First Teach No Harm

Jun 20, 2013 by

The U.S. spends $13 billion a year subsidizing graduate medical education. Yet almost all of this money winds up producing the wrong kinds of doctors in the wrong places, with America’s most elite teaching hospitals being the worst offenders.

By Phillip Longman

Perhaps you’ve noticed their full-page ads in your local newspaper. In late 2012, a new series began showing an anesthetized woman laid out on an operating table. The stark headline reads “BE CAREFUL WHAT YOU CUT.” The ad goes on to explain: “Reducing the deficit is essential. But at a time when our nation faces a critical shortage of doctors, cutting federal support for doctor training will jeopardize access to care and turn back the clock on life-saving cures and medical discoveries.”

These ads are brought to you by the Association of American Medical Colleges and are part of an extensive lobbying and public relations effort. At issue are some $13 billion in government subsidies that flow each year to medical residency programs, such as the kind depicted in the long-running, popular TV series Scrubs.

Under America’s system for educating doctors, medical school graduates may not practice on their own until they have first completed a period of on-the-job training know as residency, which typically last three to five years. Such training usually occurs in so-called “teaching hospitals” or academic medical centers, which offer residency slots in various specialty areas of medicine, such as dermatology or cardiology. If you’ve ever been treated in a teaching hospital, you may well have seen the drill in which a gray-haired attending physician comes to your bedside surrounded by a group of twentysomethings whom he quizzes about the lessons of your case.

Typically, teaching hospitals and other sponsors of residency programs receive subsidies amounting to about $100,000 per year for every resident they enroll, with about half of that going to the residents themselves in the form of stipends. Add in the additional money flowing from state Medicaid programs, and the public cost of residency programs comes to about $500,000 for every physician the hospitals produce.

The AAMC and its allies are very intent that Congress not cut these subsidies, and, indeed, want them raised. Without greater subsidies, the AAMC argues, America will face a shortage of 91,500 doctors by 2020. Just in case you don’t get the intended message, a video produced by the AAMC explains that unless the feds put more money into residency programs, Obamacare will bring “insurance in name only.”

But there is a big problem with this argument. America does indeed face a looming shortage of medical professionals, but because of the way it’s spent, that $13 billion subsidy isn’t helping us fill the gap. The nation’s residency programs are producing too many of the wrong kinds of doctors in the wrong places, while not producing enough of the kinds of doctors we most need to sustain the U.S. health care system.

Specifically, the programs turn out too many specialists who go on to practice in places where such doctors are already in oversupply, and where, according to numerous studies, they often inflate health care spending by engaging in massive amounts of unnecessary surgery and other forms of over-treatment. Meanwhile, residency programs are producing a dwindling number of primary care physicians and other generalists, who are already in chronically short supply in most parts of the country and are desperately needed to implement the kind of reforms to the health care delivery system necessary to improve its quality and efficiency.

Many hospitals and other health care providers are making strides in implementing best practices in medicine. But these reforms can only go so far as long as our system of graduate medical education remains increasingly out of sync with the kind of health care workforce the country actually needs. Unless Congress faces down the demands for more subsidies coming from the AAMC and its allies, and the public starts holding them accountable for the outcomes they produce with taxpayer money, the problem will only get worse.

Overwhelmingly, the greatest shortages of doctors today are primary care physicians and other generalists. According to a recent survey sponsored by the independent congressional agency MedPAC, finding a primary care doctor is highly problematic even for Americans with good health insurance. Among fully insured Americans over the age of fifty who went looking for a primary care doctor last year, fully one out of seven report it was a “big problem.” This is double the percent who report having trouble finding a specialist. Even in affluent parts of the country, finding a primary care doctor who is still taking new patients can require as much scheming as getting your three-year-old into Montessori. In rural and poor inner-city areas, it’s often well nigh impossible. Nearly sixty million Americans—almost one out of five—live in regions or neighborhoods designated by the federal government as primary care shortage areas.

And on current course, these shortages are about to get much more acute. As the Affordable Care Act extends health insurance coverage to thirty-two million more Americans, this alone will increase the need for primary care physicians from 25,000 to an estimated 45,000 by 2020. Meanwhile, studies predict that the aging of the Baby Boom generation will leave the country short another 35,000 to 44,000 primary care doctors. Yet our current residency programs are producing about 40 percent fewer new primary care doctors than are needed even to replace those who are currently practicing as they retire or move to other areas of medicine.

Part of the problem is that, due largely to the political power of specialists, the reimbursement rates paid by Medicare and private insurance are set far higher for specialists than for primary care doctors (for more, see “What the RUC?”). But our system for training doctors is also deeply at fault, with the country’s most elite and deeply subsidized teaching hospitals being by far the worst offenders. In the tables below, we show the nation’s largest residency programs ranked according to the percentage of primary care doctors they produce. At the top of the list are the University of Nevada School of Medicine and the Bronx-Lebanon Hospital Center. Among the residency programs sponsored by these institutions, half or more of their graduates go into primary care. These institutions may not score high on the annual rankings of the most prestigious hospitals put together by the U.S. News & World Report, but they clearly deserve to be celebrated for doing more than their part to reduce the nation’s acute shortage of primary care doctors. At the bottom of the list, by contrast, are some of America’s most prestigious medical institutions. For all the federal subsidies they receive, most are barely in the business of training primary care doctors.

Data from the Graham Center. Explore further using their online tool.

At second-to-last place, for example, is Massachusetts General Hospital, the flagship of Boston’s medical establishment. Despite receiving more than $85 million a year in taxpayer subsidies for its residency program, Mass General does an abysmal job of turning out the kinds of doctors in shortest supply. Of the 848 residents who completed training at the hospital between 2006 and 2008, only 6.49 percent went into primary care. Of all the graduates of Mass General’s residency programs, exactly none went on to practice in a federally designated rural health clinic (RHC), and only one went on to practice in a federally qualified public health clinic (FQHC), which is the kind of health care facility most needed to accommodate the tens of millions of Americans who will soon be gaining health insurance through Obamacare.

via First Teach No Harm by Phillip Longman | The Washington Monthly.

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