Medical Center officials plan to trim the residency staff of the Hospital by 30 percent during the next four years.
Shifts in the health-care marketplace and anticipated cuts in federal funding for graduate medical education prompted the change, officials said. The Hospital currently supports 495 residents in its 11 clinical departments. Residents are medical school graduates who are apprenticed to doctors for anywhere from four to 10 years.
Teaching hospitals like Duke, which supports education and research in addition to providing care, have had difficulty competing with cost-focused managed-care companies and recovering costs from insurers. As the average number of days spent in the hospital has dropped in managed-care areas, the need for residents has also diminished because their main role is taking care of inpatients, said Dr. David Sabiston, chief of staff for the Hospital.
In addition, as cuts in Medicare--the federal program which supports health care for the elderly and graduate medical education--loom on the horizon, Medical Center officials have been lobbying Washington to look elsewhere to balance the nation's budget.
The chairs of the Hospital's departments made the decision unanimously in May and will be deciding during the coming months how the reductions will be distributed, said Dr. Mark Rogers, executive director and chief executive officer of the Hospital.
Rogers added that the chairs hope to implement the plan in the fall in order to know how it will affect next year's incoming residents.
Duke is not the only teaching hospital making such cuts, however.
Harvard's Massachusetts General Hospital and Brigham and Women's Hospital have already instituted a 5 percent reduction in each hospital's non-primary-care residency staff this year, said Carolyn Castel, director of corporate communications for Partners Health Care Systems, the company which oversees the two hospitals. Castel added that each hospital will cut back up to 10 percent next year.
Nationally, about 100,000 residency positions exist, said Dr. John Gienapp, executive director of the national Accreditation Council for Graduate Medical Education. He said this number may be cut back to 75,000 during the next several years.
"We are training more doctors in our country than most people think we need, particularly with [the emergence of] managed-care companies which take larger numbers of patients and require fewer doctors," Gienapp said.
It is difficult to predict how the market changes will affect the once-unquestioned job security of medical school graduates, he said. The impact will depend on where residency position cutbacks are made and how quickly managed care penetrates particular areas of the country.
One thing is certain, he said: "It will be increasingly difficult to get jobs in certain specialties where in the past there were high ratios of physician-to-population in the fee-for-service system."
In a managed-care system, primary-care providers act as gatekeepers in diagnosing problems and directing patients to a select number of specialists. As a result, managed care requires more primary-care physicians and fewer specialists than a fee-for-service system.
As cutbacks in residents seem likely nationally, those at Duke may prove particularly hazardous to the state's health. While North Carolina has enough specialists, it has a great shortage of primary-care providers, physician assistants and nurse practitioners, said June Milby, public information officer for the State Health Planning Commission. Further reductions in the number of primary-care providers trained can only hurt the state's citizens, she said.
Of the state's 100 counties, 62 suffer from significant shortages in primary-care physicians. Of these, 33 counties--all but one of them rural--are federally designated as Health Professional Shortage Areas. A county with a physician-to-population ratio of 1-to-3,500 or higher qualifies for this designation.
"In the past, residents have been directed to specialty areas. Hopefully we can get residents redirected [to primary-care fields]," Milby said.
Gienapp said that three years ago the medical education accreditation council supported training more primary-care providers relative to specialists to correct "the imbalance."
While the Hospital is famous for its specialty training, a growing percentage of the Medical School's graduates have been choosing to pursue work in primary-care fields in recent years. Rogers said he was not sure whether specialties would be more sharply affected in the cutbacks than primary-care areas.
Get The Chronicle straight to your inbox
Signup for our weekly newsletter. Cancel at any time.