The Cost of Graduate Medical Education

Joel M. Bartfield, MD FACEP, Associate Dean for Graduate Medical Education, Albany Medical College

Introduction
It is becoming increasingly more challenging to train future physicians in the United States. The Federal Government has placed a cap on the number of training positions that each teaching hospital will be compensated for through Medicare/Medicaid funding. This cap is based upon the resident complement that hospitals had several years ago and does not necessarily anticipate the future needs of the physician workforce in the United States. As our population continues to age one can certainly anticipate future workforce needs will increase. At this point in time there is no mechanism to expand funding to support this increased need.

The Federal Government allows for teaching hospitals’’ increased cost of training residents by utilizing a complicated formula that calculates both the direct medical education costs (salary and benefits) and the indirect medical education costs (cost of supervision, increased resource expenditure, etc.) for each trainee in Graduate Medical Education. The so-called DME (direct medical education) and IME (indirect medical education) support per resident has traditionally exceeded the pure cost of each trainee at a given teaching hospital allowing for teaching and supervision of house officers. However, increased demands of the Accredited Council of Graduate Medical Education (ACGME) to provide greater and greater teaching and supervision has narrowed the gap between funding and actual cost of providing Graduate Medical Education. A recent initiative of the ACGME, the outcomes project, (conversion to competency based education which is mandated to occur over approximately one decade) is the latest example of increased demands placed upon training programs to provide quality graduate medical education that meets the standards of the accreditation body. Although New York State has had work hour regulations in place for well over a decade the ACGME has only in the last few years placed similar demands on training programs across the country in order to maintain accreditation and good standing. These demands have placed even more pressure on hospitals with training programs and have made training programs in graduate medical education “less financially viable.” Finally in a world of ever diminishing reimbursement for professional services there have been greater and greater demands placed upon academic faculty to generate revenue through patient care activities. Therefore the same faculty has less time to dedicate to the training and supervision of trainees in Graduate Medical Education.

A number of previous studies have attempted to determine the cost of providing training in graduate medical education. In one of the more comprehensive analyses, the Hunter group determined that 1 full-time equivalent (FTE) of faculty time was required per 6 trainees in primary care fields and 1 FTE per 10 trainees was required in non primary care specialties. Analyses published from the University of Florida College of Medicine determined that 76 FTEs were required for all aspects of undergraduate medical education.

In this article I hope to examine some of the issues involving resource needs for Graduate Medical Education programs. Rather than focusing on the dollar cost of providing supervision I will focus on the FTE cost and faculty hours to provide the necessary supervision and teaching for programs in Graduate Medical Education. Other costs including the institutional administrative support and secretarial support will not be included in this analysis.

An Individual Institution’s Analysis
One potential approach to determine the “cost” of Graduate Medical Education question at an individual institution is to query program directors and other educators regarding their time commitment to teaching and supervision. Simply stated the question is how many FTEs of faculty time are “spent” to provide supervision and teaching of residents. Supervision and teaching activities can be divided into the following three categories: administrative, non-clinical teaching, and clinical teaching. Administrative activities include recruiting, scheduling, curriculum development, resident evaluation, resident advising, supervision of residency coordinator and support staff, maintenance of appropriate affiliation agreements and letters of understanding for various rotations, organizing and maintaining conference and journal club schedules, faculty development and faculty recruiting and CME activities for program directors and faculty. Non-clinical activities include preparation and delivery didactic sessions in both large lecture formats and small group sessions. Clinical teaching can be broadly defined as teaching, which occurs during patient care interaction (bedside teaching). This latter category has the potential of service income generation during the teaching activity as opposed to the first two categories, which do not have this potential.

After designing a survey instrument which addresses the issues of teaching and supervision in these three major categories surveys can be administered to all faculty or representative faculty such as chairmen and program directors. The first two categories of administrative and non-clinical teaching are “costs” which are to some extent incurred by all programs regardless of the size. For instance even small training programs of just one or two residents require curriculum, evaluation, conferences and all of the features listed under administrative and non-clinical teaching costs. Therefore a reasonable approach to developing a formula to calculate the cost of supervision of teaching would be to determine what the “baseline” administrative and non-clinical teaching cost for one resident (or put another way, in order to establish a training program) and then to add to this cost the additional cost per resident above and beyond this baseline cost.

We underwent this type of exercise at our institution. We surveyed all program directors and chairs and got approximately a sixty percent return on our survey. Utilizing the data which we obtained we were able to determine the baseline cost of providing an education program in terms of administration and non-clinical teaching costs. We have calculated a multiplier per resident above and beyond this baseline cost based upon the data, which was collected. A formula was then developed as follows:

Teaching costs (in FTEs) =baseline + multiplier x (number of residents in program –1)
(note: n-1 because the first resident is accounted for in the baseline cost)

When we applied this formula to the programs for which we had data the formula predicted the FTE cost for administrative and non-clinical teaching to within approximately 10-15% for each program.

This analysis does not take the cost for clinical teaching into account.

Cost of Clinical Teaching
Depending on the clinical setting, trainees in graduate medical education can be considered work multipliers or detractors. In other words residents may increase clinical productivity, decrease clinical productivity or have a neutral affect on an individual attending ability to see patients. A number of years ago the Federal Government imposed specific restrictions on the number of trainees an individual attending could supervise at one time. These guidelines obviously directly impact an individual faculty member’s ability to generate revenue while supervising and training residents. There are some settings in which residents clearly decrease clinical productivity. Settings which demand a high degree of technical skill such as procedural areas including the operating room, cardiac-cath lab are areas where a trainee first starting out is clearly not able to perform a procedure as quickly or skillfully as a seasoned attending physician. In such settings clinical productivity of an individual attending would be decreased. On the other hand residents are likely to be work multipliers (increase productivity) in other areas, the emergency department is one of these areas. It is likely that in most environments attending physicians are able to see more patients per hour with residents present in the emergency department. Obviously this is impacted by a number of factors including residents’ experience, complexity of cases and individual attending’s comfort level in supervising trainees. All of this said it is likely that in an emergency department setting an individual attending can see more patients per hour if trainees are seeing those patients along with him or her then if there were no trainees present. This increase in clinical productivity must therefore be weighted against the fixed cost required to train residents because of administrative and non-clinical teaching responsibilities.

The “Cost” of Training Residents
The actual “cost” of training our residents can therefore be derived as follows: first a detailed analysis needs to be performed to determine the number of FTEs required to perform all of the administrative and non-clinical teaching required for the trainees. Next a detailed analysis needs to be performed to determine whether or not the presence of the trainees decreases or increases the clinical productivity of individual faculty members. In some areas of medicine this is a very complicated issue and involves looking at a number of different areas, such as the operating room, procedural labs, clinics, in-patient settings, etc. In the case of the emergency department this is a relatively simple task. There have been well established and accepted guidelines that determine the number of patients per hour an individual attending physician can be expected to see. One can compare this figure to the number of patients seen per attending hour worked in an ED staffed by residents and attendings. If this number exceeds the number which would be predicted by community standards in which no trainees are present residents can be viewed as multipliers. The magnitude that residents enhance efficiency in the clinical teaching environment of the ED can then be compared to the cost of having those residents through both administrative and non-clinical teaching. By comparing these two numbers one can determine if there is an overall cost of having trainees in emergency medicine or whether in fact the presence of trainees enhances a practice’s bottom line. As stated at the beginning of the article this analysis does not include other costs for residents or for establishing a residency program including non-faculty time and administrative institutional costs.

Summary Comments
In this article I have attempted to outline an approach that may help to determine the faculty cost (in FTEs) to provide Graduate Medical Education. It is difficult to get an accurate estimate of this cost and depending on the type of training program, residents may increase or decrease clinical efficiency of faculty members. Furthermore, this analysis does not recognize the obvious benefit of establishing training programs in Graduate Medical Education in emergency medicine and other specialties. Without these training programs the future of health care in the United States and indeed in the world would certainly suffer greatly. It is our responsibility to assure that training programs in Graduate Medical Education continue to flourish and that competent and capable physicians will continue to be trained.