“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Thursday, May 31, 2007

How do we educate residents with todays restrictions .... (part III)

“It is a miracle that curiosity survives formal education.”
~Albert Einstein

So the next question is how do we, educators, teach our audience, the learners, our craft with in the restrictions of different governing bodies, while appropriately meeting the specific needs of the current generation?

As we look at the need of the current generation, we can see that there is an emphasis on the individual yet they want to be mentored. They are in touch with the newest technology and may require different ways of communicating. You may be required to give them instant feedback. Heck, we have cell phone and the text messaging. I want to know now. Why didn't you pick you your phone? I think we, educators, must keep in mind that everyone’s time is important. The learners do not need to learn all of the information in one sitting. People learn and think best when well rested and fed. This progression to a kinder gentler medical training is a change in philosophy. It will make less bitter people.

The learners, on the other hand, must understand that they will be required to be active participants in their own education. Because less will be learned directly from the educator, the learner must be facile with the other learning media. Learners must seek out knowledge. There is not enough time to do passive learning; the learner must seek out the opportunities to gain clinical skill. This is something in the past that was provided by shear volume; now, it must be sought out and learn through alternative means. Unlike many things that can be learned by reading, those who are in clinical specialties must learn from patients. Patients and their diseases do not always follow the rules. The more patients you see, the better understanding of the possible variations in presentation. This can not be learned by computer simulation or by reading in a text book. There is no algorithm will incorporate every clinical scenario. So, the patients must be seen and evaluated. With all of the new technology, one of the key skill set of the physician is slowly being lost, the physical examination.

There are some significant changes coming in the future that will effect resident education. Many current residents and medical students harp on the 80 work week and the low pay. There are the arguments that say that the hospitals and universities get 100+ thousand dollars for each resident and the resident should get more money or have to work less hours. I say, be careful what you wish for. Let's go into some basic changes that will effect resident education directly and indirectly.


Although there are some that believe that,
There has been a systematic attempt to limit the number of spots in medical schools. With a limited supply of training institutions, there was insufficient supply to meet demand.
There have been some significant changes over the past few years to actually increase the number of physicians. Here is a little history.
In 1992, the Council on Graduate Medical Education (COGME) issued a series of reports expressing concern with potential surpluses of physicians and recommending an increase in the percent of physicians trained and practicing as generalists. These concerns led the Council to develop a recommendation that 110 percent of the number of U.S. medical graduates in 1993 should enter residency training each year (or about 19,750 physicians) and that half of these physicians should be generalists. This recommendation became known as the “110/50-50” goal for the physician workforce in the U.S.

Recently put out in the COGME's 16th report, they assessed the future supply, demand, and need for physicians in the United States (U.S.) through 2020 for both generalist and non-generalist physicians will exceed what we are currently producing.

Summarizing some of their findings:

1. Under current production and practice patterns, the supply of practicing physicians in the U.S. is expected to rise from 781,200 full-time equivalent (FTE) physicians3 in 2000 to 971,800 in 2020, a 24 percent incease.

2. At the same time, for a number of reasons and under a number of scenarios and models, the demand for physicians is likely to grow even more rapidly over this period than the supply.

3. The need for services, reflecting primarily the use of services under universal insurance and increased utilization review processes, is also expected to increase over the period.

4. The models and alternative scenarios used to make the predictions included a number of factors that could have a major impact on supply, demand, and need and, consequently, on a potential gap in the physician supply. Many of these factors are likely to add to the shortage of physicians.
> Changing lifestyles for the newest generation of physicians, with the possibility that new physicians will work fewer hours than their predecessors;
>Continuation of the rate of increase in the use of physician services by those over 45, which has been increasing for the past 20 years, and increased use of services by the baby-boom generation compared to prior generations
> Expected increases in the Nation’s wealth that would contribute to continued increases in the use of medical services.

Other factors could also lead to larger shortages and are not included in the baseline projections or alternative scenarios. These include the following:

> A potential increase in non-patient care activities by physicians, including research and administrative activities;
> A potential change in practice patterns for physicians over 50, including a reduction in hours worked before retirement and earlier retirement patterns;
> Possible increases in departures from practice due to liability concerns of physicians;
> Decreases in hours worked by physicians in training;
> Possible decreases in immigration of graduates of foreign medical schools;
> Possible increases in the number of physicians limiting the number of patients on their panel (sometimes referred to as “boutique medicine”);
> Advances in genetic testing that could lead to increases in the use of services as individuals learn they are at risk for certain illnesses or conditions; and
> Additional medical advances likely to keep individuals with chronic illnesses alive longer without curing their illnesses.


In response to the findings of COGME, medical schools have started the process of increasing the class sizes to help with predicted future needs. This is in contrast to the past where there was a decrease in both medical school classes, as well as a push towards the primary care specialties. With the current findings, there will be a need across the board. There is less of a push for those primary specialties. In June of 2006, AAMC came out with a Statement on the Physician Workforce. They recommended:

1. Enrollment in LCME-accredited medical schools should be increased by 30% from the 2002 level over the next decade. This expansion should be accomplished by increased enrollment in existing schools as well as by establishing new medical schools.

2. The aggregate number of graduate medical education (GME) positions should be expanded to accommodate the additional graduates from accredited medical schools.

3. The AAMC should assist medical schools with expanding enrollment in a cost effective manner; assuring appropriate medical education for traditional and non-traditional students; and increasing the number and preparedness of applicants.

4. The AAMC should continue to advocate for and promote efforts to increase enrollment and graduation of racial and ethnic minorities from medical school; and promote the education and training of leaders in medical education and health care from racial and ethnic minorities.

5. The AAMC should examine options for development of: (1) a formal, voluntary process for assessing medical schools outside the U.S.; and (2) a mechanism for overseeing the clinical training experiences in the U.S. of medical students enrolled in foreign medical education programs.

6. The AAMC should undertake a study of the geographic distribution of physicians and develop recommendations to address mal-distribution in the U.S.

7. National Health Service Corps (NHSC) awards should be increased by at least 1,500 per year to help meet the need for physicians caring for under-served populations and to help address rising mdical student indebtedness.

8. Studies of the relationship between physician preparation (i.e., medical education and residency training) and the quality and outcomes of care should be conducted and supported by public and private funding.


Residents are mostly funded by Centers for Medicare and Medicaid Services (CMS) and this is for taking care of Medicare patients. That funding is split into 2 parts: DGME and IME. The DGME (Direct Graduate Medical Education payment) is the direct cost of the resident (salary, benefits, malpractice, etc). The IME (Indirect Medical Education) is the indirect cost of medical education (teaching, supplies, cost of personnel for each residency and GME, and the increased cost of training institutions because of trainees). The dollar amounts vary based on an algorithm, but the gist is that the DGME is about ~$70-90,000 and the IME is ~$30,000. In the near future, like next year, the IME is being decrease by about 1/2. Another change that will affect residencies is that if a resident goes to a course for education, the government will not pay for those days, unless they were vacation days. If a resident is in an outpatient setting, unless approved by CMS, the hospital or facility will have to cover the residents salary for that given time. Every hour of a resident’s day has to be accounted for and reported to the government. If there is a question, that time will have to be covered by the institution. Many would have you believe that the hospital make a mint of of the residents. They get money from the government and then they are able to bill for facility fees and attendings bill for their work. There are actually some articles that are coming out to dispute this.

Along with the CMS guidelines the numbers of medical graduates will be increasing but the residency "cap" has not. Therefore the number of residencies paid for by CMS will not change. There have been some policies to change this, but they are not currently in place. Hospitals have responded to the lack of governmental GME funding by funding residency positions themselves.

Why do I say be careful what you wish for? I can see in the future requiring tuition for residency. When the government pulls most or all of the funding, this may be happening.


Time is going to be an issue. With many of the newer generation wanting a "life", they are going to spent less time learning in the hospital. We have run into this problem with trying to fit in a curriculum that is considered a necessity by the RRC. When do you find time to have didactics? In today’s world, the didactics must be taught between the hours of 630 am and 6pm, Monday through Friday, no weekends, no holidays. This makes things tough in the surgical specialties. Yes, we can hire PA's and NP's to cover floor work; and yes, the attendings can start the cases by themselves (I actually prefer this because I get to operate). The problem is that this is education time too. In the surgical specialties, noon conferences don't work. That means it must be at the beginning or the end of the day.

Hospitals are being crushed by decreases in reimbursements so they are pushing to get more done with less. More cases are done in less time. Start the cases early and on time so that they can get more done before the end of the day shift. They don't want to pay overtime. Many hospitals want to push the OR time back to 7am. Hospitals administrators know that residents slow down many attending surgeons and would rather not have them operate to decrease OR time. So how are we going to prevent monetary problems from effecting the education of our needed practitioners?


In the end, this question I wanted to solve has only brought more questions. I will continue to reevaluate my on education styles. I hope to keep this generations eyes open. I want them to look not only at how they are affected, but at how their choices and actions affect those who will follow them. As an educator, my ultimate goal is to put out a good product (physician/surgeon) in the end. The means of doing that may vary but hopefully the outcomes will be the same.
"In youth we learn; in age we understand.”
~Mari Von Ebner-Eschenbach


Anonymous said...

Whether a department will fund a resident without CMS funding is not a responce to a physician shortage. I simply do not believe in hospital system altruism either. This was clearly delineated by the Detroit collapse. Many programs would not take displaced residents when the hospital chose not to release CMS funds. Some did. Some are continuing to make a case to the ACGME for more spots - some may (or may not) have unfilled CMS allocations and a GME office willing to distribute them to ortho. Other programs had a work need.

Physicians and hospitals get defensive when the resident as a laborer is mentioned. Despite the debate over whether a PA or resident is more valuable, a resident definitely has a lower salary, no potential for overtime, and probably equivalent benefits. They are also a potential partner if things are a homerun between the program and individual. Most big systems are self insured for malpractice so I do not feel too remiss to say some of those costs might not have been felt to hard.

I would be shocked if there is significant nationwide expansion of GME programs if CMS funding does not follow. Maybe you ortho program, maybe programs at Mayo or Cleveland or other financially capable institutions. I will be shocked though if there is a significant change in most specialties without the funding.

Anonymous said...

Do you feel it is appropriate for you to describe others as harping over the 80hr rules? You refer to it with a negative conotation in the majority of you posts usually in reference to today's trainees having a shift work mentality or some concern that they will not be able to function at the attending level because of the coddling. Your responders often question you on it. You often respond that you are bein misunderstood and that you ultimately support the 80hr wkt. The next post brings the cycle full circle. The replies on this topic are even diminishing.

These is all book-ended by a post telling others to stay off their high horse because of the fall and now this one referring to the harping on the 80hr topic. I believe there is an inconsistency in your messages.

I am looking for the studies comparing the PA's and residents overall financial impact on the hospital. The link you provided is a blog where one person uses reasonable numbers to defend the stance commonly held by trainees. Another person says the numbers were different in his/her practice and that they are not cut and dry. No objective support (re: numbers) are provided. This is a numbers game - the most important one being #4 - it shares the key with the $ sign.

Midwife with a Knife said...

I think that the real truth for the economic advantages of residency for hospitals is somewhere in the middle. Sure, the hospitals aren't making a huge profit off of the CMS funds. However, without residents, most hospitals would have to hire a legion of NPs/PAs to take care of the inpatients, and each NP/PA would cost as much as residents (probably ~ $100,000/year) but without the CMS funds. Therefore it's probably financially better for the hospitals in general to hire people to take care of their patients who's salary is already subsidised.

A few friends of mine have gone out to practice in non-teaching hospitals, and they say that it's really difficult to do some things without residents around. So, at least in ob-gyn, there are advantages to attendings in having residents; however, most tasks as an attending can more easily and efficiently be assisted by a PA/NP/CNM(especially one who's been in the job for a while), and the increase in speed would pay for the attendings added cost of hiring a PA (especially in the outpatient arena where PAs can bill independantly but outside of primary care, residents can't).

So, I think there's still a financial advantage for the hospital (but not for the individual attendings) to train residents. Plus, in a lot of programs residents do a lot of scut, like transport patient, draw blood, put in IVs. Even hiring a transporter or phlebotomist is more expensive for the hospital than hiring a resident because of the subsidies for resident education.

With respect to protected educational time, I don't know what to say. I'm currently frustrated because I volunteer to cover the residents for their educational time, and then many of them skip the lectures. I do think that it shouldn't be a big deal to have a 4 hour period 1-4 times a month where there aren't surgeries dedicated to resident teaching. I also feel like there should be some leeway in the hours requirements so that the residents could say, come in on a Saturday morning, maybe 2 times a month.

In general, I think that some hospitals (like the DMC!) are very interested in the CMS funds, but really very much less interested in providing a quality experience for their residents. I think that attendings who chose to teach have always done so out of an interest in helping the next generation of physicians, and that that's unlikely to change.

Anonymous said...

$100,000 a yr for a PA seems low if you count benefits. It seems high for a resident - salary alone will rarely reach 50% that outside of certain cities. Many hospitals and attending bill for the services provided by residents. Its easy for the hospital b/c some attending is around. PA's can legally bill - but not 100% the attending. "But without the CMS funds" is a huge condition to that statement.

Private physicians likely do find it easier not to have a resident. Their hospitals likely do not offer the same services though. Is it easier to have an elective practice without being slowed down by a resident? Of course. once the PA has the routine down - it is even better. What about being on call in a Level I trauma center though? or in a city where pre-natal care is unheard of and every night is filled with those kinds of cases?

You cannot say how many "some" hospitals means? Why? So few have been given the opportunity to show their true colors? The same is true of the attendings who say how much better things would be without a resident (like many WSU ortho faculty did). Most bolted within a few months when they realized how long it took for their 5 page clinic dictations to be done, or dressing change rituals with no scientific merit... the list is long.

You cannot assume people's motives for having object X, until X is gone. So few ever face the loss of resident labor. When you call it labor the horns go up. How much more could be made in private practice gets spewed out. Private guys all say they work a lot harder - many salary gaurantees are gone. Some have to fill out the paperwork the asks for the attending signature that was a point of contention in a previous post. Most will admit too that worker's comp or auto usually pays better too. Diatribes about education and service - when the labor is gone, it is the first thing they complain about being gone.

Someonect said...

first i'd like to give a shout out to all my michigan folks. i'm back in the house. i am at my sons HS graduation in monroe. big shout out ot my folks @ the U. (my residency alma mater)

thank's all of you for commenting, didn't think this would get so many people interested.

anonymous #1, i thought the increase in medical students without increase in CMS funding was an interesting point. it does bring up the point of who will cover their salaries if there is no CMS funding.

"labor" is an issue. most are being supplemented with PA's. And the point has already been made that PA's can bill with their own NPI#. so they can supplement their own salaries and sometimes can make a practice or hospital money if implemented properly (billing for clinic and first assist fees).

the whole DMC issue is extremely political. lots of problems with the DMC system.

anonymous#2, i appreciate that you have read a lot of my posts on the subjects. thanks. as for the 80 hr rule, i mention the harping on it because when people mention resident work ethic or not working hard people say it is about the 80 hr changes. i don't see the 80 hr changes being an issue. changes in work ethic are problems. this is not something that i am alone at mentioning. there are many blogs and articles that mention the differences in the new generation and how to adjust to them. buisness and law saw their influence prior to medicine because our training is so long.

the high horse statement is really pointing out to always stay humble. that is something that i continually preach to my residents and truly believe.

and yes, in the end it comes down to dollars. when PA's and NP's are properly used they can actually make hospitals more effiecient because there is no need for retraining once they have been trained on the basics. (they become like chief residents eventually)

MWWAK, what up girl

things will be somewhere in the middle. it troubles me when we go through and schedule education time and it is not appreciated. as for sat. conferences, forgetaboutit. we will get more complaints about that running into their free time.

Anonymous #3,

for ortho the cost for a PA will be somewhere around $160,000+. but it increases your ability to see more new patients and bill for a first assist. so the cost for a PA is usually a wash but is use properly they can make the hospital and practice money.

i can speak from experience that when your team is experienced you can do more cases and see more patients. we had a physician who spoke to us and explained that they have done a lot to decrease their OR time. (this is not typical) he showed his cases for 1 day. we counted 10+ total knee replacements in one day . they have no residents (but the do have fellows). it is because it is a system.

again thank you all, i appreciate all of your comments.

Midwife with a Knife said...

I know what you mean about the Saturdays, it just seems like such a reasonable solution, though.

It just seems unprofessional to me when residents say, "I have to go home at 5, I'm running up against my 80 hours." Professionals don't always go home at 5 (although, as professionals we should maintain a safe work schedules), sometimes you have to be willing to put in the extra time, and I worry that hard and fast rules work against that work ethic.

Someonect said...

i think sat. lectures would be a great day because there is minimal conflict except for free time. we haven't choosen that alternative trying to meet the guidelines without interferring with people's freetime.

i don't know if it constitutes being unprofessional when you are following the rules but is surely isn't real world in the surgical specialties. you stay until your work is done. you actualy hit the nail on the head when you said that you worry about the hard and fast rules working against work ethic. that is also my worry. again, the 80 hours of work i don't care about, work 7am to 5pm, but when you come to work, be willing to work. this is a something that many have talk about outside of medicine. these are generalization, of course not every on is the same.

here is an article with lawyers speaking on the topic
another on business

these thoughts are not exclusive to medicine.

Anonymous said...

I do not believe your work ethic ideas held up when capitation was more prevelant. Physicians with bonus systems in place work differently than those strictly salaried. I do not believe that is the same as work ethic. How can I support this? Among its many findings, the Rand study showed that when you lower physician reimbursement - they work more and ultimately cost more healthcare dollars through ancillariy services, medical equipment. Lowering reimbursement didn't give them more work ethic or inspire them to worked later. The old adage "when you give a doctor a salary, you buy a good golfer" hasn't stuck around by accident. Staff routinely cancel cases when the OR has a delay, etc. Fractures have sat an extra day - always in the city hospitals though. The suburb guys sat around, angrily, but waited and did the case. Do they have more work ethic or more incentive to keeep the insured patient on track and hopefully keep a paying customer around in case they ever require future services?

Physicians have been very willing to complain and act on reimbursement changes. Now, they are insistent on owning imaging, surgicentersm etc. The ortho studies (one poorly controlled in CA, one less poorly controlled) show how difficult it is to get pediatric medicaid treatment by a physician. No ones points a finger at them and cries "poor work ethic."

Studies continue to show that research with financial backing are more likely to show positive results. Is "academic ethic" comporomised? Aren't these people the greats you spoke of when describing the role of the academic medical institution?

These are just 2 snapshots of why I feel you imply a physician "work ethic" inappropriately. To me, its the rabbit chasing the carrot, not running to stay fit.



We can't get staff to come to Wed conference. One told me that Wed AM was a good time to fill his gas tank. Another thought it was ridiculous to have different sub-specialists at topics on other sub-specialties, really the general guys in the program should be there. I'm sure if we gave them an honorarium - it would change. I know one program looking into linking teaching dollars to lectures given, attendance. I can see a "work ethic" improvement coming.

Complaining about working too much for not enough money should be applauded by staff. Finally, they can stop saying that their residents aren't listening to them and following in their footsteps.

I'm sure when today's residents are in the incentive/bonus driven practices that many are going to enter, their willingness to stay late, etc will be there. So will be the time needed to instrument that additional level or give that sponsorred talk. Hopefully we will even strive to reach the 100% divorce rate that some programs actually brag about. Meanwhile, I need to go to the nearest playground and start finding things to dislike about Generation Z.

Someonect said...


many of the topics you bring up are truly valid points. the typically salaies aademic physician is going away and we are all becoming incentivized by production. in out practice, we receive most of those patients that the privte guys don't want. those pediatric patients with the complicated buckle fracture. cases in our practice in general are not cancelled because of OR delays. but, we are at a trauma center and if it is not done today it just piles on to tomorrow.

you preach to the choir on the pediatric patient and medicaid (over 60% of my practice is medicaid.

we all know that industry studies tend to show benifit. it is that bias we are all aware of. those greats in the past, most did not have the industry supported research. that is more of a producst of the recent 10 years.

i agree money drive all in the end. the work ethic am speaking of it that is occuring during working hours. the incentive you should have is that it is your education earn as you can while you have the protection of the system before you are out on you own.

Someonect said...

anonymous, sorry i couldn't address all of your comments because i was out of town and didn't have a chance to review the articles you sited.

i am not sure where you are but as i said before salaries are not as hard and fast any more. most of the newer contracts in academics (especially in the surgical subspecialties) are tied some how to production. in my previous academic practice, i paid all of my overhead from my own collections. in the county or city hospitals, all bets are off because most of the work is almost volunteer. i have work in the private , community, military, and academic hospitals, they all have the same problems with fractures sitting around. not because people don't want to do them but because the are hamstrung by the system (OR shuting down rooms and as always our arch nemesis, Anesthesia)

you mentioned the changes in physician own facilities. this is just business. can't have the man making all the money. this was not uncommon in the past. multispecialty groups use to own pharmacy, labs, xrays, etc. increases you income.

i adressed the pediatric medicaid issue. he we are in next to the malpractice capital in the country in souther illinois and one of the worst medicaid payors (IPA) we see this all the time. is it a work ethic issue, liability issue, or a business decision. so do they not want to do the work? don't want to assume the liability until the child is 18y/o? or do they not want to loose money for every IPA (illinios medicaid) patient? i don't knwo.

i read both of the articles, the one on spine for profit and the other on the drug testor. you know we can also site many articles to the contrary. like in my old program director who hated industry repss and refused to take the free food, yet he had multiple patents including one of the 1st TKA used. i think you will see more people going to industry for funds like the music stars go to have their concerts sponsored. in the future you may see signs like this urologist is a viagra premier doctor, or maybe this spine doctor is brought to you by INFUSE. we'll see. you did forget the article that talks about how much the spine docs at wash u get paid by metronic :)

lastly, in our program, i think, we promote family and don't want people staying late. this is not about who can stay the latest or do the most surgeries. it is about how can we all within the limitations we have produce adequately trained individuals. i have no dislike for gen y. i actually have much love for them. i search for an understanding. so that i personally can help in their education. see for me, it is not about me. it is not about money. it is about the education. one of my proudest moments of the last few weeks is when one of my residents said "thanks for letting me struggle." for me, he learned more from that case he could ever learn in a book or in a computer simulation. he made an error and had to fix it (the patient was not at risk). i was there for him and he knew i would bail him out if i felt he needed it; but i felt he needed to sweat. in that moment he grew as a surgeon. that is what this is about.