Mar 11, 2016

Dr. Jones: So how is medical education after medical school funded, and why does it matter for patient care? I'm Dr. Kyle Bradford Jones, Family Physician at the University of Utah School of Medicine, and we're talking about this today on The Scope.

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Dr. Jones: Today I'm joined by Dr. Brad Poss who is a Pediatric Critical Care Physician at Primary Children's Medical Center and the Associate Dean for Graduate Medical Education at the University of Utah. So Dr. Poss, just so that we're all on the same page, explain to us what is graduate medical education.

Dr. Poss: To become a board-certified practicing physician, you need to go through a series of steps. Once you enter medical school, we call that the undergraduate medical education portion, the four years, then you go into a period of what we call graduate medical education training where you're learning to be a practicing physician in whatever specialty you choose. That can range from three years to eight years, to some even longer. Dr. Jones: So obviously with medical school the student is paying for that. Who pays for the graduate medical education?

Dr. Poss: That's a really good, complex question. Essentially it comes from a variety of sources. The major funder is the federal government, but in addition, the state government participates, the hospitals participate, the departments participate. They are paid a salary with benefits, although certainly what they're paid for is well less than a practicing physician. Dr. Jones: So where did this complex payment structure come from? How did the government get involved?

Dr. Poss: Graduate medical education has been around for quite some time and it's kind of gone through periods. The first period was really the apprenticeship model, and this was where, really, departments such as internal medicine or surgery kind of owned them. They fed them. The house staff, the residents, lived in the hospital. They worked a lot of hours and they really were there, dedicated, and they often were not paid anything.

About the time that Medicare and Medicaid, things began to change and some of the funding began being paid for by the federal government. And at that time the house staff began getting salaries, both kind of competing, one hospital against another, "I'll pay them this, you'll pay them that." And it's kind of evolved to the current system that we have today. Dr. Jones: So with graduate medical education there are multiple different specialties, areas of medicine. Some are done at hospitals. Some are done in community programs. How is it determined where the funds go and how is that allocated to the different programs?

Dr. Poss: It's really funded based on a model in 1997 where primarily the care was delivered in inpatient acute settings, and so most of the funding is really centered around care delivered within a hospital, not within ambulatory settings.

Dr. Jones: So how do we determine, with that cap, do we have enough physicians that are being trained? Are they being trained in the areas of medicine that are most needed for the community?

Dr. Poss: The short answer would be no. As you can imagine, in 1997 the population within the United States looked very different, so the funding is proportional or disproportionate to the east coast. And so as you look at the funding of residents per capita or per patient, it's definitely more concentric in large cities, especially back east. As the growth has occurred in states like Utah and others, the growth in resident funding has not kept pace with the growth in population.

As far as funding and geography, it's very mal-distributed. In addition, most training centers are set in urban settings, such as the University of Utah, and obviously that leaves, then, more rural settings to have less trainees. For example, for the University of Utah where we have not only a mission to get physicians for Utah, but this region, the Intermountain West, we are the only academic medical center and therefore we are trying to train residents for a large region even though those sites do not have their own training.

Dr. Jones: Yeah, okay.

Dr. Poss: And in addition to specialties, no, we can't force folks into the training that they want. You don't want someone who really wants to be a psychiatrist and say, "No, we're going to make you into a neurosurgeon." That's probably not good for that person, and probably more importantly, not good for the patient. So I think that's the big question of all this funding. Are we meeting the needs of the people, and are we really anticipating what the growth is and where things are.

Dr. Jones: Now, you mentioned kind of the most important part is how does this affect patients? How does this affect outcomes? Do we have any sense at this point of looking at the value of the money spent of graduate medical education and how that kind of immediately impacts patients?

Dr. Poss: We're trying to get to that answer, but I think it is important for the population. It's important for the patient to know how this money is being used, and is it being used correctly. You know, I'm a very big believer in teaching hospitals. I think that's where state-of-the-art medicine is being delivered. It's where we're training the future physicians and nurses and pharmacists of tomorrow, and I think patients actually get fantastic care here, as evidenced by all of the quality metrics.

Dr. Jones: Yeah.

Dr. Poss: But I think it's very important that patients understand, too, that the residents, we know that residents really are the primary caregivers for a lot of these interactions throughout. The attendings are certainly there, supervising the care and very involved, but the residents are really the ones who are here 24/7 and interacting with patients on end. So we need to make sure those trainees are trained safely and they're aligned with all the teams' goals.

I think that's very important to the patient, to ensure they get the best value of care. From a global scheme, we're also beginning to say, "Okay well, what's the value of graduate medical education to Utah and the region? We've developed kind of a, we feel, a pretty innovative model that we're just about right now to release and have five or six programs do a pilot study. We've already had two programs do this, and it really looks at what is the value of graduate medical education in a bunch of categories.

They're important categories. How are they succeeding educationally? How are they succeeding in enabling access to patient care? How are they enabling quality, are the residents involved in the quality? Are they being trained in value?

We're also, then, looking at retention. How many physicians are being retained within Utah, how many are being retained within the region, and how many are going into those rural areas or primary care, and giving them kind of a point system. And as we begin to do some of these experimental innovative programs, we'll know if it's working.

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