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Anesthesiology:
doi: 10.1097/ALN.0b013e3182837db5
Correspondence

Resident Research and Graduate Medical Education Funding

Nemergut, Edward C. M.D.

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To the Editor:

I sincerely enjoyed the recent article by de Oliveira et al., which analyzed various factors associated with successfully matching to a residency in anesthesiology.1 I also enjoyed the accompanying Editorial, written by four academic leaders in our specialty.2 I strongly agree with the editorialists’ sentiment that the future of anesthesiology must be built upon scholarly investigation into the basic and clinical sciences.
As the editorialists do not specifically articulate it, it is important to remind the readers of the complex process by which Graduate Medical Education is funded in the United States and how this process may affect research during residency training. The Center for Medicare & Medicaid Services (CMS) makes two types of Graduate Medical Education payments to support residency programs and teaching hospitals. Direct Graduate Medical Education payments compensate teaching institutions for costs directly related to resident education (e.g., resident salaries). Indirect Medical Education payments are intended to compensate teaching hospitals for higher inpatient costs and are calculated as a percentage add-on to basic Medicare per case diagnosis-related group payments. In 2011, CMS Direct Graduate Medical Education and Indirect Medical Education payments totaled approximately $3 billion and $6.5 billion, respectively.
To the surprise of many, CMS does not automatically continue to fund a resident if he/she decides to participate in research during the course of residency training. In August 2001, CMS indicated that it would exclude residents in the Indirect Medical Education count “to the extent that the residents are not involved in furnishing patient care but are instead engaged exclusively in research.” Further, CMS policy allows a resident to be counted for Direct Graduate Medical Education only if the resident is engaged in research that occurs in the hospital (but not in the nonhospital setting). The points were explicitly stated in section 5505 of the 2010 Patient Protection and Affordable Care Act (Public Law 111–148, Section 5505).
Thus, as residency positions are explicitly funded by CMS for clinical training, the lack of association between applicants’ prior scholarly production and a successful residency match, as observed by the authors, is not surprising. Residencies are not funded or intended for research. Similarly, one would not expect clinical experience to count as much as research productivity for positions explicitly funded for research (e.g., research fellowships).
As pressure for reform of Graduate Medical Education financing mounts, both departments and teaching hospitals may find it increasingly difficult to provide residents with protected time for research.3,4 Several departments have developed programs designed to support residents interested in an academic career. As implied in the Editorial, many of these programs specifically have National Institutes of Health (Bethesda, MD) Funding (often as part of a T32 research training grant). Unfortunately, the vast majority of residency training programs do not have these opportunities available. As the future of anesthesiology is dependent upon our ability to recruit and train not only talented clinicians but also tomorrow’s independent investigators, I hope that more departments work to expand the number of funded research positions.
Edward C. Nemergut, M.D.,
University of Virginia Health System, Charlottesville, Virginia. en3x@virginia.edu
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References

1. de Oliveira GS Jr, Akikwala T, Kendall MC, Fitzgerald PC, Sullivan JT, Zell C, McCarthy RJ. Factors affecting admission to anesthesiology residency in the United States: Choosing the future of our specialty. Anesthesiology. 2012;117:243–51

2. Fleisher LA, Evers AS, Wiener-Kronish J, Ulatowski JA. What are we looking for? The question of resident selection. Anesthesiology. 2012;117:230–1

3. Iglehart JK. The uncertain future of Medicare and graduate medical education. N Engl J Med. 2011;365:1340–5

4. Iglehart JK. Financing graduate medical education–mounting pressure for reform. N Engl J Med. 2012;366:1562–3

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