VA cuts specialty residents, increases primary care

Dept. of Veterans Affairs officials say patients are happier because continuity of care is improved.

By Jay Greene, amednews staff. Oct. 15, 2001.

Jason Berendt, MD, splits his residency rotations between the Veterans Affairs Medical Center and MUSC Medical Center, both in Charleston, S.C. While the first-year internal medicine resident hasn't noticed it, he is part of an effort by the Dept. of Veterans Affairs' 172 hospitals and 773 clinics to increase primary care specialists to take care of sicker patients.

Beginning in 1996, the VA embarked on a bold plan to increase primary care residents to 50% of its 8,900 total. As the nation's largest provider of graduate medical education, the VA accounts for 9% of the nation's 98,000 total residents. By 2000, the VA had nearly met its goal, increasing primary care residents to 48% from 38%, according to the Sept. 5 JAMA.

A not so subtle shift
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"When we began, everyone felt we needed more primary care doctors," said Stephanie Pincus, MD, VA's chief academic affiliations officer. "We also were moving inpatients to outpatient venues. Now we are looking at whether realigning the residents had any unanticipated side effects."

While some veterans expressed concerns, patient satisfaction scores went up dramatically at VA Heartland Network, an eight-hospital system based in Kansas City, Mo. "The vets found they see the same doctor every time they come in," said Matthew Kelly, Heartland's deputy director. "The residency realignment has been a positive force because in the old model the patient came in and saw whoever was in that day."

Under VA's residency realignment program, primary care residents increased 20.8%, or 715, to 4,156 in 1999-2000 from 3,441 in 1995-1996. Meanwhile, specialty residents declined 17.7%, or 965, to 4,502 from 5,467.

"We set goals for each of our 22 geographic networks," said Gloria Holland, PhD, VA's special assistant to the chief academic affiliation officer and co-author of the JAMA study. "If one network had 500 positions and 38% in primary care, the first-year goal was to move to 40%."

Nationwide during the first year, anesthesiology slots were cut to 246 from 327, pathology positions were reduced to 235 from 263 and diagnostic radiology cut to 308 from 327.

"These changes evoked widespread concerns ... that continued reduction of subspecialty positions would impair the system's capacity to provide quality care for its many seriously and chronically ill patients," the study said.

To address these concerns, Dr. Holland said new training strategies were developed to improve access and continuity of care. VA grouped patients with common symptoms into clinics. For example, patients with advanced complications of diabetes went into clinics managed by endocrinologists.

"The veterans get good primary care here and like their doctors," said Dr. Berendt. "In the hospital, I refer to specialists when necessary."

While the VA is the largest system to increase primary care residents, the five-campus University of California also mandated a 50-50 ratio. From 1992 to 1998, California increased primary care slots to 52% from 45%.

Since the early 1990s, many physician groups, including the AMA and the Council on Graduate Medical Education, have concluded more primary care doctors are needed. But as anecdotes emerge of shortages of specialists, some experts now question the goal of training 50% primary care physicians.

"The world is changing at a sufficient rate that data built on previous experiences is increasingly hazardous," said David Stevens, MD, co-author of the JAMA study and former VA chief academic affiliations officer.

"It may be less important to get a 50-50 mix as to make sure physicians are trained with a specific set of competencies," said Dr. Stevens, vice president of medical school standards and assessments at the Assn. of American Medical Colleges.

ADDITIONAL INFORMATION:

A not so subtle shift

Dept. of Veteran Affairs realigns training programs to increase primary care residents

                     1995-   1997-   1998-   1999-
Primary care         1996    1998    1999    2000 
                     ----    ----    ----    ---- 
Family practice       109     135     136     147 
Internal medicine    3195    3338    3439    3475 
Geriatric medicine    104     132     159     169 
Gynecology              8      15      20      21 
Obstetrics-gynecology   0       2       5       7 
Occupational medicine   4       4      14      16 
Preventive medicine    21      32      38      38 
Primary specialist      0       0     199     280 
------------------------------------------------- 
Total                3441    3659    4012    4156 

                        1995-   1997-   1998-   1999-
Specialties             1996    1998    1999    2000 
                        ----    ----    ----    ---- 
Geriatric psychiatry      19      18      23      22 
Physical medicine/       199     196     191     187 
rehab                                                
Psychiatry               849     819     723     689 
General surgery          834     802     733     706 
Neurological surgery      65      58      56      57 
Neurology                308     283     246     224 
Ophthalmology            240     237     238     237 
Orthopedic surgery       231     230     221     216 
Plastic surgery           49      49      45      47 
Urology                  189     189     185     179 
Vascular surgery           9       8       8       7 
Allergy/immunology        12      11      10       9 
Anesthesiology           327     246     198     187 
Cardiology               270     266     238     229 
Colon/rectal surgery       1       1       1       1 
Critical care              7       7       7       7 
Dermatology              142     144     148     140 
Diagnostic radiology     327     308     273     262 
Emergency medicine         3       6       6       5 
Endocrinology             62      61      57      53 
Gastroenterology         193     184     166     159 
Hematology                16      11       8      13 
Hematology/oncology      102     105      89      78 
Infectious diseases       90      87      70      66 
Nephrology                92      86      75      70 
Nuclear medicine          46      38      30      28 
Oncology                  13      12       6       6 
Otolaryngology           183     177     165     161 
Pathology                263     235     211     197 
Pulmonary disease          0       0       0       2 
Pulmonary/               175     170     151     141 
critical care                                        
Radiation oncology        27      28      26      24 
Rheumatology              59      52      44      40 
Thoracic surgery          58      56      51      48 
---------------------------------------------------- 
Total                  5,467   5,187   4,708   4,502

NOTE: Totals may not add up because of rounding and not including some small fields.

Source: "Results of a Nationwide Veterans Affairs Initiative to Align Graduate Medical Education and Patient Care," Sept. 5, Journal of the American Medical Association

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Article, "Results of a Nationwide Veterans Affairs Initiative to Align Graduate Medical Education and Patient Care," JAMA, Sept. 5 (vol. 286, issue 9) (http://jama.ama-assn.org/issues/v286n9/abs/jsc10253.html)

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