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New HCFA project means fewer slots, more pressure

Financial incentives in New York aim to reduce resident numbers, but at what cost to patient care?

From the September 1997 ACP Observer, copyright 1997 by the American College of Physicians.

By Christine Wiebe

Just when residents thought their jobs couldn't get much more difficult, a new round of training cuts is threatening to dump more work on them. Earlier this summer, residents at nearly half of New York's training programs became part of a bold experiment to slash training positions.

More than 40 of New York's 77 teaching hospitals are participating in a HCFA demonstration project that allows them to reduce residency slots while retaining some federal funding for those positions. Under the project, which is based on the view that hospitals are producing too many doctors, hospitals that trim their training slots will receive funds to come up with other ways to care for patients. Options include hiring ancillary staff such as physician assistants, restructuring training programs to be more efficient and investing in labor-saving technology, according to project designers.

The program has been praised as an innovative way to address physician work force issues, but because HCFA is not requiring hospitals to invest funds they receive for cutting residency slots into alternative methods of care, some program directors and residents are concerned. They worry that hospital administrators will use the funds they receive from the HCFA project for other projects and expect residents to simply work harder.

The goal of the HCFA project, which began in July with the new residency year, is to study how hospitals can downsize training programs without compromising education or patient care, according to Tom Gustafson, deputy director of HCFA's Office of Research and Demonstrations. Hospitals that participate in the project must cut their training slots by 25% over five years, or 20% if they substantially increase their proportion of primary care training or coordinate medical education through a consortium of hospitals. Overall, the project is expected to cut about 2,000 training positions in New York, the only state currently participating.

HCFA will give participating hospitals a total of $400 million over six years, effectively paying them to reduce their training slots and their dependence on housestaff to provide patient care. Even after making the payments, HCFA expects to save approximately $300 million on training costs.

Given that residents provide relatively cheap labor, many say that the hospitals will be hard pressed to replace residents, even with the $400 million in payments from HCFA. Project designers at HCFA argue that residents were never meant to provide cheap labor, and that training programs should save on education costs as they downsize. Furthermore, they hope programs will make creative changes rather than simply hire a new ancillary staff person for each residency slot they eliminate.

Under pressure

Already, however, one immediate effect appears to be more work for residents. "The residency workload has skyrocketed," said Stephan L. Kamholz, FACP, program director in internal medicine at SUNY Health Science Center in Brooklyn.

To make matters worse, reductions triggered by the HCFA project come on the heels of earlier cuts driven by economic pressure on hospitals. The HCFA project also comes at a time when there is growing pressure to limit the number of international medical graduates (IMGs) in training programs. (See In the next round of residency cutbacks, IMGs are the likely target.)

HCFA's Mr. Gustafson said he is not surprised that many residency leaders are grumbling about the HCFA project now that the impact is being felt. However, he added that many residency programs in New York grew by about 20% between 1988 and 1994. "What this project does is ask them to go down a comparable amount in a comparable period," he said.

Even some educators admit that there are too many housestaff. "In New York, we are training an inexcusably high number of residents," said Lawrence G. Smith, FACP, program director in internal medicine at Mt. Sinai Medical Center.

The HCFA project at least allows programs to make the reductions carefully. "This is an opportunity to redesign programs," Dr. Smith said. He shares others' concerns that hospital administrators could misapply the HCFA funds, but he doubts the end result will be overworked residents.

Those sentiments may explain the popularity of the project. While HCFA officials anticipated fewer than 10 hospitals would want to participate in the demonstration, 42 have so far signed on for the first phase, said Mr. Gustafson. In fact, hospitals outside New York have complained about being shut out, leading Congress to include language in the new budget that would expand the project throughout the country.

Deep and deeper

Program directors like Mt. Sinai's Dr. Smith may be optimistic for now because making cuts required by the HCFA project is relatively easy. At his program, for example, he had to eliminate only four of about 40 first-year training positions, a number he said will produce no significant changes in the program this year. Dr. Smith acknowledged that the future may bring more difficult choices. "As we approach the five-year mark and everyone has to be at 20% down," he said, "there will be a lot more hard decisions to be made."

In fact, how training programs will be affected by participating in the HCFA project will likely depend on what kind of cuts they made before entering the HCFA project. Programs that were planning to cut fat out of their programs, for example, will receive a financial bonus for doing something they needed to do anyway. Programs that already made cuts before joining the project, on the other hand, will have to make even deeper cuts.

"There's a tremendous concern among program directors at institutions that are already precarious," said SUNY program director Dr. Kamholz. His program lost eight of about 100 positions due to financial cuts the previous year, and this year another three slots were eliminated for the HCFA project. Dr. Kamholz is concerned that the heavier demands on residents could threaten the program's accreditation, which puts strict limits on the number of patients residents see.

Dr. Kamholz said that just before the start of the new residency year, he persuaded hospital administrators to allocate some of the HCFA funds to hire ancillary staff. However, he was concerned that those funds would not be enough to pay the salaries of staff like physicians assistants. In the meantime, residents still have to shoulder the extra work.

Residents aren't the only ones affected by the cuts, according to Mahender K. Gaba, ACP Associate, who served as chief resident last year at SUNY-Brooklyn. "It definitely will impair patient care," he said. Under the HCFA program, residents are forced to look for shortcuts just to finish all their work, he explained. For instance, some write shorter notes in patient charts and some postpone non-essential tasks until the next day. "It's mental torture sometimes," Dr. Gaba said.

"The problem is that this whole thing is being driven by finances," said Mark S. Pecker, MD, program director at New York Hospital-Cornell Medical Center, which is struggling to meet the HCFA program's requirements because it had already cut subspecialty positions to the bone. "Residents have played an enormous role in the health of this city," he said. "If you take the residents away, who's going to take care of the poor people?"

Christine Wiebe, of Providence, Utah, writes frequently on issues related to medical residency.


In the next round of residency cutbacks, IMGs are the likely target

By Jennifer Fisher Wilson

Cutting training slots as part of HCFA's new demonstration project may be difficult, but teaching hospitals may soon face an even bigger hurdle if limits are placed on how many international medical graduates (IMGs) can train in U.S. residency programs.

While Congress has yet to pass any bills that would limit the presence of IMGs in training programs, various medical groups including ACP, the AMA and the Association of American Medical Colleges (AAMC) have issued statements in the past year calling for significant limits on the number of IMGs allowed to train in the United States.

Limits on IMG residents would particularly affect New York, where two of every five medical residents are IMGs—the highest ratio in the country. According to physicians at one inner-city residency program, IMG cutbacks would throw already overburdened hospital staff into crisis mode.

"If there were cuts in the number of foreign medical graduates, there would be a very big problem here," said Stephan L. Kamholz, FACP, who directs the internal medicine residency program at SUNY Health Science Center in Brooklyn, where almost all of his residents are IMGs. "We would have a hard time filling slots, and there are no quick and ready provisions to switch the care of patients over to other kinds of providers."

Dr. Kamholz's program has already cut residency slots as part of HCFA's project to reduce hospitals' reliance on residents for patient care, and he wonders how much more cutting the program could survive. "The resident workload went up," he said, "and it's been extremely hard to convince the hospitals that they need to reallocate the GME money to hiring alternate providers."

Dr. Kamholz and other program directors in inner-city and rural areas of New York agree with the goal of IMG cutbacks—eliminating unessential residencies to help better regulate the nation's oversupply of physicians—but they argue that their residency positions are far from unessential. As Dr. Kamholz explained, IMG limits would mean one thing: "There wouldn't be anybody to take care of the patients."

Physician workforce papers haven't entirely ignored these issues. Both the ACP and AMA positions, for example, suggest that the government should expand programs like the National Health Services Corps to serve inner-city and rural communities hardest hit by cuts. The AMA paper also recommends establishing new programs to recruit more U.S. medical graduates to underserved areas.

Residents at SUNY Brooklyn, however, are skeptical. "I don't think many U.S. medical graduates will go to the inner city," said Shirley A. Albano, ACP Associate, an IMG from the Philippines who is a third-year internal medicine resident at SUNY Brooklyn.

Physicians are just as skeptical about other proposed solutions. "If they say we're going to just fill those slots with allied medical professionals, I don't think that will work because the physician assistants and nurse practitioners only work a limited number of hours a week," Dr. Albano said. "Residents work unlimited numbers of hours."

Faced with few options, hospitals like Kings County Hospital, an affiliate of the SUNY Brooklyn program, are trying to learn to live not only with fewer residents, but fewer IMGs. For example, the hospital is looking at a plan to pair physician assistants with attending physicians to take care of more patients without adding physicians. The physician assistants would be hired with money from the HCFA project. And to deal with the threat of IMG cutbacks, Kings County is trying to become more attractive to U.S. medical graduates. According to Steven M. Weiss, ACP Member, the associate director of medicine at SUNY Health Science Center in Brooklyn, the city recently announced a $260 million proposal to rebuild and help modernize the 60-year-old hospital, which needs some repairs.

But Dr. Weiss acknowledged that no matter how much money the city pours into hospitals like Kings County, there is no escaping reality. "You can't get away from the fact that we're inner city," he said. "That alone makes it hard to attract U.S. medical graduates."


IMGs: what the College says

While ACP supports cutting IMG residency slots to regulate the physician workforce, it also maintains that medicine must not discriminate against IMGs who are already in training programs or the workforce.

In a position paper released last year, the College outlined ways to make sure that IMGs already in the United States receive fair treatment in education, licensure, practice and leadership. The paper calls for equal compensation for IMGs and U.S. medical graduates, a centralized program to credential IMGs who want licensure in this country, and equal opportunities for IMGs to take on leadership roles in the College and the overall profession.

Copies of the position statement, "Fairness and Equity for International Medical Graduates in the United States," are available from ACP Customer Service. Information: 800-523-1546, ext. 2600. This position statement is also available on ACP Online (www.acponline.org/hpp/pospaper/img.htm).

Copies of the College's work-force recommendations, "The Physician Workforce and Financing of Graduate Medical Education," are also available from Customer Service.

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