• Blue Cross and Blue Shield of Maryland have instituted a “SelectCare" program that directs patients to hospitals that charge less, thus bypassing some hospitals where costs are boosted by education expenses.

Employers seeking to control costs of health benefits are inducing employees to get their care from low-bid providers, which constitutes a refusal to pay the costs of education.

The Issue of Size

The size of graduate medical education programs has been determined largely by the demands of newly-graduated medical students and the service needs of teaching hospitals. Individual institutions, either hospitals or medical schools, have not taken responsibility for producing the amounts and types of physicians to match the nation's medical manpower needs (Tarlov, 1983).

Some observers are predicting an oversupply of physicians in the United States before the turn of the century, but projections that were stated in firm numbers hardly more than a year ago now are couched in less certain terms. Reasons for uncertainty include a shrinking number of students enrolling in medical schools, which will mean fewer new M.D.s seeking residencies a few years from now.

In any event, the planners of graduate medical education programs in the future will have to take into account not only the costs of those programs but also the obligations that will result from the number of physicians trained.

The Issue of Control

The size and design of graduate inedical education programs are influenced, to a greater or lesser extent, by many agents, as was described in detail earlier: the Accreditation Council on Graduate Medical Education and its five parent organizations, 24 residency review committees, 23 specialty boards, 24 specialty societies, hospital directors, medical school deans, program directors, training directors, faculty and house staff.

Some of these can be grouped coherently, as shown in Figure 1. The ACGME and the RRCs, for instance, are responsible for accrediting residency programs, whose size and operating characteristics are affected by the hierarchy of people in the teaching hospital, from director to house officer. Playing in a separate ring are the specialty boards, which set up educational criteria for certification of physicians and do the certifying, but have little say in the rest of the action. In yet another ring are the specialty societies, some of which nominate members to some RRCs and some specialty boards-and some of which do not. The main interest of the specialty societies is that graduate medical education produce highly skilled physicians.

The lack of dependable and constructive relationships among the players in the three rings is readily apparent. But something else is missing: None of the players is in the chain of funding for graduate medical education. This funding is anchored in the reimbursement of teaching hospitals for patient care. The teaching hospitals have the responsibility of providing graduate education but have little influence on the decisions made elsewhere in the system that determine costs.

Two problems arise when separate players can make decisions independently of each other and apart from considerations of funding. One is that,

if the players disagree, there is no built-in mechanism to settle their differences. The other is that decisions about program or certification can be made without knowledge of their costs to the teaching hospital.

An example of the first problem is the recent decision of the American Board of Pathology to increase from four to five years the training required for certification. The board acted in the belief that knowledge in the discipline had greatly expanded and that longer training was necessary. However, members of the pathology RRC and many academic pathologists disagreed with the decision or objected that it was made without consulting them. At this writing, the RRC has not changed its accreditation requirements to conform with the board decision, and some program directors have declared that they will not offer the fifth year that the board now requires for certification.

Unilateral changes in training requirements by specialty boards are not novel-14 boards have made such changes since 1976-—but they introduce dispute into a system that cannot be certain of accomplishing reconciliation. When specialty boards flex their autonomy in establishing educational standards, something else has to give way. The RRCs ostensibly are independent bodies, operating with the authority delegated by the ACGME, an authority that includes rights to disapprove changes in the length or content of training programs. But seldom has the ACGME or an RRC gone against edicts of a specialty board.

The second problem inherent in the current disjointed systein of control also can be illustrated by the pathology situation. The added fifth year of training in pathology has been estimated to pose an added cost of $21.3 million nationwide (Colloton, 1983). In simpler days, a decision to extend a training program would mostly affect the residents in that program.

Today, however, the impact of such a decision is pervasive in the teaching hospital. Hospital directors must decide whether to increase financial support for the program, to reduce the size of the program and offset the cost of its greater length, or to discontinue one or another program altogether. The one thing the hospital director cannot do is passively accept decisions that require more funding for education, when payers for medical care already are questioning the high expense of teaching hospitals. It is increasingly likely that a hospital director today would have to drop entire educational programs in order to become more price competitive.

The Issue of
Program Content

The medical service rendered during residency training and the required educational experience have never been a perfect fit. What the hospital needs from the resident in the way of patient care is not congruent with the content of an ideal training program. A long-standing incongruency, for example, exists in the commitment of many academic health center hospitals to provide graduate medical education in every specialty, although a hospital seldom needs such a depth of service in every specialty. The result of this lack of fit is inefficiency.

Basic differences in aims between service and education are now being overlaid with new disparities as the means and functions of hospital care change because of cost considerations and technologic advances. A few examples make the point.

Shorter Hospitalizations. Both financial pressures and changes in clinical practice are reducing hospital length-of-stay. Some of the consequences are greater patient turnover, more admission work-ups, and more