The Invisible Hand of the Government in Medical Education
Authors: Paul T. Kefalides
Journal: Annals of Internal Medicine (2000)

Currents18 April 2000The Invisible Hand of the Government in Medical EducationPaul T. Kefalides, MDPaul T. Kefalides, MDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-132-8-200004180-00102 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Leaders in medical education have long questioned the government's proper role in directing the teaching of young doctors. But there are many examples in which special interests and local political agendas motivate state legislators to pass new laws affecting medical training. And state governments have for a long time influenced undergraduate, graduate, and continuing medical education (CME) through a system of laws, financial incentives, and sometimes content mandates. Popular notions are frequently the driving force behind specific initiatives that emerge from state houses, encouraging medical schools to redirect resources. The impact of these anecdotal initiatives pales, however, in comparison with the ways in which the federal government's balanced budget amendment and its widely touted campaign against Medicare fraud affect teaching institutions. The reduction in Medicare funds and the enforcement of documentation requirements have changed the way students and physicians work and learn on hospital wards.Control of Funding and LicensingThe government directly influences medical education in two principal ways: restricting medical school funding and imposing requirements for licensing or relicensure. Such interventions are frequently developed to direct the geographic distribution and subspecialty choices of medical school graduates or to target various social needs.“In states that have state-supported schools, the legislators feel that they can lean on the curriculum,” noted William Kissick, professor of public health and preventive medicine at the University of Pennsylvania School of Medicine in Philadelphia. According to Kissick, the state houses rarely pass laws that mandate coursework; instead, they influence curriculum through suggestion and pressure when budgets are being drafted.A more recent proposal to mandate instruction in pain management was successfully blocked in Texas's legislature by the state's medical schools, according to James Battles, Ph.D. “Our legislature is not afraid to play in areas of medical education,” Battles remarked. “That can be good and bad,” he explained, depending on whether the legislators' wishes align with the school's own plans. “Our family medicine programs are extremely well funded,” he cited as one example.According to one medical educator at a large research university who preferred to comment anonymously, state funding incentives have tilted curriculum toward primary care. But the primary care initiative has led to students being sent to suburban or rural private practices where the quality of instruction is suspect. She stated that many educators do not agree with the new emphasis on outpatient primary care clerkships, which replace hospital rotations that involve more critically ill patients. “When the pressure for primary care is over, we'll go back and say that the more intensive in-hospital training you can get in medical school is more valuable,” she predicted.In the Pacific Northwest, state lawmakers urge medical schools to pursue high “return rates”—percentages of students who return to their native state after completing their residencies. John Coombs, MD, is the associate vice president for clinical systems and the networks associate dean for regional affairs at the University of Washington in Seattle. He reports that at his institution, the return rates for the five states in the region approach 70% to 80%. Because of that statistic, Coombs says, he has an affable relationship with legislatures in the surrounding states.In New Jersey, another initiative seeks to change physician behavior while stopping short of mandates. State assemblywoman Charlotte Vandervalk has introduced several bills to improve physician awareness about pain management and promote the adoption of a pain scale as the “fifth vital sign” in clinical medicine.“Many of these legislative reforms are reactions to what happened to one patient,” observed Deborah Danoff, MD, assistant vice president of the division of medical education at the Association of American Medical Colleges (AAMC). Directives, she says, are a form of micromanagement and fail to consider a school's total curriculum and the continuum of physicians' lifetime learning.In New York, following the death of Libby Zion, legislation was passed stating that most residents could work no more than 80 hours per week. Amendments to the legislation over the past 2 years have strengthened enforcement.Mandates for Continuing Medical EducationA review of state relicensure requirements, provided by the Federation of State Medical Boards and the American Medical Association, shows that 31 states have laws that direct the format of CME. Four of those states mandate that specific topics be covered. Florida requires that all physicians take CME classes in HIV and AIDS and domestic violence. Kentucky and Rhode Island also mandate HIV education before relicensure. In New York, child abuse must be covered in CME classes, and in Nevada and Texas, physicians renewing their licenses must receive instruction on ethics and professional responsibility. Massachusetts has an unusual law that requires all physicians to read from the Board of Registrations' book of regulations. “It's a pretty onerous restriction,” commented Henry Tulgan, MD, director of medical education and associate dean at University of Massachusetts Medical School's Berkshire Medical Center.One state's licensing law has affected medical students everywhere. To receive a California medical license, all medical school graduates from 1998 onward must show completion of a family medicine clerkship. The California Academy of Family Physicians advocated the law to address a perceived shortage in family physicians that is expected to intensify as older physicians retire. According to Wanda Wallis, special programs coordinator of the licensing program of the Medical Board of California, the new rule has not been contested by schools in other states or by young physicians who are forced to take a remedial clerkship before beginning a California residency. “Most of the schools already had it [family medicine] in the curriculum,” she explained, “and the law is flexible; we can accept primary care rotations and other types of coursework.” Despite the flexibility, Wallis added that she is unable to document compliance for about one third of all international medical schools and that she is unsure of the family medicine clerkships offered at two U.S. medical schools—Mount Sinai in New York and Loyola in Illinois.In the wake of heightened public concern about the frequency of medical mistakes, the ethical protection of human research participants, and the appropriate allocation of scarce health care resources, some educators anticipate more legislative activism in medicine. “My concern is that [the Institute of Medicine report on medical errors] will lead to more CME mandates, and they will be well-intentioned but wind up being trivial,” offered Nancy Bennett, PhD, director of educational development and evaluation in the department of continuing education at Harvard Medical School in Cambridge, Massachusetts. “We know that 80% of clinical mistakes are not a result of a lack of knowledge,” she added. “I think you need to help physicians have a self-directed curriculum—we should help physicians look at their own performance and think about the behaviors they need to change.”The Balanced Budget Act and Residency CapsCuriously, most medical educators view the intrusion by state lawmakers as relatively benign compared with the effects of federal policies on medical training. Chief among these policies are the Balanced Budget Act of 1997 and the Health Care Financing Administration (HCFA)'s highly publicized crackdown on Medicare fraud.The Balanced Budget Act limited funding for residents at teaching hospitals and included a financial disincentive for adding new residency slots. According to Ivy Baer, JD, MPH, director and regulatory counsel for the division of health care affairs at the AAMC, the law was meant to save money and to prevent busy hospitals from using residents as cheap labor. “It argued that this had been a service-related construct rather than an educational program,” explained Baer of the old system, which allowed hospitals to enroll an unlimited number of residents as long as their training programs were accredited.However, the lawmakers who drafted the Balanced Budget Act made no provision for a growing and shifting population. In addition, some experts say that the law is unrealistic in its expectation that residents not be considered part of health care's labor equation.In some states, like Washington, the population is growing and there is no surplus of physicians. University of Washington's Coombs noted that the residency limits make it hard for academic centers to continue to serve as safety nets for their communities. Baer responded that academic centers will need to find alternate providers, such as physician assistants and nurse practitioners, to care for the growing population rather than expect the government to pay for more residency slots.How Medicare Documentation Requirements Distort TrainingThe other major cost-saving federal initiative—the HCFA crackdown—drew the greatest venom from medical educators. The government's sting of several high-profile academic centers returned billions of dollars in Medicare charges to the federal treasury. Now, to comply explicitly with HCFA guidelines and prevent future raids, academic medical centers have instituted elaborate documentation methods for the medical record and have sharply increased the presence of attending physicians on the wards.In the traditional teaching model, housestaff managed patients and an attending physician provided advice by telephone, as part of a didactic session in teaching rounds, or briefly at the bedside. This model has been widely replaced with a structure in which attending physicians personally examine patients every day to maximize billing. Instead of making a short note in the chart or countersigning a trainee's assessment, the attending now completes a full progress note. Hence, less time is available for direct teaching of students and residents, and housestaff autonomy and importance has diminished considerably.These concerns will be highlighted in a study by James Woolliscroft, MD, professor of medical education and executive associate dean for graduate medical education at the University of Michigan in Ann Arbor. Woolliscroft sent surveys to award-winning teaching physicians at every U.S. medical school. Eight hundred physicians from 80 medical schools responded. According to Woolliscroft, many respondents believe that the new documentation requirements are having a profound negative effect on medical training. Some respondents said that they had less time to teach, and others reported that they had eliminated students from their clinics to make time for documentation.Perhaps more worrisome is the fear that students and residents who were once part of the health care team now feel marginalized and irrelevant. “Students now sense their role is peripheral,” commented Woolliscroft, explaining instances in which students' history and physical write-ups were deemed “unofficial” and were pulled from the medical record.A similar survey conducted by leaders of the housestaff training program at the University of Chicago drew equally strong reactions. “The housestaff felt that the quality and quantity of teaching was negatively affected, and the faculty felt even more strongly than the residents,” stressed Holly Humphrey, MD, associate professor of medicine and director of housestaff and student programs. Humphrey fears that the quality of U.S. clinical training programs, which have produced generations of exemplary physicians, is being eroded. She worries that U.S. medical training may come to resemble that seen in many other countries, where students are isolated from meaningful involvement in patient management.Because trainees' independent, “hands-on” experience with patients is now perceived as a threat to the financial health of the institution and is being curtailed, educators worry that graduates will begin practice with a skills set inferior to that of earlier generations of physicians. “I am concerned that [practicing] physicians will be facing challenges that they should have learned how to handle as residents, but couldn't because they weren't independent enough,” said Woolliscroft.Medical educators cited the HCFA reforms as an example of policy created in a vacuum with little thought to consequences. Some also noted that the tradition of medical training that follows an apprenticeship model is poorly understood by federal bureaucrats and the voting public. “We haven't begun to think about [educating the public about the principles of medical training],” commented Woolliscroft.Others take a more moderate view of the changes forced by HCFA. “This is the way it ought to have been. It was abusive and we shouldn't have needed the federal government raids to reform it,” stated James Howard MD, senior vice president and medical director of The Washington Hospital Center, Washington, D.C. “The teaching physician has an obligation to be present. It is a different paradigm now, but it is still very workable.”The University of Washington's Coombs suggested that the HCFA policy should undergo a critical review. “We need to look at explicit outcomes data for the HCFA regulations,” he said. “We need to ask what were the objectives of the HCFA rules and what have been the effects.” Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoGovernment and Medical Education Scott A. Levin Metrics Cited byAssessing medical student documentation using simulated charts in emergency medicinePain Education in North American Medical SchoolsGovernment and Medical EducationScott A. Levin, MDEmergency Medicine Resident Documentation: Results of the 1999 American Board of Emergency Medicine In-Training Examination Survey 18 April 2000Volume 132, Issue 8Page: 686KeywordsGraduate medical educationHealth careMedical educationMedical lawMedicareMotivationOutpatient clinicsPain managementPreventive medicineResidency Issue Published: 18 April 2000 Copyright & PermissionsCopyright © 2000 by American College of Physicians. All Rights Reserved.Loading ...