More On a New Model Residency

Why do doctors become residency faculty and attending physicians? A few like to teach and want to mentor young doctors, but most want the life-style. They simply do not work as hard as their colleagues in private practice. Why? Because the residents do the work for them, and because that system is paid for by the federal government which does not question it. Rarely does an attending physician on call have to come in to the hospital at night to see a patient that is being admitted, and an attending almost never handles phone calls from patients. In practice the residents manage almost everything with little attending input. So how can a teaching hospital afford such an arrangement and remain economically viable? A family practice resident is paid about one-quarter the salary of an attending physician, and puts in 50% to 100% more time. It is essentially 3 years of resident indentured servitude that allows attending physicians to live well. So the doctors in a successful residency do not want to see any significant reform that would rock the boat, even if such change would reduce patient error and/or create a healthy life-style for residents.

Graduate medical education (GME) is funded both directly and indirectly by the federal government through various programs. The system is so complex that everybody that studies it says that it is a black box in which there is little accountability. Private insurance companies also pay teaching hospitals more than non-teaching hospitals, and drug companies and medical device manufacturers provide gifts and grants, but it is essentially a government-run system with multiple agency actors and nobody in charge. What residency directors know is that the money keeps flowing regardless of what they do or do not do. For example, private practice doctors must compete against hospital systems that get paid “facility fees”, that is a hospital doctor in an outpatient practice gets reimbursed up to twice as much by Medicare and private insurers for the same service that a private family practice physician provides. Therefore, private physicians must hire consultants to guide them through the byzantine and ever-changing regulations on coding, or leave money on the table in this zero-sum game. This struggle to get paid takes much time and effort that could be used to treat patients, but strangely residents receive very little training on coding. So not only are the residents ill-prepared for the real world upon graduation, the residency programs are not maximizing their revenue, yet the money they receive in subsidy is so good that they apparently do not care.

Clearly, adequate residency training requires a certain number of hours on the job, even if a resident learns more when he is well rested than when exhausted. So in the new model family practice residency the resident would work 40 hours a week instead of 60, and the training would be extended from 3 years to 4 years. The extra year would come from reducing medical school from 4 years to 3 years, so the doctor would spend no more time overall in training than currently required. How do we know that this would work? Because it is already being done at several medical schools associated with their own residency programs, including Hershey. Hershey’s family practice residency program had difficulty filling its slots and had to take foreign graduates to do so. To solve the problem, it offered Hershey’s medical students a year off medical school if they would commit to the residency, and it worked. The fourth year in medical school is of little value and American doctors spend too much time in school as it is. Most countries require less schooling for doctors so they start their medical careers at a younger average age; and about a quarter of physicians now practicing in the U.S. are foreign graduates. Moreover many states now allow nurse practitioners to practice independently despite much less extensive education and training.

In the new model residency, the resident would be offered training in two different forms of medical care delivery: traditional insurance-based practice and direct primary care. The former would become masters of coding and the latter masters of medicine. Both would be given small business training so that they need not feel compelled to become cogs in some hospital system bureaucracy. They would also train in urgent care or emergency rooms settings so they could support themselves upon graduation while in the process of establishing their own privately owned practices.

A family practice residency program that is struggling to fill its slots would do well do consider the above ideas. I suspect that it would quickly become known as innovative and caring. It would draw the right kind of medical school graduate into family medicine and preserve that idealism that once motivated many of us.

– Gary Gallo, MD