ACADEMIA
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The Downsizing of Internal Medicine Residency Programs David A. Asch, MD, MBA, and Jack Ende, MD
• A variety of forces are converging to reduce the number of internal medicine residency positions offered in this country. This reduction, referred to as downsizing, has been proposed as the solution to several of the problems facing internal medicine. We examine the forces that underlie the current enthusiasm for downsizing; we consider the alternative strategies by which downsizing might be implemented; and we consider the implications of these alternatives on different groups of stakeholders. Although downsizing may represent a legitimate approach to real problems, any mechanism to reduce the number of training positions in internal medicine will have broad implications for medical education and patient care well into the next century. Special efforts must be taken to ensure that downsizing will not exacerbate the existing problems of overspecialization and limited access to care. Annals of Internal Medicine. 1992;117:839-844. From the University of Pennsylvania School of Medicine, Leonard Davis Institute of Health Economics, and the Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania. For current author addresses, see end of text.
lWithin the next few years the number of residency training positions in internal medicine will most likely be reduced. This reduction, referred to as downsizing, has been offered as the solution to several of the problems facing internal medicine. Whether or not these problems are real and whether or not downsizing will solve them, any reduction in the number of residency training positions in internal medicine will have a broad effect on medical education and care that will last well into the next century. We examine the forces that underlie the current enthusiasm for downsizing; we consider the alternative strategies by which downsizing might be implemented; and we consider the implications of these alternatives on different groups of stakeholders. We conclude with recommendations for those in a position to move the concept of downsizing into actual policy. The Declining Appeal of Internal Medicine Downsizing has been suggested as a way to overcome several concerns facing internal medicine. These concerns include a predicted oversupply of physicians; a service-driven system of graduate medical education; and the growth of specialization and the rising cost of medical care. Although these trends may support the
direction of downsizing, they are not the primary forces from which the pressure to downsize has emerged. The real and proximate cause of the current interest in downsizing is the recognition that careers in internal medicine are no longer as popular as they used to be. Before 1987, the number of internal medicine residency positions grew rapidly. During this period, many institutions found they needed more residents to satisfy their service needs and at the same time found that the cost of these residents was well subsidized by Medicare's favorable reimbursement system for the direct and indirect costs of graduate medical education (1-3). From 1978 to 1987, the total number of first-year categorical and primary care internal medicine residency positions increased nearly 20% from 4667 to 5578. The number of 3-year positions has declined slightly in more recent years. In 1992, 5141 3-year positions were offered. In contrast to the overall expansion in the number of residency slots, the number of graduating U.S. medical students filling those slots has dropped. In 1987, only 65% of these positions were filled by U.S. graduates. By this time, the year of the "black Tuesday" match day, it was clear to many how dire the situation really was (4). Those who dismissed the declining fill rates as a temporary disturbance were proved wrong by the steady decline in later years. By the 1992 resident match, only 57% of 3-year internal medicine residency positions were filled by U.S. graduates, the lowest level to date. At the same time, the percentage of offered positions filled by non-U.S. graduates increased from about 10% in 1978 to 29% in 1992. Increases in these non-U.S. graduates entering programs only partially offset the declining percentage of U.S. graduates entering programs, and so total fill rates have also fallen. Moreover, the distribution of U.S. graduates has favored some programs to the exclusion of others. In 1984, 64 of 413 internal medicine residency programs (15%) had no U.S. graduates. By 1992 that proportion rose to 34% (129 of 384). These trends represent symptoms of an underlying problem and are problems themselves. Although not all programs have experienced these declines, on the whole internal medicine residency positions have become less attractive. Several recent surveys of graduating medical students suggest that students continue to perceive a career in internal medicine to be intellectually challenging, but they also perceive these careers to be more stressful and demanding of time and effort, less personally satisfying, and less financially rewarding than other career options. Students also perceive internal medicine residency positions as easier to attain (5, 6). Perhaps of greater importance, the decrease in fill
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rates is coupled with the concern that the U.S. applicants who are attracted are of lower quality. A comparison of performance on items common to different American Board of Internal Medicine (ABIM) certifying examinations suggests a decline for graduates of U.S. schools (7). A casualty of these trends may be that internal medicine can no longer portray itself as the elite profession it once was. Whether or not these conclusions are correct, most would agree that it is a problem if, because of decreasing fill rates, internal medicine programs no longer attract the most promising students. Downsizing addresses these concerns by reducing the supply of internal medicine residency positions, thereby raising the standards for acceptable candidates. The response to internal medicine's declining appeal, however, has not been limited to calls for downsizing. Considerable effort by leading organizations has been directed toward expanding the pool of qualified applicants and increasing internal medicine's attractiveness both during and after training. Much of this effort is targeted toward increasing the number of qualified students who enter primary care fields such as general internal medicine. To the extent that these measures succeed, the pressures to downsize may relax. Meanwhile, however, downsizing represents one additional way to raise standards. Physician Supply Several studies have projected a physician surplus as we move into the next century (8, 9), and it seems logical that a reaction to these projections is a second potential source of support for downsizing. Despite this apparent logic, it is not clear whether the surplus many predict should play a major role in the pressures toward downsizing: first, because some projections suggest there will be no such surplus (10); second, because the manpower issue is more a question of distribution and access than a question of absolute numbers; and third, because the moves toward downsizing are occurring simultaneously with the widespread recognition that we need more primary care physicians, many of whom will be internists (11). Service-Education Dichotomy A third argument in support of downsizing is that the number of residency positions should be determined by the educational resources available for training and that this number is lower than the present number defined by hospital needs. In the past, the growth in the number of internal medicine residency positions has been driven by the service needs of hospitals. The recent resolution by the Federated Council for Internal Medicine (FCIM), echoed in the Residency Review Committee for Internal Medicine (RRC-IM) new Special Requirements, is intended to reorient the residency experience from service toward education. The resolution states that the primary objective for residency training is education; that in the past internal medicine residencies have satisfied their service needs by offering more positions than are appropriate for their educational resources; that hospitals should shift excess service needs to other 840
personnel; and that the RRC-IM should develop guidelines for the assessment of educational resources to define the maximum number of positions that each program can support (Federated Council for Internal Medicine Resolution, 21 May 1990). Obviously, residents both provide service and receive education. Perhaps in the past it was more easily accepted that education was received in the very act of providing service—that the two were inseparable. Recently, however, the perception is not only that service and education are distinct and separable but that the service-education dichotomy represents a tension that must be addressed. It is common to hear residents complain, ironically, that patients get in the way of their education (12). Education is not all that is at stake. In addition, residents are perhaps more willing now than in the past to recognize life-style, leisure, and other personal goals as legitimate competitors for their time. One reason for this tension may be that the service demands on internal medicine residents have increased, particularly as hospitals have seen residents as an elastic source of inexpensive labor. A related reason is that the services provided by residents may now be of less educational value. In a recent time study, Lurie and colleagues found that internal medicine residents on call spend little time in direct patient care and considerably more time engaged in clerical duties or doing procedures that could easily be performed by nonphysicians (13). Further, as much of the evaluation and management of medical patients moves to the outpatient setting, inpatient service requirements—which remain the bulk of the internal medicine residency experience— have become progressively menial. The recognition of education as the appropriate priority within the service-education tension supports the notion that internal medicine residency positions should be reduced from their service-driven number to a lower number driven by educational resources. The basis of this argument is the belief that there is a determinate limit to the number of residents that can be adequately trained. If each internal medicine resident needs 20 hours of small-group teaching a week, for example, then the number of residents each program can train is limited by the number of faculty available. If the service demands of the institution cannot be satisfied with that number of residents, then those demands must be satisfied outside of the training program. Linking program size with educational resources makes sense, although it makes more sense for residency programs in general surgery, for example, where residents need to be exposed to determined numbers of clinical cases, and these experiences cannot easily be shared. In internal medicine, different clinical settings provide educational resources that are somewhat expandable. The number of internal medicine residents who can share the experience of caring for a particular medical inpatient may be more elastic than the number of surgical residents who can share in a patient's surgery. The number of residents who can be assigned to an office-based ambulatory care experience is indeed limited, but additional practice sites can often be found. One-to-one attending supervision will always be a limited resource, but many of the other educational expe-
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riences of residency training are not so limited. And because so much of what internal medicine residents learn is learned from other residents, the educational resources of an institution are to a degree self-generating. Most important, however, although it makes sense to link program size to the available educational resources, this task will be exceedingly difficult until we know better how to measure teaching capacity and how teaching capacity relates to learning outcomes. Mechanisms for Downsizing Downsizing can be accomplished by one or more of the following means. The number of positions within existing programs can be reduced, whole programs can be eliminated, or trainees who previously were accommodated in programs can be barred. Each mechanism will probably have unique consequences. The first mechanism reduces the number of positions offered by each program. This mechanism might come about through the augmented structural requirements imposed on programs by the RRC-IM. These requirements specify what resources are necessary to satisfy the training needs of internal medicine residents. In theory, programs might reduce the number of positions they offer to ensure that they have sufficient educational resources for each resident. Alternatively, groups of small hospitals—perhaps even those that are in other senses competitors—might band together to offer more joint residency programs. In addition, small hospitals might increasingly seek affiliations with nearby academic medical centers so that residents from the larger institutions would rotate through the services of the smaller institution. Such arrangements might be perceived as a simple reduction in the number of residency programs when, in fact, the reality would be more complex. The ability of separate institutions to create these affiliations means that the distinction between a decrease in the number of programs and a decrease in the size of programs may be a false one. Many of the RRC-IM special requirements address overall program size, the availability of training programs in other specialties, and other factors related to the program as a whole rather than to the number of positions. Individual programs may face the all-or-none question of whether they can support a program at all, and the fates of training programs in diverse specialties are often linked (Larned FS, Gray PD, Hillman RS. The impact of changing ACGME general and specific requirements for residencies upon teaching hospitals. American Hospital Association, Atlanta, Georgia, April 1990). As such, downsizing may naturally occur by a reduction in the number of programs rather than by a reduction in their average size. Institutions might abandon their own residency program but still have residents rotating through their services. These rotating residents might satisfy many of the institution's interests by improving the institution's reputation, by attracting professional staff, and by helping to meet service needs. A second model (not exclusive of the first) would reduce the number of internal medicine residency positions by eliminating weak programs. These programs
might be identified by the success of their graduates on the ABIM certifying examination. Current RRC-IM special requirements suggest that, in aggregate, the graduates of an internal medicine residency program should achieve a floating 3-year pass rate of 50% on the certifying examination (14). John A. Benson, Jr., while ABIM president, supported this position and suggested that downsizing should be accomplished by eliminating these "marginal programs." Approximately 20% of existing programs can be classified as marginal by this standard (15). This criterion has many appealing characteristics. The 50% threshold has the virtues that it is determinate and at least intuitively reasonable. More rigorous quantitative techniques might suggest that the 50% threshold should be reset at a different level, but these techniques would require some agreement about what this threshold is expected to optimize. More important, perhaps, to the extent that achievement on the certifying examination is an accepted proxy for quality, this model links downsizing with at least one outcome that residency programs are expected to achieve. Internal medicine residency programs have other goals besides the production of board-certified internists, however. Calling a program "marginal" because its graduates fail to achieve a 50% 3-year pass rate seems to beg the question of what these goals are. Further, in some sense using the certifying examination to define marginal programs is double-counting. The certifying examination is used as a screen twice if it is the final step in defining a board-certified internist and also—by using aggregate pass rates—if it defines which trainees are entitled to take the examination in the first place. Because residency accreditation and eligibility to sit for the certifying examination are linked, the marginal program model double counts the certifying examination and uses an outcome measure where a structure or process measure might be better suited. Nevertheless, even though a low aggregate pass rate is not the underlying problem, it may signal that something in the program's ability to recruit or train residents is flawed. In fact, aggregate pass rates might best be used in combination with other measures of program quality assayed during RRC-IM review. The RRC-IM's rate of closing residency programs has been lower than the average in other specialties (16), but proposed changes in the special requirements promise to make review broader and more stringent. A third mechanism would focus on international medical graduates. A report from the Department of Manpower and Demographic Studies of the American Medical Association analyzed several manpower strategies specifically targeting the number of international medical graduates entering practice in this country (17). Taking its lead from this report, a recent Council on Graduate Medical Education discussion paper recommended limiting the number of training positions to the number of U.S. graduates plus a quota for international medical graduates (Physician Manpower Subcommittee. Discussion paper. Council on Graduate Medical Education, 29 October 1991). Although these suggestions ostensibly address the concern of physician oversupply, they represent alternative strategies for downsizing.
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Recognizing Different Stakeholders Whatever method is used to reduce the number of training positions, downsizing will have important secondary effects. The potential impact of downsizing will vary depending on one's perspective. Three groups of stakeholders need to be considered: hospitals (and programs within hospitals), vulnerable populations of patients, and prospective trainees. Hospitals and Teaching Programs For hospitals, the obvious challenge presented by downsizing is making do with fewer residents. If part of the service-education tension has resulted from an increase in service demands on residents, how are these needs to be met in the face of downsizing? This problem echoes the problem faced by residency programs in the wake of the Libby Zion case, particularly in New York where regulatory constraints on work hours prompted hospitals to restructure the clinical responsibilities of established physicians and hire additional staff to replace the lost resident labor (18). Such restructuring is expensive: One study suggests that the New York regulations will cost over $350 million annually in that state alone (19). As the number of internal medicine residents is reduced and, more generally, as the emphasis in residency training shifts from service to education, hospitals will have to identify alternative sources of clinical labor. Phlebotomists, intravenous team nurses, and other health professionals might be hired to assume some of the services previously performed by housestaff. There are compelling arguments for doing so anyway, because these professionals improve care (20), and they perform tasks that have little educational merit for physician trainees. In some teaching hospitals, patients felt to provide little educational value are admitted to wards where physicians' assistants substitute for residents. For non-critical care units the direct cost of this form of alternative coverage compares favorably with the cost of using resident physicians (21). Nevertheless, the financing of graduate medical education has been largely service-based. Hospitals with fewer residents will receive less Medicare support for medical education. For this reason, resident substitutes, perhaps better for other reasons, will probably cost hospitals more money. Institutions contemplating abandoning their programs—or forced to—will have to consider carefully the costs of replacing the services previously provided by residents. In fact, some have argued that hospitals do not really consume resources as they support graduate medical education, although the effect of residency programs on the financial performance of teaching hospitals seems to be favorable for large hospitals but unfavorable for small hospitals (22). Residents appear to provide services at a reduced rate—perhaps in exchange for the education and credentialing they receive (23)—but for smaller hospitals that are presumably less efficient at education, these services may not offset the costs associated with supporting a training program (24). As service and education disengage, however, what842
ever balance there is among residents, hospitals, and payers may change. In fact, the growing distinction between service and education enhances the notion that although the services provided by medical residents should be supported by payers, the education they receive need not be. Unless other stakeholders move in, residents will have to receive lower stipends, hospitals will have to provide uncompensated support for graduate medical education, or payers will have to increase their patient care reimbursement to reflect the fact that residents will no longer be providing the effort that in the past was subsidized in the name of graduate medical education. Burdens on hospital inpatient services may increase further if, as many hope, the financing of graduate medical education follows residents into the outpatient setting, where an increasing amount of their activity and education now takes place (25, 26). Large programs benefiting from economies of scale might find themselves able to provide sufficient educational resources to increase the number of residents. At the same time, if the defining criteria for internal medicine residency programs shifts from service to education, reimbursement for the direct and indirect costs of graduate medical education might shift from hospitals to medical schools or training programs. Hospitals may lose control of their programs to schools, and small hospitals might lose control to nearby academic medical centers. Vulnerable Populations Any plan to downsize internal medicine residency positions will also affect the patients that downsized hospitals serve. If small programs based in small hospitals are at greater risk because they find it difficult to support more structured educational requirements, patients serviced by those hospitals will see a change in their care. Services are likely to decrease not only because residents are no longer available to provide them, but also because residency programs are effective recruiting tools to attract other physicians and are themselves pools from which future staff physicians are often drawn. Unless downsizing is accompanied by successful efforts to direct internists into underserved areas, the already limited access of indigent patients is likely to be threatened further. Teaching hospitals provide a disproportionate share of indigent care (27). Indigent patients who in the past may have relied heavily on resident physicians for care will find these sources of care reduced. And as service previously relied on becomes less available for all patients, care for indigent patients is likely to be the first to go and the last to return. In fact, the care of vulnerable patient groups is threatened by many other forces in graduate medical education besides downsizing. Graduating seniors choose which programs to enter, and there is evidence that some avoid programs that, for example, offer heavy exposure to patients infected with the human immunodeficiency virus (28). These influences may threaten selected patient groups much more so than mandated changes in the overall number of residency positions. Efforts to direct internists to underserved areas should
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be stepped up in parallel with efforts to downsize so that we do not worsen our existing problems of access to care. Also potentially at odds with downsizing is the goal of increasing the number of internal medicine trainees who enter general internal medicine. A recent analysis of the inputs, process, and products of internal medicine training suggests that residents emerging from small hospitals with relatively few subspecialty fellowship programs are more likely to enter primary care (29). It is unclear whether this finding reflects the greater exposure to subspecialties that residents receive in large programs or that large programs preferentially attract medical school graduates who have already made the decision to subspecialize. The distinction may be important: If the former is the case and if small programs are more vulnerable to downsizing, then the profession must work even harder to direct internists into primary care. Trainees and Future Practitioners Trainees also will be affected, not only because of reductions in the number of training slots, but also because of changes in the training environment itself. Graduating medical students are looking for strong educational programs that will provide them with the best chances of achieving personal and career goals. For those graduates who obtain one of the more limited number of positions, downsizing is likely to be a step forward in this regard. Graduates also want tolerable working conditions and attractive salaries. The latter may be at issue should the balance between service and education shift so much that the traditional payment sources for graduate medical education no longer seem relevant to what residents actually do. If salaries are reduced as the service component of residency diminishes, moonlighting might become increasingly important for residents who need the extra money and hospitals who need the extra hands (30). Although moonlighting experiences might be structured to provide educational benefits, one might ask why they were separated to begin with. Graduating medical students who would have been offered an accredited residency position before downsizing but cannot obtain a position afterward lose out. These stakeholders may not engender much sympathy. To the extent that programs are able to judge quality, those not chosen ought to be applicants of lower quality. And if some system akin to the marginal-program model is used to downsize residency positions, those denied a position in an accredited residency training program would have been less likely to pass the certifying examination anyway. Weaker graduates may be vulnerable even if they obtain residency positions. Program directors, fearful that low pass rates will make their programs vulnerable, might find themselves in conflict with individual residents perceived as unlikely to pass. Current RRC-IM guidelines suggest that at least 75% of graduating residents in each internal medicine residency training program should take the ABIM certifying examination. Within these guidelines, directors might develop much
stricter criteria for deciding which graduating residents to support as candidates for the examination. At the same time, the way that downsizing is accomplished will have a profound effect on the perception and the reality of certification in internal medicine. There is no bright line that distinguishes certification standards designed to uphold professional quality and those designed as trade barriers to reduce competition. One's perception depends largely on which side of the fence one falls: Those excluded from certification are likely to perceive the impact of residency downsizing as an additional anti-competitive trade barrier. The substance of this distinction will depend on the validity of the assumption that it is better to have fewer internists of higher quality than more of lower quality. Even if the profession can demonstrate that downsizing in fact improves the quality of internists on the whole, it will face the criticism that perhaps this was a trade not worth making. Regional service needs might go unsatisfied with a smaller and more concentrated supply of more qualified internists. If this is so, then in addition to increasing the diffusion of internists, the profession might support efforts to facilitate other health professionals, such as nurse practitioners and physicians' assistants, to provide some of the care that has traditionally been provided by internists. Conclusions The pitfalls and promises of downsizing are sufficiently uncertain that there is an appeal to maintaining the status quo. Many arguments that might support downsizing are weak or of questionable basis. The physician manpower projections do not unanimously predict a surplus of physicians; in fact, many now believe we face a shortage of primary care physicians, many of whom are, or should be, internists. And although it is likely educational resources and physician training are somehow related, we have no sense yet how these resources should be structured or how much is enough. Given the potential for harm to vulnerable stakeholders, perhaps the most prudent policy is to wait and see and allow the supply and demand for each program determine its size. This free market approach, however, ignores the compelling fact that careers in internal medicine are less attractive now than in the past. This decline in internal medicine's appeal is challenging the profession's ability to maintain its standards. Historically, programs have swelled to their current size in response to increasing service needs in an era when qualified applicants were plentiful. This condition no longer obtains. If internal medicine is to maintain its standards, a program's size should not be governed by its service needs, but by the quality of the applicants it can attract and the quality of the training it can provide. Quality may prove to be a signpost as well as a goal. A strategy that limits the size of all programs will affect programs that are strong as well as those that are weak. Similarly, a strategy that limits access to training for certain groups of trainees may turn away many who are qualified. Attention should be trained on the programs whose quality is judged to be marginal.
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Identifying such programs will not be simple. Using a floating 3-year pass rate of 50% on the ABIM certifying examination is one way marginal programs might be identified, but there may be better, more specific methods to judge programs. The RRC-IM, through a series of proxy measures, attempts to assay educational quality as programs are reviewed. For the most part, these proxy measures are unsupported by data and open to question; thus, it might be tempting to delay action on marginal programs while awaiting data. These data are unlikely to be forthcoming, however, and internal medicine cannot abide programs of questionable quality indefinitely. Steps need to be taken now. At the same time, the profession must control the negative impact of downsizing on the individuals, institutions, and patient groups likely to be affected. Qualified applicants will be able to identify other sites for training, but solutions for hospitals denied their traditional sources of labor and patients denied their traditional sources of care may not be so easily obtained. Downsizing need not be implemented in a large scale at once. We propose that efforts to downsize be coupled with efforts to mitigate downsizing's negative effects. Such efforts should address several concerns. We must identify alternative ways for hospitals to meet their service needs. We must step up even further our efforts to direct physicians (and other clinicians) to underserved areas. We must develop more innovative health care delivery systems that rely less on house staff. The daunting nature of this list reflects the fact that the downsizing of internal medicine residency programs is a single strategy in the larger movement of health care reform. It is an important strategy and one that demonstrates the central role of graduate medical education, but downsizing is only one of many strategies. Efforts to improve the appeal of careers in internal medicine must continue unabated. Likewise, efforts to improve the quality of marginal training programs, for example, through consultative services provided by professional organizations such as the ABIM, the Association of Program Directors in Internal Medicine, and the Society of General Internal Medicine, seem more constructive than efforts to identify which programs to close. A realistic assessment of internal medicine's short- and long-term prospects, however, suggests that several strategies must be used simultaneously if the profession is to maintain its high standards. Downsizing promises to play an important role as internal medicine is reshaped. Acknowledgments: The authors thank Susan C. Day, MD and Judy A. Shea, PhD who provided valuable assistance in the preparation of this article. Grant Support: Dr. Asch was a Measey Foundation Faculty Fellow and a John A. Hartford Foundation Fellow when this work was completed. Requests for Reprints: David A. Asch, MD, Division of General Internal Medicine, 317 Ralston House, 3615 Chestnut Street, Philadelphia, PA 19104-2676. Current Author Addresses: Dr. icine, 317 Ralston House, 3615 2676. Dr. Ende: Division of General versity of Pennsylvania, 3400 4283.
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Asch: Division of General Internal MedChestnut Street, Philadelphia, PA 19104Internal Medicine, Hospital of the UniSpruce Street, Philadelphia, PA 19104-
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The Downsizing of Internal Medicine Residency Programs David A. Asch, MD, MBA, and Jack Ende, MD
• A variety of forces are converging to reduce the number of internal medicine residency positions offered in this country. This reduction, referred to as downsizing, has been proposed as the solution to several of the problems facing internal medicine. We examine the forces that underlie the current enthusiasm for downsizing; we consider the alternative strategies by which downsizing might be implemented; and we consider the implications of these alternatives on different groups of stakeholders. Although downsizing may represent a legitimate approach to real problems, any mechanism to reduce the number of training positions in internal medicine will have broad implications for medical education and patient care well into the next century. Special efforts must be taken to ensure that downsizing will not exacerbate the existing problems of overspecialization and limited access to care. Annals of Internal Medicine. 1992;117:839-844. From the University of Pennsylvania School of Medicine, Leonard Davis Institute of Health Economics, and the Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania. For current author addresses, see end of text.
lWithin the next few years the number of residency training positions in internal medicine will most likely be reduced. This reduction, referred to as downsizing, has been offered as the solution to several of the problems facing internal medicine. Whether or not these problems are real and whether or not downsizing will solve them, any reduction in the number of residency training positions in internal medicine will have a broad effect on medical education and care that will last well into the next century. We examine the forces that underlie the current enthusiasm for downsizing; we consider the alternative strategies by which downsizing might be implemented; and we consider the implications of these alternatives on different groups of stakeholders. We conclude with recommendations for those in a position to move the concept of downsizing into actual policy. The Declining Appeal of Internal Medicine Downsizing has been suggested as a way to overcome several concerns facing internal medicine. These concerns include a predicted oversupply of physicians; a service-driven system of graduate medical education; and the growth of specialization and the rising cost of medical care. Although these trends may support the
direction of downsizing, they are not the primary forces from which the pressure to downsize has emerged. The real and proximate cause of the current interest in downsizing is the recognition that careers in internal medicine are no longer as popular as they used to be. Before 1987, the number of internal medicine residency positions grew rapidly. During this period, many institutions found they needed more residents to satisfy their service needs and at the same time found that the cost of these residents was well subsidized by Medicare's favorable reimbursement system for the direct and indirect costs of graduate medical education (1-3). From 1978 to 1987, the total number of first-year categorical and primary care internal medicine residency positions increased nearly 20% from 4667 to 5578. The number of 3-year positions has declined slightly in more recent years. In 1992, 5141 3-year positions were offered. In contrast to the overall expansion in the number of residency slots, the number of graduating U.S. medical students filling those slots has dropped. In 1987, only 65% of these positions were filled by U.S. graduates. By this time, the year of the "black Tuesday" match day, it was clear to many how dire the situation really was (4). Those who dismissed the declining fill rates as a temporary disturbance were proved wrong by the steady decline in later years. By the 1992 resident match, only 57% of 3-year internal medicine residency positions were filled by U.S. graduates, the lowest level to date. At the same time, the percentage of offered positions filled by non-U.S. graduates increased from about 10% in 1978 to 29% in 1992. Increases in these non-U.S. graduates entering programs only partially offset the declining percentage of U.S. graduates entering programs, and so total fill rates have also fallen. Moreover, the distribution of U.S. graduates has favored some programs to the exclusion of others. In 1984, 64 of 413 internal medicine residency programs (15%) had no U.S. graduates. By 1992 that proportion rose to 34% (129 of 384). These trends represent symptoms of an underlying problem and are problems themselves. Although not all programs have experienced these declines, on the whole internal medicine residency positions have become less attractive. Several recent surveys of graduating medical students suggest that students continue to perceive a career in internal medicine to be intellectually challenging, but they also perceive these careers to be more stressful and demanding of time and effort, less personally satisfying, and less financially rewarding than other career options. Students also perceive internal medicine residency positions as easier to attain (5, 6). Perhaps of greater importance, the decrease in fill
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rates is coupled with the concern that the U.S. applicants who are attracted are of lower quality. A comparison of performance on items common to different American Board of Internal Medicine (ABIM) certifying examinations suggests a decline for graduates of U.S. schools (7). A casualty of these trends may be that internal medicine can no longer portray itself as the elite profession it once was. Whether or not these conclusions are correct, most would agree that it is a problem if, because of decreasing fill rates, internal medicine programs no longer attract the most promising students. Downsizing addresses these concerns by reducing the supply of internal medicine residency positions, thereby raising the standards for acceptable candidates. The response to internal medicine's declining appeal, however, has not been limited to calls for downsizing. Considerable effort by leading organizations has been directed toward expanding the pool of qualified applicants and increasing internal medicine's attractiveness both during and after training. Much of this effort is targeted toward increasing the number of qualified students who enter primary care fields such as general internal medicine. To the extent that these measures succeed, the pressures to downsize may relax. Meanwhile, however, downsizing represents one additional way to raise standards. Physician Supply Several studies have projected a physician surplus as we move into the next century (8, 9), and it seems logical that a reaction to these projections is a second potential source of support for downsizing. Despite this apparent logic, it is not clear whether the surplus many predict should play a major role in the pressures toward downsizing: first, because some projections suggest there will be no such surplus (10); second, because the manpower issue is more a question of distribution and access than a question of absolute numbers; and third, because the moves toward downsizing are occurring simultaneously with the widespread recognition that we need more primary care physicians, many of whom will be internists (11). Service-Education Dichotomy A third argument in support of downsizing is that the number of residency positions should be determined by the educational resources available for training and that this number is lower than the present number defined by hospital needs. In the past, the growth in the number of internal medicine residency positions has been driven by the service needs of hospitals. The recent resolution by the Federated Council for Internal Medicine (FCIM), echoed in the Residency Review Committee for Internal Medicine (RRC-IM) new Special Requirements, is intended to reorient the residency experience from service toward education. The resolution states that the primary objective for residency training is education; that in the past internal medicine residencies have satisfied their service needs by offering more positions than are appropriate for their educational resources; that hospitals should shift excess service needs to other 840
personnel; and that the RRC-IM should develop guidelines for the assessment of educational resources to define the maximum number of positions that each program can support (Federated Council for Internal Medicine Resolution, 21 May 1990). Obviously, residents both provide service and receive education. Perhaps in the past it was more easily accepted that education was received in the very act of providing service—that the two were inseparable. Recently, however, the perception is not only that service and education are distinct and separable but that the service-education dichotomy represents a tension that must be addressed. It is common to hear residents complain, ironically, that patients get in the way of their education (12). Education is not all that is at stake. In addition, residents are perhaps more willing now than in the past to recognize life-style, leisure, and other personal goals as legitimate competitors for their time. One reason for this tension may be that the service demands on internal medicine residents have increased, particularly as hospitals have seen residents as an elastic source of inexpensive labor. A related reason is that the services provided by residents may now be of less educational value. In a recent time study, Lurie and colleagues found that internal medicine residents on call spend little time in direct patient care and considerably more time engaged in clerical duties or doing procedures that could easily be performed by nonphysicians (13). Further, as much of the evaluation and management of medical patients moves to the outpatient setting, inpatient service requirements—which remain the bulk of the internal medicine residency experience— have become progressively menial. The recognition of education as the appropriate priority within the service-education tension supports the notion that internal medicine residency positions should be reduced from their service-driven number to a lower number driven by educational resources. The basis of this argument is the belief that there is a determinate limit to the number of residents that can be adequately trained. If each internal medicine resident needs 20 hours of small-group teaching a week, for example, then the number of residents each program can train is limited by the number of faculty available. If the service demands of the institution cannot be satisfied with that number of residents, then those demands must be satisfied outside of the training program. Linking program size with educational resources makes sense, although it makes more sense for residency programs in general surgery, for example, where residents need to be exposed to determined numbers of clinical cases, and these experiences cannot easily be shared. In internal medicine, different clinical settings provide educational resources that are somewhat expandable. The number of internal medicine residents who can share the experience of caring for a particular medical inpatient may be more elastic than the number of surgical residents who can share in a patient's surgery. The number of residents who can be assigned to an office-based ambulatory care experience is indeed limited, but additional practice sites can often be found. One-to-one attending supervision will always be a limited resource, but many of the other educational expe-
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riences of residency training are not so limited. And because so much of what internal medicine residents learn is learned from other residents, the educational resources of an institution are to a degree self-generating. Most important, however, although it makes sense to link program size to the available educational resources, this task will be exceedingly difficult until we know better how to measure teaching capacity and how teaching capacity relates to learning outcomes. Mechanisms for Downsizing Downsizing can be accomplished by one or more of the following means. The number of positions within existing programs can be reduced, whole programs can be eliminated, or trainees who previously were accommodated in programs can be barred. Each mechanism will probably have unique consequences. The first mechanism reduces the number of positions offered by each program. This mechanism might come about through the augmented structural requirements imposed on programs by the RRC-IM. These requirements specify what resources are necessary to satisfy the training needs of internal medicine residents. In theory, programs might reduce the number of positions they offer to ensure that they have sufficient educational resources for each resident. Alternatively, groups of small hospitals—perhaps even those that are in other senses competitors—might band together to offer more joint residency programs. In addition, small hospitals might increasingly seek affiliations with nearby academic medical centers so that residents from the larger institutions would rotate through the services of the smaller institution. Such arrangements might be perceived as a simple reduction in the number of residency programs when, in fact, the reality would be more complex. The ability of separate institutions to create these affiliations means that the distinction between a decrease in the number of programs and a decrease in the size of programs may be a false one. Many of the RRC-IM special requirements address overall program size, the availability of training programs in other specialties, and other factors related to the program as a whole rather than to the number of positions. Individual programs may face the all-or-none question of whether they can support a program at all, and the fates of training programs in diverse specialties are often linked (Larned FS, Gray PD, Hillman RS. The impact of changing ACGME general and specific requirements for residencies upon teaching hospitals. American Hospital Association, Atlanta, Georgia, April 1990). As such, downsizing may naturally occur by a reduction in the number of programs rather than by a reduction in their average size. Institutions might abandon their own residency program but still have residents rotating through their services. These rotating residents might satisfy many of the institution's interests by improving the institution's reputation, by attracting professional staff, and by helping to meet service needs. A second model (not exclusive of the first) would reduce the number of internal medicine residency positions by eliminating weak programs. These programs
might be identified by the success of their graduates on the ABIM certifying examination. Current RRC-IM special requirements suggest that, in aggregate, the graduates of an internal medicine residency program should achieve a floating 3-year pass rate of 50% on the certifying examination (14). John A. Benson, Jr., while ABIM president, supported this position and suggested that downsizing should be accomplished by eliminating these "marginal programs." Approximately 20% of existing programs can be classified as marginal by this standard (15). This criterion has many appealing characteristics. The 50% threshold has the virtues that it is determinate and at least intuitively reasonable. More rigorous quantitative techniques might suggest that the 50% threshold should be reset at a different level, but these techniques would require some agreement about what this threshold is expected to optimize. More important, perhaps, to the extent that achievement on the certifying examination is an accepted proxy for quality, this model links downsizing with at least one outcome that residency programs are expected to achieve. Internal medicine residency programs have other goals besides the production of board-certified internists, however. Calling a program "marginal" because its graduates fail to achieve a 50% 3-year pass rate seems to beg the question of what these goals are. Further, in some sense using the certifying examination to define marginal programs is double-counting. The certifying examination is used as a screen twice if it is the final step in defining a board-certified internist and also—by using aggregate pass rates—if it defines which trainees are entitled to take the examination in the first place. Because residency accreditation and eligibility to sit for the certifying examination are linked, the marginal program model double counts the certifying examination and uses an outcome measure where a structure or process measure might be better suited. Nevertheless, even though a low aggregate pass rate is not the underlying problem, it may signal that something in the program's ability to recruit or train residents is flawed. In fact, aggregate pass rates might best be used in combination with other measures of program quality assayed during RRC-IM review. The RRC-IM's rate of closing residency programs has been lower than the average in other specialties (16), but proposed changes in the special requirements promise to make review broader and more stringent. A third mechanism would focus on international medical graduates. A report from the Department of Manpower and Demographic Studies of the American Medical Association analyzed several manpower strategies specifically targeting the number of international medical graduates entering practice in this country (17). Taking its lead from this report, a recent Council on Graduate Medical Education discussion paper recommended limiting the number of training positions to the number of U.S. graduates plus a quota for international medical graduates (Physician Manpower Subcommittee. Discussion paper. Council on Graduate Medical Education, 29 October 1991). Although these suggestions ostensibly address the concern of physician oversupply, they represent alternative strategies for downsizing.
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Recognizing Different Stakeholders Whatever method is used to reduce the number of training positions, downsizing will have important secondary effects. The potential impact of downsizing will vary depending on one's perspective. Three groups of stakeholders need to be considered: hospitals (and programs within hospitals), vulnerable populations of patients, and prospective trainees. Hospitals and Teaching Programs For hospitals, the obvious challenge presented by downsizing is making do with fewer residents. If part of the service-education tension has resulted from an increase in service demands on residents, how are these needs to be met in the face of downsizing? This problem echoes the problem faced by residency programs in the wake of the Libby Zion case, particularly in New York where regulatory constraints on work hours prompted hospitals to restructure the clinical responsibilities of established physicians and hire additional staff to replace the lost resident labor (18). Such restructuring is expensive: One study suggests that the New York regulations will cost over $350 million annually in that state alone (19). As the number of internal medicine residents is reduced and, more generally, as the emphasis in residency training shifts from service to education, hospitals will have to identify alternative sources of clinical labor. Phlebotomists, intravenous team nurses, and other health professionals might be hired to assume some of the services previously performed by housestaff. There are compelling arguments for doing so anyway, because these professionals improve care (20), and they perform tasks that have little educational merit for physician trainees. In some teaching hospitals, patients felt to provide little educational value are admitted to wards where physicians' assistants substitute for residents. For non-critical care units the direct cost of this form of alternative coverage compares favorably with the cost of using resident physicians (21). Nevertheless, the financing of graduate medical education has been largely service-based. Hospitals with fewer residents will receive less Medicare support for medical education. For this reason, resident substitutes, perhaps better for other reasons, will probably cost hospitals more money. Institutions contemplating abandoning their programs—or forced to—will have to consider carefully the costs of replacing the services previously provided by residents. In fact, some have argued that hospitals do not really consume resources as they support graduate medical education, although the effect of residency programs on the financial performance of teaching hospitals seems to be favorable for large hospitals but unfavorable for small hospitals (22). Residents appear to provide services at a reduced rate—perhaps in exchange for the education and credentialing they receive (23)—but for smaller hospitals that are presumably less efficient at education, these services may not offset the costs associated with supporting a training program (24). As service and education disengage, however, what842
ever balance there is among residents, hospitals, and payers may change. In fact, the growing distinction between service and education enhances the notion that although the services provided by medical residents should be supported by payers, the education they receive need not be. Unless other stakeholders move in, residents will have to receive lower stipends, hospitals will have to provide uncompensated support for graduate medical education, or payers will have to increase their patient care reimbursement to reflect the fact that residents will no longer be providing the effort that in the past was subsidized in the name of graduate medical education. Burdens on hospital inpatient services may increase further if, as many hope, the financing of graduate medical education follows residents into the outpatient setting, where an increasing amount of their activity and education now takes place (25, 26). Large programs benefiting from economies of scale might find themselves able to provide sufficient educational resources to increase the number of residents. At the same time, if the defining criteria for internal medicine residency programs shifts from service to education, reimbursement for the direct and indirect costs of graduate medical education might shift from hospitals to medical schools or training programs. Hospitals may lose control of their programs to schools, and small hospitals might lose control to nearby academic medical centers. Vulnerable Populations Any plan to downsize internal medicine residency positions will also affect the patients that downsized hospitals serve. If small programs based in small hospitals are at greater risk because they find it difficult to support more structured educational requirements, patients serviced by those hospitals will see a change in their care. Services are likely to decrease not only because residents are no longer available to provide them, but also because residency programs are effective recruiting tools to attract other physicians and are themselves pools from which future staff physicians are often drawn. Unless downsizing is accompanied by successful efforts to direct internists into underserved areas, the already limited access of indigent patients is likely to be threatened further. Teaching hospitals provide a disproportionate share of indigent care (27). Indigent patients who in the past may have relied heavily on resident physicians for care will find these sources of care reduced. And as service previously relied on becomes less available for all patients, care for indigent patients is likely to be the first to go and the last to return. In fact, the care of vulnerable patient groups is threatened by many other forces in graduate medical education besides downsizing. Graduating seniors choose which programs to enter, and there is evidence that some avoid programs that, for example, offer heavy exposure to patients infected with the human immunodeficiency virus (28). These influences may threaten selected patient groups much more so than mandated changes in the overall number of residency positions. Efforts to direct internists to underserved areas should
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be stepped up in parallel with efforts to downsize so that we do not worsen our existing problems of access to care. Also potentially at odds with downsizing is the goal of increasing the number of internal medicine trainees who enter general internal medicine. A recent analysis of the inputs, process, and products of internal medicine training suggests that residents emerging from small hospitals with relatively few subspecialty fellowship programs are more likely to enter primary care (29). It is unclear whether this finding reflects the greater exposure to subspecialties that residents receive in large programs or that large programs preferentially attract medical school graduates who have already made the decision to subspecialize. The distinction may be important: If the former is the case and if small programs are more vulnerable to downsizing, then the profession must work even harder to direct internists into primary care. Trainees and Future Practitioners Trainees also will be affected, not only because of reductions in the number of training slots, but also because of changes in the training environment itself. Graduating medical students are looking for strong educational programs that will provide them with the best chances of achieving personal and career goals. For those graduates who obtain one of the more limited number of positions, downsizing is likely to be a step forward in this regard. Graduates also want tolerable working conditions and attractive salaries. The latter may be at issue should the balance between service and education shift so much that the traditional payment sources for graduate medical education no longer seem relevant to what residents actually do. If salaries are reduced as the service component of residency diminishes, moonlighting might become increasingly important for residents who need the extra money and hospitals who need the extra hands (30). Although moonlighting experiences might be structured to provide educational benefits, one might ask why they were separated to begin with. Graduating medical students who would have been offered an accredited residency position before downsizing but cannot obtain a position afterward lose out. These stakeholders may not engender much sympathy. To the extent that programs are able to judge quality, those not chosen ought to be applicants of lower quality. And if some system akin to the marginal-program model is used to downsize residency positions, those denied a position in an accredited residency training program would have been less likely to pass the certifying examination anyway. Weaker graduates may be vulnerable even if they obtain residency positions. Program directors, fearful that low pass rates will make their programs vulnerable, might find themselves in conflict with individual residents perceived as unlikely to pass. Current RRC-IM guidelines suggest that at least 75% of graduating residents in each internal medicine residency training program should take the ABIM certifying examination. Within these guidelines, directors might develop much
stricter criteria for deciding which graduating residents to support as candidates for the examination. At the same time, the way that downsizing is accomplished will have a profound effect on the perception and the reality of certification in internal medicine. There is no bright line that distinguishes certification standards designed to uphold professional quality and those designed as trade barriers to reduce competition. One's perception depends largely on which side of the fence one falls: Those excluded from certification are likely to perceive the impact of residency downsizing as an additional anti-competitive trade barrier. The substance of this distinction will depend on the validity of the assumption that it is better to have fewer internists of higher quality than more of lower quality. Even if the profession can demonstrate that downsizing in fact improves the quality of internists on the whole, it will face the criticism that perhaps this was a trade not worth making. Regional service needs might go unsatisfied with a smaller and more concentrated supply of more qualified internists. If this is so, then in addition to increasing the diffusion of internists, the profession might support efforts to facilitate other health professionals, such as nurse practitioners and physicians' assistants, to provide some of the care that has traditionally been provided by internists. Conclusions The pitfalls and promises of downsizing are sufficiently uncertain that there is an appeal to maintaining the status quo. Many arguments that might support downsizing are weak or of questionable basis. The physician manpower projections do not unanimously predict a surplus of physicians; in fact, many now believe we face a shortage of primary care physicians, many of whom are, or should be, internists. And although it is likely educational resources and physician training are somehow related, we have no sense yet how these resources should be structured or how much is enough. Given the potential for harm to vulnerable stakeholders, perhaps the most prudent policy is to wait and see and allow the supply and demand for each program determine its size. This free market approach, however, ignores the compelling fact that careers in internal medicine are less attractive now than in the past. This decline in internal medicine's appeal is challenging the profession's ability to maintain its standards. Historically, programs have swelled to their current size in response to increasing service needs in an era when qualified applicants were plentiful. This condition no longer obtains. If internal medicine is to maintain its standards, a program's size should not be governed by its service needs, but by the quality of the applicants it can attract and the quality of the training it can provide. Quality may prove to be a signpost as well as a goal. A strategy that limits the size of all programs will affect programs that are strong as well as those that are weak. Similarly, a strategy that limits access to training for certain groups of trainees may turn away many who are qualified. Attention should be trained on the programs whose quality is judged to be marginal.
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Identifying such programs will not be simple. Using a floating 3-year pass rate of 50% on the ABIM certifying examination is one way marginal programs might be identified, but there may be better, more specific methods to judge programs. The RRC-IM, through a series of proxy measures, attempts to assay educational quality as programs are reviewed. For the most part, these proxy measures are unsupported by data and open to question; thus, it might be tempting to delay action on marginal programs while awaiting data. These data are unlikely to be forthcoming, however, and internal medicine cannot abide programs of questionable quality indefinitely. Steps need to be taken now. At the same time, the profession must control the negative impact of downsizing on the individuals, institutions, and patient groups likely to be affected. Qualified applicants will be able to identify other sites for training, but solutions for hospitals denied their traditional sources of labor and patients denied their traditional sources of care may not be so easily obtained. Downsizing need not be implemented in a large scale at once. We propose that efforts to downsize be coupled with efforts to mitigate downsizing's negative effects. Such efforts should address several concerns. We must identify alternative ways for hospitals to meet their service needs. We must step up even further our efforts to direct physicians (and other clinicians) to underserved areas. We must develop more innovative health care delivery systems that rely less on house staff. The daunting nature of this list reflects the fact that the downsizing of internal medicine residency programs is a single strategy in the larger movement of health care reform. It is an important strategy and one that demonstrates the central role of graduate medical education, but downsizing is only one of many strategies. Efforts to improve the appeal of careers in internal medicine must continue unabated. Likewise, efforts to improve the quality of marginal training programs, for example, through consultative services provided by professional organizations such as the ABIM, the Association of Program Directors in Internal Medicine, and the Society of General Internal Medicine, seem more constructive than efforts to identify which programs to close. A realistic assessment of internal medicine's short- and long-term prospects, however, suggests that several strategies must be used simultaneously if the profession is to maintain its high standards. Downsizing promises to play an important role as internal medicine is reshaped. Acknowledgments: The authors thank Susan C. Day, MD and Judy A. Shea, PhD who provided valuable assistance in the preparation of this article. Grant Support: Dr. Asch was a Measey Foundation Faculty Fellow and a John A. Hartford Foundation Fellow when this work was completed. Requests for Reprints: David A. Asch, MD, Division of General Internal Medicine, 317 Ralston House, 3615 Chestnut Street, Philadelphia, PA 19104-2676. Current Author Addresses: Dr. icine, 317 Ralston House, 3615 2676. Dr. Ende: Division of General versity of Pennsylvania, 3400 4283.
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Asch: Division of General Internal MedChestnut Street, Philadelphia, PA 19104Internal Medicine, Hospital of the UniSpruce Street, Philadelphia, PA 19104-
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