Correspondence
The Physician Work Force in the United States
N Engl J Med 1996; 335:598-599August 22, 1996
- Article
To the Editor:
Rivo and Kindig (April 4 issue)1 provide a report card on the physician work force in the United States. Evidently, the residency programs in certain urban areas do not have the educational quality to attract the best residents, perhaps because they are used primarily for service. If the federal government, through Medicare and Medicaid, is indeed subsidizing residency positions at $70,000 per year per resident, the redirection of this money should permit the hiring of full-time, salaried, licensed doctors to meet the service needs.
The accreditation of residencies is the key to the future allocation of our physician work force to primary care or procedure-oriented specialties, as well as the geographic distribution of practitioners and whether there are reasonably uniform national standards of care. Even if we had the right number of residency positions in the right proportion and locations to meet our needs, it is doubtful that the graduating classes would fill all the positions each year voluntarily. The only way to make that happen would be to mandate that all graduates take a year of primary care residency before going on to a secondary specialty or to the completion of the remainder of their primary care training. Providing an earlier practice option in this way (two more years of residency for primary care vs. four years for others) would persuade larger numbers to elect primary care.
1 ReferencesE. Wayne Martz, M.D.
, Wilmington, DE 198061
Rivo ML ,Kindig DA . A report card on the physician work force in the United States. N Engl J Med 1996;334:892-896
Full Text | Web of Science | Medline
To the Editor:
Rivo and Kindig state that graduates of foreign medical schools who are in residency training programs are congregated in five states: Michigan, Illinois, New York, New Jersey, and Pennsylvania. These states all have enormous indigent populations in their cities. Their inner-city hospitals, however, have chronically lacked American medical school graduates to work in them; they depend on residents who are graduates of foreign medical schools.
This situation is an old one. In 1975, when I was secretary–treasurer of the Committee of Interns and Residents, the union represented 3500 residents in city and nonprofit hospitals in New York City. In many of the city hospitals and poorer nonprofit hospitals, 90 percent or more of the residents were graduates of foreign medical schools. At that time, a new law authorized the U.S. secretary of state to curtail sharply the immigration of graduates of foreign medical schools into this country. This would have had a severe negative impact on the ability of inner-city hospitals to care for indigent populations, but the crisis was averted. Graduates of foreign medical schools continued to staff these hospitals, and they still provide care in difficult situations.
Since 1975, no planning has been done. Attitudes of medical students have not changed enough to increase the numbers who train in inner-city hospitals. Nothing has been done to address the continued use of graduates of foreign medical schools to staff inner-city hospitals. These hospitals are threatened with cuts in funds from Medicare, Medicaid, and other sources. Who will plan for dramatic change? Where will the new physicians come from? Who will provide the desperately needed care for poor people?
Irwin Abraham, M.D.
2128 East Henrietta Rd., Rochester, NY 14623To the Editor:
In his editorial on the physician work force (April 4 issue),1 Mullan has in at least one specific area diluted the policy debate. He states, “A growing number of analysts and commentators — and, more recently, Congress itself — have questioned the wisdom of paying more than $6 billion a year (an average of $70,000 per resident) to teaching hospitals to support graduate medical education.”
Mullan misleads in citing this statistic. In fiscal year 1995, only one third of this amount, or about $2 billion, supported the direct costs of graduate medical education. Too often those engaged in the policy debate fail to distinguish between the two Medicare payments with an “education” label. Direct payments for graduate medical education include Medicare's proportionate share of the salaries and fringe benefits of residents and fellows and the faculty who supervise them, clerical support, other direct costs, and allocated overhead costs such as those of electricity and maintenance. The Medicare program recognizes the higher costs of teaching hospitals through a payment called the indirect medical-education adjustment, which at $4 billion in fiscal year 1995 provides substantial support for teaching hospitals' operational functions. To maintain that this latter pool of dollars is totally devoted to supporting graduate medical education is simply not accurate. These funds are necessary, in part, to provide services to the sicker patients in teaching hospitals.
1 ReferencesRichard M. Knapp, Ph.D.
Association of American Medical Colleges, Washington, DC 20037-11251
Mullan F . Graduate medical education and water in the soup. N Engl J Med 1996;334:916-917
Full Text | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: A mandatory year of primary care training for all residents, as proposed by Dr. Martz, could be a valid approach to improving physician knowledge of and attitudes toward primary care and the role of the generalist physician. However, it may not encourage more residents to choose generalist careers and would lengthen training for those pursuing other specialties. We share Dr. Abraham's concern that the elimination of excess resident positions may reduce care of the medically underserved. Such reductions in the numbers of resident slots must be accompanied by other plans to provide care. Strategies may include transitional funding to teaching institutions that reduce the number of resident positions and increased funding for replacement physicians and other health professionals through the National Health Service Corps. We also recognize that policies are available to expand health care to the medically uninsured that are more direct and cost effective than providing incentives to hospitals to recruit and train graduates of foreign medical schools.
As Dr. Abraham notes, many of these problems (and solutions) are not new. The historic transformation of health care structure, delivery, and financing requires changes of similar magnitude in academic medicine to increase its value to society.1 Changes in the financing of medical education would help academic medicine move training more rapidly from the hospital to community, primary, and managed-care settings. In the meantime, physicians in medical schools and in the community, students, and residents should carefully monitor changes in the health care marketplace and both teach and acquire the requisite competencies for quality and cost-effective practice.
1 ReferencesMarc L. Rivo, M.D., M.P.H.
PCA Health Plans of Florida, Miami, FL 33126David A. Kindig, M.D., Ph.D.
University of Wisconsin School of Medicine, Madison, WI 537061
Cohen JJ . Learning to care, for a healthier tomorrow. Acad Med 1996;71:121-125
CrossRef | Web of Science | Medline
Author/Editor Response
Dr. Knapp is correct in citing the differences in origin and intent between the direct and indirect payments for medical education that Medicare makes to teaching hospitals. Notwithstanding origin and intent, however, both types of payments are made to institutions on the basis of the numbers of interns, residents, and fellows that they employ, rendering both types of payments powerful incentives for the expansion of house-staff positions — a phenomenon that has, indeed, taken place in recent years.1 The indirect funds are, as Dr. Knapp notes, twice the size of the direct payments for medical education. This mattered little when the continued growth of the physician work force was deemed a national asset. Faced now with an impending surplus of physicians, it is not possible for medical educators and policy makers to segregate the indirect payments and ignore their power as a stimulant to house-staff hiring and, ultimately, their role in determining the size of the physician work force.
The problem with the current system of indirect payments is that the funds are not apportioned on the basis of the purpose for which they were legislated — to compensate for the greater intensity of care and amounts of uncompensated care that certain institutions provide. Although the use of the ratio of interns and residents to beds in an institution may once have served as a convenient, if imprecise, proxy for those hospitals treating sicker and poorer patients, this convention now also reflects the overgrowth and overspecialization of the physician work force. The best bet for preserving these funds is to clarify their purpose and to modify their apportionment to meet clear and current policy goals such as those proposed by the Council on Graduate Medical Education.2
2 ReferencesFitzhugh Mullan, M.D.
, Bethesda, MD 208141
Rivo ML ,Kindig DA . A report card on the physician work force in the United States. N Engl J Med 1996;334:892-896
Full Text | Web of Science | Medline2
Council on Graduate Medical Education. Seventh report: COGME 1995 physician workforce funding recommendations for Department of Health and Human Services' programs. Washington, D.C.: Department of Health and Human Services, 1995.
