We thank Drs. Volpintesta and Manthous for their interest and comments.
We agree that educating physicians simply takes too long and also agree with proposals to reduce the length of residency by focusing training on preparing residents for what they actually want to do, including practicing primary care.1 Training for primary care physicians, however, should continue to be rooted in medicine and differentiate itself from that of other providers engaged in primary care. The solution to the increased demand for social and coordinating skills mentioned by Dr. Volpintesta is not to train primary care physicians at considerable personal and taxpayer expense to provide these services but to either eliminate low-value services or find alternative providers to meet this demand.
We also agree with the need for higher reimbursement for primary care to encourage all physicians, including primary care physicians, to provide primary care. Some specialists are already de facto primary care physicians for patients with certain chronic conditions (e.g., asthma, diabetes, multiple sclerosis). Absent higher pay, access to such physicians will remain limited, and incentives for physicians (both specialists and primary care physicians) to pursue more highly remunerative procedures will remain. Additional incentives for international medical graduates to practice primary care could be attractive in the short term, but once those incentives are removed (e.g., citizenship granted), ensuring an adequate supply of primary care practitioners will be difficult.
As Congress continues to look for ways to reduce federal expenditures—including outlays for graduate medical education—shortening the duration of training for physicians and thus the subsidies for teaching hospitals is, as Dr. Volpintesta wrote, “an idea whose time has come.” What also has come is the need for greater financial accountability2 for how these subsidies are spent. Devoting a greater proportion to the salaries of resident physicians will address the issue of accountability and give future physicians greater financial freedom to choose specialties, such as primary care and geriatrics, that society needs. Finally, higher pay for primary care will address the perverse incentives in medicine and enable physicians to afford to provide primary care.
E. Ray Dorsey, MD, MBA
Associate professor of neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland; [email protected].
Sean Nicholson, PhD
Associate professor, Department of Policy Analysis and Management, Cornell University, Ithaca, New York.
William H. Frist, MD
Former majority leader, U.S. Senate, Nashville, Tennessee.
1Goldman L. Modernizing the paths to certification in internal medicine and its subspecialties. Am J Med. 2004;117:133–136.
2Iglehart JK. Medicare, graduate medical education, and new policy directions. N Engl J Med. 2008;359:643–650.