Educational Pipeline for Physicians in Peril

ACGME Study Highlights Impact of Potential Cuts to GME Funding

November 15, 2011 05:45 pm Sheri Porter

As the Joint Select Committee on Deficit Reduction, known as the "supercommittee," goes about its budget-trimming business in Washington, the Accreditation Council for Graduate Medical Education, or ACGME, released the results of a survey aimed at assessing the impact that potential cuts to GME funding, which currently are under consideration by the supercommittee, would have on America's educational pipeline for physicians.

[There was a more dramatic reduction than we expected in core residency programs which has huge implications for the country. Thomas Nasca, M.D., Exec. Dir. and CEO-ACGME]

The survey findings are outlined in "The Potential Impact of Reduction in Federal GME Funding in the United States: A Study of the Estimates of Designated Institutional Officials(" The report paints a picture that greatly concerns ACGME Executive Director and CEO Thomas Nasca, M.D.

"We will actually reduce the number of physicians who are trained in the United States at a time when all workforce studies are demonstrating a mounting deficit of physicians," said Nasca in an interview with AAFP News Now. "That will place us in a position where our physician-to-population ratio in 2020 and beyond is below (that of) most of the developed countries in the world."

Nasca pointed out that program reductions were not confined to what he called the "GME-heavy states" in the Northeast and on the West Cost. "They are across the country, which indicates that rural family medicine and general internal medicine programs will equally be harmed," he said.

Story highlights

  • The Accreditation Council for Graduate Medical Education, or ACGME, recently released a study based on survey responses from institutions representing nearly 70 percent of all U.S. ACGME accredited programs.
  • The study assesses the impact of potential GME funding cuts being discussed by the Congressional "supercommittee" on the U.S. educational pipeline for physicians.
  • Core residency programs, such as family medicine and general internal programs, likely would see dramatic reductions in residency positions, which could leave underserved communities without access to medical care, according to the study.

In addition, Nasca noted, "There was a more dramatic reduction than we expected in core (or specialty) residency programs -- which has huge implications for the country."

Perry Pugno, M.D., M.P.H., AAFP vice president for education, agreed. "The fact is that any cuts to GME that go across the board are going to hurt primary care -- especially those of us who disproportionately take care of adults with chronic illnesses," said Pugno. "In communities where primary care residency programs are present, those programs become the access point for the poor and disenfranchised of the area. That's the reality."

Pugno pointed out that it's not unusual for family medicine residency programs to see patients who live both in poverty and with numerous chronic illnesses. "The payment for taking care of those patients is so low that the local medical community often doesn't want to provide that care," said Pugno. "But residency programs take all comers."

Survey responders also spoke to this issue. "In the comment section of the study, we heard from a large number of institutional officials that their ability to provide access to the poor and underserved would be dramatically and adversely impacted, and that is true whether it's a large urban inner-city hospital or whether it's a rural community," said Nasca.

Study Highlights

The study is based on e-mail survey responses from 306 institutions representing nearly 68.9 percent of all U.S. ACGME-accredited programs and 68.4 percent of all resident positions available in 2011.

The survey instructed responders -- designated institutional officials, or DIOs -- to indicate how federal funding would affect their institutions' programs and positions. DIOs were asked to estimate the potential impact under three different funding scenarios:

  • funding to remain stable at 2011 levels,
  • funding to be reduced by 33 percent and
  • funding to be reduced by 50 percent.

Stable funding did not produce dramatic changes in programs and positions. However, the outlook worsened when cuts were introduced into the equation. With a 33 percent reduction in GME funding

  • 68.3 percent of responders said they would reduce the number of core residency positions,
  • 60.3 percent would reduce the number of subspecialty fellowship positions,
  • 4.3 percent would close all core residency programs, and
  • 7.8 percent would close all subspecialty programs.

Core residency programs and their positions include specialties -- such as family medicine or general internal medicine -- that lead to initial board eligibility by an American Board of Medical Specialties certifying board. Subspecialty programs and subspecialty fellowship positions involve training that occurs after initial board certification.

Significantly, even though there were fewer core, or specialty, programs, core positions (2,783) outnumbered subspecialty positions (1,151); therefore, the majority of positions lost would be core positions. The number of those core positions would drop from 2,783 to 1,656 with this level of funding cut.

The numbers dropped even lower with a 50 percent reduction in GME funding. At this level,

  • 82.3 percent of responders would reduce the number of core residency positions,
  • 76.2 percent would reduce the number of subspecialty fellowship positions,
  • 14 percent of responders would close all core residency programs, and
  • 20.9 percent would close all subspecialty programs.

A 50 percent funding cut would result in the elimination of 3,037 core medical specialty positions.

Looking Forward

Nasca said that the increase in U.S. medical school enrollment in recent years was a step forward in finding a solution to the nation's looming physician deficit. However, he added, GME positions have not been increased.

"Now we're talking about significant reductions in the number of GME positions, to the point where we may not even have enough residency positions for the graduates of our domestic allopathic and osteopathic medical schools," said Nasca.

He pointed out that another 3,700 U.S. citizens enter the United States after training in Caribbean medical schools. "There would be no spaces for any of those individuals under some of these scenarios," said Nasca.

The ACGME also is concerned that just discussing cuts in GME funding could cause a reduction in programs and positions, even if cuts don't materialize. Residents represent a significant financial investment, said Nasca, and the anxiety about possible removal of funding "might cause institutions to either limit their growth or even begin to reduce just to be on the safe side."

"I think the irony is that the graduate medical education community is responding to the needs of the public, as expressed in the new (ACGME) competencies and a whole series of other areas, to meet future needs. At a time when we need a stable training environment, we're forced into a situation of talking about dramatic reductions in funding," Nasca said.