After medical school, the new graduates are required to do further training in residency programs which can last from 3 to 8 years. This training takes place in hospitals around the country and is overseen by the Accreditation Counsel on Graduate Medical Education (ACGME). During this training, the residents spend long hours in the hospitals and clinics where they learn from attending physicians. This added training is essential as the four years of medical school is just not enough to learn all the material and skill sets necessary to safely and independently take care of the multitude of problems that these physicians will face from the patient population.

Unlike medical school where the student is paying a tuition for the education, the resident physicians are paid a salary. They are providing valuable work for the hospitals and clinics as they are taking care of patients and providing coverage day and night, weekends and holidays. This salary is about $50,000 per year. In comparison, a physician assistant salary is about $86,000 per year. Surprisingly, most of a resident’s salary is funded by the United States government. This funding emanated from Congressional hearings which occurred during the formation of Medicare in 1965.

“Educational activities enhance the quality of care in an institution, and it is intended, until the community undertakes to bear such education costs in some other way, that a part of the net cost of such activities (including stipends of trainees, as well as compensation of teachers and other costs) should be borne to an appropriate extent by the hospital insurance program.” (House Report, Number 213, 89th Congress, 1st session 32 (1965) and Senate Report, Number 404, Pt. 1 89th Congress 1 Session 36 (1965))

Under President Lyndon Johnson, the Social Security Act of 1965, established Medicare. A part of Medicare was funding for the residency positions throughout the country. Since there are about 100,000 residents in training, the salary for these residents is about $5 billion. There are other costs associated with educating residents such as malpractice coverage, attending salaries attached to the teaching component of the practice, and the added costs of the clinical tests ordered by the residents who have a tendency to order more than a more senior physician may be inclined to do. Other costs include a Graduate Medical Education office to administer the training programs, accreditation fees, and educational space. Medicare also pays for a portion of these added costs so that, today, about $10 billion is distributed to the various teaching hospitals in the country to cover the costs of this graduate medical education.

Medicare payments for these Direct Graduate Medical Education (DGME) costs go directly to the hospitals that train the residents. Payments to the residents come from the hospitals. In many states, Medicaid also provides some funding for Graduate Medical Education. Veterans Administration Hospitals also provide funding for residents in their hospitals.

Teaching hospitals also receive an Indirect Medical Education (IME) payment from Medicare for the increased medical costs associated with treating more complex patients. This payment is directed for maintaining a standby capacity for such things as burn units and trauma centers; these payments are not for resident training costs.

The United States funding of graduate medical education serves a strong public interest. A knowledgeable, trained, experienced, and skilled physician work force is essential to provide the health care needed for our society.

Prior to the establishment of Medicare, residents would work for the hospital but they were paid very little. They would generally live in the hospital, thus the term “resident.” They would rarely get time off but they would usually be fed and have their uniforms and malpractice insurance premiums paid for by the hospital. The elite residency programs like Johns Hopkins, Massachusetts General, the University of Chicago, and Mayo were highly sought after and, as a result, the salary could be kept low. In a way, the prestige of the training institution led to a de facto tuition payment, in the form of work provided, by those seeking to do the residency.

It may seem like the costs for resident education are high, but the return on investment is significant. With the present duty hour restrictions which limits the resident to just 80 hours in the hospital per week, doing the math reveals that the resident is being paid about $12 per hour. Since residents actually do a significant amount of the patient care in the hospitals and clinics, those facilities with residents can actually take care of many more patients and they are better able to manage patients with highly complex (and expensive) disease processes.

In 1997, Congress put a 100,000 cap on the number of residents it was willing to fund. This cap has been one of the reasons that the United States is facing a physician shortage. Existing medical schools have increased their capacity and new medical schools have been started to help address the projected shortage, but the cap on residency slots may prevent some of these new medical school graduates from getting the residency training they will need to, eventually, go into practice.

Since the hospitals are making money on the resident’s labor, perhaps they should contribute more to resident salaries. As there are more medical students graduating each year than there are residency slots available to them, perhaps it is time to refigure the graduate medical education funding which could help alleviate the projected physician shortages being projected in the near future. Perhaps, the United States can only afford to fund 100,000 residency slots per year. If so, it is time for the hospitals, the states and the cities to contribute to this essential graduate medical education. Let’s pay our medical school graduates for the work that they do and this pay should better reflect the value they bring to our health care industry.

Becoming a physician is a costly endeavor. A four year public university medical tuition is about $208,000; a private school medical tuition is about $280,000 (Association of American Medical Colleges 2013 data). The four years of medical school would result in lost salary ($57,000 per year for a bachelor degree holding American). Assuming no tuition support, this leaves a typical medical school graduate over $400,000 in debt. Now, with physician pay cuts resulting from an artificial health care market mandated by Obamacare, it will be years before a physician starts seeing a reasonable return on the investment which may allow him to justify the years of study, lost sleep, aggravation from a contentious malpractice environment, and loss of esteem held by an unknowing public. It is not surprising that many of our best students are opting out of a potential career as a physician.

The added pay which our medical and surgical residents deserve should go a long way in helping these young physicians get out from the debt they have accrued in getting their undergraduate and medical education. This pay adjustment may not be enough to keep our best and brightest interested in pursuing a medical career, but it would be a good start.

by Darryl S. Weiman, M.D., J.D.

Professor, Cardiothoracic Surgery, University of Tennessee Health Science Center and Chief of Surgery, VAMC Memphis, TN

MORE ABOUT THE AUTHOR: Darryl Weiman is a featured expert in www.healthcaredive.com on February 17, 2016. 

This article originally was posted November 4, 2016 on Huffington Post.

I hate it when someone tries to tell me how I should take care of my patients. However, we are now working with the politics of “evidence-based medicine”. This era is characterized by groups of “experts” who get together and compile guidelines on how best to manage various medical conditions. The fact that our knowledge of patient management is constantly changing is of little concern to these “experts” nor are they of concern to third party payers who insist that the guidelines be followed or they will not pay for the care provided.

Guidelines are generally based on a review of the literature pertaining to a particular condition and the evidence is classified as to its credibility. For example, the most reliable evidence is graded as IA, meaning that it is based on more than one prospective randomized trial without important limitations. Level IB evidence is based on a single controlled randomized trial or non-randomized studies but the trial(s) have limitations such as inconsistent results or flaws in the methods used to derive the conclusions. A Level I classifications means that there is general agreement that the procedure or treatment is beneficial and effective. Examples of methodological flaws would be lack of blinding of the researchers or subjective determinations of the results. Trials which lose a large number of patients to follow up would probably be classified as IB.

Observational studies may be cited in the guidelines but they would not have the weight of reliability as the prospective randomized trials would have. Observational studies are generally cited as IIC, implying that the evidence for the alleged benefit of a treatment may not be clear and there is a difference of opinion about the usefulness of the procedure or treatment.

Guidelines are meant for the “ideal” patient that presents with a certain disease entity. I have never seen such “ideal” patient as they all have individual characteristics which must be taken into account when making a treatment plan. In fact, the publishers of the guidelines make it clear that the recommendations may not apply to all of the patients all of the time, but this is generally ignored by third party payers, the Joint Commission on Accreditation of Hospitals, and the Veterans Administration. If a physician has not followed a guideline, he is assumed to have given substandard care by many plaintiff attorneys.

Here is an example. There is good evidence that the incidence of surgical wound infections is decreased if prophylactic antibiotics are given within one hour prior to the skin incision. There are times when the incision is made a few minutes after the one hour time frame because there may be a delay in getting the patient intubated, and various catheters and lines placed. Clinically, these extra few minutes have no effect on the incidence of wound infections, but the people monitoring this performance measure will classify it as a violation of the guideline.

Now you have to understand that the people hired to monitor these “performance measures” may not be a nurse or physician. They are following rigid written protocols to make their determinations and they are not allowed to use their own judgment. When this type of violation occurs, the surgeon may be deemed to have provided substandard care and may not be paid as much for the procedure even if the results are excellent. This can be aggravating to the health care provider.

Another example deals with the choice of peri-operative antibiotics. We are currently faced with a crisis involving a very virulent form of bacteria called Staphylococcus aureus which is resistant to many antibiotics. We are allowed to use Vancomycin, an effective antibiotic to Staphylococcus aureus, but only if the patient fits certain criteria. The reason we are not allowed to use the drug for all patients is to try and limit the selection of bacterial strains which may be resistant to this drug; this would, theoretically, make treating future infections even more difficult. We are allowed to use the drug in patients who have been hospitalized within one year prior to the planned operation.

In cardiac surgery, most of our patients fit this latter requirement as they have been previously hospitalized to evaluate them for cardiac disease. However, the people who monitor the use of peri-operative antibiotics will consider the provider to be in violation of the measure if there is no documentation as to why the drug was used. In other words, the physician must write that Vancomycin was used because the patient had been hospitalized within the previous year. The provider must write what is inherently obvious in the medical records.

You can see why surgeons and other physicians are frustrated. We are forced to do more documentation which, we believe, does nothing to improve the care being provided to the patients while at the same time, if we do not do this documentation, it may be published that we are not good physicians! I know of no other profession which faces such scrutiny. There are no good options except to try to comply the best we can knowing that every year the third party payers will do their best to pay us less no matter what we do. Plus, what may be deemed the “standard of care” today, may not be the “standard of care” tomorrow.

When I was a resident in surgery in the early 80’s, it was considered wrong to give a blood transfusion without a compelling reason to a patient with renal failure as this would hurt the patient’s chance of having a successful kidney transplant in the future. We now know that patients who get transfusions are less likely to reject a transplanted kidney. Our knowledge and practice changed as a result of solid clinical research. If we forego clinical research in deference to “guidelines”, then advances in medicine are going to slow down and stop. Clearly, this will not be good for health care in America, or the world for that matter, as the United States has always been a leader in making advances in clinical care.

I like to tell my residents and the medical students that guidelines are just that; they are not the law. There is no one better able to take care of an individual patient than the physician taking care of that patient on a very personal level. After all, the patient’s individual characteristics may be such that he does not fit into the guidelines.

For now, the physician who does not follow the guidelines may be denied pay for his work or worse, his name may be published in a database accessible to the public and press where he may be deemed as a less than satisfactory practitioner. This cannot be in our public’s best interest.

Simulation: the imitative representation of the functioning of one system or process by means of the functioning of another—Webster’s Collegiate Dictionary, seventh edition.

For the last several years, a group of “seasoned” cardiothoracic surgeons from around the country gather in Chapel Hill, North Carolina, where they are joined by many young surgeons who are starting their residency in the specialty. The meeting is three days of intensive training using simulation models to replicate surgical situations the residents will be confronting during their surgical training. Getting familiar with the instruments, scopes, dissection techniques, heart lung machine, valve replacements, and small vessel suturing are some of the basic skills learned.

The “boot camp”, sponsored by the Thoracic Surgery Directors Association, is a rare opportunity for the residents to get individualized training with some of the most experienced surgeons in the field.

Historically, surgical training involved the resident getting graded levels of responsibility for doing procedures in the operating room (OR) and at the bedside. The training also involved pre and post-operative care but technical skills, cognitive knowledge, and clinical acumen were usually dependent on real patients in the operating room. The residents work one on one with an “attending” surgeon who will supervise as the resident does parts of the procedure.

Jonathan Nesbitt, M.D., director of the Cardiac Simulation Program at Vanderbilt University and one of the teachers at the Chapel Hill program, says “[b]y immediately imparting these skills early in training, we significantly compress the learning curve to allow [the residents] to work effectively and safely in the clinical realm.” Not only do the residents get to learn the basic technical skills required in the specialty, they get to experience realistic models of surgical catastrophes so they can learn what to do before a real patient’s life is on the line.

The rise in simulation in surgical training is being driven by several factors. Minimally invasive surgical techniques make it difficult for the attending to first assist in such a way as to keep the trainee out of trouble. Only one person can drive the robot or the scope. Reductions in duty hours, mandated by law, cuts down on the actual OR time a resident may have to learn what to do and how best to do it. And, of course, the ethicists are now making it more difficult to justify allowing inexperienced physicians to learn on actual patients.

Under the stresses brought on by the Affordable Care Act, many surgeons have become employees of hospitals or medical groups. This model has forced the surgeons into a productivity model based on fees generated for services rendered. The employer looks to the surgeon to generate income and the surgical education component of the practice is suffering. The surgery residents, generally slower than the attendings, are getting to do fewer cases so the attending can generate more income.

As third party payers are moving to pay based on quality models, attending surgeons may be even more inclined to do the operations themselves instead of helping a surgical trainee. One of my attendings in the surgical training program I went through believed that the best surgeon in the room should do the operation. Since he was always the best surgeon in the room, the resident could do no more than first assist. First assisting was frowned upon by us residents, but we did it the best we could so as to learn from this superb surgeon. However, there is no substitute from being the primary surgeon.

Although the simulators are good for teaching the basic skills, they have not reached the level needed to teach the skills that must be acquired when things go terribly wrong or when the dissections are difficult from aberrant anatomy or intense scarring.

In a patient with previous surgery, the scarring can be so dense that the blood vessels may not be seen until they are cut. The sudden fear felt by a surgeon who is confronted by hemorrhage that is so brisk as to be audible can lead to a complete inability to cope with the situation and may lead to the death of the patient. The same feeling of horror can occur with unintentional injuries to other structures like the common bile duct, ureter, heart, and brain. How to handle these potential disasters is hard to teach on the simulators.

Simulators are costly and the restrictions of the 80 hour work-week make it difficult for residents to find the time to use them. Dedicated simulation time, such as that provided in Chapel Hill, is very valuable.

Some facilities have built simulation centers that are recreating whole operating rooms, delivery suites, intensive care units, and endoscopy suites. The University of Tennessee where I work is finishing a new building devoted totally to simulation. I would expect that these large facilities can be used to train health care providers from other areas who will come in for specific training.

It is hard to prove that skills learned from simulation training will lead to improved care for patients but I think it does based on what I see from the residents I worked with at Chapel Hill. Small sample sizes and the ability to detect small changes in skill sets make training assessments difficult. However, since practice makes perfect and since there are not enough patients to go around, I believe the role for simulation in surgery will only increase in importance.

Another benefit of simulation is to learn how to deal with possible catastrophes before confronting them with a real patient. Brilliant saves rarely occur the first time a problem is seen; saves do occur in subsequent cases.

Teaching residents to act in a professional manner is usually done by surgical mentors who serve as role models. This training could be enhanced by using actors in vignettes presented in videos which can be viewed by the residents—a form of simulation.

Outcomes research and cost comparisons need to be done but simulation is here to stay. There are cognitive skills and communication skills which are also very important in surgery and there is a role for simulation in these areas which will need to be developed—sort of like the “mock trials” that law students have to go thru. For now, we are concentrating on technical skill enhancement.

Although surgical simulation does not replace the skill sets learned from actually operating on patients, the models do allow for repetitive practice of the basic technical skills needed by the surgeon without having to rely on actual patients. The attending surgeon is more inclined to let the resident do more if the basic skills are being demonstrated on a daily basis.

I think the time spent on simulators should not count towards the statutory mandated 80 hour work week restriction. I would consider it as time spent studying and unrelated to actual patient care. The time spent on patient care in the hospital setting is critical for surgical training and should not be further diminished.

It is said that surgeons do four things unique to patient care. These are (1) control hemorrhage; (2) drain pus; (3) restore normal (functional?) anatomy, and (4) train future surgeons. By participating in the boot camp at Chapel Hill, I am helping with #4. I enjoy doing it very much.