This is the final installment in a three-part series on major changes in medical education.
As academic medical centers across the nation prepare to perform surgery on graduate medical education, their leaders are trying to be careful not to damage its vital elements.
The University is no exception. This spring, the Hospital's governing board unanimously voted to reduce the size of its residency staff by roughly 30 percent over the next four years. Residents are medical school graduates who spend three to ten years in grueling training.
"It's very easy to say that in concept, but very hard to figure out how to implement," said Dr. Mark Rogers, vice chancellor for health services and executive director of the Hospital.
Among the more difficult issues, academic leaders are trying to figure out how to adjust the number and distribution of generalists and specialists without affecting the quality of American health care and without creating barriers to opportunity. The other problem deals with the controversial issue of cutting the number of international medical school graduates--the main providers of care in the nation's inner-cities--admitted to American residency programs.
Currently, the direct costs of graduate medical education are covered by the Medicare program and traditional insurance revenues. A major portion of these funds support residents' salaries. Combined, these sources provide the University with about $20 million each year. The indirect costs of graduate medical education, which include the intangible costs of training students in a clinical setting, are also covered by the Medicare program.
The pillars of funding are slowly crumbling. Current Congressional proposals to reduce Medicare could cost the Hospital as much as $30 million in direct and indirect costs each year for the next four years, Rogers said. In addition, the 950-bed Hospital is downsizing to about 650 beds over the next several years as managed-care insurers demand a shorter length of stay and more ambulatory care. As a result, fewer residents--whose primary training and service is tending to hospital patients--will be required. These federal and market forces have prompted the Hospital's administrators to reevaluate their residency programs.
"We are now faced with several problems. We are indeed training too many specialists. Some of our residents who are completing training in our outstanding programs are having trouble [finding jobs]," Rogers said.
The Hospital's leadership is trying to adjust without causing larger problems. "If we start removing [resident slots] too fast, we can run into problems with the need to have ever-more experienced [and expensive] other professionals to replace them," Rogers said.
For now, the Hospital's clinical departments have been asked to voluntarily give up slots. There will be a 5 percent voluntary reduction in residency positions in surgery and anesthesiology for next year's class, Rogers said. "We have tried to protect the number of residency slots in internal medicine, pediatric, and family and community medicine since there is clearly a need for these people in our country and our areas," he added. "We will then spend the next year going into detail on how best to make the next round of adjustments."
Despite the market and federal forces demanding change, some medical colleagues are unsure about the need for cuts. Dr. James Bowie, director of the radiology residency program, said he has heard from other programs that employment has been an issue, but "that seems to be overblown a great deal." He added that radiology residents have not had a problem with finding jobs.
Other University medical leaders, while acknowledging the national problem, regretted that Duke is being forced to trim back its programs. "It's unfortunate that a place like Duke, which is very much a leader in all areas of physician training, will have to reduce the number of physicians it trains when we have the faculty, patients and all the other resources to be able to train them," said Dr. Peter Smith, chair of thoracic surgery. "[There are] too many specialists and not enough general physicians, but it's the very nature of Duke to train the best specialists, and for Duke to train fewer specialists makes a small contribution to the national problem."
Dr. Ralph Corey, director of the residency program in internal medicine, expressed similar concerns. "I think a lot of this is a political decision... A small reduction in the subspecialties of medicine is warranted, but I think a large reduction would lose sight of the fact that Duke is a premier institution and that we're going to need subspecialties in the future," Corey said.
Dr. Joseph Reves, chair of anesthesiology, agreed and added that the government should allow institutions like Duke to maintain their programs and close entire programs elsewhere that are deemed marginal in quality or applicant demand. In anesthesiology, for example, 1,400 anesthesiology residency positions exist, but only 240 American medical school graduates applied for these positions last year. The remainder are filled by international medical school graduates. "We think nationally there needs to be a 70 percent reduction [in the number of anesthesiology residency slots]," Reves said.
"It's going to take some hard decisions, but are we going to penalize everybody... or are we going to close medical schools and centers [that are marginal]?" he added.
The danger of allowing such a disparity between the number of positions and the number of applicants, Reves said, is that the quality of physicians in these areas will decline as international medical school graduates, generally considered less qualified, fill them. "I would hate for the American college student to think that there was a glut of physicians [in this country] and therefore decide not to pursue a career in medicine," he added.
The issue of closing U.S. doors to international medical school graduates is controversial. The United States admitted large numbers of them in the 1960s and 1970s when the nation was suffering from a severe shortage of physicians. Now, that has changed, and a proposal that has gained bipartisan support in Congress would cap the number of U.S. resident positions available to 110 percent of the nation's medical school graduates.
This, in turn, would have a dramatic impact on the nation's underserved inner cities, which lack willing doctors and are therefore served by low-salaried international students paid for by the federal government.
Residents receive part of their education through training with physicians, but in the inner cities their training can come entirely from service with less supervision.
"It is not clear that these programs train doctors as well as they need to be trained," said Dan Blazer, dean of medical education.
He added that health-policy makers should examine other options of serving the inner cities "without making them training sites," such as an expansion of the National Health Corps.
"My guess is that if this country has a conscience, [it] might uncouple service from training," Blazer said.
Reves agreed with Blazer, but said that the changes in graduate medical education could be beneficial.
"This [cut in residency slots] forces you to come up with other ways to get the service done... there has to be a different solution other than exploitation of international medical graduates to take care of the underserved in the inner cities," he said.
As a result of uncoupling service from training, medical graduates would receive a better education. "We will focus on [providing] the optimal education and not using them for service... Residents [would] get the more interesting work instead of a lot of the scut kind of stuff," Reves said.
Nevertheless, it is not clear how the nation's inner cities will be served if residency slots are dramatically reduced. "We have overspecialized in this country, but that doesn't mean we have too many doctors," Blazer said.
The next year of intense political debate over the fate of graduate medical education may have important repercussions for the nation's health care. "Market forces are going to be a major factor in the shift [between] generalists and specialists. What does the American public want? Many people are upset that they can't see their specialist [directly]. [It is] far from clear that Americans are willing to give up [their right to see a specialist]," Blazer said.
"I would hope we don't change the way we train our doctors. U.S. physicians are generally thought of as the best doctors in the world."
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