Correspondence
Who Will Pay for Graduate Medical Education?
N Engl J Med 1998; 339:52-53July 2, 1998
- Article
To the Editor:
Iglehart's analysis of government support for graduate medical education (Feb. 5 issue)1 contains a quotation from Gail Wilensky. The critical question she raises deserves a vigorous response: Why should the government, or for that matter the insurance industry, support graduate medical education? Her statement makes it sound as though no profession other than medicine receives the equivalent of postgraduate support. How wrong she is! Who supports the work of the countless number of legal clerks for the judiciary? Who supports government interns? Does she not recognize that the largest program for training commercial jet pilots is conducted through the military, not through private courses?
The reasons to support graduate medical education are clear: It is not the same as medical school. It is a form of on-the-job training (where work requires fair pay), but one that requires time- and labor-intensive infrastructure. No one expects physicians directly out of medical school to function as the primary health care providers for the American public.
The public and those who pay for their health care expect decisions about that care to be based on quality and cost effectiveness, and the judgment necessary to make those decisions can be developed only with time and close educational feedback.
The argument supporting government subsidies for graduate medical education is a strong one, and in fact, the private insurance industry, as a beneficiary of this expertise, should contribute, too.
1 ReferencesJeffrey L. Kaufman, M.D.
Baystate Medical Center, Springfield, MA 011991
Iglehart JK . Medicare and graduate medical education. N Engl J Med 1998;338:402-407
Full Text | Web of Science | Medline
To the Editor:
Graduate students in law, engineering, and business generally complete their studies and are employed within five years of completing their undergraduate education. Medical residents, on the other hand, have already completed their four years of graduate education. Often they have borrowed heavily to finance their tuition and living expenses during medical school. They must complete postgraduate education (sometimes lasting as long as six or seven years) before they can begin to practice. They are heavily in debt already and are providing a valuable service to the community. I think Dr. Wilensky makes a specious comparison to bolster her claim that education for residents should not be subsidized.
Joan Venes, M.D.
University of Michigan, Ann Arbor, MI 48109Mr. Iglehart referred this correspondence to Dr. Wilensky, who replies as follows:
To the Editor: Let me try to make my position clear on Medicare's subsidization of graduate medical education, although I doubt it will change the opinions of Drs. Kaufman and Venes.
First, we have a substantial, if not excess, supply of physicians, particularly specialists. Second, Dr. Kaufman's comments notwithstanding, it is unusual for the federal government to subsidize postgraduate training. To the extent that the government wants to ensure an adequate number of physicians in particular specialties or located in particular parts of the country, it would make more sense to provide grants or low-cost loans to physicians who agreed to whatever terms accompanied the monies than to provide institutions with the funding and then try to direct them to pursue particular training programs. If the government is concerned that disadvantaged students would be unable to participate in lengthy residency programs, it can and should make loans or grants available to such students.
Dr. Kaufman's examples are not at all analogous to the government's support of graduate medical education. Judges (who are direct government employees) have an amount of money allocated to hire administrative and legal staff to support their judicial activities. These are low-paid, high-prestige jobs offered to what are usually but not always new lawyers and involve no more than 5 percent of new lawyers. Government offices are sometimes able to use special funds set aside for summer interns or the Presidential Management Intern Program for master's-level graduates to provide them with experience in several government offices. These programs are also opportunities for young people to be exposed to government service as part of a time-limited job. Finally, the military's training of pilots is for its own use and is not done as a service for commercial airlines.
We need physicians to have postgraduate training for many specialties, although it is not certain that some of the training couldn't be shorter and more focused. Physicians in training provide services for which they should be paid, and they are. They also receive training, for which they should pay. If they did, it would probably force a reconsideration of the length and content of residency programs. Disadvantaged physicians, physicians in certain specialties, or physicians willing to practice in areas where there is a shortage of care could receive grants, loans, or loan forgiveness from the federal government. It would take several years to be able to move in an orderly way from the current Medicare subsidies to institutions for graduate medical education to a system that focused on individuals, but it would be a much more rational and consistent use of federal funds.
Gail R. Wilensky, Ph.D.
Project Hope, Bethesda, MD 20814-6133- Citing Articles (4)
Citing Articles
1
Richard J. Shemin, John S. Ikonomidis. (2012) Thoracic Surgery Workforce: Report of STS/AATS Thoracic Surgery Practice and Access Task Force—Snapshot 2010. The Journal of Thoracic and Cardiovascular Surgery 143:1, 39-46.e6
CrossRef2
Judith Green-McKenzie, Edward A. Emmett. (2006) Outcomes From the Occupational Physicians Scholarship Fund: Private Support for Physician Residency Training. Journal of Occupational and Environmental Medicine 48:5, 513-522
CrossRef3
Richard J. Shemin, Stanley W. Dziuban, Larry R. Kaiser, James E. Lowe, William C. Nugent, Mehmet C. Oz, Donald A. Turney, Jaimie K. Wallace. (2002) Thoracic surgery workforce: snapshot at the end of the twentieth century and implications for the new millennium. The Annals of Thoracic Surgery 73:6, 2014-2032
CrossRef4
Edward A. Emmett, Judith Green-McKenzie. (2001) External Practicum-Year Residency Training in Occupational and Environmental Medicine: The University of Pennsylvania Medical Center Program. Journal of Occupational and Environmental Medicine 43:5, 501-511
CrossRef
