The looming GME funding crisis

David Silberswieg, Professor of psychiatry and Academic Dean at Harvard Medical School, writing in the Washington Post about the increasingly underfunded mission of academic medicine:

But while there is a need for oversight, in some political and journalistic quarters there are exaggerated senses of mistrust, attack, mixed messages (if not hypocrisy), and mis-aligned incentives…Ever-increasing regulation brings more and more unfunded mandates and documentation requirements, which while very important to a degree, require extensive amounts of organizational and personnel time, detracting from patient care and increasing professional burn out.

The IOM’s To Err is Human and the resultant quality improvement mandates have done some important things, but fetishizing quality improvement has resulted in countless ways to try to optimize some metrics at the expense of others (as well as other unintended externalities). When you tie reimbursement to a metric, you better be sure that metric is what you really care about. When it’s not, the system suffers (such as the issues that arise with optimizing patient satisfaction).

All of this has resulted in the corporatization of the culture at many teaching hospitals. Endless meetings and initiatives to make processes leaner and to remove waste may be imperative for the responsible, viable running of the teaching hospitals. But the relentless focus on these real concerns increasingly comes up against a point beyond which staffing and funding cuts endanger the academic mission, before endangering patient safety — the point no one wants to reach.

This has been become more and more of an issue during the past four years of my residency. In addition to more documentation, various best practice warnings, mandates, programs, and the unending growth in “vice-presidents” of various manufactured responsibilities, the GME funding dollars are simply getting tighter and tighter. Even our duty hours are now being scrutinized from both directions. A resident still can’t work too much (at least on paper), but the hospitals we work for also want to make sure each is getting their money’s worth for our salary as well. They’re even starting to compete within the system with each other for their share of the pie (if I’m working at hospital A, then why am I call on at hospital B?).

How, then, can we save our academic medical centers, cutting costs and improving efficiency, without compromising the high caliber of care, patient safety, workforce development and discovery? How can we attract, educate, retain and develop our best medical talent, who have spent many years training while incurring crushing debt, and allow them to do their best work on behalf of society?

I’m not sure you can without big changes in the structure and length of medical training from college through residency. With trainees caught within the ever-grinding gears of the bureaucratic machine, the clinical and regulatory missions will absolutely try to kill the academic mission. How can the average trainee learn over a reasonable timespan in an environment of relentless oversight and pseudo-clinical distractors? How can we continue to attract driven and smart people to medicine when the journey and even the destination are becoming more unpalatable? More young physicians want “part time” work (which would often still be considered full time outside of medicine) in order to match the non-medicine lifestyles of their peers. Meanwhile student debt grows unabated. Big things change slowly, and the GME is no exception. But we’re slowly approaching a crossroads.

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