By Jeet Guram
Readers, my name is Jeet Guram. I am honored to join this blog with Avik and such a great group. I just finished my third year of medical school, which students spend in an academic hospital as a member of clinical teams caring for patients. Leading these teams are “attendings,” or fully certified physicians. In between medical students and attendings are “residents,” who have completed medical school and are training in a particular field. Non-academic hospitals usually do not have medical students and residents.
While we medical students are mostly there to learn (and to try to stay out of the way!), residents are the ones responsible for providing much of the care a patient receives. Residents examine patients when they get to the hospital, decide on diagnostic tests, establish treatment plans, and carry out these plans by administering medications and conducting or assisting with procedures and surgeries. Residents are typically the first members of the team to respond to urgent issues, such as a patient developing chest pain. They are always under the supervision of attendings but take on increasing independence as they progress through training.
All medical students must complete residency in a field of their choosing before they can practice medicine. New medical schools are opening across the country, but strangely, the number of medical residency spots is remaining nearly constant. Most residency programs receive funding from Medicare. The number of residency positions that Medicare will pay for was set in a 1997 law called the Balanced Budget Act. No new federally funded positions have been added since then, even though the U.S. population has grown by 49 million people and the complexity of medical care has increased by orders of magnitude.
By the end of the decade, the number of US medical and osteopathic school graduates is projected to exceed the number of residency positions (currently the extra residency spots are filled by graduates of foreign medical schools, who have historically helped provide much-needed primary care services and care in rural settings). Already many students are not able to train in the field they prefer due to a lack of available residency spots. Soon, students who have gone through the medical school admissions process and the long hours and considerable expense of medical school will not be able to continue to any residency position.
As our country faces a shortage of physicians, a problem that will only worsen as more citizens gain coverage under Obamacare, we are not offering enough opportunities for individuals qualified to be physicians to complete their training. And this is not for a lack of available work. Residency is notoriously busy. This year I worked with residents who had to keep track of dozens of patients in the hospital at the same time.
One evening I was out with one of my clinical teams at a museum, where we reflected on how works of art made us think of the process of caring for patients. We saw a statue of Hercules, who, we were told, was given a series of dangerous tasks to complete to atone for a sin. First he had to slay a lion with rock-solid golden fur. After killing the beast, Hercules was elated, but a glance at his list of remaining challenges quickly pulled him back to reality. After hearing this story, one of my residents joked that it reminded her of the start of a day of patient care, when you finished one task and felt excited, only to look down at your list and be reminded of the daunting number of assignments remaining.
In a national survey of hospital-based physicians, forty percent of physicians reported that the size of their patient load exceeded a safe level at least monthly. Adding more residents would not only train more physicians but it would also leave each resident covering fewer patients. Residents could spend more time with each patient, increasing the quality of hospital care.
The bottleneck of medical residency spots should be seen as a cautionary tale about centralizing decision-making in health care. In a 2008 article entitled “The Problem with Single-Payer Plans,” Ezekiel J. Emanuel, MD, PhD, a former advisor to the Obama administration, wrote about the danger of politicized decision making in government-controlled health care programs. “Every Medicare decision is subject to political pressure from somewhere,” Emanuel wrote. “The result is that Medicare decisions are made slowly, and rarely on their merits.”
As resident workloads and the need for additional fully trained physicians both increase, an expansion in the number of residency spots is long overdue. I fear that as Obamacare moves more decision-making to the federal level, we will see a similar lag emerge in other areas of our health care system between a need being identified and it being met.