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How do we fix medical education?

In a recent issue of the GME e-Letter, we described the many stresses facing our medical education system and reiterated the need to lift the cap on residency program slots to ensure that our nation has enough physicians. Following are edited responses on this topic from our readers.

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The last time the federal government took any action regarding limits on Medicare-funded residency slots, they redistributed unused resident positions, but with a 50 percent reduction in the Indirect Medical Education reimbursement rate. Don't be surprised if the feds take this same approach in response to the clamor for lifting the cap -- 15,000 new positions, but all funded at 50 percent of the current rate.  
 
The number of MD and DO graduates from US schools will soon exceed the number of first-year resident positions offered in the Match. When US grads cannot find resident positions it seems unlikely the Match will survive.
 
Further, what are the legal ramifications of foreign nationals obtaining jobs through the Match while qualified US citizens are left on the sidelines? Sounds like a field day for the lawyers. Maybe there is still time to go to law school. 
 
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As we look at ways to increase the number of primary care physicians, one must take a real hard look at internal medicine-pediatrics, which cross-trains physicians in pediatrics, internal medicine, geriatrics, adolescent medicine, and transitional care medicine.
 
This is an important field when one looks at the role of gatekeeper and considers the depth and breath of the chronic disease burden facing multiple generations. Physicians with this training are uniquely positioned to lead the fight against childhood obesity, diabetes, congenital diseases, and genetic issues. It is often overshadowed by family medicine not in content nor degree of training of training but simply by being outnumbered. Used to its fullest, internal medicine-pediatrics can have a great impact on the diseases and illnesses affecting our nation.

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Of course every problem has many facets. I would just like to point to a few facets of the primary care physician shortage that would be made worse by a global increase in "primary care" residency slots. I would postulate that internal medicine residencies do not produce "primary care physicians," since the vast majority of internists will subspecialize and turn away patients who want a primary care doctor. I would also postulate that pediatrics has the same problem, but with a slightly smaller majority subspecializing.

Family medicine has consistently provided dedicated primary care and rural care doctors for this country but has consistently been discouraged as a specialty for US students to choose. Furthermore, family medicine residency slots go unfilled each year, and the overall goal of teaching and producing family physicians has been consistently discouraged by academic medicine (which insists on teaching medical students almost exclusively in hospital settings), organized medicine (which overrepresents subspecialists in all arguments regarding value to society, value to individuals, and value to the profession as a whole), and most public and private payers (through direct discrimination that a minute of one doctor’s time is worth only a tiny fraction of a minute of another doctor’s time.)

I wish someone could write me with something that would disprove any of the above, or which would predict a decrease in the primary care shortage in this country, but until all of these health care organizations begin to value primary care family medicine for its emphasis on longitudinal prevention, chronic disease control, and public health at lower costs, I do not think things will improve in this country.

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The American Academy of Pediatrics, in collaboration with two other prominent pediatric organizations (the Association of Medical School Pediatric Department Chairs and the Association of Pediatric Program Directors) weighed in on proposed Amendment 2909 with a perspective that is unique to pediatrics.

Throughout this past decade, the Maternal and Child Health Bureau has documented that across the United States access to pediatric subspecialty care has faltered. Chronic conditions, including autism, obesity, and asthma, to name just three, are increasingly prevalent. Medical and surgical advances have extended the life expectancy of many children with complex conditions. Contributing factors, ranging from low birth-weight to violence and abuse, continue to persist. All of these contribute to an increasing need at a time when we are facing a declining supply of pediatric medical subspecialists and pediatric surgical specialists.

The Senate is striving to approve legislation that would expand health care coverage to millions of individuals presently uninsured, including our vulnerable population of children. We need to ensure that there are adequate numbers of primary care physicians, including pediatricians, pediatric surgical subspecialists, and surgical specialists, to meet this need. Increasing the number of GME positions, with appropriate funding, will help us meet these needs and work toward providing an adequate physician workforce for children.

Still, we cannot overlook the glaring financial gaps that contribute to our physician shortages. The remuneration for physicians entering all pediatric careers is substantially less than for physicians in comparable adult specialties, despite the same or greater investment of time and money for education and similar practice workloads. This problem is particularly acute for the non-procedural pediatric medical subspecialists and pediatric surgical specialists, creating significant recruiting challenges that an increase in GME positions alone will not ameliorate.
 
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I have a daughter who's a junior in college and hoping to go on to medical school. The idea that we've spent $35,000 a year for undergraduate school, followed by the highly competitive medical school application process and those related costs, makes me feel ill when I hear that MD grads cannot get a residency position.

I understand the need to educate grads from around the world, but my experience is they come here not just for the education to take those learned skills back home, but to stay in the U.S. When I worked in GME, seldom did any of our IMG grads go “home.” Positions can be "created" in the current system, regardless of visa status—“employers” just create a job posting that is very specific to the international graduate they want to keep, which allows them to stay in the U.S. for good. It doesn't take much to realize that our own graduates can lose out in the competition for positions, based not on merit, but on ethnicity and the institution’s desire to promote diversity and look good on paper; this applies to medical schools and residency programs as well.

In addition, because our American fellows had undergraduate and medical school bills to pay, once they finished with residency, they were broke and in the hole financially. We had people decide not to pursue a career in a subspecialty, even though that was their goal, because it meant another three to four years of more loans. I did not see the same financial struggle with international fellows; often their countries supplemented their needs and had paid for their medical educations! Many IMGs also managed to obtain waivers of the requirement to return to their home countries for two years by paying a small fee (depending on country). When we allow this to happen, we are removing our own citizens from the possibility of obtaining these jobs and putting our own youth at a disadvantage in the competition for a career in medicine. 

At some point, we need to recognize that our own youths’ education should be our priority, like other countries do. We should reform the system so they do not have to worry about the financial costs of education and then have to compete with mediocre offshore applicants (which many of our rural areas are accepting) or international students. We should educate our own first, and if there are positions left open to fill in programs or jobs, then offer those up to the best applicants.

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Americans want medical care by American doctors. They want their doctor to speak English, to understand them easily, to know their culture. The sick should not be forced to adapt to diversity. I believe it is time to limit the influx of international medical graduates.

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I have not yet heard anyone address how teaching faculty, who are already struggling under heavy patient loads that cause them to limit their teaching time, will find the time to teach more residents and manage more patients if and when health system reform is implemented. Every American should have access to good quality care, but if this problem is not solved it seems to me that resident education and the work environment will continue to deteriorate. Will GME see more doctors throwing in the towel and going into private practice? Everyone is focusing on patient care and increasing caps—what about teaching and education? Good teachers are becoming extinct, and we need to increase the teacher supply chain. If residents are not properly taught, the doctors that we will produce will be a threat to society.

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We see some really horrible graduates of Caribbean medical schools who should never be doctors—we shouldn’t increase GME slots for them. We don’t owe them the opportunity to become U.S. physicians.
 
There is concern as well that increased funding will only increase the number of non-primary care specialty spots, perpetuating the imbalance that is driving up U.S. health care costs.
 
Nonetheless, we would love to see more and better funding—we are underfunded here in our rural family medicine program. Almost all of our residents hold J-1 visas, and we are able to pick the best and the brightest from all over the world. We have seen applications grow markedly but not from domestic grads.
 
Again, the nation needs to have some structured way of getting more individuals into more primary care slots.
 
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I would lift caps on primary care (medicine, family practice, pediatrics, geriatrics, even perhaps general surgery) but absolutely not on fellowships or surgical subspecialties. Why increase the already severe imbalance?

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It seems intuitively obvious that you can’t offer to provide health care to 30 million Americans not receiving health care now without training more physicians. If a primary care provider can handle a patient pool of 3,000 at the most, then we need a minimum of 10,000 additional primary care physicians, not to mention the corresponding number of subspecialists.

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I was forced to leave the country and study abroad to become a physician. I was born here and served my country—still no deal! There is too much red tape in our medical education system, and now our country is losing ground in the medical field. We deserve that for not helping dedicated U.S.-born IMGs. In short, I am very disgruntled.