As I was reading my departmental, end-of-the-academic-year newsletter, I was pondering my own group’s hospitalist pipeline. Each year, I earnestly read the list of internal-medicine-program graduates, focusing on what and where they are going to practice. I first selfishly scan the list for “hospital medicine, MUSC.” Then I go back and reread the list to see who I can now send my discharges to or who I can refer any new friends or relatives who move to town, scanning the list for “primary care, MUSC.”
This year, similar to recent years, the list for “primary care” is slim.
SHM has long been motivated to think about the pipeline, about how to get the best and the brightest interested in practicing HM, and practicing primary care, as they are vital partners in the spectrum of generalist care. We need to know and understand our pipeline: Where will they train, how will they be trained, will they be prepared to function and thrive in the medical industry of tomorrow? Regardless of how or where you practice, all of us should be thinking about our pipeline.
As such, all of us should be thinking about graduate medical education (GME), how it is funded, how much it is funded, and what regulations control the types of specialties that come out of U.S. training programs.1 This is especially true given the projected need for more hospitalists in all areas of the hospital of the future, the ever-expanding role of “specialty hospitalists,” and the need for hospitalists during the “peri-hospital” stay (from pre-operative clinics to post-discharge clinics). And this is especially true given the ongoing projected expanse of the primary-care shortage.
The career path for physicians starts long before medical school and is heavily shaped by what types of physicians they are exposed to, when they are exposed to them, and what their experience was. The periods of medical school and graduate medical education training can have a profound impact on the “health” of the U.S. health-care system and whether it is equipped to care for the needs of its citizens.
American taxpayers have long been in the business of funding the physician pipeline. The federal government invests $13 billion annually on graduate medical education subsidies. The money flows directly to teaching hospitals to pay for the salaries of the trainees and the salaries of the attendings who supervise their work, as well as the hospital overhead that has to be invested to house these trainees during their tenure.
Federal subsidies for apprenticeships are relatively unheard of in other industries; this funding stream was initiated with the passage of Medicare almost 50 years ago, under the provision that additional training for medical students would result in better and safer medical care for all Americans. However, what was not set up as a tagline to these federal subsidies was any type of accountability on process or outcome measures, such as how exactly do teaching hospitals invest their GME money, and how will they produce the types and amounts of physicians that the U.S. needs?
Cold, Hard Facts
So what do Americans get for that annual $13 billion investment? We get what we should expect out of the “free will” of graduating residents: We get an oversupply of specialists in areas of abundance and an undersupply of generalists in most areas. The system “produces” the most appealing specialties (those handsomely reimbursed and highly prestigious), leaving a dwindling number of generalists to be spread thinly. And the most prestigious and top-ranked academic medical centers are the least likely to produce generalists. In many of these highly ranked training programs, less than 10% of their graduates go on to work in primary care, and even fewer work in rural or public health facilities. More than 20% of all residency programs produce no primary-care physicians (PCPs) at all. Despite the $13 billion annual investment, the American Association of Medical Colleges (AAMC) predicts a shortage of 45,000 primary-care physicians by 2020.2