Yes. Primary-care physicians' training is already suffering, and harmful effects on specialists' training are not far behind.
Since more care is given on an outpatient basis, there are fewer hospitalized patients to give residents and students clinical experience. And the patients they do treat tend to have complex, atypical illnesses -- not the common ones they are likely to see in practice.
To compensate, physicians in training have to put in more clinic time. But clinics are chaotic at best, and care is usually discontinuous. This means they can't follow patients from day to day.
Hospital learning opportunities are also reduced because third parties limit house-staff payments. Hospitals now use more paramedics to do routine work formerly done by physicians in training.
Specialty training is being hurt by cost cutting, too. Third parties aren't willing to pay for it, so residents who want to become fellows have to take stiff salary cuts. Many young doctors with families can't afford this. People who might have become superb specialists and teachers are going to high-paying HMOs. I've already lost one excellent hematology fellow.
The trend toward making medicine a business, not a profession, also puts joint training programs -- such as medicine and pediatrics -- in jeopardy because payers cover only three of the four years.
If the trend continues, medicine will again become a rich person's profession -- with well-trained physicians and specialists in short supply.
I'm glad I'm not so young now, because I think that in 20 years I'd have a hard time finding a good doctor. -- Dr. Mary Kaufman Director of Pediatrics, Long Island College Hospital, Brooklyn
No. Good medical training isn't compromised, unless you equate it with giving lots of hospital care -- which I don't.
With so many procedures now being done on an outpatient basis, the solution is to move teaching from hospitals to outpatient settings, such as clinics, doctors' offices and surgical centers. The bulk of most doctors' work isn't done in hospitals, and even before cost cutting, many authorities advocated moving medical education outside hospitals.
Yes, clinic care is discontinuous, but it doesn't have to be. I've run hospital clinics, and with time and work, they can be organized so that care is continuous. Some hospitals are already doing this.
Having fellows quit and go into primary care is a move to be supported. Most fellows stay in hospitals to study rare diseases, not to teach.
Also, the Graduate Medical Education National Advisory Committee has predicted an oversupply of all subspecialists by 1990. As for four-year joint programs, what needs do they serve? Family-medicine residencies take three years.
The really serious education problems have nothing to do with cost cutting. In 1984, the Association of American Medical Colleges published a highly critical report. It said we teach medical students a lot of unrelated facts, may of which have little significance in clinical medicine; we teach by rote; and we stress short-term memory skills at the cost of problem-solving.
It found that we aren't producing doctors to meet the needs of the people -- such as forestalling preventable chronic diseases, solving environmental and occupational health problems, and serving an aging population.
The major problems in medical training relate to what and how we teach. Cost containment is a straw man. -- Dr. Steven Jonas Professor of Community and Preventive Medicine, State University of New York at Stony Brook