Future Docs 5: Are We Training Enough New Doctors?

Jan 15, 2013

The nation spends billions of dollars every year training future doctors. But health care experts worry we’re still not training enough doctors to prevent a serious shortage.

Next in our Future Docs series, we explore the problem and some possible solutions.

Brian Drolet, MD preps for a busy day in the Rhode Island Hospital surgery clinic.
Credit Kristin Gourlay / RIPR

Brian Drolet is a fourth year plastic surgery resident at Rhode Island Hospital. He’s originally from New Hampshire, and went to medical school at Vanderbilt University. He says he’s drawn to plastic surgery because of the variety of cases.

“…head to toe, cradle to grave, so it’s all ages, all areas of the body. That’s one of the interesting things about plastic surgery, is there’s really no zone, you know. Plastic surgery is kind of everything, everyone.”

Residency is the next step after medical school. About 115,000 residents like Drolet are training on-the-job in teaching hospitals across the country, at any one time. And depending on the specialty, most residents spend four to seven years caring for patients under the supervision of more experienced doctors. But some hospitals say they’re so busy, they need more.

At a surgical clinic in Rhode Island Hospital, Drolet steps into an exam room to see the first of a long list of patients.

Brian Drolet, MD examines his patient's burn-scarred hand.
Credit Kristin Gourlay / RIPR
Fourth year plastic surgery resident Brian Drolet, MD explains the diagnosis.
Credit Kristin Gourlay / RIPR

“So, can I take off your whole sweat shirt here so I can see your whole arm?”

The whole arm belongs to Brian, a patient in his 30s who survived a house fire. Scar tissue has twisted up his face and left his arms stiff and red. Drolet examines Brian’s hands, which don’t seem to want to unfurl.

“The tendons may have been injured on the back of your hand, based on the look of the burn. But on this side of your hand, I don’t see any reason that the tendons would be injured, ok? What you have is a flexion contracture.”

This clinic is staffed entirely by residents, who play a huge role at Rhode Island Hospital and its sister institutions. They employ about 600 residents and fellows, plus a couple hundred more who visit for more specialized training. That might seem like plenty. But some say we don’t have enough residents in the pipeline. Medicare capped the number of residency slots 16 years ago, and the funding has stayed flat ever since.

Residents draw a modest salary, but it costs a lot more than that to train them: around $150,000 a year, per resident. Most of that money, nearly $10 billion dollars, comes from the federal government –Medicare--and a little from state-based Medicaid.

To meet the growing need, hospitals are picking up a percentage of the tab to train more residents. But for some, like Rhode Island Hospital, it’s not sustainable. Dr. Staci Fischer oversees the hospital’s graduate medical education program.

“As a hospital that provides a lot of uncompensated care to the community, as are a lot of hospitals where residents throughout the country train, we’re in the position of dealing with budgets that are such that perhaps hospitals won’t be able to continue to support all those people.”

Dr. Staci Fischer at her desk at Rhode Island Hospital.
Credit Kristin Gourlay / RIPR

Unless, Fischer says, the cap on residency slots is lifted and more funding flows from the federal government. Or new streams of funding open up.

“Most people in graduate medical education believe this really needs to come from Congress and that this needs to be on a national level if we can do it. There’ve been a number of proposals over the years to also engage private health insurance companies in the graduate medical education business, the notion being that we are providing education and training for the people that will become providers for Blue Cross, United Healthcare, you name the private insurer.”

So far, those proposals haven’t panned out. But many experts, from the Association of American Medical Colleges to analysts at the Robert Wood Johnson Foundation, believe we have to do something. And soon, says Fischer.

“But the reality is across the entire country, there’s going to be a shortage if we don’t have more funding to be able to train the physicians that we need to meet the demands of the population.”

A shortage of about 60,000 doctors in just a couple of years, and of nearly 90,000 by the year 2020, according to some estimates. The biggest shortfalls will be in primary care, and in rural and underserved areas. Why? In part because the Affordable Care Act will bring an estimated 30 million newly insured patients into the fold. And in part because the nation is getting older and more of us are suffering from chronic diseases – and needing more health care. While hospitals, medical schools, and other groups have been calling for more funding for residency programs, Capitol Hill has been leaning toward cutting that funding, or at least getting more bang for the buck it’s already spending. One way to do that seems to be through a new program under the Affordable Care Act.

“The Teaching Health Center program is unique because it’s a new way to pay for graduate medical education.”

That’s George Washington University health policy researcher Candice Chen. Teaching Health Centers are outpatient clinics and community health centers--places that, until now, couldn’t afford to train residents. Now, the pilot program is funding 11 such centers. Chen says their mission is to develop the next generation of primary care doctors. And even though many are in rural or poor urban settings, it’s working.

“That mission attracts medical students and resident applicants. The nice thing was that both in year one and year two for these inaugural 11, they completely filled their slots.”

Chen says their funding is also tied to things like the quality of patient care and resident performance. But in light of a projected doctor shortage, these teaching health centers are pretty much a drop in the bucket. Many believe we simply need more residency slots. Some lawmakers, like Rhode Island Sen. Jack Reed, think we should make sure the money we are spending is resulting in high quality health care and turning out the kind of doctors the nation needs. The Institute of Medicine will be coming out with a set of recommendations later this year on how to fix graduate medical education funding. But given the long time it takes to train a new physician, it could be years before those ideas can even make a dent in the problem.

Do you have insight or expertise on this topic? Please email us, we'd like to hear from you.  news@ripr.org