Visit tma.tips/physicianburnout for more information.
“People joke and call it the $300,000 mistake, but a lot of us are doing this because it’s what we are passionate about.”
CLOSING THE GAPS Fellowships also help expand the scope of opportunities educational institutions provide and serve as a good recruiting tool for high-caliber trainees and faculty, says Surendra K. Varma, MD, a member of the TMA Subcommittee for Academic Physi- cians and executive associate dean for GME and resident affairs at Texas Tech University Health Sciences Cen- ter (TTUHSC) in Lubbock. But he acknowledges those benefits
can come to the detriment of less lu- crative but equally necessary general care. Often the hospitals that teaching institutions partner with to provide fellowship training “would rather fund a cardiology fellowship than an infectious disease fellowship because [the hospitals] are going to benefit more from procedure-oriented sub- specialties.” At TTUHSC, for example, out of 36
internal medicine residents, only six or eight will remain in primary care, Dr. Varma says. Most go on to choose subspecialties like nephrology, hema- tology-oncology, or pulmonary and critical care, and all of the school’s in- ternal medicine fellowships “are full,” he said.
Educators do not deny the need
for subspecialty care, pointing to the Association of American Medical Colleges’ most recent prediction of a national shortage of nearly 46,000 to 90,000 physicians by 2025. That in- cludes shortages in primary care and specialty care. Download the full re- port at tma.tips/AAMCprojections. “But the gap between specialty care
and primary care is too high,” Dr. Ca- ble says, due largely to an imbalanced payment system that undervalues pri- mary and general care. The maldistribution also under-
lies the Institute of Medicine’s recent study of the issue and controversial recommendations for reform of GME financing. (See “GME Gamble,” Octo-
44 TEXAS MEDICINE July 2015
ber 2014 Texas Medicine, pages 27–31, or
www.texmed.org/GMEGamble.) Federal antitrust law precludes
ACGME from actively managing the number or type of residency and fel- lowship positions offered. Dr. Nasca says ACGME, one of sev-
eral fellowship accreditors, has largely responded to the subspecialty move- ment, having accredited programs in 146 different disciplines — up from 28 in 1981 — and assuring high-quality training in those disciplines. “But in reality, the public does not need as large numbers of subspecialists, as we need generalists, and not just primary care.”
The gap could shrink, he says, as
ACGME moves to a new model that places more emphasis on demon- strating community need as a part of programs’ assessment. (See “Learn- ing Curve,” April 2014 Texas Medicine, pages 27–31, or
www.texmed.org/ LearningCurve.) “We are struggling to go beyond
merely assuring the public of the qual- ity of education to try and understand how potentially helpful or harmful continued subspecialization is to over- all clinical care efforts. One challenge is balancing scientific advancements and the delivery of sophisticated ser- vices with trying to create a physician workforce that meets all of the needs of the American public in an efficient and effective fashion,” Dr. Nasca said. “What’s clear is, there is a delicate bal- ance that needs to be struck, keeping in mind graduates are going to prac- tice in the areas where they train. So we are asking programs to ask those fundamental questions: What does the community need? And are we prepar- ing people well to meet the needs of the populations we serve?” Educators also walk a fine line in counseling their trainees. “I knew I could make a meaningful contribution taking care of people at the end of life. Not only would I have been willing to make less, but I would have pursued it, no matter what,” Dr. Cable said. “So my message to my stu-
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