Graduate Medical Education

New York Academy of Sciences

Speech at Conference October 1999 and printed NY Academy of Science's publication:

in MEDICAL EDUCATION MEETS THE MARKETPLACE

(published by the New York Academy of Sciences, 2000.)       http://www.nyas.org

Graduate Medical Education Expenditures and State Policy: The Importance of Speaking Clearly

THE HONORABLE KEMP HANNON

Chair, Health Committee
New York State Senate

 

The debate on funding for graduate medical education (GME) in New York State is longstanding. There is a gap in understanding between the medical education community and many other parts of society regarding the importance of GME support to the state and to the health of individual citizens.

In the debates, the most vocal critics often are to be found in the business community. Their impression is of medical institutions that have high costs—higher than in other states—and hence represent a drag on economic competitiveness, via both unnecessarily high tax rates and higher costs for employee benefits. But the misperceptions are not limited to the business community. My colleagues in Albany, the media, community leaders—nearly all express confusion about issues related to paying for medical education. What is it? How much does it cost? How do we pay for it? Why should we pay for it, especially since only half of the physicians trained in New York stay to practice in the state?

One of the central problems in developing support for GME funding at the state level is the complexity of the academic institutions themselves and the multidimensional role they play in the state. When decisions must be made between supporting things that are complex and vague and things that are (apparently) simple and straightforward, busy leaders (whether private or political) tend to support the latter. If you do not have an intuitively understandable case, you often do not have a politically supportable case.

If perceptions are to change, and if business, taxpayers, and elected officials are to become supportive of stabilized or even increased support for medical education, then academic medical leaders must speak more clearly. The case for GME must be simplified both in the nature of the data used to buttress the argument and in the nature of the presentation.

This should not be a difficult task. There are examples that have illuminated the importance of health care delivery for all to see. The nation, and the state, has faced significant public health crises in the past several years, including the persistent spread of asthma among children and the likely recurrence of encephalitis. The public’s awareness of the importance of health issues is high. In an environment shaped by these realities, the medical community of the academic health center should be able to develop a series of convincing arguments that highlight the importance of maintaining a steady stream of well-trained young physicians to serve the state's needs.

In addition, there is significant concern with the directions of managed care. Frequent changes in plans offered by employers and hence frequent changes in physicians for employees; restricted access to specialists; and increasing prescription premiums bring health care issues into every home. Also, physician dissatisfaction is apparent to many patients. Patients are deeply concerned over the implications for health care access and quality.

Moreover, there is concern over health care in some economic quarters that are of immediate relevance to academic institutions. Unions, for example, are deeply concerned over the question of access to health care of lower-income workers in urban areas. It is to just such a population that academic medical centers, and their graduate medical residents, provide health services. The interests of lower-income families will be compromised if the viability of academic medical centers erodes.

There is a case to be made for a robust GME capacity even within the current evolution of health care problems and systems. And it should be made by those directly involved in the academic institutions that conduct GME. But the case needs to be made clearly, simply, and with compelling data.

If we do not train our physicians well, we are not going to have good physicians. If we do not have a system of residencies, we will lack physicians in our urban hospitals, particularly in hospitals serving the poor. If we do not support research-based institutions, there will not be a next generation of medicines available to our children.

But such a case must also be made with clear and complete cost transparency. Academic medical leaders must know and understand the costs of their institutions and must ensure that efficiency is an organizational touchstone. Resource limitations are real. New York’s businesses are concerned about rising health care costs. The population is aging, and its use of health care will grow. The budget process, in Albany and in Washington, is very aware of these facts. The pressure for efficiency and cost constraint will continue. The case for GME and for academic medical centers must be made clearly, but it must be made within the resource realities.

Together, leaders in medicine, business, and politics must identify a moderate, collaborative course of action. We must not abandon the value we have created in New York State’s health system. We must build upon it in the interests of medicine, public health, business, ourselves, and our children.