July/ August 2013 First Teach No Harm

The U.S. spends $13 billion a year subsidizing graduate medical education. Yet almost all of this money winds up producing the wrong kinds of doctors in the wrong places, with America’s most elite teaching hospitals being the worst offenders.

By Phillip Longman

At second-to-last place, for example, is Massachusetts General Hospital, the flagship of Boston’s medical establishment. Despite receiving more than $85 million a year in taxpayer subsidies for its residency program, Mass General does an abysmal job of turning out the kinds of doctors in shortest supply. Of the 848 residents who completed training at the hospital between 2006 and 2008, only 6.49 percent went into primary care. Of all the graduates of Mass General’s residency programs, exactly none went on to practice in a federally designated rural health clinic (RHC), and only one went on to practice in a federally qualified public health clinic (FQHC), which is the kind of health care facility most needed to accommodate the tens of millions of Americans who will soon be gaining health insurance through Obamacare.

Then there is Johns Hopkins University School of Medicine. Its teaching hospital in Baltimore towers over a low-income neighborhood designated by the federal government to be suffering from a shortage of primary care doctors. Yet between 2006 and 2008, of the 1,148 residents who graduated from Hopkins’s residency programs, only 8.97 percent went into primary care. Only two graduates went on to practice in an FQHC, and not one participated the National Health Service Corps, a program designed to encourage doctors to practice in underserved areas. In 2009, Hopkins residency programs costs the taxpayers $80.7 million.

The picture among residency programs generally is not much better. Of the 759 institutions sponsoring residency programs, 158 produced no primary graduates at all. Overall, only a quarter of all residents go into primary care, and far fewer than that go to work where they are most needed. While the Affordable Care Act calls for a doubling in the capacity of public clinics and other “safety net” providers, a full 283 residency programs produce no graduates who take up that critically needed line of work.

Data from Graham Center and George Washington University. Explore further using their online tool.

As disturbing as these numbers are, however, the problems go much deeper. Almost everything about our current way of training doctors is at odds with the current needs of the health care system, and even more so with the changes required to make that system sustainable.

To begin with, while most physicians get their training almost exclusively in hospitals, most health care takes place in doctors’ offices and outpatient clinics, settings that require far different clinical, managerial, and communication skills from providers. In an average month, for every eight patients admitted to a hospital, 217 visit a doctor’s office.

More fundamentally, today’s residency programs are producing a generation of doctors whose members are typically indoctrinated by their training to resist the very changes that nearly everyone now agrees must occur in the practice of American medicine. “There is only limited recognition that the delivery system is the same as the learning system,” says Dr. Malcolm Cox, formerly dean for medical education at Harvard Medical School and now head of the Veterans Health Administration’s academic medical programs. “The delivery people and the education people are not always synchronized.”

Dr. Cox is putting it diplomatically. There has long been broad agreement among experts about the kinds of changes to the delivery system that must occur to improve its quality and contain its costs, to the point where they are now almost clichés. They include much more emphasis on prevention, patient education, and effective management of chronic conditions such as diabetes and heart disease. They also include care that is centered on patients rather than on maximizing the income and convenience of providers, and that is coordinated through careful teamwork among doctors, nurses, and other medical professionals to treat the whole patient, as opposed to isolated specialists treating just one body part at a time.

We know from the example of integrated providers like Utah’s Intermountain Healthcare that when such changes are implemented they improve patient outcomes while reducing costs by as much as 40 percent. That’s why the architects of Obamacare were able to creditably claim that it is possible to vastly expand access to health care, improve its quality, and control costs all at the same time. But that will never happen as long as America’s system for training doctors remains unreformed.

A sense of cultural and attitudinal problems fostered by most of today’s typical residency programs can be gathered from watching Scrubs. To be sure, the show takes many licenses, and its characters are often cartoonish. But many doctors recognize its essential realism, and its example helps to illustrate the kind of educational experience that young doctors typically have in today’s medical residency programs and why it must change.

On day one, newly minted MDs arrive at a real hospital that looks much like the program’s fictional Sacred Heart and are immediately thrown into a chaotic mix of ongoing acute patient care. At first these young residents often must rely on nurses to teach them how to do the most basic procedures, but as they gain confidence they soon become acculturated to viewing nurses as mere support staff rather than equal members of a team. They learn this attitude from attending physicians, who reinforce their own dominance in the hierarchy by mercilessly quizzing the residents during rounds about the symptomology and biochemistry of obscure diseases—all while talking in front of patients as if they weren’t there.

Meanwhile, a pecking order emerges as well between surgical residents and those training in “lesser” fields, with mere psychologists and social workers being particularly marginalized. Lower yet are internists and primary care doctors, and lowest of all is anyone who works in a public clinic. By the fifth season of Scrubs, when one of the show’s erstwhile idealistic young doctors finds herself forced to take a job providing health care to the homeless, both she and the residents she trained with at Sacred Heart have all absorbed values that cause them to regard this as a cosmic injustice.

Scrubs is also realistic in showing residents working some eighty hours a week in a hospital that deals almost exclusively with patients who are already very sick and often dying. In this setting, prevention is an afterthought, and there is no time or incentive for dealing with the whole circumstances of a patient’s life, as a good primary care doctor would do. In one episode of the show, a patient is advised upon discharge that he will die young if he doesn’t stop smoking, but then, as happens often in real life, the patient disappears into the wider world with no follow-up.

The show is also particularly good at illustrating how the system in which residents are training is constantly breaking down and forcing them to improvise. The premise of Scrubs is echoed in its theme song: “I can’t do it all on my own, / I’m no Superman.” Young residents learn the hard way that the nature of the work demands constant collaboration and teamwork with other staff in low and high places, yet the rigid, hierarchal structure of the hospital provides few ways to pull this off except by forming ad hoc alliances and sucking up to power.

Phillip Longman is a senior editor at the Washington Monthly and a lecturer at Johns Hopkins University, where he teaches health care policy. He is also a senior fellow at the New America Foundation, where Atul Gawande is a board member.


  • Brian Crownover MD on June 21, 2013 12:22 PM:

    Finally, someone is talking about REAL health care reform, not health care ACCESS reform which the ACA addressed. This review should be mandatory reading for every congressman and especially Pres Obama. For clear insight on the need to reform physician payment which directly impacts specialty choice, read about the RUC. http://well.blogs.nytimes.com/2011/09/22/how-one-small-group-sets-doctors-pay/?_r=0

  • Henrietta McClellan on June 21, 2013 1:18 PM:

    Great article. Am looking for a link to forward to some of my friends on my email list!

  • Denise Shungu on June 21, 2013 3:03 PM:

    Something you almost completely leave out of this thoughtful article is the student loans from the 4 years of medical school and sometimes of college as well. If you would cancel half of the loans for anyone going into Family medicine or whatever the Primary Care is called, you would have many more students who would take that specialty and residency programs would be forced to change because of increased demand.

    My own son who is doing his residency in Primary Care at Thomas Jefferson was able to able to do this because he received a full tuition scholarship to a medical school. His fiancee who had both college loans and medical school loans felt forced to choose a specialty.

  • Bohdan A Oryshkevich, MD, MPH on June 21, 2013 6:10 PM:

    This is a great article. It hits the problem right on the head.

    I would have put a bit more emphasis on the financing of medical education as part of the strategy of acclimatizing medical residents to choosing procedure oriented specialties.

    The Wright Center program is great, but such programs are not likely to produce the numbers of primary care physicians that we need.

    Second, in the process of promoting primary care, we should not demonize specialists. We need them also but perhaps in not such great numbers. They need to be part of the solution.

    Something has to give.

    Bohdan A Oryshkevich, MD, MPH
    New York City

  • Robert C. Bowman, M.D. on June 22, 2013 2:08 AM:

    Common sense indicates specific solutions for primary care and a need for departures from the last 30 years of stagnation. This collaboration has taken a step closer to a specific design.

    Specific preparation for primary care begins as an employee or volunteer in a site focused upon health access.

    Specific training for primary care involves medical school and residency at the health access site.

    Specific primary care result at the current time is seen in 90% of family physicians who resist departure from primary care over their careers - despite adverse policy.

    Hospital and subspecialty preparation and training plus training that is flexible in primary care career result plus national health policy designs fail most Americans in their basic health access needs.

  • Anonymous on June 24, 2013 3:26 PM:

    Why no mention of nurse practicioners are primary care providers?

  • American Association of Colleges of Osteopathic Medicine (AACOM) on June 27, 2013 1:11 PM:

    This article discusses several important concerns surrounding the primary care physician workforce shortage facing the nation. The American Association of Colleges of Osteopathic Medicine (AACOM) agrees with the writer, Mr. Phillip Longman, that the nationwide gap between primary care need and availability is a critical issue and that the need to develop solutions has never been more important. However, we feel that the ongoing efforts put forth by AACOM and its member colleges of osteopathic medicine to address the primary care physician shortage are essential to finding a solution to this crisis.

    In the U.S. today, more than 20 percent of medical students are training to become osteopathic physicians (DOs). While osteopathic medical students may pursue any medical specialty, more than 40 percent of these students enter into a primary care or family medicine residency.

    Currently, there are 29 colleges of osteopathic medicine in the U.S., offering instruction at 37 locations in 28 states, with many of these campuses situated in medically underserved areas highlighted in “First Teach No Harm.” According to data published in the April 2012 issue of Academic Medicine on physician supply in Appalachia, three of the nation’s colleges of osteopathic medicine fall within the top 10 U.S. medical schools supplying the most graduates to the primary care workforce in at-risk counties in Appalachia (as of 2009). These schools are the West Virginia School of Osteopathic Medicine (WVSOM), the University of Pikeville Kentucky College of Osteopathic Medicine (UP-KYCOM), and the Ohio University Heritage College of Osteopathic Medicine (OU-HCOM). Taking this data into account, along with the more than 40 percent of all DO graduates who accept primary care residencies, compounded with the rising total number of osteopathic medical school graduates each year, it is clear that osteopathic medical schools play a key role in increasing the number of medical students entering into primary care residencies, thus are integral in developing a stronger primary care workforce, particularly in medically underserved and at-risk regions.

    Through our advocacy efforts, AACOM strongly supports legislative initiatives that establish and implement innovative and cost-effective solutions to strengthen the nation’s primary care physician workforce. Recently, AACOM endorsed its support of the “Building a Health Care Workforce for the Future Act.” This legislation supports, among other priorities, the expansion of programs such as the National Health Service Corps (NHSC) Scholarship Program, which incentivizes primary care residency training in underserved areas. AACOM also strongly supports the continuation and sustainment of the Health Resources and Services Administration’s (HRSA) Teaching Health Center Graduate Medical Education (GME) Program, which increases opportunities for primary care GME, sets a strong precedent to fund GME outside of the traditional Centers for Medicare & Medicaid Services funding stream, and creates new avenues for training medical residents in community-based, non-hospital settings.

    AACOM and the osteopathic medical education community are dedicated to ensuring a well-trained physician workforce capable of meeting the current and impending health care needs of the nation. For more information, please contact Lindsey Jurd, AACOM editor and communications associate, at ljurd@aacom.org.

  • Mark Asplund on July 02, 2013 10:00 AM:

    Great article although it leaves out that it is actually medicare and medicaid that pay for medical students to become actual doctors..

    Not many people realize that is why they are expected to treat medicare and medicaid patient for less. They are essentially expected to "pay back" the cost of their 1/2 million in training.. Anyone who has a mortgage or a car loan that you pay back about 2x the cost

    So any doc's who opt out of medicare and medicaid are breaking their trust with US taxpayers and should be required to pay back in full (interest plus pentalty) or at the very least make this exchange of training for profession a legally binding document.

    We could easily shift the % paid to residents and give family practice docs 80k a year vs the typical 50k in residency and cut the $ to specality providers

  • jim jaffe on July 02, 2013 1:46 PM:

    while most of your subsidiary criticisms are on point, the basic one is flawed. America does NOT face a physician shortage. The ratio between physicians and patients has been improving for years. The ratio between primary care physicians and patients has been also, albeit more slowly. The explosion of walk-in doc-in-box operation gives patients easier access than ever before.

    The only thing a rising physician supply will give us is a larger national medical bill. As Wennberg and others have been documenting for years, enlarging the physician supply simply increases costs without improving health status.

    It makes more sense to let supply shrink and take up the slack with cheaper, but competent folks like nurse practitioners and physician assistants.

  • Atul Grover, Chief Public Policy Officer, Association of American Medical Colleges on July 02, 2013 3:27 PM:

    The AAMC is very disappointed that Mr. Longman did not contact the AAMC for information or comment when he was writing his article. We are writing to clarify a number of important points that his article fails to reflect.

    Read the rest of Dr. Grover's comment here.

  • Ashfaq Khan on July 04, 2013 1:44 PM:

    In this country a primary care physician cannot work without some assistance from a specialist. Mal practice environment potentates this to a greater extent. Non MD/DOs can fill the gap easily on a day to day general practice work. Modern day stethoscope is imaging (X ray,ultrasound and CT machines)making diagnostic decisions on the basis of clinical skills is not the standard of care in USA. We need a balance approach to address the issue.

  • Leena Varughese MD on July 07, 2013 12:11 AM:

    Well-written article from a concerned citizen regarding the state of graduate medical education that explores several areas of problems in graduate medical education. It's important to recognize that great harm comes from the lack of oversight in medical education system and it's a runaway gravy train for major hospitals, where 500k dollars is a conservative estimate of the funding and profitability and value of each medical resident. Clearly, many programs are using the system to enrich themselves, rather than teach residents in residency programs. The program directors do not prioritize teaching residents but utilizes the system to systematically misguide, not teach, and obfuscate appropriate diagnostic information from medical residents. I have certainly experienced this while I was at Mount Sinai Medical Center/ Mount Sinai Hospital in NYC doing Anatomic and Clinical Pathology residency program.

  • BSatiani on July 16, 2013 12:50 PM:

    There is no doubt that the impact of the shortage of all physicians is going to be felt even more with the entry of millions into the elective pool of patients. I also completely agree that throwing more money at the problem without much more accountability from teaching hospitals would be wrong.
    However, the article is simply myopic as Atul Grover implies and denies any impact of specialists shortages. We have documented the upcoming shortages in surgical specialties. Until we have disruptive models of surgical care, with the aging population there is no substitute for these specialists using NP's and PA's. His statement "inflate health care spending by engaging in massive amounts of unnecessary surgery and other forms of over-treatment" is offensive to most specialists who are honest and follow guidelines.I assume primary care physicians have some bad apples as well.
    The best solution for primary care shortages is to not only encourage our residents to enter the field but open up many more NP and PA schools. Much as the author won't like the solution, they are much cheaper to train and can provide the same care to a large percentage of the population. Hence, the entry of CVS/Walmart into the field employing NP's and PA's and now branching into chronic diseases. Why not?

  • Frustrated primary doc on July 16, 2013 6:38 PM:

    1) Documentation is stifling: in order to get paid for the time and effort I put into caring for a patient, I have to document a lot a boat load of information to prove the complexity of the visit I coded for. In addition to the documentation for each visit I get a mountain of forms via fax from insurance companies, drug companies and pharmacies to substantiate the Rx's I write or to tell me to consider a drug from another company, one that gives the insurance company a discount.

    2) Every one want's to abuse the system and it seems the Medicare is putting the burden of policing this on the primary care doc in the way of forms to fill out.

    3) Specialists dump on the primary care doc. A patient gets wrist surgery etc and needs needs his workman's comp form filled out, and the surgeon tells the patient "take it to your primary care doc". Dermatologist does surgery on a patient and if the patient has a problem after hours, on the weekend, has a recording that says, call your primary care doc. Patient's surgeon does surgery on a patient's back and tell him, "my work is done, call you primary care doc if you need pain pills".

    4) Copays are ever higher so patient's want to squeeze ever so much into every visit which goes on longer and longer. But the reimbursement is capped by the coding requirements.

    The time I spend with all this paper work is without reimbursement, yet my nurses want to be paid for the overtime they put in.

    I became a doc to care for people not to push paper or be a Medicare cop or Specialists' scut monkey. And if pushing paper & being a scut monkey paid, I continue but it doesn't.

    I introduced myself to a new radiologist at the hospital while going over X-rays and he asked what specialty I was in, I told him and he responds "oh my god the paper work" My feelings exactly. It is the real reason for the primary care doc shortage. The answer: just as in anesthesiology: one doc who sees a few patients but manages a large team of nurse practitioners and PA's.

    I can't wait to get out. I can't retire, but I'm going to work part time to at least enjoy my sanity.