During the last few years, a great deal of legislative reform has been proposed with respect to graduate medical education(GME).1-8 This legislation has been based on the belief that there is a significant oversupply of physicians in the United States, as well as a severe problem with geographic distribution and an excessive number of specialists. Several proposals are under consideration at the national and state levels that would have a direct effect on training programs in physical medicine and rehabilitation. These include the following: (1) total United States residency positions may be reduced; (2) emphasis may shift from specialist to generalist training; (3) programs may need to join together in training consortia to determine local residency position allocation strategy; (4) funding of international medical graduates may be reduced; (5) funding of fellowship positions, especially non-Accreditation Council for Graduate Medical Education (ACGME) accredited positions, may be reduced; (6) funding of double-boarding programs will be reduced beyond the time period required to complete a single training program. 1-8 Presently, even without major reform legislation, it is our opinion that many physiatry training programs are working on improvements in the organization of their residents' training, and this may include a reduction of trainee positions.
A 5-page, 24-item questionnaire was designed with a descriptive database concerning physiatry training programs in the United States and how their institutions might respond to the proposed changes in the funding of graduate medical education. This questionnaire was mailed to all physiatry training directors using the mailing labels provided by the Association of Academic Physiatrists. Fifty-eight (73%) of the residency training directors responded to the survey with one follow-up mailing. The statistical responses were calculated using percentages or means and standard deviations.
Seventy-three percent of the residency training directors who responded indicated that their residency training program's sponsoring institution was a university hospital/academic medical center, and 13.8% noted a community hospital. Ninety percent of the sponsoring institutions were not-for-profit. The sponsoring academic institutions fund a relatively small faculty (more than one-half full time equivalent (FTE)), with 67% being less than 10 and 24% less than 5 (Table 1). The PhD staffing is noted in Table 2. Many programs (31%) do not have salaried PhDs or have only a few, with 75% having three or fewer.
Training demographics are noted in Table 3. Twenty-four (41%) institutions have some of their trainees in an integrated four-year program. Very few programs (32%) have subspecialty fellows, and none reported more than two sponsored at their institution. Although the majority of our responding residency programs reported having international medical graduates (IMGs), only two reported having IMGs in their fellowship programs (Table 4).Table 5 displays the small number of residents in the five-year double-boarding programs. Most of these programs have fewer than one trainee per year. Sites for ambulatory care training are listed in Table 6, with the number of beds available for training shown in Table 7.
The training directors were asked to answer three questions concerning the main mission of their programs. These were ranked on a three-point scale as follows: (1) very important; (2) somewhat important; (3) not at all important. They ranked training physiatry generalists as 1.14 ± 0.35, training physiatry subspecialists as 2.24 ± 0.73, and training research fellows as 2.27 ± 0.72.
Medical student teaching results are noted in Table 8. Elective clerkships are almost universal, whereas mandatory clerkships are uncommon.
Table 9 notes how the training directors believe their institutions would respond to a reduction in resident positions patterned after the following criteria: the number of Postgraduate Year-1 residency positions fixed at 110% of United States medical school graduates (compared with 140% currently) and the proportion of physicians entering practice as generalists fixed at 50 to 55% (compared with 35% currently).1-8 There is a workload issue that needs to be addressed. Three-quarters of the responding institutions indicated that the current faculty's clinical workload would have to increase whereas physician extenders were noted as well as new hires or funding residents' salary from other sources.
Currently, 29% (17/58) have experience with a voluntary collaboration with other institutions to resolve local GME issues. Eighty-two percent (14/17) of these report that the collaboration is successful. Sixty-seven percent (34/58) would, if mandated, prefer working with a local or regional GME consortium for allocation of trainee slots as opposed to a national review body. Sixty-nine percent (40/58) believed a consortium could function successfully, with 10% (6/58) not sure. The barriers to the training programs joining with other institutions in a coalition or consortium for GME position allocation are noted in Table 10. These were rated on a three-point scale(1 = major barrier; 2 = barrier; 3 = no barrier). Governance, academic, bureaucratic, and competition issues all seem to be viewed as possible barriers that could make implementing consortia collaborations difficult.
If there are more physicians graduating from United States residency programs than are necessary to provide for the health of United States citizens, then public funding should probably be used only to subsidize the education and training of the number and specialty mix of physicians needed for patient care and biomedical research. This trend may start very soon, and residency training programs in all specialties should start planning for how to deal with these changes.
Transitional year programs are becoming more difficult to obtain, and residency training directors need to explore various options to provide this required first year of training (Postgraduate Year-1) including the integrated four-year program.9 The total number of physical medicine and rehabilitation (PM&R) residency training slots offered have progressively grown from 1,005 in 1988-1989 to 1,369 in 1996-1997 and then decreased slightly to 1,302 in 1997-1998, with 1,249 positions filled. In 1992-1993, American medical graduates comprised 91% of the residency slots. However, by 1997-1998, this was reduced to 84%.
A bias against international medical graduates (IMGs) has developed in the United States.10 This is despite the fact that on the 1996 internal medicine in-training examination the scores of IMGs at all postgraduate levels of training were higher than the scores of United States graduates.10 There are no comparable studies published with respect to physiatry. The authors believe that IMGs should be welcomed into the specialty when physiatry is their career choice and they are near the top of their medical school class.
The PM&R workforce study conducted by Lewin11 indicates that PM&R is still a shortage specialty through the year 2000 and perhaps beyond if its cost effectiveness and the value of services provided by physiatrists are demonstrated to managed care organizations and other health care purchasers.11, 12 The South appears to be the region with the greatest growth potential, whereas the Northeast and Great Lakes region are more likely to experience an excess supply.11 However, in estimating any physician workforce requirements, the devil is in the assumptions.13 It is the authors' opinions that if training position reductions occur, they will be driven by reduced financial reimbursements for graduate medical education. As long as the direct and indirect reimbursement by Medicare and other providers exceeds the costs of the house staff and the replacement service needs, there will be little incentive by hospital administrators, training directors, or chairs to cut training slots. However, if physiatry training slots are not filled, hospital administrators may be unwilling to continue to fund them because of the fear of losing the unfilled slots.
Mandatory medical student clerkships in physiatry are relatively uncommon, but 16% (9) of the respondents indicated they were willing to develop these clerkships if they were provided additional resources. However, in this era of fiscal constraint, this may be hard to obtain. It is unclear why other programs were unwilling to expand, but it may be related to their other academic commitments such as patient care, program development, and research. Medical schools do consider the education of medical students more important than training residents. One of the productivity measurements of a medical school department is how many medical students they train. Also, the exposure of medical students to the specialty acquaints them with the expertise and services we can provide their patients and leads to future referrals. It also is an opportunity to recruit them into the specialty.14 Physiatrists need to do a better job of promoting PM&R to United States medical students to attract the best and the brightest graduates, especially those with good interpersonal and communications skills.15
The double-boarding programs have not been very popular, with more sites than candidates available at each level. The number of candidates in each of the programs by year was provided by the American Board of Physical Medicine and Rehabilitation and is presented in Table 11. As the respective boards tighten training requirements, especially rotation integration and continuity clinics, and because Medicare has declined to reimburse a full FTE for the fifth year, these programs may be in jeopardy.16 It would be helpful if physiatry could get the Pediatric/PM&R and Internal Medicine/PM&R slots declared as primary care, which would probably result in complete GME reimbursement through the entire five years of the double-boarding programs.
The training directors strongly believe that their top priority is training general physiatrists and that fellowship and research training has a much lower priority. The number of fellowship positions offered by the specialty is fairly low, with 18 responding programs offering a total of 48 positions. The goal of a fellowship is to produce experts in that subspecialty of medicine.17 Currently, our specialty has only one accredited fellowship, spinal cord injury medicine. It is unclear from these data how many of these fellowships are clinical rather than research in nature. For PM&R to survive as a viable clinical specialty, it must develop a stronger research base.18 Research training is critical to having funded researchers in the future.19 The difficulties in recruiting research fellows and in maintaining their research interests have been well documented in internal medicine, psychiatry, and other areas.20 A survey of 5,604 faculty members in departments of medicine,21 4,200 of whom had postdoctoral training, indicated that 43.8% of individuals with MD/PhD degrees and no additional training as fellows were active researchers. By contrast, only 15.2% of MDs without research fellowship training actively pursued research as academic faculty. This does not mean that you must receive a PhD to perform research. For physicians receiving one year of postdoctoral research training, the percentage of individuals who were active researchers increased to 37.5%. Acquiring research training for four years increased this percentage to only 58%. Thus, with one year of postdoctoral research training, the percentage of MDs becoming active researchers is almost equivalent to the percentage of MD/PhDs who become involved in research.
It is also clear from the data that most physiatry departments have few PhDs. The data do not indicate whether these individuals spend the majority of their time in research, teaching, administration, or patient care. This is important because PhDs are a critical catalyst for most successful research programs.
All specialties are putting more emphasis on ambulatory care training. Table 6 indicates a diversity of ambulatory training sites, with a large number of training experiences at satellite clinics and even private physicians' offices. The authors found the latter surprising because with Health Care Financing Administration accounting many hospitals want the house staff on site. This is an important area of training that many physiatrists in practice believe was underemphasized in their training.22 The experience with health maintenance organizations appears to be a problem for most programs.
Table 3 was interesting because 21 training programs had access to fewer than 75 inpatient beds and only 9 had access to more than 150 beds. This is potentially problematic when you consider that of the 81 accredited residency training programs, 12 have 20 to 29 residents and 5 have 30 to 39 residents.23 If all residents must spend at least one-third of their residency experience in the care of hospitalized patients and a minimal census of eight physical medicine and rehabilitation inpatients should be available for each resident while assigned full time to an inpatient rehabilitation service, then some of the programs may not have the inpatient beds to meet the standards.24
One of the most interesting findings is the training directors' proposed solutions to a house staff reduction. The largest response was to shift the workload to the faculty or to hire nurse practitioners and physician assistants. However, the department chairmen and the hospital administrators who were not surveyed may have other opinions. The authors were pleasantly surprised that 12 programs indicated the training of house staff from other specialties as a solution. However, these specialties may also experience resident position cuts and may be reluctant to out-rotate their remaining residents.
If training slot reductions occur, collaboration within and between institutions will be essential. Twenty-nine percent of those responding had experience with voluntary collaboration, and 82% of those had a positive experience. Those responding favor a local or regional review body for allocation of training slots. They noted possible barriers to this being a successful process and were most concerned about governance, academic issues, fiscal competition, and bureaucratic issues.
It is hoped that physiatry, through its professional organizations at the national level, can start to plan and discuss this issue and to agree on some common ground for assumptions if significant reductions in training slots are mandated or dictated by the job market. It is clear that programs in each state will need to be proactive with respect to proposed legislation and the benefits their training programs have on the health of the citizens of their states.
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