Tuohy E. GME Funding and Specialty Choice, Part II. JAMA. 1999;282(24):2366. doi:10.1001/jama.282.24.2366
Prepared by Ashish Bajaj, Department of Resident
and Fellow Services, American Medical Association.
Last week's Resident Physician Forum column contained a brief summary
of how Medicare funds graduate medical education (GME). Residents who plan
to switch programs need to understand that Medicare may reduce funding for
a resident who moves from one program to another, depending on the length
of the initial residency period. Medicare defines an "initial residency period"
as the number of years it takes for a resident to become board eligible in
the first medical specialty the resident entered. The initial residency period
is set when a physician enters residency, and it does not change. Hospitals
with training programs will receive slightly less when a resident is beyond
the initial residency period. Some hospitals are using this cut in funding
to eliminate applicants to their programs.
Because of the way Medicare defines the initial residency period, residents
who first enter specialties with longer initial residency periods may be better
positioned to switch specialties than those whose initial residency periods
are shorter. For example, a physician who first enters a general surgery program
will be fully funded for 5 years of residency, whereas a physician who first
enters an internal medicine program will be funded for 3 years. If a general
surgery resident completes 2 years of training in general surgery and switches
to a 3-year specialty, such as internal medicine or pediatrics, Medicare will
fully fund that resident for both programs. If a resident first enters an
internal medicine program, completes 1 year and then decides to switch to
another specialty, Medicare will fully fund that resident for only 2 more
Medicare makes an allowance for residents who enter transitional year
programs. In this case, if a resident switches to a specialty that requires
a year of general medical training as a prerequisite, Medicare will fully
fund the resident for that specialty and for 1 year of general training. However,
if the new program does not require 1 year of general training, that transitional
year will be counted as 1 year of the initial residency period.
Medical students and international medical graduates should be aware
that not all programs will eliminate applicants who have already completed
some residency training. Many hospitals may feel that the decrease in funding
for these residents is relatively small. Nevertheless, applicants to residency
programs should be aware of these implications when selecting a specialty.
Medical students and physicians should also understand that the current
structure of GME funding is at a crossroads. The shift of training to nontraditional
outpatient sites and the advent of programs sponsored by managed care entities
have altered the residency landscape. Congress is considering several changes
to the Medicare program, including changes to GME funding. The American Medical
Association and its Resident and Fellow Section are following this issue closely
and will continue to report on proposed changes and their implications.