As the nation takes a giant step toward training more primary-care physicians, some academic medical officials are saying the change may be too swift and specialty education could suffer.
Market pressures and cutbacks in graduate medical education funding are creating a quandary for some teaching hospitals as they watch their primary-care residency programs fill up at the expense of their prestigious specialist programs (See related story, p. 68). For the first time in seven years, a majority of U.S. medical school seniors said last month they will pursue training as generalist physicians (March 20, p. 10).
Despite the need for more primary-care practitioners, medical schools and hospitals still need to maintain credible specialty programs, experts say.
"We have a great fear that as the market gets tougher and tougher, it will have an impact on our ability to maintain our mission," said Robert Dickler, vice president of clinical services for the Association of American Medical Colleges, which represents some 400 academic medical centers. "That is just beginning to be seen in some places."
Of the 13,549 medical school seniors who secured residency positions this year through the Washington-based National Resident Matching Program, 51% will spend their first year of residency training in family practice, internal medicine or pediatrics. In 1994, 48.1% pursued such generalist careers.
An all-time record 2,081 medical school seniors will undertake family practice residencies, the largest such group in the NRMP's 43-year history.
Meanwhile, some specialist disciplines are coming up short.
In Texas, the state's teaching hospitals aren't able to fill their anesthesiology residency slots.
"There's going to be a balance, and it's going to be based on supply and demand," said Boone Powell Jr., president and chief executive officer of 954-bed Baylor Health Care System, Dallas, which trains about 160 medical students in its residency programs.
Medical students are having their Medical education
pick of residency programs, Powell said. "We're seeing internal medicine students where there's not as many picking subspecialties."
State and federal governments are debating how they will deal with financing designed to emphasize primary care while reducing an overabundance of physicians.
The House Ways and Means health subcommittee will consider a proposal that would freeze the number of medical residencies it subsidizes, pay for only three years of graduate medical education and replace the current financing structure with a voucher system (March 27, p. 10).
In Tennessee, teaching hospitals are beginning to reduce the number of residencies because the state ended earlier this year a $217 million annual supplemental TennCare funding, which helps support physician training.
At the Regional Medical Center at Memphis (Tenn.), about 30 residency slots were expected to be cut. Many of those residents come from the University of Tennessee College of Medicine at Memphis.
"A lot of those (graduate medical education) cuts won't come for four years because residents have three-year contracts," said Gil Hayes, assistant vice chancellor for university relations at University of Tennessee. "So the effect (of the cuts) won't be felt for three years down the road depending on the length of the residency."
Residents sign contracts that guarantee their residency will remain viable for the life of the program, which is usually three years.