The second largest for-profit hospital company in the United States, Hospital Corporation of America (HCA), is expanding its operations in graduate medical education (GME). (Tampa Bay Times. Nov. 14, 2012; http://bit.ly/2eJPrQ4.) The company, which has a gross annual revenue of more than $39 billion and more than 160 hospitals, is aggressively developing residency programs with 500 new training slots over the next few years. One of the first programs will be an emergency medicine residency near Tampa Bay. HCA also announced a collaboration with the University of Central Florida College of Medicine to create 550 residency slots. (Orlando Sentinel. Oct. 12, 2015; http://bit.ly/2eJPI5y.)
This enormous private hospital system getting into academic medicine is a game changer, but why are they doing it? An HCA faculty recruiter talked to me about why they were making such a huge investment in training residents. Their goal was simple: “Train and retain.”
Florida is similar to most states. Physician shortages have stimulated the development of a lot of new medical schools, most of which are set up as for-profit entities with tuition well in excess of $50,000 per year (and stunning potential for making money). The federal government froze GME funding in the 1990s, however, so commensurate increases in the number of training programs have not materialized.
Academic institutions got used to their GME programs being paid for by the government, and the limited money supply slowly began to eat away at the relative oversupply of residency positions. Medical school graduates not matching into a residency was inconceivable in the past, but in recent years, roughly six percent of U.S. medical graduates could not find work, and nearly all international medical graduates are no longer competitive for these positions. (Results and Data: 2016 Main Residency Match, National Resident Matching Program; http://bit.ly/2fXa7XQ.) This is even more remarkable when you consider that everyone needs doctors, especially large hospital corporations that cannot function without a continuous supply of new physicians.
Filling the Market Gap
But big corporations with lots of money are not dummies, and market-based economies are designed to exploit scarcity, even for elite professionals like physicians. Business always moves faster than government or academia, and we arrive at the crux of this column: You better get used to the marriage of corporate health care and GME. Big business will not wait.
It is well-documented that the majority of residency graduates practice in the state where they trained. (Association of American Medical Colleges; http://bit.ly/2fE6Rg8.) But it is even more profound in emergency medicine. Seventy-eight percent stay put. That is more than any other specialty. So for large staffing companies or even a smaller group like mine, it is not only more common to manage residencies, it can also be perceived as a survival tactic.
Recruiting physicians is expensive, time-consuming, and risky. Growing your own doctors gives you the chance to watch them for three years, and everyone understands what they are getting into if the resident decides to stay with the company. But there will always be a conflict of interest, and it is that conflict that creates the opportunity for abuse.
I have tried over the years to develop an ability to look at problems as opportunities, and I encourage residents to do the same. With the incredibly competitive selection process for emergency medicine in the match, the ability for even rural hospital systems to offer training with assistance from massively funded health care companies provides additional access to emergency medicine training. Great medical school graduates without killer board scores now have options. This is likely a great thing, provided ACGME can ensure the quality of training. But the other less obvious dividend is an opportunity for newer residency graduates to pursue academic careers that might otherwise not have been possible.
Next month: The most serious problem in emergency medicine: the shortage of emergency nurses.
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