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.
Yet while this is very encouraging, the great preponderance of Yale’s residency programs remain focused on training still more specialists—enough so that Yale ranks in the bottom twenty in its percentage of graduates going into primary care (see the “Bottom 20” Table). That’s partly a reflection of how deeply the particular culture of specialty care remains entrenched in academic medicine, and especially at our most elite institutions. It also reflects the reality that under the reimbursement rates offered by Medicare and private insurance, specialty care is far more lucrative than primary care. With the total number of subsidized residency slots capped by Congress since 1997, it’s no wonder that even the many people trying to do the right thing in academic medicine have a hard time persuading elite teaching hospitals to carve out more residency slots for primary care.
Yet the outlines of a policy fix are clear. It may well be that we will need to increase the number of slots available for training doctors in the face of worsening shortages. But Congress needs to demand that sponsoring institutions increase their production of primary care doctors and of other health care professionals of the kinds we need, or else risk losing their subsidies. It’s not that the direct cost of these subsidies is such a large amount of money; compared to the $2.8 trillion America spends on health care, $13 billion is a pittance. But failure to get medical residency programs to produce the right kind of health care workforce does incalculable damage to the quality and efficiency of the health care system, and, by extension, to the long-term health of the U.S. economy and our way of life.
Despite the long history of failed attempts at reform, there is reason for optimism, including generational change. Within today’s rising Millennial generation, there is a wellspring of idealistic young people trying to be part of the solution to America’s health care crisis by becoming team players in primary care and community-based medicine. This is true despite compounding student loans and often the prospect of forfeiting enormous potential future earning streams by not going into lucrative specialties. But the greatest obstacle of all is an incumbent system of graduate medical education that with too few exceptions crushes their idealism and teaches a hidden curriculum of counterproductive values and attitudes. At the very least, the public needs to wake up from its anesthesia and start asking hard questions about why it continues to subsidize such a system without demanding accountability.
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