A joy of practicing medicine for me for the past several years has been to have medical residents and students rotate through my office from the Alpert Medical School of Brown University. Those visits have been characterized by high energy, great dialogue, curiosity, and an unvarnished view of internal medicine. Patients appreciate the thorough evaluations and universally comment on the students' enthusiasm.
Within the course of their rotation, the students are witness to the art and science of medicine as practiced in the outpatient setting. For example, in the course of one such day this week, they experienced the spectrum of patients from health to such serious acute problems as a dissecting aortic aneurysm to discussions about end-of-life care. They learned about team-based care with the help of clinical nurse managers and pharmacists and the importance of workflow in preventing burnout. They also learned about setting up office systems to maximize time with patients, reduce administrative tasks, and simplify data entry into the medical record.
All of the above are some of the critical elements of undergraduate and graduate medical education (GME). But the current system is in need of serious financial and structural reform.
ACP, along with the Alliance for Academic Internal Medicine (AAIM), published a paper in Annals of Internal Medicine in May on financing GME. At present, the federal government provides $15 billion in GME funding annually, primarily through the Medicare program. The types and number of residents in a teaching program are based primarily on the staffing needs of the hospital and a “cap” on positions that was imposed in the Balanced Budget Act of 1997. Paradoxically, the Department of Health and Human Services predicts a shortage of 20,400 primary care physicians and 28,000 to 63,000 non-primary care physicians by year 2025. With a freeze on funding and residency positions, it is impossible for GME to meet the workforce needs of the near future.
Medicare's support for GME has 2 mechanisms: a direct GME payment to hospitals for resident stipends, faculty salaries, administrative costs, and overhead, and an indirect medical education adjustment to teaching hospitals for the higher costs of patient care due to teaching and the severity of patient illnesses. The Medicare Payment Advisory Commission has identified indirect GME costs as a potential area for cuts to the GME program. The Institute of Medicine has called for increased transparency and overhaul of GME funding and governance structure, but its report did not recognize the looming physician shortage. Instead, it posited that changes in care delivery, team-based care, advanced practice clinicians, and innovations in health care delivery, such as telemedicine, would avert workforce shortages.
ACP and AAIM have made several recommendations.
1. The federal government should maintain and increase GME funding with adjustments to meet the needs of the nation's workforce.
2. All payers should be required to contribute to financing supply, specialty mix, and training sites.
3. Direct and indirect GME payments should be combined into a payment program that creates a new financial model.
4. Funds should be allocated to programs to cover costs of both outpatient and inpatient training and should not be allocated to meet other financial needs of the parent institution.
5. GME caps should be lifted to meet the needs of the general internal medicine and subspecialty medicine workforce.
6. The Accreditation Council for Graduate Medical Education should thoughtfully develop and objectively measure performance-based GME, which is an interesting concept worthy of a pilot program.
7. Internal medicine residents should receive primary care training in ambulatory settings with adequate financial support, creating a learning experience that promotes primary care.
All of these changes are important and critical to ensuring an adequate workforce in the United States. I claim that we also need the following.
We need to optimize the learning environment with more emphasis on outpatient care in well-functioning patient-centered team-based offices. Residents need exposure to the satisfaction of caring for patients with simple, complex, and chronic problems. They need exposure to offices with good workflow, minimal administrative tasks, and minimal data entry functions. They need exposure to disparities in health care delivery and social determinants of health.
Residents and students need role-model clinicians who practice evidence-based medicine with careful and thorough patient evaluations and judicious use of laboratory and imaging tests. These community physicians need adequate funding to be able to perform this critical work.
We need to reform the reimbursement system to value the importance of general internal medicine in the delivery of high-value, cost-effective care. With current levels of medical student debt and disparities in income between primary care and subspecialties, the lack of interest in primary care among residents and students is no surprise.
Increased funding and workforce will not solve the problem of burnout if we cannot create models of care that allow internists to practice in an environment of intellectual stimulation that leads to satisfaction with the rewards of patient care, teaching the next generation of residents and students and recommending internal medicine as an excellent career choice.
I have been in practice for 28 years and have witnessed a sea change in the practice of medicine. If we can continue to provide affordable health care to all U.S. residents, and if we have a strong primary care workforce that practices disease prevention and provides accurate diagnoses and treatment and empathetic, cost-effective care, we will all be better off and internists will continue to thrive as leaders in medicine for the 21st century.