical school loans felt forced to choose a specialty.

  • Bohdan A Oryshkevich, MD, MPH on June 21, 2013 6:10 PM:

    This is a great article. It hits the problem right on the head.

    I would have put a bit more emphasis on the financing of medical education as part of the strategy of acclimatizing medical residents to choosing procedure oriented specialties.

    The Wright Center program is great, but such programs are not likely to produce the numbers of primary care physicians that we need.

    Second, in the process of promoting primary care, we should not demonize specialists. We need them also but perhaps in not such great numbers. They need to be part of the solution.

    Something has to give.

    Bohdan A Oryshkevich, MD, MPH
    New York City

  • Robert C. Bowman, M.D. on June 22, 2013 2:08 AM:

    Common sense indicates specific solutions for primary care and a need for departures from the last 30 years of stagnation. This collaboration has taken a step closer to a specific design.

    Specific preparation for primary care begins as an employee or volunteer in a site focused upon health access.

    Specific training for primary care involves medical school and residency at the health access site.

    Specific primary care result at the current time is seen in 90% of family physicians who resist departure from primary care over their careers - despite adverse policy.

    Hospital and subspecialty preparation and training plus training that is flexible in primary care career result plus national health policy designs fail most Americans in their basic health access needs.

  • Anonymous on June 24, 2013 3:26 PM:

    Why no mention of nurse practicioners are primary care providers?

  • American Association of Colleges of Osteopathic Medicine (AACOM) on June 27, 2013 1:11 PM:

    This article discusses several important concerns surrounding the primary care physician workforce shortage facing the nation. The American Association of Colleges of Osteopathic Medicine (AACOM) agrees with the writer, Mr. Phillip Longman, that the nationwide gap between primary care need and availability is a critical issue and that the need to develop solutions has never been more important. However, we feel that the ongoing efforts put forth by AACOM and its member colleges of osteopathic medicine to address the primary care physician shortage are essential to finding a solution to this crisis.

    In the U.S. today, more than 20 percent of medical students are training to become osteopathic physicians (DOs). While osteopathic medical students may pursue any medical specialty, more than 40 percent of these students enter into a primary care or family medicine residency.

    Currently, there are 29 colleges of osteopathic medicine in the U.S., offering instruction at 37 locations in 28 states, with many of these campuses situated in medically underserved areas highlighted in “First Teach No Harm.” According to data published in the April 2012 issue of Academic Medicine on physician supply in Appalachia, three of the nation’s colleges of osteopathic medicine fall within the top 10 U.S. medical schools supplying the most graduates to the primary care workforce in at-risk counties in Appalachia (as of 2009). These schools are the West Virginia School of Osteopathic Medicine (WVSOM), the University of Pikeville Kentucky College of Osteopathic Medicine (UP-KYCOM), and the Ohio University Heritage College of Osteopathic Medicine (OU-HCOM). Taking this data into account, along with the more than 40 percent of all DO graduates who accept primary care residencies, compounded with the rising total number of osteopathic medical school graduates each year, it is clear that osteopathic medical schools play a key role in increasing the number of medical students entering into primary care residencies, thus are integral in developing a stronger primary care workforce, particularly in medically underserved and at-risk regions.

    Through our advocacy efforts, AACOM strongly supports legislative initiatives that establish and implement innovative and cost-effective solutions to strengthen the nation’s primary care physician workforce. Recently, AACOM endorsed its support of the “Building a Health Care Workforce for the Future Act.” This legislation supports, among other priorities, the expansion of programs such as the National Health Service Corps (NHSC) Scholarship Program, which incentivizes primary care residency training in underserved areas. AACOM also strongly supports the continuation and sustainment of the Health Resources and Services Administration’s (HRSA) Teaching Health Center Graduate Medical Education (GME) Program, which increases opportunities for primary care GME, sets a strong precedent to fund GME outside of the traditional Centers for Medicare & Medicaid Services funding stream, and creates new avenues for training medical residents in community-based, non-hospital settings.

    AACOM and the osteopathic medical education community are dedicated to ensuring a well-trained physician workforce capable of meeting the current and impending health care needs of the nation. For more information, please contact Lindsey Jurd, AACOM editor and communications associate, at ljurd@aacom.org.

  • Mark Asplund on July 02, 2013 10:00 AM:

    Great article although it leaves out that it is actually medicare and medicaid that pay for medical students to become actual doctors..

    Not many people realize that is why they are expected to treat medicare and medicaid patient for less. They are essentially expected to "pay back" the cost of their 1/2 million in training.. Anyone who has a mortgage or a car loan that you pay back about 2x the cost

    So any doc's who opt out of medicare and medicaid are breaking their trust with US taxpayers and should be required to pay back in full (interest plus pentalty) or at the very least make this exchange of training for profession a legally binding document.

    We could easily shift the % paid to residents and give family practice docs 80k a year vs the typical 50k in residency and cut the $ to specality providers

  • jim jaffe on July 02, 2013 1:46 PM:

    while most of your subsidiary criticisms are on point, the basic one is flawed. America does NOT face a physician shortage. The ratio between physicians and patients has been improving for years. The ratio between primary care physicians and patients has been also, albeit more slowly. The explosion of walk-in doc-in-box operation gives patients easier access than ever before.

    The only thing a rising physician supply will give us is a larger national medical bill. As Wennberg and others have been documenting for years, enlarging the physician supply simply increases costs without improving health status.

    It makes more sense to let supply shrink and take up the slack with cheaper, but competent folks like nurse practitioners and physician assistants.

  • Atul Grover, Chief Public Policy Officer, Association of American Medical Colleges on July 02, 2013 3:27 PM:

    The AAMC is very disappointed that Mr. Longman did not contact the AAMC for information or comment when he was writing his article. We are writing to clarify a number of important points that his article fails to reflect.

    Read the rest of Dr. Grover's comment here.

  • Ashfaq Khan on July 04, 2013 1:44 PM:

    In this country a primary care physician cannot work without some assistance from a specialist. Mal practice environment potentates this to a greater extent. Non MD/DOs can fill the gap easily on a day to day general practice work. Modern day stethoscope is imaging (X ray,ultrasound and CT machines)making diagnostic decisions on the basis of clinical skills is not the standard of care in USA. We need a balance approach to address the issue.

  • Leena Varughese MD on July 07, 2013 12:11 AM:

    Well-written article from a concerned citizen regarding the state of graduate medical education that explores several areas of problems in graduate medical education. It's important to recognize that great harm comes from the lack of oversight in medical education system and it's a runaway gravy train for major hospitals, where 500k dollars is a conservative estimate of the funding and profitability and value of each medical resident. Clearly, many programs are using the system to enrich themselves, rather than teach residents in residency programs. The program directors do not prioritize teaching residents but utilizes the system to systematically misguide, not teach, and obfuscate appropriate diagnostic information from medical residents. I have certainly experienced this while I was at Mount Sinai Medical Center/ Mount Sinai Hospital in NYC doing Anatomic and Clinical Pathology residency program.

  • BSatiani on July 16, 2013 12:50 PM:

    There is no doubt that the impact of the shortage of all physicians is going to be felt even more with the entry of millions into the elective pool of patients. I also completely agree that throwing more money at the problem without much more accountability from teaching hospitals would be wrong.
    However, the article is simply myopic as Atul Grover implies and denies any impact of specialists shortages. We have documented the upcoming shortages in surgical specialties. Until we have disruptive models of surgical care, with the aging population there is no substitute for these specialists using NP's and PA's. His statement "inflate health care spending by engaging in massive amounts of unnecessary surgery and other forms of over-treatment" is offensive to most specialists who are honest and follow guidelines.I assume primary care physicians have some bad apples as well.
    The best solution for primary care shortages is to not only encourage our residents to enter the field but open up many more NP and PA schools. Much as the author won't like the solution, they are much cheaper to train and can provide the same care to a large percentage of the population. Hence, the entry of CVS/Walmart into the field employing NP's and PA's and now branching into chronic diseases. Why not?

  • Frustrated primary doc on July 16, 2013 6:38 PM:

    1) Documentation is stifling: in order to get paid for the time and effort I put into caring for a patient, I have to document a lot a boat load of information to prove the complexity of the visit I coded for. In addition to the documentation for each visit I get a mountain of forms via fax from insurance companies, drug companies and pharmacies to substantiate the Rx's I write or to tell me to consider a drug from another company, one that gives the insurance company a discount.

    2) Every one want's to abuse the system and it seems the Medicare is putting the burden of policing this on the primary care doc in the way of forms to fill out.

    3) Specialists dump on the primary care doc. A patient gets wrist surgery etc and needs needs his workman's comp form filled out, and the surgeon tells the patient "take it to your primary care doc". Dermatologist does surgery on a patient and if the patient has a problem after hours, on the weekend, has a recording that says, call your primary care doc. Patient's surgeon does surgery on a patient's back and tell him, "my work is done, call you primary care doc if you need pain pills".

    4) Copays are ever higher so patient's want to squeeze ever so much into every visit which goes on longer and longer. But the reimbursement is capped by the coding requirements.

    The time I spend with all this paper work is without reimbursement, yet my nurses want to be paid for the overtime they put in.

    I became a doc to care for people not to push paper or be a Medicare cop or Specialists' scut monkey. And if pushing paper & being a scut monkey paid, I continue but it doesn't.

    I introduced myself to a new radiologist at the hospital while going over X-rays and he asked what specialty I was in, I told him and he responds "oh my god the paper work" My feelings exactly. It is the real reason for the primary care doc shortage. The answer: just as in anesthesiology: one doc who sees a few patients but manages a large team of nurse practitioners and PA's.

    I can't wait to get out. I can't retire, but I'm going to work part time to at least enjoy my sanity.