When Path Switched From Being a 5 year program to a 4 year program

[pathstudent]

why weren't the slots cut by 20%? Has anyone ever seen an explanation for this?

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[yaah]

No. But there were a lot of programs who acted like 4 year training programs anyway - having some residents go elsewhere for the fifth year.

It is probably related to the fact that switching from 5 to 4 years is a pathology-related issue, whereas changing the number of training spots is an ACGME issue. Thus, too much paperwork, easier to keep the same number of spots because budgets were based on it, etc (basically laziness and lack of though).

 

[caffeinegirl]

Check out a recent article in this month's Archives:

http://arpa.allenpress.com/arpaonline/?request=get-document&doi=10.1043/1543-2165-133.9.1431

Basically confirms the prevalence of residents pursuing one and/or two fellowships after the shortening of residency training.

 

[exPCM]

Two main reasons why spots were not cut:
1. Money - the programs are paid for each filled spot by CMS to the tune of 100-150K per year (DME and IME) reimbursement per resident. If you cut slots you are cutting your CMS funding. CMS subtracts reimbursement for each unfilled spot and for each spot you cut.
2. Cheap Labor - programs want to preserve their cheap labor supply.

 

[pathstudent]

Check out a recent article in this month's Archives:

http://arpa.allenpress.com/arpaonline/?request=get-document&doi=10.1043/1543-2165-133.9.1431

Basically confirms the prevalence of residents pursuing one and/or two fellowships after the shortening of residency training.

But didn't residents do 1-2 fellowships before the shortening also.


But regardless of whether people are doing more fellowships now, there has to be a greater output of trainees. If a program had 20 spots to spread out over 5 years (4 trainees per year), now they can spread it out over 4 years (5 trainees per year). By shortening the length of AP/CP training, they may not have shortened the length of total years training but they increased the class size by 20%. So at this point there are 20% more people completing training every year, now that 5-6 years have gone by since they shortened it. Not trimming the programs by 20% was a serious lack of foresight by the ABP/ACGME or CMS or whoever.

 

[exPCM]

But didn't residents do 1-2 fellowships before the shortening also.


But regardless of whether people are doing more fellowships now, there has to be a greater output of trainees. If a program had 20 spots to spread out over 5 years (4 trainees per year), now they can spread it out over 4 years (5 trainees per year). By shortening the length of AP/CP training, they may not have shortened the length of total years training but they increased the class size by 20%. So at this point there are 20% more people completing training every year, now that 5-6 years have gone by since they shortened it. Not trimming the programs by 20% was a serious lack of foresight by the ABP/ACGME or CMS or whoever.

Yes, and I have mentioned this exact issue as a contributor to the crappy job market. Actually the math is slightly worse. Previously we had about 2300 residents spread over 5 years (460 per year). Now we have about 2300 residents spread over 4 years ( 575 per year) - this is actually a 25% PERCENT INCREASE.

Do not look at the match figures to determine how many people are going into path - you need to look at the ACGME resident counts. Pathology gives many spots outside the match so match numbers are misleading. Remember also that there are programs like Lennox Hill who do not participate in the match at all - see: http://www.lenoxhillhospital.org/residency_training.aspx?id=368

"All candidates must apply to the program using the AAMC (Association of American College) ERAS (Electrotonic Residency Application System) website. We do not participate in the NRMP, the "Match". Candidates must be graduates of approved medical schools in the United States or Canada. Foreign medical graduates must possess an ECFMG (Education Commission for Foreign Medical Graduates) certificate and valid visa by the July 1st start date of the residency training. Lenox Hill Hospital does not initially sponsor H1 visas."

The change from the 5 yr to 4 yr residency has made the job market much worse by increasing the output of residents. However it is great for the ABP since they get to collect more board exam fees.

 

[pathstudent]

Yes, and I have mentioned this exact issue as a contributor to the crappy job market. Actually the math is slightly worse. Previously we had about 2300 residents spread over 5 years (460 per year). Now we have about 2300 residents spread over 4 years ( 575 per year) - this is actually a 25% PERCENT INCREASE.

Do not look at the match figures to determine how many people are going into path - you need to look at the ACGME resident counts. Pathology gives many spots outside the match so match numbers are misleading. Remember also that there are programs like Lennox Hill who do not participate in the match at all - see: http://www.lenoxhillhospital.org/residency_training.aspx?id=368

"All candidates must apply to the program using the AAMC (Association of American College) ERAS (Electrotonic Residency Application System) website. We do not participate in the NRMP, the “Match”. Candidates must be graduates of approved medical schools in the United States or Canada. Foreign medical graduates must possess an ECFMG (Education Commission for Foreign Medical Graduates) certificate and valid visa by the July 1st start date of the residency training. Lenox Hill Hospital does not initially sponsor H1 visas."

The change from the 5 yr to 4 yr residency has made the job market much worse by increasing the output of residents. However it is great for the ABP since they get to collect more board exam fees.

Yes this is so true. Although the total time spent training by residents might not have changed due to the switch, the number of trainees per year has unequivocally increased.

 

[exPCM]

Yes this is so true. Although the total time spent training by residents might not have changed due to the switch, the number of trainees per year has unequivocally increased.

Many may not know that when path was 5 years the fifth year was AKA the "credentialing year". Medicare did not reimburse for the credentialing year and the programs had to pay for the 5th year residents out of pocket. So the big reason for putting all those 2300 residents into 4 years IMHO was in order to get Medicare reimbursement for all path residents. I think education was not the major factor behind the change but it was mainly about the money.

Dr. Bruce Alexander's 2001 article about Trends in Pathology Graduate Medical Education talked some about the longstanding concerns regarding the credentialing year funding.

 

[yaah]

Many may not know that when path was 5 years the fifth year was AKA the "credentialing year". Medicare did not reimbursement for the credentialing year and the programs had to pay for the 5th year residents out of pocket. So the big reason for putting all those 2300 residents into 4 years IMHO was in order to get Medicare reimbursement for all path residents. I think education was not the major factor behind the change but it was mainly about the money.

Dr. Bruce Alexander's 2001 article about Trends in Pathology Graduate Medical Education talked some about the longstanding concerns regarding the credentialing year funding.

If this is true then some of your logic and what has happened doesn't make much sense - if programs had 20 residents over 5 years, for example, but were only reimbursed for 16 (because the 4 5th year residents weren't reimbursed), then why would they suddenly get reimbursed for 20 when it was reduced to a 4 year program? Or did the loss of the 5th year happen to coincide with an increase in training slots?

 

[exPCM]

If this is true then some of your logic and what has happened doesn't make much sense - if programs had 20 residents over 5 years, for example, but were only reimbursed for 16 (because the 4 5th year residents weren't reimbursed), then why would they suddenly get reimbursed for 20 when it was reduced to a 4 year program? Or did the loss of the 5th year happen to coincide with an increase in training slots?

It is true and it makes perfect sense. Here is an excerpt from a previous Archives article.
The federal Medicare program that funds residencies covers only 4 years of pathology training. As a result, some programs (approximately 20%) do not even offer fifth-year positions, and only about 40% of programs guarantee a funded fifth-year position for residents whose performance has been satisfactory. A resident whose program does not fund the fifth year usually fulfills this requirement by finding a "fellowship" position at another program and in so doing faces uncertainty, an application process, and a move. (Note that although a fifth-year resident may be in a "fellowship" position, the ABP will give credit either for the credentialing year or for subspecialty training: no "double-dipping" is allowed. Thus, if John, a fifth-year resident, and Jane, a postresidency fellow, both do a year of cytology at an ABP-recognized program, only Jane will be eligible for board certification in cytology. John will have simply completed his residency.)
http://arpa.allenpress.com/arpaonli....1043/0003-9985(2000)124<0853:IEOPRP>2.0.CO;2

So the feds would only pay for 4 years: the solution was to make the residency 4 years. That way we can get all our slots reimbursed by the feds. Remember that the number of slots accredited is an ACGME issue and the funding is a federal issue. It all makes perfect sense. This whole process of shortening the residency eliminated programs having to pay out of pocket for 5th year residents. This rearrangement generally did not change the total number of residents at a given hospital since in your example there would still be 20 path residents (just 5/yr x 4 yrs instead of 4/yr x 5 yrs) - thus you did not have to "increase" total slots but just rearrange the slots.

I can not say more firmly that the graduate medical education system is driven by money ( these programs and hospitals are not Mother Teresas but they are driven by self interest in general ). .

Do you have any hard data to post on this?

 

[yaah]

Whoah there, I was just asking a question because it didn't make sense to me. Just because I ask a question doesn't mean I am arguing with you. Obviously I understand the fact that you can rearrange the total number of slots - that's basic math and is obvious. My question was about reimbursement and funding from the program's point of view, not from the resident's point of view. If I am understanding what you are saying correctly, the fifth year was a money sink where no one was paying programs for resident work. Is that right? Because if that was true, then reimbursed slots did not change and therefore should not have increased. It would make sense if programs had 20 ACGME approved slots, but only filled 16 of them each year, and now that they are all reimbursed they then fill those extra four slots. Is that true?

If the federal government was only paying for four years of training, then it still does not make sense. If programs were only training residents for four years then nothing has changed for the PROGRAM. If they were reimbursed for 20 residents then they were training 5 per year before, and training 5 per year after (because the fifth year did not exist at the program). I think most of us would agree that the less desirable training programs are often the ones that don't provide any fellowships, work their residents as glorified PAs, etc. So how have the new rules changed things at all for these programs? Have spots increased at these programs? And if so, how?

Do you understand my point? You are saying that before the change, only four years were funded. Currently, four years are funded. But residency spots have increased. Does not compute. It makes sense for programs that did provide fifth years, because now they can shift these spots to residency slots and create new "fellowship" spots. But these programs are not the whole story (as you said above, at least 20% of programs did not provide fifth year spots anyway). I always just assumed the fifth year was paid for, and it made sense to me that residency spots increased even if I didn't agree with it.

 

[exPCM]

Whoah there, I was just asking a question because it didn't make sense to me. Just because I ask a question doesn't mean I am arguing with you. Obviously I understand the fact that you can rearrange the total number of slots - that's basic math and is obvious. My question was about reimbursement and funding from the program's point of view, not from the resident's point of view. If I am understanding what you are saying correctly, the fifth year was a money sink where no one was paying programs for resident work. Is that right? Because if that was true, then reimbursed slots did not change and therefore should not have increased. It would make sense if programs had 20 ACGME approved slots, but only filled 16 of them each year, and now that they are all reimbursed they then fill those extra four slots. Is that true?

If the federal government was only paying for four years of training, then it still does not make sense. If programs were only training residents for four years then nothing has changed for the PROGRAM. If they were reimbursed for 20 residents then they were training 5 per year before, and training 5 per year after (because the fifth year did not exist at the program). I think most of us would agree that the less desirable training programs are often the ones that don't provide any fellowships, work their residents as glorified PAs, etc. So how have the new rules changed things at all for these programs? Have spots increased at these programs? And if so, how?

Do you understand my point? You are saying that before the change, only four years were funded. Currently, four years are funded. But residency spots have increased. Does not compute. It makes sense for programs that did provide fifth years, because now they can shift these spots to residency slots and create new "fellowship" spots. But these programs are not the whole story (as you said above, at least 20% of programs did not provide fifth year spots anyway).

You are still confusing ACGME approval of slots and Medicare funding. As I posted above 20 slots is still 20 slots - they are now just crammed into 4 years instead of five. Now however the 20 slots are all funded slots (20 funded PGY1-4 instead of 16 funded PGY1-4 and 4 unfunded PGY-5) - the unfunded 5th years were eliminated. What do you mean with this "what you are saying" stuff - I am not just saying it - I referenced an Archives article that discusses this issue. I do not see the source of confusion. Now the programs have funded slots but the total number of slots in the example is the same at 20.
CMS probably liked the older system better since they did not have to pay for the 5th years.
The only programs where the change to 4 years had little impact is at those 20% of programs that did not offer a 5th year - since they would have had their 20 residents packed in 4 years both now and before the change. However those programs are in the minority and are generally low tier programs. Not offering a 5th year was a competitive disadvantage in recruiting residents when a 5th year was still required.

From the ACGME website:
ACGME approves the maximum number of residents per program, in the aggregate, and not per year, for residency programs in the specialty and subspecialties of internal medicine, neurology, psychiatry, medical genetics, dermatology, pathology (except neuropathology), radiation oncology, preventive medicine, diagnostic radiology, and transitional year.
http://www.acgme.org/adspublic/

 

[yaah]

No, I am not confusing the two (at least in my mind, maybe not explaining it well). What I am still wondering about is what changed at the substandard programs. Has anything changed? Are these programs training more residents now because they are filling spots that previously they did not try to fill? Because if they were jettisoning residents after four years but approved for five years worth of slots, then they weren't filling all their spots. And now they can. So are they?

Because from my perspective, good programs are adding residency slots both because of the 5 to 4 year switch and because they are getting approved for even more slots (because of specimen growth, etc). But the good programs are not really the main problem. What I still don't understand is how ACGME works and how they approve # of spots at each program. If they were approving spots beforehand based on the 5 year length of pathology training, then they should be reducing slots after the switch, but they are not. I figure many in ACGME probably still thought pathology trainees were doing a medical/surgical internship, however And if big programs are truly expanding, why not remove spots from lesser quality programs and shift them to the bigger programs?

 

[exPCM]

No, I am not confusing the two (at least in my mind, maybe not explaining it well). What I am still wondering about is what changed at the substandard programs. Has anything changed? Are these programs training more residents now because they are filling spots that previously they did not try to fill? Because if they were jettisoning residents after four years but approved for five years worth of slots, then they weren't filling all their spots. And now they can. So are they?

Because from my perspective, good programs are adding residency slots both because of the 5 to 4 year switch and because they are getting approved for even more slots (because of specimen growth, etc). But the good programs are not really the main problem. What I still don't understand is how ACGME works and how they approve # of spots at each program. If they were approving spots beforehand based on the 5 year length of pathology training, then they should be reducing slots after the switch, but they are not. I figure many in ACGME probably still thought pathology trainees were doing a medical/surgical internship, however And if big programs are truly expanding, why not remove spots from lesser quality programs and shift them to the bigger programs?

From the ACGME website:
ACGME approves the maximum number of residents per program, in the aggregate, and not per year, for residency programs in the specialty and subspecialties of internal medicine, neurology, psychiatry, medical genetics, dermatology, pathology (except neuropathology), radiation oncology, preventive medicine, diagnostic radiology, and transitional year.
http://www.acgme.org/adspublic/

Yes, I think you are confused at how ACGME approves the spots - it is total spots that are approved.

"Because if they were jettisoning residents after four years but approved for five years worth of slots, then they weren't filling all their spots. And now they can. So are they?"

Again - this statement is not correct. They were never approved for "five years worth of slots" they were approved for a total aggregate number of slots (in our example 20).

And as pathstudent has pointed out we have seen a major increase in the number of residents finishing training per year as a result of the switch to 4 years since the programs are just cramming the same 20 residents into 4 years instead of 5.

Anyhow, I wish you a Happy Labor Day.

P.S. The fact that the aggregate number is what the ACGME approves IMO leads to situations like at the BU path residency where they currently have posted on their website a program with 1 PGY-4 resident, 0 Pgy-3 residents, 6 PGY-2 residents, and 4 PGY-1 residents.
http://www.bumc.bu.edu/busm-pathology/residency-program/resident-profiles/

I think it would be great to see the number of path resident spots cut due to the dismal job market but programs will generally not cut their spots and lose CMS money voluntarily and the ACGME can not force programs to cut spots without some reason. There was some hope that programs would have to cut spots when autopsy numbers went down at programs but instead the ACGME Pathology RRC just reduced the required number of autopsies during residency and the ABP followed suit.

"In fact, the required number of autopsies for board qualification was 75 a few years ago, but the number was reduced to 50 because of insufficient autopsy rates in many training institutions. It is now permissible for two pathology residents to share in the performance of an autopsy for the purpose of board qualification, another adjustment necessitated by low autopsy rates."
http://www.cdc.gov/nchs/data/series/sr_03/sr03_032.pdf

I disagree with the statement that the cut in numbers for board certification was "necessitated" or absolutely necessary - an equally valid fix would have been to cut the number of residents. However who would expect programs to cut back on their resident cash cows. Again it is not about education - why did people need 75 before and only 50 now if it was deemed an essential part of the education for a resident to perform at least 75 autopsies.

 

[2121115]

At my program there is often much complaining from the faculty that we don't have enough residents to cover all the service work (astoundingly though, community practice pathologists get the same amount of work done, or more, without any residents at all). As far as I can tell, the belief in academics is that we aren't training enough pathologists. I recently asked about the inconsistency in the number of residents finishing training every year in our state vs the number of good jobs the response was basically "umm, well, even if that is a problem, it isn't our program that is the issue. obviously we deserve to have the spots and those other programs should reduce their spots". I think that the number of residency spots is like a badge of honor or something and to an academic decreasing residency spots is like admitting that your program is weak.

 

[Arctic Char]

I personally spoke with Dr Ronald Weinstein, former president of USCAP, about the 4-5 year change. according to him, it was his idea (along with others), and it was inspired by the recognition that information was getting easier for path residents to obtain. i.e. he noticed that with the advent of the internet, path residents were learning in 4 years what historically had taken a lot longer.

this is his rationale, and it was his baby.

 

[exPCM]

I personally spoke with Dr Ronald Weinstein, former president of USCAP, about the 4-5 year change. according to him, it was his idea (along with others), and it was inspired by the recognition that information was getting easier for path residents to obtain. i.e. he noticed that with the advent of the internet, path residents were learning in 4 years what historically had taken a lot longer.

this is his rationale, and it was his baby.

Do you really believe this was the primary motivation?
I personally don't believe this spin any more than I believe the current USCAP president's spin on the job market.
If pathology can really be learned on the internet then how about having the programs let residents stay at home and just surf and learn. Sounds great.

Here is a quote from a Dr. Weinstein article
"A majority of Pathology department chairs are of the opinion that: (1) the fifth year requirement is unnecessary; (2) the extra year cannot be cost-justified; (3) the additional year may significantly reduce the pool of United States graduates for residency positions; and (4) the year adds significantly to the indebtedness of many residents. On the other hand, some chairs and program directors feel that the additional year is justified by the increasing complexity of the field and the benefits of additional clinical exposure during pathology residency training."
See reference: http://linkinghub.elsevier.com/retrieve/pii/S0046-8177(01)76413-1

 

[Arctic Char]

Do you really believe this was the primary motivation?
I personally don't believe this spin any more than I believe the current USCAP president's spin on the job market.
If pathology can really be learned on the internet then how about having the programs let residents stay at home and just surf and learn. Sounds great.

Here is a quote from a Dr. Weinstein article
"A majority of Pathology department chairs are of the opinion that: (1) the fifth year requirement is unnecessary; (2) the extra year cannot be cost-justified; (3) the additional year may significantly reduce the pool of United States graduates for residency positions; and (4) the year adds significantly to the indebtedness of many residents. On the other hand, some chairs and program directors feel that the additional year is justified by the increasing complexity of the field and the benefits of additional clinical exposure during pathology residency training."
See reference: http://linkinghub.elsevier.com/retrieve/pii/S0046-8177(01)76413-1

i read that article too. thanks for posting it. i'm not suggesting a belief or disbelief in any proposed rationales, just repeating what the horse said, nothing more.

 

[exPCM]

i read that article too. thanks for posting it. i'm not suggesting a belief or disbelief in any proposed rationales, just repeating what the horse said, nothing more.

Well it is interesting to hear what the USCAP horse told you.
IMHO we have had too many in pathology leadership positions who were more interested in propaganda than truth. Hopefully that will start to change after the current CAP elections.

 

[gbwillner]

Yes, and I have mentioned this exact issue as a contributor to the crappy job market. Actually the math is slightly worse. Previously we had about 2300 residents spread over 5 years (460 per year). Now we have about 2300 residents spread over 4 years ( 575 per year) - this is actually a 25% PERCENT INCREASE.

I may be ******ed, because I just don't understand this math. If 500 residents are choose pathology every year, and, let's assume, that number has been stable since before the switch, how is it that we have 20-25% more residents graduating every year?

I understand how there was effectively a doubling of the graduating residents the YEAR OF THE SWITCH, but since then I don't understand how there have been more residents coming out of the system since the same number are going in (roughly)... Don't we now still have about 500 graduating every year? Yeah, training is 20% shorter... but that extra year people are practicing (in theory) would be diluted over the total number of practicing pathologists and not resident classes. I don't mean to sound obtuse but everyone seems to be sold on this number and I just don't understand it.

 

[djmd]

I may be ******ed, because I just don't understand this math. If 500 residents are choose pathology every year, and, let's assume, that number has been stable since before the switch, how is it that we have 20-25% more residents graduating every year?

This issue is the number of spots offered has nothing to do with anything EXCEPT the number of total slots a program is accredited for.

So before a program that was accredited for 20 total residents took 4 per year (for 5 years). Now they take 5 per year for 4 years.

So the double class year was the least of the problems. Painful to the people directly involved in it, but the market would eventually smooth that out... However, now with the numbers shift we produce an extra 1/4 a class every year... Not going to help the oversupply problem in the least

 

[Adrian Cocot]

I personally spoke with Dr Ronald Weinstein, former president of USCAP, about the 4-5 year change. according to him, it was his idea (along with others), and it was inspired by the recognition that information was getting easier for path residents to obtain. i.e. he noticed that with the advent of the internet, path residents were learning in 4 years what historically had taken a lot longer.

this is his rationale, and it was his baby.

Hurm. I was a PSF when the change was finalized, and the official line I heard at the time was that there weren't enough American grads going into path because of the 5 years of training, and by shortening the residency it would make the specialty more attractive. Unofficially, it was about getting rid of the fifth, unfunded year.

It's the first I've ever heard of an intarwebs theory, and it doesn't sound very credible, either.

 

[Arctic Char]

Hurm. I was a PSF when the change was finalized, and the official line I heard at the time was that there weren't enough American grads going into path because of the 5 years of training, and by shortening the residency it would make the specialty more attractive. Unofficially, it was about getting rid of the fifth, unfunded year.

It's the first I've ever heard of an intarwebs theory, and it doesn't sound very credible, either.

Ok.

 

[lipomas]

I really don't buy this whole "cheap labor" argument. Our group does not have residents, even though we could, because it would be a drain on our practice and be more inefficient. We have PAs who gross and who we pay, they are far far cheaper than having residents who you have to train, and who can't gross all day. Maybe residents are cheap labor at the bottom 10-20% of programs that have no business training residents, but these programs are not the ones making policy. Residents are expensive to have, both in the sense of money (their benefits, their books, their offices, their bull**** that they whine about) and in time.

As far as it being a revenue source in general, I agree with that though. The people who see this revenue source are department chairs and administrators, who are also the ones who ask for more residents. They tend not to care about cheap labor because they don't directly oversee the labs. They care about the bottom line and their department reputation and potential for growth. I really don't think that money is the primary motivator though. I think it has to do more with prestige and recruiting research money. The more residents you can have, the more you can spread them out, the more research residents you can recruit, etc etc. So let's not make it all about money. That's the easy response, but it isn't necessarily true.

 

[djmd]

I really don't buy this whole "cheap labor" argument. Our group does not have residents, even though we could, because it would be a drain on our practice and be more inefficient.

While I buy that, once your program has been a residency program, the first tipping point has been crossed.. after that having more residents is better than having fewer... from both the cheap labor and the funding arguments...

Part of the reason why few programs ever decrease the number of spots they allowed for..