Advocacy and policy news for internists

ACP Urges Changes in Graduate Medical Education

The Institute of Medicine is preparing to issue a report about the future of graduate medical education that could inspire significant change in a system that isn't churning out enough internists.

The problem? "Residents and medical students are not choosing to practice internal medicine," said Dr. Charles Cutler, who will take over this spring as chairman of the ACP Board of Regents. "We need more doctors practicing internal medicine. But by and large, they're choosing medical specialties."

The Institute can be part of the solution, Cutler said, by urging Congress to change priorities to emphasize internal medicine and expand the funding of graduate medical education by including insurance companies in the picture. Cutler, a Philadelphia-area internist, testified on behalf of the ACP at a public meeting on the topic sponsored by the Institute and held in December in Washington, D.C.

The Institute committee that's developing recommendations on the training of physicians is exploring, among other things, the financing of graduate medical education and the geographic distribution of various types of physicians.

The committee has had several public meetings and is expected to issue a report late this year. Christine Stencel, a spokeswoman for the institute, said the committee is still figuring out what it believes.

"There's a lot of work ahead, and committee members generally refrain from expressing comment on any piece or group of information they've looked at so far lest any comment now be taken as a final conclusion or recommendation that will be in the report," she said. "There's a lot of deliberation and report drafting ahead and lots of opportunity for their thoughts to evolve."

Cutler said that ACP is worried about cutbacks in funding for graduate medical education. One option would be to find a role for insurance companies in the funding process, something that Cutler said ACP supports. The College also is concerned about the current system's failure to allow for adjustments to be made as fields experience shortages.

"The money is spread more or less evenly across the system," he said. "Dermatology, where there is virtually no shortage, gets funded to a similar extent as internal medicine. What we're advocating for is preferential funding to internal medicine so there will be more slots and more opportunities for students to go into internal medicine."

He noted that there's justification for such a focus.

"A lot of research establishes that good primary care saves money," Cutler said. "Let's say you go to a primary doctor and get screened for colon cancer. The cancer is picked up at an early stage, and you don't need a $50,000 operation and $100,000 worth of chemotherapy and radiation."

But there's a major gap between the pay of internists and specialists. In 2010, primary care physicians made $202,000 a year, on average, compared with $357,000 for specialists, according to the Medical Group Management Association.

That can be especially important to doctors just starting out, explained Dr. Tiffany Groover, a resident in Boston Medical Center's primary care program who served as a health policy intern in ACP's Washington, D.C., office last spring.

"Throughout my medical school training and most notably in residency, many of my colleagues made it clear that primary care would not be an option and specializing was the only viable decision," Groover told the Institute committee when she testified at the meeting in Washington, D.C. "One of the most prominent reasons was the need to repay the staggering educational loans acquired during medical school, in addition to those from prior education. Many of my fellow students and trainees also expressed that primary care is a field that may not survive health care reform, raising concerns about a stable career in medicine."

"Unfortunately for many, a focus in primary care is an afterthought," she said.

But in addition to improving compensation, Cutler said, the system needs to improve the quality of work life for internists by reducing paperwork and boosting teamwork, which is rewarding.

In the big picture, he said, "we're optimistic that new payment models will encourage more doctors and more students to go into or stay in primary care."

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January 23, 2013
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