Why do you have to do 3 years of IM before you can even subspecialize?

[Lord_Vader]

I get that internal medicine is the basis of all medicine subspecialities but shouldn't doing just 1 year of internship be enough before you subspecialize? If anesthesiology and radiology can do it, why can't we? And for the most part as an internist you're pretty much consulting other services anyway when someone shows up with something interesting (or even routine like CHF) and you're left managing the boring stuff like pain meds, social work, disposition and meds for their chronic conditions like COPD, diabetes, and HTN. All of the interesting conditions and actual treatment tend to be managed by subspecialists. And many of the patients are repeat offenders that keep coming back for the same problem even though you tell them how to take their meds and how to change their lifestyle. So why do we have to do 3 years of boring micro management and then dealing with tons of paperwork before we can actually start treating patients as fellows in cardiology, oncology, etc.?

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[W19]

I think there should be a 2+3 pathway for people who will sub-specialize instead of a whole 3 years IM...

 

[niblet]

Those other specialties would be subspecialties of IM if they required background as an internist like, well, the actual IM subspecialties do. But they don't.

Your description of an IM residency is exaggerated. Those are the commonly talked about downsides and, while they're pretty true, there's a bit more to IM than that; and an IM residency isn't all general wards anyway.

Yeah there probably exists a more efficient way to train IM subspecialists than through the current system, but whatever that way is, it's still gonna require more IM training than a radiologist or anesthesiologist will need.

 

[Tenk]

Because people would die.

 

[Raryn]

I get that internal medicine is the basis of all medicine subspecialities but shouldn't doing just 1 year of internship be enough before you subspecialize? If anesthesiology and radiology can do it, why can't we? And for the most part as an internist you're pretty much consulting other services anyway when someone shows up with something interesting (or even routine like CHF) and you're left managing the boring stuff like pain meds, social work, disposition and meds for their chronic conditions like COPD, diabetes, and HTN. All of the interesting conditions and actual treatment tend to be managed by subspecialists. And many of the patients are repeat offenders that keep coming back for the same problem even though you tell them how to take their meds and how to change their lifestyle. So why do we have to do 3 years of boring micro management and then dealing with tons of paperwork before we can actually start treating patients as fellows in cardiology, oncology, etc.?

Because there are organs other than the heart, and people smarter than you have decided you should know about them before you can make your $500k a year cathing people.

Just because you've never worked with a decent internist doesn't mean that it's useless trying to become one.

 

[Voodoo Chile]

For the same reason future radiologists are expected to do one year of prelim med/surgery:

slave labor.

 

[Crayola227]

very bird's eye view given this is a *medical* student declaring how much training is needed to be a competent attending.....

You gotta have a grip on the whole body before you focus in. Just because you've decided to become extra expert at, say, the lungs, doesn't mean you don't need the whole host of experience you gained from your 3 years with the whole body

Intern year is a totally different ballgame. A lot of people don't really feel like the world stops spinning and they pick up medicine and making more complex decisions until halfway through the year. PGY2 the first part of the year is a lot of learning AND for the first time you're supervising. Before someone says that supervising someone else's medical decision-making and leadership is only a thing if you're in academia with a residency, no. Especially if you subspecialize you always will be watching what the primary is doing and adjusting what you do, not to mention midlevels.

Lastly, PGY3 goes different ways for different folks. Some people have said by the time they hit PGY3 they're already essentially functioning at the level of attending, and the year is redundant. Good for them, I guess. I still see some value in them having a year operating at that level with someone watching.

Others, don't feel that they make that stride until later in the year. In which case, 1 year shorter wouldn't be awesome.

Others graduate an IM program and feel *barely* prepared to be practicing independently. Now, do you need to graduate feeling a fully fledged internist before being prepared for fellowship??

I've heard more from fellows saying that fellowship is challenging in a whole different way that IM didn't prepare them for. But, that doesn't really tell us the value of IM training. Other fellows have told me how glad they are to be essentially attending-level in gen IM before working on the organ system of their choice.

Also, your genius plan doesn't really take into account that matching to fellowship isn't a given, and if you don't complete 3 years in IM.... what you going to do? can't be BC. If you go with a general license which only requires a year... after you've done two.... that's not a great plan for competency either.

Also, some people (hopefully not the OP) hit a block and consult, and that's it for them. A good internist learns from their consultants. You're never going to stop needing consults, but their complexity should increase to a certain point over time.

TLDR:
It's very easy outside the specialty to declare what experience is needed, and be wrong
Each year of IM residency has its own flavor for what experience is gained
Some people, some specialties, may declare they had more IM than necessary
That doesn't seem to be the norm
How do we figure out who needs *less* training in an atmosphere where people feel like more is more??
Good internists know their limits, they also learn from their consults

 

[WheezyBaby]

Because there are organs other than the heart, and people smarter than you have decided you should know about them before you can make your $500k a year cathing people.

Just because you've never worked with a decent internist doesn't mean that it's useless trying to become one.

Have you informed cardiology of this??

 

[Raryn]

As an IM resident I agree completely with this and I'm not kidding. I don't see why there cannot be an intern year and then jump into these specialties. Will the first year fellow be weaker than someone who did 3 years of IM first? Yea absolutely but by the 6 month mark I don't see why after several 80 hour weeks you would not get the knowledge and training to do what you need to do within your specialty. I absolutely agree that they need the labor. It should be one year IM + 3-4 years of the specialty

There does exist a "fast-track" where you can do 2 years of IM and then your subspeciality. It typically makes the fellowship at least 2 years longer with significant research requirements (i.e. it's a research track) that take more time than you save, but if you hate IM residency that much...

 

[Lawpy]

Because there are organs other than the heart, and people smarter than you have decided you should know about them before you can make your $500k a year cathing people.

Just because you've never worked with a decent internist doesn't mean that it's useless trying to become one.

very bird's eye view given this is a *medical* student declaring how much training is needed to be a competent attending.....

You gotta have a grip on the whole body before you focus in. Just because you've decided to become extra expert at, say, the lungs, doesn't mean you don't need the whole host of experience you gained from your 3 years with the whole body

Intern year is a totally different ballgame. A lot of people don't really feel like the world stops spinning and they pick up medicine and making more complex decisions until halfway through the year. PGY2 the first part of the year is a lot of learning AND for the first time you're supervising. Before someone says that supervising someone else's medical decision-making and leadership is only a thing if you're in academia with a residency, no. Especially if you subspecialize you always will be watching what the primary is doing and adjusting what you do, not to mention midlevels.

Lastly, PGY3 goes different ways for different folks. Some people have said by the time they hit PGY3 they're already essentially functioning at the level of attending, and the year is redundant. Good for them, I guess. I still see some value in them having a year operating at that level with someone watching.

Others, don't feel that they make that stride until later in the year. In which case, 1 year shorter wouldn't be awesome.

Others graduate an IM program and feel *barely* prepared to be practicing independently. Now, do you need to graduate feeling a fully fledged internist before being prepared for fellowship??

I've heard more from fellows saying that fellowship is challenging in a whole different way that IM didn't prepare them for. But, that doesn't really tell us the value of IM training. Other fellows have told me how glad they are to be essentially attending-level in gen IM before working on the organ system of their choice.

Also, your genius plan doesn't really take into account that matching to fellowship isn't a given, and if you don't complete 3 years in IM.... what you going to do? can't be BC. If you go with a general license which only requires a year... after you've done two.... that's not a great plan for competency either.

Also, some people (hopefully not the OP) hit a block and consult, and that's it for them. A good internist learns from their consultants. You're never going to stop needing consults, but their complexity should increase to a certain point over time.

TLDR:
It's very easy outside the specialty to declare what experience is needed, and be wrong
Each year of IM residency has its own flavor for what experience is gained
Some people, some specialties, may declare they had more IM than necessary
That doesn't seem to be the norm
How do we figure out who needs *less* training in an atmosphere where people feel like more is more??
Good internists know their limits, they also learn from their consults

There does exist a "fast-track" where you can do 2 years of IM and then your subspeciality. It typically makes the fellowship at least 2 years longer with significant research requirements (i.e. it's a research track) that take more time than you save, but if you hate IM residency that much...

so i'm curious and it's somewhat related, but why is neurology a separate residency? why couldn't it be 3 years IM + neuro fellowship?

i was thinking neuro could be a good example of trying to make the IM subspecialties into their own residencies rather than fellowship. so it could be 1 year IM internship + 3 years of IM subspecialty.

 

[Raryn]

so i'm curious and somewhat related, but why is neurology a separate residency? why couldn't it be 3 years IM + neuro fellowship?

i was thinking neuro could be a good example of trying to make the IM subspecialties into their own residencies rather than fellowship. so it could be 1 year IM internship + 3 years of IM subspecialty.

Historical happenstance. Neurology was already seen as a distinct field in 1934 when the boards were being established. Same with Dermatology (in 1933).

 

[Lawpy]

Historical happenstance. Neurology was already seen as a distinct field in 1934 when the boards were being established. Same with Dermatology (in 1933).

There is no reason why. They could all be separate fields.

i guess i'm confused why IM subspecialties are currently fellowships given the recent medical advances. many of those (say cardiology) have their own subspecializations. i would think IM subspecialties would be distinct from rest of IM to warrant its own residencies, and make those field-specific subspecializations as fellowships.

 

[Psai]

So that you can understand what it's like to call someone in the wee hours of the morning and get bitched out even when it's legitimate

 

[Perrotfish]

So that you can understand what it's like to call someone in the wee hours of the morning and get bitched out even when it's legitimate

I feel like I had that down at the end of Intern year, though.

 

[NWwildcat2013]

This is basically exactly what neurology does. Didn't they used to be a subspecialty of IM? They have managed to just do an intern year and not kill anybody, so I don't see why the neurology model couldn't be applied to things like rheum, endo, immuno, etc.

 

[Anicetus]

I get that internal medicine is the basis of all medicine subspecialities but shouldn't doing just 1 year of internship be enough before you subspecialize? If anesthesiology and radiology can do it, why can't we? And for the most part as an internist you're pretty much consulting other services anyway when someone shows up with something interesting (or even routine like CHF) and you're left managing the boring stuff like pain meds, social work, disposition and meds for their chronic conditions like COPD, diabetes, and HTN. All of the interesting conditions and actual treatment tend to be managed by subspecialists. And many of the patients are repeat offenders that keep coming back for the same problem even though you tell them how to take their meds and how to change their lifestyle. So why do we have to do 3 years of boring micro management and then dealing with tons of paperwork before we can actually start treating patients as fellows in cardiology, oncology, etc.?

Because honestly we need more ****ing people in primary guys. This is the only way to scam people into staying in purely internal medicine in hopes that some people aren't motivated enough to continue on to a fellowship.

 

[J ROD]

It's all a game. Warm bodies needed to do the grunt work of medicine.

 

[Crayola227]

My best friend is in neuro and I think you guys are underestimating the number of gen med months they do, even going on through the 4 years. Neuro residencies still think, as I argued, that you need more wards time not only as a PG1 but also in supervisory roles in the rest of the years. Plus, you still need seniors supervising the PG1s and they're not always going to structure that the neuro wards rotations are with the IM residents, or at least not to a mix where you don't have to throw some neuro seniors in.

Also, they have other months like consult and EM that would overlap with an IM residency.

As @Raryn mentioned, sure you could create subspecialty tracks, but I bet the bulk of the months overlap with what is already required by the ABIM.

I think all you would do is introduce a lot more variability into what you could consider the existing base education for subspecialites, IM.

There may be some other specialties, besides radiology, derm, neuro, that could be structured separately, but I don't think most of them.

TLDR:
More overlap in neuro and IM months than is appreciated
Subspecialty track fellowship+IM all in one not likely to save much time
Question the quality control of this
Less training is not more

 

[Slack3r]

This is basically exactly what neurology does. Didn't they used to be a subspecialty of IM? They have managed to just do an intern year and not kill anybody, so I don't see why the neurology model couldn't be applied to things like rheum, endo, immuno, etc.

That's because Neuro consults medicine for anything remotely medically complicated.

 

[Slack3r]

Yea but still. A gastroenterologist does not need more years training than a surgeon. I know it's different, but I mean, if you do an extra GI year like a lot of people do you, it's literally as long as a neurosurgeon. It's just not necessary. Once again, this is coming from an IM resident. My buddy is going to be a general surgeon and I will be in training 2 years longer than him. You could argue the same amount of years is perhaps needed. But srsly is GI so complex that it needs to be 6-7 years of training? Or cards for that matter? They need the bodies... that's the only logic explanation for the model.

There are enough scope-jockeys that just do their scopes and consult for everything as is. I don't think we need to truncate their medical knowledge any more, do we?

 

[oncology2020]

I'm currently an IM resident and absolutely love what I do. But the truth is that the entire medical education system needs an overhaul it's just so inefficient and frankly a waste of time. 4 years of useless premed + 4 years of inefficient med school + 4 licensing exams (2 of which are unnecessary) + 3 years of IM (with many programs having total of 9 months of elective) + 3 years of fellowship (one year which is often required research) + 1-2 years of subspecialization+ several board certification exams.

There is one and only one reason for the current system: $$ for the all stakeholders involved at the expense of students and trainees. It's a billion dollar business--students are a source of money while residents and fellows are cheap labor.

They make radiologists do an internship, 4 years of radiology and most have to do 2 additional fellowships before they can find a job. Similar story with pathology. Rad onc invented useless unaccredited fellowships to train fellows in stuff they should have already learned in residency. Really? It's a scam of epic proportions at every level.

My proposed medical education model:
--2 years of premed for those that know they want to do med school (allow for 4 years for those that are unsure but absolutely no need to make students take on additional debt and waste time)
---3 years of med school (make basic sciences 1-1.5 yrs..and 4th year can be condensed, besides being a nice break, it is a complete waste of time for the most part)
---2 years of IM residency for those that want to practice primary care independently (no need to force 9 months of elective time for these people) or 1 year of IM + specialty training

Saves several years and lowers debt and allows people to start making a decent salary at a normal age. We already have the most rigorous licensing and board exams in the world--we are constantly tested at a high level at every step from the MCAT to the 4 USMLEs to board exams and recertification exams. If all those exams are doing their job then that should ensure quality of doctors produced isn't negatively affected.

 

[Goro]

A lot of interesting comments in this thread!

Onco, I will point out a medical school can get as much money from indirect out of a decent research department, like, say, Physiology or Pathology, than from the tuition of an entire med school class.

And multiple attendings and residents in these fora have pointed out that residencies lose money in training people.

I'm currently an IM resident and absolutely love what I do. But the truth is that the entire medical education system needs an overhaul it's just so inefficient and frankly a waste of time. 4 years of useless premed + 4 years of inefficient med school + 4 licensing exams (2 of which are unnecessary) + 3 years of IM (with many programs having total of 9 months of elective) + 3 years of fellowship (one year which is often required research) + 1-2 years of subspecialization+ several board certification exams.

There is one and only one reason for the current system: $$ for the all stakeholders involved at the expense of students and trainees. It's a billion dollar business--students are a source of money while residents and fellows are cheap labor.

They make radiologists do an internship, 4 years of radiology and most have to do 2 additional fellowships before they can find a job. Similar story with pathology. Rad onc invented useless unaccredited fellowships to train fellows in stuff they should have already learned in residency. Really? It's a scam of epic proportions at every level.

My proposed medical education model:
--2 years of premed for those that know they want to do med school (allow for 4 years for those that are unsure but absolutely no need to make students take on additional debt and waste time)
---3 years of med school (make basic sciences 1-1.5 yrs..and 4th year can be condensed, besides being a nice break, it is a complete waste of time for the most part)
---2 years of IM residency for those that want to practice primary care independently (no need to force 9 months of elective time for these people) or 1 year of IM + specialty training

Saves several years and lowers debt and allows people to start making a decent salary at a normal age. We already have the most rigorous licensing and board exams in the world--we are constantly tested at a high level at every step from the MCAT to the 4 USMLEs to board exams and recertification exams. If all those exams are doing their job then that should ensure quality of doctors produced isn't negatively affected.

 

[NWwildcat2013]

That's because Neuro consults medicine for anything remotely medically complicated.

Not where I am. They consult subspecialties for big problems they can't handle (e.g. massive GI bleed of unknown origin) but they treat most routine "medicine" problems easily. Im sure it is different at each institution but where I am the neuro inpatient wards are rounded on by primarily neuro critical care and vascular trained neurologists and they know how to deal with basic medicine issues.

 

[GoldenFish]

For the same reason future radiologists are expected to do one year of prelim med/surgery:

slave labor.

As an intern at a medicine program going into an advanced specialty, I agree 100%. Prelim residents are routinely worked to the bone; the categoricals get easier schedules while prelims are thrown into endless months of wards. I could see why you need to be at least a somewhat competent internist to move on, but the pathway could be shortened to two years of IM only at the very least.

Also, general IM sucks. You get **** on regularly by everyone, from nurses, to angry pt/friends/family, other services etc. Way too much of your day is clerical busy work and you barely get to spend any time actually thinking through problems because of all the nonsense documentation and because you have 8 other patients. By this point, any coworkers who don't put the utmost priority on efficiency (saying it really nicely) drive me up the wall. Endless rounds while getting bombarded w/ pages, call days where you're regularly there two hours after your shift is supposed to be over, nurses asking about the most mundane things repeatedly, getting yelled at by the consultant etc... I could spend all day talking about it.

I liked medicine much more before this year; now I absolutely can't wait to be done and am counting down the miserable call days until I'm home free.

 

[Crayola227]

I'm hearing excellent arguments why doctors should do less clerical work and more medical decision-making as the major part of their day.

Still not getting great arguments that upon conversion to a more medically dense day that one does not still need just as many days. I take Osler's view that following disease and follow up matters, so to some extent there is no substitute for the normal progression of human illness and us being there for it.

If you see me argue against work hours, it's because I want us doing less BS, more patient facetime educating, time in EHR thinking time, and to BALANCE the Oslerian need to be bedside with pissing and kissing your kids goodnight.

TLDR
Aside from how the practice of medicine is incompatible with doctors being themselves biological creatures,
I agree the training could be more dense but I still wouldn't want to see less of it.

 

[W19]

Why is everyone sh**** on IM in this thread? Surgery is no better!

 

[Voodoo Chile]

As an IM resident I agree completely with this and I'm not kidding. I don't see why there cannot be an intern year and then jump into these specialties. Will the first year fellow be weaker than someone who did 3 years of IM first? Yea absolutely but by the 6 month mark I don't see why after several 80 hour weeks you would not get the knowledge and training to do what you need to do within your specialty. I absolutely agree that they need the labor. It should be one year IM + 3-4 years of the specialty

This was actually brought up during a conversation with a couple of my PGY3 medicine resident buddies who are off to fellowships in a couple of months. 20-30 years ago, it was probably necessary. These days, it's probably a bit overkill given how little I've actually used my brain over the course of PGY1 year. I can't imagine doing this for another couple of years. It's a shame that a lot of really smart IM residents just get run down over the 3 year stretch, and are completely unmotivated by the time they start fellowship.

 

[NWwildcat2013]

This was actually brought up during a conversation with a couple of my PGY3 medicine resident buddies who are off to fellowships in a couple of months. 20-30 years ago, it was probably necessary. These days, it's probably a bit overkill given how little I've actually used my brain over the course of PGY1 year. I can't imagine doing this for another couple of years. It's a shame that a lot of really smart IM residents just get run down over the 3 year stretch, and are completely unmotivated by the time they start fellowship.

Yikes.

Sounds pretty dismal. I suspected this happened in IM residencies but I never had proof. This thread is at least some anecdotal proof.

 

[ProfMD]

Why is everyone sh**** on IM in this thread? Surgery is no better!

I don't really have an opinion on whether there should be fast tracks for IM subspecialties. However, surgery is moving in that direction with integrated programs for plastics, vascular, and cardiothoracic.

 

[GadRads]

And multiple attendings and residents in these fora have pointed out that residencies lose money in training people.

You really believe this? Lol. Medicare gives each hospital additional funds on top of the salary for each resident. http://www.modernhealthcare.com/article/20150719/news/307199999

 

[W19]

IM sucks. Don't let anyone convince you to stay in it.

I will sub specialize if I do IM and I am looking into psych as well. Neurology is still a possibility if my advisor thinks I might have a decent shot at it. I agree with you that general IM is not what I envision myself doing for the next 25+ years...

 

[ProfMD]

You really believe this? Lol. Medicare gives each hospital additional funds on top of the salary for each resident. http://www.modernhealthcare.com/article/20150719/news/307199999

Your own article points out that the hospital is subsidizing the residency program.

GME funding via Medicaid is a complex, non-linear calculation. It is not as simple as "x dollars per resident." However, hospitals get ~$75000 per resident. This goes to paying salary, benefits, malpractice, etc of the resident along with costs of running the programs (GME office, residency coordinator). In addition, teaching hospitals are inefficient and tend to care for sicker patients. Therefore, this money also goes toward covering patients care costs that are not otherwise reimbursed.

http://www.acgme.org/Portals/0/PDFs/2015 AEC/Presentations/PC001/PC001g_Financial.pdf

So, @Goro is right, hospitals don't make money off residents.

 

[Lord_Vader]

IM sucks. Don't let anyone convince you to stay in it.

I hope you're referring to just general IM and not the subspecialities as well.

 

[Señor S]

Healthcare and education are two of the most hidebound and least innovative fields out there, so combining them in the form of "medical education" is a recipe for disaster.

The problem is that rather than reworking the system from the ground up they always do the much easier thing of just appending it; it would be as if Ford's 2017 production line was just a bunch of Model T's with GPS and satellite radio added on. Why? Inertia, lack of imagination, "we had to do it so they should too."

 

[W19]

I don't understand the economics around this, admittedly. I mean does it save the hospital money to hire more hospitalists to do the residents' job? Do hospitalists generate money for the hospital? Because if you get rid of the residents or let them just go into their specialty from the outset, you have to fill that void. I don't know how that becomes profitable.

I think hospitals make money off residents... I see 2nd/3rd year IM/FM residents and child and adolescent psych fellows working with very little attending inputs in the hospitals I have been in so far...

 

[W19]

Just general IM. I'm not that jaded bro. I like cards, GI, and pulm/crit. Heme/onc and allergy are good options for those interested. The rest honestly sucks though 🙂

ID is not bad...

 

[GadRads]

Your own article points out that the hospital is subsidizing the residency program.

GME funding via Medicaid is a complex, non-linear calculation. It is not as simple as "x dollars per resident." However, hospitals get ~$75000 per resident. This goes to paying salary, benefits, malpractice, etc of the resident along with costs of running the programs (GME office, residency coordinator). In addition, teaching hospitals are inefficient and tend to care for sicker patients. Therefore, this money also goes toward covering patients care costs that are not otherwise reimbursed.

http://www.acgme.org/Portals/0/PDFs/2015 AEC/Presentations/PC001/PC001g_Financial.pdf

So, @Goro is right, hospitals don't make money off residents.

There is indirect funding on top of direct funding, both of which are linked to the number of residents. The number you listed is direct funding. The problem is that indirect funds are used like discretionary funds and are not directly accounted for in terms of "per-resident" expense.

From the article: "Of Beaumont Hospital's 395 residents, 91 are not covered by Medicare and so are paid for by Beaumont. The $57 million for GME represents 4.73% of Beaumont's net patient revenue in 2013, or about $189,368 per resident"

Here is the question to ask yourself: If hospitals are losing money by having residents, why don't they hire more attendings to cut costs instead of using their private money to fund additional residency spots?

 

[GadRads]

I don't understand the economics around this, admittedly. I mean does it save the hospital money to hire more hospitalists to do the residents' job? Do hospitalists generate money for the hospital? Because if you get rid of the residents or let them just go into their specialty from the outset, you have to fill that void. I don't know how that becomes profitable.

Hospital management will always claim that they lose money from having residents, especially when the funders of GME are always trying to cut funding. While direct payments do not cover costs, the combination of indirect and direct payments end up creating a profit for many hospitals. If the IM residents were just a drain, my program would be cutting spots and trying to hire more hospitalists, but that is NOT happening. In fact, management wants MORE residency spots.

"With average resident salaries at $50,000, benefits and perks averaging another $50,000 and administrative expenses adding another $25,000 to $50,000 per resident, the average cost to train a single resident is $120,000 to $145,000, Gassett said.

Medicare direct payments "absolutely do not cover the costs," Gassett said. "What we find is some hospitals do not account for all faculty and other costs."

But Gassett acknowledged that if indirect payments are added, some hospitals are close to breaking even or making money, Gassett said."

 

[ProfMD]

There is indirect funding on top of direct funding, both of which are linked to the number of residents. The number you listed is direct funding. The problem is that indirect funds are used like discretionary funds and are not directly accounted for in terms of "per-resident" expense.

From the article: "Of Beaumont Hospital's 395 residents, 91 are not covered by Medicare and so are paid for by Beaumont. The $57 million for GME represents 4.73% of Beaumont's net patient revenue in 2013, or about $189,368 per resident"

Here is the question to ask yourself: If hospitals are losing money by having residents, why don't they hire more attendings to cut costs instead of using their private money to fund additional residency spots?

Hospital management will always claim that they lose money from having residents, especially when the funders of GME are always trying to cut funding. While direct payments do not cover costs, the combination of indirect and direct payments end up creating a profit for many hospitals. If the IM residents were just a drain, my program would be cutting spots and trying to hire more hospitalists, but that is NOT happening. In fact, management wants MORE residency spots.

"With average resident salaries at $50,000, benefits and perks averaging another $50,000 and administrative expenses adding another $25,000 to $50,000 per resident, the average cost to train a single resident is $120,000 to $145,000, Gassett said.

Medicare direct payments "absolutely do not cover the costs," Gassett said. "What we find is some hospitals do not account for all faculty and other costs."

But Gassett acknowledged that if indirect payments are added, some hospitals are close to breaking even or making money, Gassett said."

I can't speak to Beaumont specifically. As I said the amount per resident is not linear, and varies by hospital depending on their Medicare population and the factors. However, the ACGME link I provided does include both direct and indirect in the $75000 estimate per resident ($25000 direct and $50000 indirect).

I also can't speak to your hospital. In my hospital, we would like to have more residents because we have ample clinic and surgical volume to train more. However, we do not do this because Medicare funding of GME is capped and the hospital will not fund any more GME spots.

The reasons to have residents are not purely financial. It is extremely cynical to think that residents are a profit generator for hospitals and that this is the reason they exist. Fact of the matter is that most attendings in academic practice like teaching, research, taking care of the sickest patients, etc. This is why we do it. If attendings really were all about the money, the would go elsewhere since most of us take a pay cut to work in academia.

Edit:
This article quotes and average of $137,000 per resident. It also details the methodology for determining how much a hospital gets:
https://fas.org/sgp/crs/misc/R44376.pdf

This article points out the regional differences. Per resident is lowest in Wyoming (~$64000) and highest in Connecticut (~$155,000).
https://economix.blogs.nytimes.com/2013/12/17/how-medicare-subsidizes-doctor-training/?_r=0

Still barely enough to cover salary, benefits, malpractice, administration, inefficiencies, etc.

 

[allantois]

Just an observation: a lot of sub-specialists seem to be foreign-trained (at least where I am), and I am sure that 3 years of American IM training is beneficial in that case.

 

[Spectre of Ockham]

Because people would die.

Bingo - 3 years IM and 3 years as a Oncology fellow ? Man I wish I'd had that in EM or neurosurgery. I'd run for president just to get that.

 

[nlax30]

I think there are certainly valid arguments both for and against the current model. I'm finishing Cardio fellowship and about to start 2 MORE years of an EP fellowship so hell, all told I'll have had 8 years of post graduate training to be an EP..... that's just ridiculous. EP just got got extending to 2 years in 2015 and most of the Cardio/EP guys think that there should be some sort of condensed path, either taking a year or two off at some point during IM or general cardio training.

I don't know what the answer is because you still want to put out good well rounded internists as not everyone is going to sub-specialize. For those that do end up doing certainly sub-sub-specialty training, namely some of the Cardio sub-fields, maybe EUS for GI, etc.... then I definitely think some sort of condensed path is reasonable.

 

[Lawpy]

I think there are certainly valid arguments both for and against the current model. I'm finishing Cardio fellowship and about to start 2 MORE years of an EP fellowship so hell, all told I'll have had 8 years of post graduate training to be an EP..... that's just ridiculous. EP just got got extending to 2 years in 2015 and most of the Cardio/EP guys think that there should be some sort of condensed path, either taking a year or two off at some point during IM or general cardio training.

I don't know what the answer is because you still want to put out good well rounded internists as not everyone is going to sub-specialize. For those that do end up doing certainly sub-sub-specialty training, namely some of the Cardio sub-fields, maybe EUS for GI, etc.... then I definitely think some sort of condensed path is reasonable.

I'm still reading the discussion although the medical jargon used is making things unclear and my questions weren't directly answered. My question is simple: why not just make IM subspecialties like cardiology, gastroenterology, oncology, nephrology etc. their own separate residencies and make the field-specific specializations as fellowships? Is it absolutely necessary to have 3 years of IM training before specialization?

A lot of the arguments rest on residents changing minds against specializing. I thought the time to make the decision was in medical school or in intern year?

 

[Mad Jack]

This absolutely does happen, even in the upper tier programs. There are a handful who originally wanted to do a subspecialty who are quitting and going full primary against their better judgement.

Or people with high debt burdens are going into hospitalist work to try and pay things down before the compound interest becomes insurmountable... I literally can't afford to specialize right away if I were to go IM, the pay differential with fellowship wouldn't compensate for the interest I'd accrue and the income I'd lose versus a rural hospitalist position

 

[Levo]

Of all of the ways medical training is inefficient, making IM subspecialists complete a 3-year IM residency seems like one of the most reasonable and least onerous. Take a look at other specialties. ENT-trained plastics fellows first spend 5-6 years learning about neuro-otology and management of sinus disease. Ortho-trained spine fellows first spend 5 years scrubbing in on pelvic fractures, major joint cases, and carpal tunnel surgeries. Gyn-onc fellows first learn to deliver babies. All of those experiences are, in my mind, a heck of a lot less useful with regards to those specialists' goals than it would be for a cardiologist to complete IM residency. All internal medicine subspecialties are highly related. I've seen cardiologists diagnose Grave's Disease and syphilis. Sure, they consulted endocrinology and ID respectively to help with the finer points of treatment, but they knew to look and knew how to interpret the results of the diagnostic tests.

 

[Lawpy]

There has been extensive discussion regarding your question... Basically the argument comes down to 1) The hospital wants the fresh bodies for 3 years for IM or 2) The subspecialists still need a good foundation in IM so it's necessary to get that training. Those will be the majority of the responses to your question for why v.s. why not make the residencies/fellowships separate.

IM is 3 years. You apply at the end of your second year. There is room for changing your mind in those 2 years, but fellowships like GI or cards, which are more competitive, will necessitate (not always) some form of research/getting letters of recommendation within those specialties, so making the decision earlier rather than later in residency is beneficial. There are plenty of people who decide to switch their fellowship interest in their second year of residency who match successfully. It's just harder.

Ok thanks for the summary! Helps clarify a lot. My only concern with the current system is it makes IM a necessary 3-year extension of medical school involving general medical training and principles before specializing.

If an MS1 decided to pursue medical oncology no matter what (say because of personal tragedy), they would need to endure 7 years of necessary general education and training before they could even train as an oncologist. Seems rather unusually long, although assuming said MS1 does cancer research throughout medical school and residency, that's 7 years worth of solid productive research.

 

[Mad Jack]

Yea I don't know how common that is or anyway we can quantitate that. I have never heard someone give that reason, but that does not mean they just don't divulge that information. Nevertheless... I am sure there are some people with your debt burden who go into surgical specialties with 5 year+ of training and do okay and the IM subspecialties after training can give similar compensation. I don't know though, I'm lucky to not have a considerable amount of debt compared to others.

It's usually nontrads like myself. When you've only got 20-25 years to train and practice, spending 6 of them training doesn't make financial sense, nor is supporting a family on a resident's salary with ballooning debt for 3-4 additional years appealing.

 

[Levo]

You basically need to take step 2 to be able to diagnose that **** though. And you mentioned a bunch of cases of surgical specialties. Learning how to operate is a different beast dude, and it ends up being less training than the IM specialties sometimes! Haha. I think matching directly into "spine surgery" is a lot more selective than matching directly into cardiology, a field which has several subspecialties of its own.

You're ahead of me in training, so I'm going to defer to you on this, but that has not been my experience. When I took step 2, they always had the "classic" presentation of the disease, test results were never equivocal or conflicting, and there were never any additional diagnoses to distract you or complicate the workup. On the wards, all of above happens. I have always been shocked by how many nuances and complications can occur with working up real patients for something that would make an easy USMLE question.

Also, how is surgical training completely different with regards to this discussion?

 

[oncology2020]

Do not be fooled to think hospital administrators lose money on residents. They save money indirectly because they dont have to hire staff at full salaries. You really think they would be increasing residency spots if they were losing money? You are only looking at direct costs but residents/fellows do most of the work to keep a hospital running 24/7/365. IM residents run the hospital in a teaching institution. Imagine having mulitple attendings covering those hours instead of residents on a subsidized $50K a year salary.

 

[Danbo1957]

We are training you to become an internist. That's it. Three years.

With that said, there's this: https://www.mdanderson.org/educatio...esidencies-fellowships/internal-medicine.html