Primary Care Doctors Shouldn't Be Training in Hospitals (Op-Ed)

Dr. Bruce Koeppen is founding dean of the Frank H. Netter MD School of Medicine at Quinnipiac University. Koeppen contributed this article to Live Science's Expert Voices: Op-Ed & Insights.

If health care's goal is to keep patients out of the hospital, why are primary care physicians training in hospitals?

There are several compelling reasons to train primary care physicians outside hospital settings. With the rising cost of medical education, even the most dedicated resident planning a career in a primary care discipline often reconsiders that plan. During a three-year hospital residency, that future physician is surrounded by specialists whose work is often perceived as more prestigious, and certainly more lucrative.

As the Affordable Care Act brings millions of previously uninsured Americans into the health care system, the flaws in our current system of hospital-based residencies and reimbursement practices have reached critical mass. The system is in desperate need of an overhaul, and there is not a minute to spare.

Here is another problem: By 2017, the number of American medical school graduates (M.D. and D.O.) will exceed the number of existing residencies. And, without a residency, physicians — who dedicated years to the pursuit of a medical education and incurred significant debt doing so — will not be able to practice medicine. [Doctor Shortage Looms in Health Care Reform (Op-Ed)]

This is tragic, and quite a turn of events in a profession where medical school graduates have historically been guaranteed a job at a time when physicians are needed more than ever before.

The reasons behind this situation are complex and go back many years. It began during the administration of President Bill Clinton, when the Balanced Budget Act of 1997 capped the number of first-year residency slots funded by Medicare (which covers the majority of the cost of training medical residents) to help balance the budget.

As new medical schools opened to try to stem the physician shortage — including ours, the Frank H. Netter School of Medicine at Quinnipiac — the number of U.S. medical school graduates began to rise, increasing competition for the fixed number of residency slots — unchanged since 1997.

Last year, more than 400 medical school graduates across the United States did not receive a residency match. With more students graduating from medical school in the coming years, this number will only increase.

It is possible for hospitals to expand the number of residency slots, but to do so, they must fund those positions. While trends in patient care emphasize wellness and prevention, the current reimbursement system is based on the number of procedures performed. As a result, there is an incentive for hospitals to fund additional residences in specialties that produce revenue, such as cardiology, gastroenterology and orthopedic surgery — another blow to that primary care shortage problem.

Earlier this year, Reps. Allyson Schwartz (D-PA) and Aaron Schock (R-IL) introduced the bipartisan Training Tomorrow's Doctors Today Act, which would increase the number of Graduate Medical Education (GME) slots by 15,000 over the next five years. However, its passage in the current Congress is unlikely.

Currently, there is another approach to train primary care physicians that totally bypasses hospital-based residencies. The Affordable Care Act's $230 million Teaching Health Center Graduate Medical Education Program has funded 11 Teaching Health Centers to train primary care physicians outside hospital settings, many of which serve underserved communities. The residency programs do not rely on Medicare funding, but must be self-supporting by 2017.

Teaching Health Centers not only provide slots for medical students interested in practicing primary care, they create the right kind of residency programs to nurture aspiring primary care physicians.

Primary care is delivered outside hospitals, and residency training for primary care disciplines must also take place, predominately, outside hospitals. We need to learn from these Teaching Health Centers, expand them, and provide new training sites with stable funding beyond the term of these initial grants.

No one said changing the American health care system would be easy, and balancing the physician patient equation will require some creative accounting. But, we must solve these problems if we want to do right by patients and the medical students who have invested so much to care for them.

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