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.
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.
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