We Need a Revolution in Physician Training to Promote Efficient Care

After four years of medical school, physicians enter that "twilight zone" known as residency training.  This intensive, hazing-like program of on-the-job training is characterized by very long hours and increasing levels of responsibility.  I'm sure many readers have been in the great teaching hospitals that are bursting at the seams with residents.  However, even the most educated people oftentimes have no idea that they are not only paying for this training, but they're sometimes getting a raw deal to boot!

Post-medical school training, called Graduate Medical Education, or GME, is primarily funded with public money, to the tune of $10 billion dollars a year, paid by Medicare.  Your tax dollars, in part, go to pay the salaries of physicians in training.  Currently, the average resident makes $112,642 per year, but on an hourly basis, that's about on par with an unskilled laborer without a high school diploma.

GME is divided into two components.  Direct GME takes up about one-third of the dedicated Medicare funding; that pays for the trainees and the supervising faculty who watch over their work in the hospital.  The other two-thirds is called Indirect GME.  This compensates teaching hospitals for the higher costs associated with training new physicians and for the "lower clinical efficiency" - these new doctors tend to order more tests and are not as efficient as their older, more experienced colleagues.

Among the many challenges presented by this $10 billion dollar tab is the fact that the Affordable Care Act or "Obamacare" allocated no new money to support any aspect of GME funding.  Now, that may not seem like a big problem, but it really is a gigantic challenge moving forward.

It turns out that this GME pipeline is anchored to the numbers of residents that were funded at the time of the passage of the Balanced Budget Act in 1997.  So, despite the fact that most experts agree we need more primary care doctors and even more of certain sub-specialties, the total number of training spots is capped at a level that everyone agrees is too low.

In addition to this arbitrary cap, we have another big problem – residency programs, as long as they remain accredited, get their full amount of funding each year, even if the doctors in training achieve poor clinical outcomes.  Many experts agree that there are deficiencies in the training itself and in the funding mechanism as well.  Are there any opportunities to address these challenges?

One way to address this problem would be to fund GME slots based in part on innovative changes in the training system and improvements in the outcomes of patient care.  What if we were to allocate more money to GME programs where residents do a better job, or to programs where more residents choose primary care specialties?  How about giving more money to residency programs that are preparing doctors to practice in a team setting? All of these proposals are getting more national attention (read more about these proposals at www.healthaffairs.org).

Other experts have called for the creation of yet another public entity in Washington to provide oversight of all of GME.  Leading researchers from Dartmouth Medical School and the Chicago Medical School call for "coordinated public guidance" to address these challenges.  They also have proposed the idea of competitively awarding GME funding, up to a certain percentage, to programs that meet these challenges and actually innovate based on the new needs in the marketplace.

I believe that policymakers in Washington are unlikely to feel sympathy for big teaching hospitals and aren't going to allocate more dollars to pay the salaries of doctors in training anytime soon.  What might work is improving the training itself and competitively seeking more support based on how well those same teaching hospitals can innovate their training programs to better prepare doctors for the future.

Here in Philadelphia, with our great tradition of training a large percentage of all of the doctors in the nation, we could make a big impact on the GME story for the future.  Training the right kind of doctor to meet the needs of the population and perform at a higher level in a team setting seems like an important and laudable goal, especially under reform.  Now we need to incentivize training programs to make some changes in the production process and build a doctor ready to practice more effectively in the 21st century.  I remain hopeful that our great city, with all of its teaching hospitals, is up to this challenge.

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