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Not Enough Doctors Or Not Enough Teaching Hospitals?

Traditionally, medical schools could count on relationships with public hospitals to provide a vast number of uninsured or Medicaid patients, who would be treated by residents and medical students, under the supervision of fully qualified physicians. But, the supply of low-income patients available for medical education is drying up. No one in the profession much likes to admit it, but in many big-city hospitals today the best place to find med students and residents is the lounge or the nurses’ station, not the patients’ ward.

University of Colorado Hospital remains one of the few.

Why is this happening? One reason is that the notion of using poor patients as guinea pigs for med students has come under attack from legislators and physicians who increasingly realize that everyone is entitled to the same level of care regardless of income. But an even more important factor is the continuing revolution in health-care economics. Thanks to changes in Medicaid funding and to hospital cost-cutting efforts emphasizing treatment on an outpatient basis, many indigent patients who were once considered prime candidates for treatment by medical apprentices are now being signed up by health plans that pay health-care providers at least as much, if not more, than other third-party insurance payers.

Private insurers, such as New York’s HIP, have realized that they can provide health care to Medicaid patients at a tiny fraction of the government’s cost–and pocket the difference. Thus, Medicaid patients, once the unwashed castoffs of the health-care system, have become a hot commodity for health plans and hospitals, to the point where one plan recently was penalized for recruiting more patients than it could provide care for. The trend will probably accelerate now that the federal authorities have allowed New York State to start mandated managed care for 2.4 million Medicaid patients, most of whom live in New York City.

That will mean a significant blurring of the formerly clear distinction between “public” and “private” patients, and a drop in the number of patients available to serve as teaching cases for students and residents–especially in New York, which trains a disproportionate 15 percent of the nation’s residents. Formerly undesirable Medicaid patients are now considered lucrative private patients, and many faculty physicians now keep their residents and students as far away from them as possible. (I was recently kicked out of a delivery room by such a physician.) As a result, the number of cases in which doctors-in-training can really get involved is dwindling.

Compounding the problem is the fact that patients are perfectly happy to allow physician assistants (PAs) and nurse practitioners (NPs), rather than doctors, to perform procedures and take part in medical decision-making. An ad running in many New York newspapers and magazines touts the expertise of the Columbia Advanced Practice Nurse Associates, “a new choice in primary care”–never mind that the ad features what appears to be a fake x-ray of a broken bone. PAs and NPs get paid less than doctors, largely because their training and education is far more superficial than that of doctors. But they deliver babies, write medication orders, and manage their own patients, all with the full support of the law, and of managed-care companies, who see them as cheap medical labor.

The solution to this “volume shortage” facing medical education is not to prohibit private health plans from enrolling Medicaid patients, although this practice ought to be carefully regulated. The solution is for all patients, rich and poor, and all health-care providers, at every stage of training, to acknowledge everyone’s obligation to all patients, present and future. Insured–that is, higher-income–patients at the most private of hospitals should not consider themselves above being examined by a resident, any more than uninsured patients at Bellevue Hospital should consider themselves guinea pigs for medical students and residents.

Physicians who have admitting privileges at private teaching hospitals should explain that medical students and residents are crucial members of the health-care team–especially because it is often the student who actually has the most time to listen to the patient. This role should extend also to outpatient visits, where the focus of medical education should shift to reflect changes in medical practice wrought by managed care. Denying medical trainees the experience they need will only hurt all patients, rich and poor, in the future.

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