Graduate medical education downsizing: perceived effects of participating in the HCFA demonstration project in New York State

Abstract

Objective: Financial support for graduate medical education (GME) is shrinking nationally as Medicare cuts GME funds. Thirty-nine hospitals in New York State (NYS) voluntarily participated in a Health Care Financing Administration demonstration project (HCFADP)-the goal of which was to reduce total residency training positions by 4-5%/year over a five-year period, while increasing primary care positions. The objective of this study was to determine the effect of downsizing on emergency department (ED) staffing and emergency medicine (EM) residency training.

Methods: Structured interviews and surveys of NYS program directors (PDs) were conducted in October-December 1999. Simple frequencies are reported.

Results: One hundred percent of 17 PDs completed the interviews and seven of 12 participants in the HCFADP returned surveys. Twelve of 17 programs participated in HCFADP and two programs downsized outside HCFADP. Seven of 12 participants lost EM positions. Six of 12 programs were forced to exclude outside residents from rotating in their ED, leading to a need for one participating program and one non-participating program to find alternative sites for trauma. Five of 12 institutions provided resident staffing data, reporting a reduction in ED resident coverage in year 1 of the project of 9-40%. Programs compensated by increasing the number of shifts worked (4/12), increasing shift length (1/12), decreasing pediatric ED shifts (1/12), decreasing elective or research time (2/12), and decreasing off-service rotations (4/12). Six departments hired physician assistants or nurse practitioners, two hired faculty, and two hired resident moonlighters. Six of 12 programs withdrew from HCFADP and returned to previous resident numbers. Eight of 12 PDs thought that they had decreased time for clinical teaching.

Conclusions: A 4-5% reduction in residency positions was associated with a marked reduction in ED resident staffing and EM residency curriculum changes.