GME Funding and Specialty Choice, Part II FREE

Last week's Resident Physician Forum column contained a brief summary of how Medicare funds graduate medical education (GME). Residents who plan to switch programs need to understand that Medicare may reduce funding for a resident who moves from one program to another, depending on the length of the initial residency period. Medicare defines an "initial residency period" as the number of years it takes for a resident to become board eligible in the first medical specialty the resident entered. The initial residency period is set when a physician enters residency, and it does not change. Hospitals with training programs will receive slightly less when a resident is beyond the initial residency period. Some hospitals are using this cut in funding to eliminate applicants to their programs.

Because of the way Medicare defines the initial residency period, residents who first enter specialties with longer initial residency periods may be better positioned to switch specialties than those whose initial residency periods are shorter. For example, a physician who first enters a general surgery program will be fully funded for 5 years of residency, whereas a physician who first enters an internal medicine program will be funded for 3 years. If a general surgery resident completes 2 years of training in general surgery and switches to a 3-year specialty, such as internal medicine or pediatrics, Medicare will fully fund that resident for both programs. If a resident first enters an internal medicine program, completes 1 year and then decides to switch to another specialty, Medicare will fully fund that resident for only 2 more years.

Medicare makes an allowance for residents who enter transitional year programs. In this case, if a resident switches to a specialty that requires a year of general medical training as a prerequisite, Medicare will fully fund the resident for that specialty and for 1 year of general training. However, if the new program does not require 1 year of general training, that transitional year will be counted as 1 year of the initial residency period.

Medical students and international medical graduates should be aware that not all programs will eliminate applicants who have already completed some residency training. Many hospitals may feel that the decrease in funding for these residents is relatively small. Nevertheless, applicants to residency programs should be aware of these implications when selecting a specialty.

Medical students and physicians should also understand that the current structure of GME funding is at a crossroads. The shift of training to nontraditional outpatient sites and the advent of programs sponsored by managed care entities have altered the residency landscape. Congress is considering several changes to the Medicare program, including changes to GME funding. The American Medical Association and its Resident and Fellow Section are following this issue closely and will continue to report on proposed changes and their implications.