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Although a moment of calm has descended on federal legislative efforts to overhaul our national health care system, a quiet revolution is still at work. The driving force of that change will be US business interests.1,2 Under a system pioneered by health maintenance organizations, doctors are now asked to deliver adequate care, instead of care that maximizes the use of advanced medical resources.3 Residency education has been caught in the crosshairs of this new paradigm.
Cost consciousness in medicine was barely on the horizon 30 years ago. Residents were trained to recognize and treat improbable and rare diseases. Today, the medical case that does not fit a neat algorithm quickly comes to the attention of a small battalion of case managers. It is not unheard of for discharge planning to begin even before the patient enters the hospital. Perhaps more than anything, the hurried pace of health care delivery has changed the resident's appreciation of the course of illness.
An increasing proportion of resident training now takes place in the outpatient setting. Diagnosis is quicker, and more time is spent with healthier patients. While these changes are not without benefit to patients, for medical trainees educational opportunities are lost by not being able to follow a particular illness until it is resolved.
Today's decisions are made farther from the bedside and according to algorithms established by statisticians. While this reduces idiosyncrasies in treatment, it also tends to shortcut the process of thinking through complex problems and all their alternative solutions.4 At the same time, as Lloyd Krieger points out in this issue of MSJAMA, the increased supervision of residents demanded by third-party payers and government regulators has reduced the responsibility and autonomy of trainees.5 Funding for residency training is itself constrained and, as Bobby Jindal discusses, this leaves medical educators with little wiggle room from which to escape the intentions of those who would place profits ahead of sound medical education.6
As in any struggle, these changes lack moral certainty and immediacy of effect. Subtle effects lie hidden and sometimes unfold in further doubts. In this issue, Ivan Oransky discusses concerns over the number of residents leaving medicine. Perhaps this is one early indicator that something is amiss. The final outcome of current changes in residency training will not arrive soon. It will be heralded by neither a new, sweeping legislative bill nor another corporate initiative to trim spending on health care services. The final analysis will be made in another time, when today's medical trainees take the helm and exercise the knowledge, skills, and virtues that they are learning now.
Robinson JD, Gottlieb S. The New Face of Medical Education. JAMA. 1999;281(13):1226. doi:10.1001/jama.281.13.1226
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