Myth and Reality Underlying the Needed Expansion of Graduate Medical Education
2009; Elsevier BV; Volume: 136; Issue: 7 Linguagem: Inglês
10.1053/j.gastro.2009.04.024
ISSN1528-0012
Autores Tópico(s)Global Health Workforce Issues
ResumoThe nation is facing a profound shortage of physicians. The Lewin Group estimated recently that there will be 1000–1500 too few gastroenterologists a decade from now,1Dall T. Sen N. Zhang Y. The impact of improved colorectal cancer screening rates on adequacy of future supply of gastroenterologists; final report. The Lewin Group, Inc, Falls Church, VA2009Google Scholar part of an overall physician shortage that is projected to reach 150,000–200,000 by 2025.2Cooper R.A. Getzen T.E. McKee H.J. et al.Economic and demographic trends signal an impending physician shortage.Health Affairs. 2002; 21: 140-154Crossref PubMed Scopus (379) Google Scholar, 3Cooper R.A. Weighing the evidence for expanding physician supply.Ann Intern Med. 2004; 141: 705-714Crossref PubMed Scopus (144) Google Scholar, 4Dill M.J. Salsberg E.S. The complexities of physician supply and demand: projections through 2025. Association of American Medical Colleges, Washington, DC2008Google Scholar If health care reform leads to a major expansion of insurance coverage, this could grow by another 40,000. To meet these needs, training capacity will have to be increased by at least one third. But because of the long lead times associated with training physicians, supply will not match demand until well after 2030, a time point that stretches ever further as action to remedy these shortages is continually delayed. Part of the solution lies in expanding the output of medical schools, which has begun. But more medical graduates will not add to the total supply of physicians unless graduate medical education (GME) is also expanded, and that process has been stalled since 1996, when Medicare, the single largest source of support for residents, capped the number of residency positions it would fund. As a result, larger numbers of US medical graduates will simply displace international medical graduates in the existing programs. The Association of American Medical Colleges, American Medical Association, and numerous specialty societies have urged that the caps be lifted, but GME expansion remains unchanged. One reason is that expanding GME is more complicated than just lifting the caps.5Cooper R.A. It's time to address the problem of physician shortages: Graduate medical education is the key.Ann Surg. 2007; 246: 527-534Crossref PubMed Scopus (48) Google Scholar Any change in funding is likely to require new sources, such as additional payers, which has occurred in New York. Unfortunately, many specialty societies take the narrower view that more vigorous resident recruitment is the best strategy. But it is a zero-sum game without more residency positions, adequate numbers of trainees cannot be ensured. Another obstacle to GME expansion is a long-standing belief among some individuals and organizations that increasing the number of physicians—particularly specialists—would not be wise. In the 1990s, this view garnered statistical support from projections of physician surpluses by the Council on Graduate Medical Education,6Council on Graduate Medical Education (COGME)Fourth report.Recommendations to improve access to health care through physician workforce reform. US Department of Health and Human Services, Washington, DC1994Google Scholar a position it reversed 5 years ago when it accepted our approach to workforce planning2Cooper R.A. Getzen T.E. McKee H.J. et al.Economic and demographic trends signal an impending physician shortage.Health Affairs. 2002; 21: 140-154Crossref PubMed Scopus (379) Google Scholar and recognized that shortages were on the horizon instead.7Council on Graduate Medical EducationSixteenth report: Physician workforce policy guidelines for the united states, 2000–2020. US Department of Health and Human Services, Health Resources and Services Administration, Washington, DC2005Google Scholar With the loss of this prop, arguments against expanding specialist supply turned to epidemiologic studies, 3 of which have become particularly prominent. The first is by Starfield et al,8Shi L. Macinko J. Starfield B. et al.The relationship between primary care, income inequality, and mortality in US states, 1980–1995.J Am Board Fam Pract. 2003; 16: 412-422Crossref PubMed Scopus (156) Google Scholar, 9Shi L. Primary care, specialty care, and life chances.Int J Health Serv. 1994; 24: 431-458Crossref PubMed Scopus (138) Google Scholar who have fostered the notion that states with more family physicians have better patient outcomes, including better self-rated health status, longer life expectancy, lower all-cause mortality, lower mortality from cancer, heart disease, stroke, fewer low-birth-weight babies, and lower infant mortality—really quite remarkable for a few additional family physicians. But this set of observations is simply a statistical anomaly that relates to the fact that there are larger numbers of family physicians in the Northwest, upper Midwest, and northern New England, where there are fewer minorities, no major urban centers, and lower mortality rates. Other areas of the country have more internists and pediatricians who practice in a similar way, but fail to show the same statistical relationships because the areas in which they practice are skewed in the opposite direction. A second prominent study is from the Dartmouth–Harvard collaborative group. It claims that “states with more specialists have higher costs and lower quality,”10Baicker K. Chandra A. Medicare spending, the physician workforce, and beneficiaries quality of care.Health Affairs. 2004; 23 (Web Exclusive, w4-184–w4-197)Google Scholar a potent argument for having fewer. Unlike Starfield's work, this is not simply a statistical anomaly—it is a statistical fabrication. The relationship between specialists and health care quality was never examined. Rather, a theoretical model was employed in which specialists and family physicians were “exchanged” for each other. The fallacy of this approach is evident in the fact that Mississippi was represented as having more specialists than most other states, whereas it actually has the fewest.11Cooper R.A. More is more and less is less: the case of Mississippi.Health Affairs. 2009; 28 (published online 4 December 2008): w124http://content.healthaffairs.org/cgi/content/short/hlthaff.28.1.w124Crossref Scopus (4) Google Scholar But more to the point, a direct comparison between the actual numbers of specialists per capita and quality shows that states with more specialists have better quality health care.11Cooper R.A. More is more and less is less: the case of Mississippi.Health Affairs. 2009; 28 (published online 4 December 2008): w124http://content.healthaffairs.org/cgi/content/short/hlthaff.28.1.w124Crossref Scopus (4) Google Scholar, 12Cooper R.A. States with more physicians have better-quality health care.Health Affairs. 2009; 28 (published online 4 December 2008): w91-w102http://content.healthaffairs.org/cgi/content/full/hlthaff.28.1.w91/DC1Crossref PubMed Scopus (41) Google Scholar, 13Cooper R.A. States with more health care spending have better quality health care—lessons for Medicare.Health Affairs. 2009; 28 (published online 4 December 2008): w103-w115http://content.healthaffairs.org/cgi/content/full/hlthaff.28.1.w103/DC1Crossref PubMed Scopus (41) Google Scholar The third body of work, also from the Dartmouth group, has urged Congress to “resist efforts to remove limits on GME,” because “holding the line on new specialists will dampen future cost increases.”14Wennberg J.E. Brownlee S. Fisher E.S. et al.Improving quality and curbing health care spending: opportunities for the congress and the Obama administration: a Dartmouth Atlas White Paper. Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH2008Google Scholar As phrased by one member of the group, “if we sent 30% of the doctors in this country to Africa, we might raise the level of health on both continents.”15Fisher E.S. Brownlee S. Overdose: The health-care crisis no candidate is addressing? Too many doctorsDecember, 2007Google Scholar The Dartmouth group's “30% solution” has been influential. It is embraced by MedPAC,16Hackbarth G. Reischauer R. Mutti A. Collective accountability for medical care—toward bundled Medicare payments.N Engl J Med. 2008; 359: 3-5Crossref PubMed Scopus (135) Google Scholar the Congressional Budget Office, and the director of the Office of Management and Budget.17Orszag P.R. Ellis P. The challenge of rising health care costs—a view from the Congressional Budget Office.N Engl J Med. 2007; 357: 1793-1795Crossref PubMed Scopus (139) Google Scholar Leaders of the Obama health reform team echo it, claiming that “one-third of medical costs go for services that are at best ineffective and at worst harmful”18Cutler D.M. DeLong B. Marciarille A.M. et al.Why Obama's health plan is better.The Wall Street Journal. September 18, 2008Google Scholar; similar sentiments have been expressed by Senators Daschle19Daschle T. Critical: what we can do about the health-care crisis. Thomas Dunne Books-St. Martins Press, New York2008Google Scholar and Baucus.20Baucus M. Reforming America's health care system: a call to action.December 2008http://finance.senate.gov/healthreform2009/finalwhitepaper.pdfGoogle Scholar This perspective has also has also been endorsed in editorials in The New York Times21The high cost of health care [Editorial]. The New York Times, November 25, 2007Google Scholar and the St. Louis Post Dispatch.22The 30 percent solution [Editorial]. St. Louis Post-Dispatch, December 30, 2008Google Scholar The editor of Health Affairs, who serves on Dartmouth's Board of Overseers, cautions that “the greater the amount of health care you receive, the more likely it is to kill you,”23Dentzer S. From the editor.Health Affairs. 2009; 28 (published online 4 December 2008): w87-w88http://content.healthaffairs.org/cgi/content/full/hlthaff.28.1.w87/DC1Crossref Scopus (1) Google Scholar a bias that she has infused into her editorial positions and actions.24Dentzer S. The future of U.S.health policy.September 30, 2008http://publiclife.luther.edu/Library/Dentzer%20-%20LC%20Presentation.ppsGoogle Scholar Is it true? Are more specialists bad for America? Does the nation already have more gastroenterologists than are needed? The short answer is “no”—but understanding why is complicated. Indeed, the failure to quickly grasp its weaknesses is one reason why the “30% solution” is so widely embraced and that is why understanding it is so important. The study underlying the “30% solution” was constructed by dividing the nation into 306 hospital referral regions, distributing these regions into 5 population “quintiles,” based on Medicare spending in each, and comparing broad outcomes, such as access, satisfaction, and mortality among the 5 quintiles.25Fisher E.S. Wennberg D.E. Stukel T.A. et al.The health implications of regional variations in Medicare spending: part 1 The content, quality and accessibility of care.Ann Intern Med. 2003; 138: 273-287Crossref PubMed Scopus (1238) Google Scholar, 26Fisher E.S. Wennberg D.E. Stukel T.A. et al.The health implications of regional variations in Medicare spending: part 2 Health outcomes and satisfaction with care.Ann Intern Med. 2003; 138: 288-298Crossref PubMed Scopus (1068) Google Scholar Unlike clinical trials, these outcomes are not patient specific, but rather reflect hospital- or community-wide characteristics that draw on the total resources available rather than the payments from any single source. Because Medicare expenditures were used to allocate hospital regions into quintiles, it was essential that Medicare be representative of total health care spending. Indeed, the Dartmouth group claims that it is.27Sirovich B.E. Gottlieb D.J. Welch H.G. et al.Discretionary decision making by primary care physicians and the cost of U.S. health care.Health Affairs. 2008; 27: 813-823Crossref PubMed Scopus (207) Google Scholar But it is not. Medicare spending per enrollee does not correlate with overall health care spending per capita.13Cooper R.A. States with more health care spending have better quality health care—lessons for Medicare.Health Affairs. 2009; 28 (published online 4 December 2008): w103-w115http://content.healthaffairs.org/cgi/content/full/hlthaff.28.1.w103/DC1Crossref PubMed Scopus (41) Google Scholar, 28Goodman D.C. Stukel T.A. Chang C. et al.End-of-life care at academic medical centers: implications for future workforce requirements.Health Affairs. 2006; 25: 521-531Crossref PubMed Scopus (32) Google Scholar It is not a proxy for the whole. As a result, hospital regions with varying levels of total spending—some high, some low—were included within each quintile. The fundamental basis for stratifying quintiles based on spending levels was faulty. A second requirement of the quintiles model was that, except for Medicare spending, all other characteristics that might affect outcomes must be randomly represented among the quintiles.25Fisher E.S. Wennberg D.E. Stukel T.A. et al.The health implications of regional variations in Medicare spending: part 1 The content, quality and accessibility of care.Ann Intern Med. 2003; 138: 273-287Crossref PubMed Scopus (1238) Google Scholar But even a casual inspection reveals how nonrandom they were. The highest-spending quintile was composed principally of America's largest cities, such as Chicago, Detroit, Miami, New York, and Los Angeles, whereas the lowest stretched across the northern tier, from Alaska through Washington and Oregon all the way to Maine. This same dichotomy exists in the Dartmouth group's comparison of academic medical centers, where the high utilization (“inefficient”) ones were all in dense urban centers, like Newark, Houston, and Washington, DC, whereas the “efficient” ones were mainly in smaller communities, like Mayo, the University of Wisconsin, and Dartmouth's Medical Center.29Martin A.B. Whittle L. Heffler S. et al.Health spending by state of residence, 1991–2004.Health Affairs. 2007; 26 (Web exclusive,): w651-w663Crossref PubMed Scopus (29) Google Scholar Although attempts were made to adjust for the social, economic, and demographic differences among quintiles using statistical tools, these differences were so vast and numerous that valid adjustments were not possible. The surprising observation was that outcomes were the same in all of the quintiles. The lowest-spending quintile was like the highest. How was that possible? The answer lies in a third problem—the aggregation error. By including a diverse range of hospital regions with diverse total health care spending (despite similar Medicare spending) and a diversity of subpopulations in each, the averages within each quintile regressed to the mean. The extremes of affluence and poverty in the highest-spending quintile came to resemble middle America. However, had meaningful subpopulations within each quintile been compared, striking differences in utilization and outcomes would have been observed, and their strong relationship to communal wealth, individual income, and clinical risk would have been appreciated. The Dartmouth group apparently saw no need to disaggregate their quintiles to reveal the effects of income and risk. They were content with the knowledge that nothing was “necessarily better,” nor was anything worse. And, because nothing was better in the highest-spending quintile, the added spending was assumed to have been wasted; and because this waste was unexplained, it must have been due to the excess use of “supply-sensitive services”; and these services must have resulted from an oversupply of specialists. Therefore, if high-use areas had no more specialists than low-use areas—if, for example, Newark could more closely resemble Minnesota, as posited by the Director of the Office of Management and Budget30Orszag P.R. A federal perspective on health care policy and costs. Center for Public Health, Stanford University, Stanford, C.ASeptember 16, 2008http://healthpolicy.stanford.edu/events/recording/5239/1/145/Google Scholar—the nation could save 30% of its health care spending. And by stringing together politically charged expressions, such as “unexplained,” “waste,” “supply-sensitive,” and “inefficiency,” the Dartmouth group succeeded in recruiting large numbers of believers. But what really were strung together were 3 profound errors: (1) Medicare is not a proxy for the whole; (2) the populations in each quintile were not random; and (3) aggregation and averaging masked important differences. Like Churchill's Russia, the quintiles study was “a riddle wrapped in a mystery inside an enigma.” But the riddle is solved, and like communist Russia, nothing is there. Almost 50 years ago, John F. Kennedy cautioned that “the great enemy of the truth is very often not the lie—the deliberate, contrived and dishonest—but the myth, persistent, persuasive, and unrealistic.” GME is trapped in just such a myth. Most specialties face a future in which there will be too few trainees, and the solution to this dilemma is being held hostage by a series of unrealistic but persuasive myths emanating principally from studies of geographic variation in health care. Yet the reality is that specialty care is not unwarranted because variation in its utilization is not fully explained, nor is it induced by specialists because it is they who provide it. Medical care is driven by illness, aging, poverty, and the economy, and both specialists and generalists are needed for it to function smoothly. Sadly, there are deepening shortages of both. The solution is to expand GME. To that end, specialty societies and related organizations must come together with government and private insurers to begin the arduous task of crafting a blueprint for GME for the future. Such a blueprint will necessarily encompass a wide range of issues that relate both to the financing of GME and to the educational process of residency training.5Cooper R.A. It's time to address the problem of physician shortages: Graduate medical education is the key.Ann Surg. 2007; 246: 527-534Crossref PubMed Scopus (48) Google Scholar But expanding GME cannot wait for a final blueprint. The caps must be removed so that GME can begin to move forward. And that must happen now.
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