Correspondence

Redesigning Graduate Medical Education — Location and Content

N Engl J Med 1996; 335:1459-1460November 7, 1996

Article

To the Editor:

Your editorial (Aug. 15 issue)1 addresses critical issues in outpatient training. Having recently finished a training program in neurology, I would emphasize the lack of adequate exposure in such programs to diseases that are now treated in the office. Patients with multiple sclerosis and myasthenia gravis are most often seen by residents when they are admitted to the hospital — that is, when they are already very ill.. Diseases such as these are managed successfully in the outpatient setting, where residents spend little time. I am adequately trained to evaluate and treat patients with acute neurologic diseases, but not those with chronic diseases or diseases curable in ambulatory care settings.

You are correct in suggesting that hospitals should not control the Medicare funds allocated for training. The individual departments should pay the hospital on the basis of the percentage of time faculty members spend teaching on the wards or in hospital-based clinics. The departments should likewise reimburse practitioners who train residents in their offices. This would create an environment in which physicians in private practice would have an incentive to spend extra time teaching, instead of viewing such efforts as lost time and lost money. I believe that the system that trained me was inadequate and needs to be adjusted now, before another generation of physicians completes its residency training with insufficient exposure to outpatients. Where is the powerful lobby of the American Medical Association and other medical societies in the face of a true crisis in graduate medical education?

Daniel M. Feinberg, M.D.
Brigham and Women's Hospital, Boston, MA 02115

1 References

1. 1

   Kassirer JP. Redesigning graduate medical education -- location and content. N Engl J Med 1996;335:507-509
   Full Text | Web of Science | Medline

To the Editor:

Although we agree that it is time for residency training to move beyond the hospital, the alternatives are not limited to ambulatory care. Facilities that provide long-term care, such as nursing homes, hospices, adult day health care centers, and home care programs, are underused teaching sites with important advantages for medical education. Many of the deficiencies of hospital training that result from the increasing emphasis on rapid turnover and the care of extremely sick patients can be remedied by experience in long-term care. In long-term care settings, physicians in training have the opportunity to manage chronic illness, learn the principles of geriatric medicine and rehabilitation, and care for dying patients without an undue emphasis on invasive procedures.

With nursing home beds outnumbering hospital beds by nearly two to one, facilities for long-term care are already important sites for the provision of health care in the United States.1 The rapid growth in the numbers of the oldest old is expected to increase the demand for long-term care dramatically over the next several decades.2 Although considerable effort has already been expended on developing educational programs in nursing homes, only one third of residency programs in internal medicine offer nursing home rotations.3 Formal training in hospice, home care, and adult day health care programs is even more limited.

Carol Joseph, M.D.
Nora Tobin, M.D.
Portland Veterans Affairs Medical Center, Portland, OR 97201

3 References

1. 1

   Schick FL, Schick R, eds. Statistical handbook on aging americans. Phoenix: Oryx Press, 1994:159.
   

2. 2

   Schneider E, Guralnik J. The aging of America: impact on health care costs. JAMA 1990;263:2335-2340
   CrossRef | Web of Science | Medline

3. 3

   Katz PR, Karuza J, Hall N. Residency education in the nursing home: a national survey of internal medicine and family practice programs. J Gen Intern Med 1992;7:52-56
   CrossRef | Web of Science | Medline

To the Editor:

Your editorial recommended that residency training move to ambulatory care sites with a managed-care emphasis, that financing for graduate medical education be restructured to involve a government-mediated program supported by all payers, and that managed-care organizations take more responsibility for medical education.

In 1994 FHP, a for-profit health maintenance organization, started an independent, community-based residency program in family medicine that was approved by the Accreditation Council for Graduate Medical Education. Although first-year residents in most family medicine programs spend one half-day per week in a family practice center, in our program residents see their own patients every weekday at the center. This continuity-of-care experience is more like the real practice of a family physician.

Our program is very popular and competitive, but institutional financial support has fluctuated. During the development phase (1990–1994) FHP's board chairman directed the institutional support actively, but in 1995, when FHP restructured and sold its hospitals, support became tenuous. At present the residency program is supported by a joint agreement between Paracelsus Healthcare Corporation (the buyer of the FHP Hospital in Salt Lake City) and Talbert Medical Group of Utah. Because the program is sponsored by for-profit organizations, it is ineligible for Title VII federal training grants.

We agree with you that federal funds should follow residents as their training moves to ambulatory care sites and that graduate medical education should be funded on an all-payer basis. However, programs such as ours will not prosper if they are excluded from federal training grants because of the for-profit status of their sponsoring institutions.

John W. Robinson, M.D.
Camille Collett, M.D.
David Spendlove, Ph.D.
PHC of Utah Family Medicine Residency, Salt Lake City, Ut 84115

To the Editor:

Once again you have addressed an important issue in American medicine. You recognize the need for graduate and undergraduate medical education to change and for training to shift from hospitals to ambulatory care settings.

I believe you have struck the right note in recommending an all-payer tax through which the entire health care system would contribute to producing the physicians of tomorrow. To expect individual health maintenance organizations or managed-care organizations to accept these costs in a highly competitive environment is unreasonable. Although hospitals previously accepted the costs, they did so during times of cost-plus reimbursement, and they continue to do so when billions of dollars for graduate medical education are forthcoming from Medicare. Graduate medical education is a public good; financing it is the responsibility of all of us.

Leonard A. Katz, M.D.
State University of New York at Buffalo, Buffalo, NY 14202

To the Editor:

Your editorial appropriately points out the very serious challenges to medical education, graduate and undergraduate, in today's radically changing health care system. The call for expanded efforts in ambulatory teaching is well advised, given the shift in the locus of medical care, and the call for federal assistance in financing these changes is well taken, in the context of the dramatic challenges to many sources of revenue at all academic medical centers.

We remain optimistic about the passage of legislation mandating financial support for medical education. Support for medical education made it into the Health Care Reform Act of 1992 and into the Medicare reforms proposed in this session of Congress, but it failed when the legislative proposal as a whole did not pass. It is important to note that there was strong Republican support for graduate medical education and academic health centers.

As you point out, Senator Daniel P. Moynihan (D-N.Y.), the ranking minority member of the Senate Finance Committee and one of the most articulate and tenacious advocates of medical education and academic medical centers, recently introduced a comprehensive bill that should receive serious consideration in the Congress in 1997. Senator Edward M. Kennedy (D-Mass.) and Representatives Nancy L. Johnson (R-Conn.), Benjamin L. Cardin (D-Md.), William Archer (R-Tex.), James McCrery (R-La.), and William M. Thomas (R-Calif.) have added their voices to those of other leaders of both parties who support academic medicine, medical education, and medical research. This is a time for all concerned to lend their voices to the call for such federal support. At risk is not merely the high-quality education of future clinicians, but the strength of the leading medical research enterprise in the world.

Herbert Pardes, M.D.
College of Physicians and Surgeons of Columbia University, New York, NY 10032

Michael Johns, M.D.
Emory University, Atlanta, GA 30322