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CHAPTER 1
CONCERNS ABOUT PRIMARY CARE RESIDENCY TRAINING
This chapter outlines some of the concerns about the production of primary
care physicians to meet the nation's future requirements. Included are discussions
of primary care manpower and the interactions between the provision of indigent
care and the financing of primary care residencies. Although the content of
primary care residency training is not the focus of these last two topics, they
discussed here because they are topics of national importance that can be
influenced by the financing of primary care residencies.
New Directions for Primary Care Residencies
are
The education of primary care physicians being prepared to work in the late
twentieth and early twenty-first century must respond to changes that have
occurred and are occurring in the organization and delivery of health care. The
following sections outline some of those changes and the extent to which GME for
primary care physicians has adapted.
Why is There a Need to Increase Ambulatory GME?
Changes in the content of inpatient and outpatient care, and in the roles that
primary care physicians are called upon to play, have made the inpatient hospital
setting less appropriate as the principal site for primary care education. These
changes and why they are important can be summarized briefly:
0 For a number of reasons, including technological changes, economic
incentives, and decreased length of stay, hospital patients are sicker than they
used to be. Therefore the inpatient educational experience is becoming
increasingly narrow, and the inpatients seen by primary care residents are less
like those they will encounter in their practices.
O The length of hospital stay has decreased. As a result inpatient
residencies do not provide an ongoing interaction between resident and patient,
nor are residents able to participate in the diagnosis or post-operative care of
patients to any great extent. Residents on inpatient service also have little chance
to view the full course of disease.
15
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o Key patient decisions and interactions between patients and physicians,
such as those that involve consideration of life-style or behavioral aspects of care
increasingly occur in the ambulatory care setting.
O The range of disease seen in inpatient settings has decreased as the
ability to manage disease without hospital admission has increased.
The crux of the problem is described by Rueben et al. (1988) who state that
the mismatch between education and clinical practice can result in suboptimal
preparation of primary care physicians for patient care. Much of the residency
experience involves patients with end-stage diseases complicated by co-morbid
chronic conditions, with care taking place in a setting where speed and efficiency
are at a premium. This compares with a practice setting in which the physician
is generally alone with the patient, where the physician must establish trust lest
the patient disregard advice or fail to return, and where the range of diseases and
ailments encountered will be substantially different from those encountered in the
inpatient setting. In addition, the primary care physician should be particularly
well-versed in the behavioral sciences and epidemiology in order to understand the
complex interactions of patients with their environments. A primary care
physician should also be familiar with local agencies that can offer assistance to
patients.
The Match Between Training and Practice Sites
The importance of ambulatory care and the role of primary care physicians
can easily get lost in today's high technology, specialty oriented approach to care.
It is also easy to forget that the primary care practitioner is likely to deal with a
different range of problems than other specialists, and than physicians in
specialties and subspecialties that are hospital based. In addition, the primary
care practitioner most often practices outside the hospital, in a physician's office.
The ambulatory care workload of primary care specialists is illustrated by data
from the National Ambulatory Care Survey. This survey of 2,000 office-based
non-governmental physicians, collects data about the ambulatory patients
encountered during a randomly selected study week. Regarding the patient
problems seen in ambulatory practice, 15 diagnostic clusters in 1978 accounted for
50 percent of the half billion annual ambulatory care visits. General and family
physicians, general internists, and pediatricians together provided well over 50
percent of outpatient visits for these diagnostic clusters (Rosenblatt et al., 1983~.
Figure 1.1 illustrates the nature of the primary care ambulatory practice and the
emphasis on conditions that are usually not seen in the inpatient setting.
Although the composition of primary care ambulatory visits may have shown some
change in the past decade, it seems reasonable to conclude that primary care
16
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Figure 1.1 Diagnosic Clusters Accounting for the Majonty of Ambulatory Visits
to U.S. Physician In Selected Specialties In 1977 and 1978.
50+
o
o
3
o
-
~ 30
E
-
o
40
bC
-
20
10
DJD (16)
diabetes
Mell (15)
.
Dep/Anx
(5)
_
Isch HI
Dis (8)
Pre &
Postntl
(3)
acute
LR!
(10)
- acute
Sp & St
(9)
soft
tissue
. .
nJurles
(6)
hour
tension
(4)
general
medical
exam
(1)
acute
URI
(2)
acute Sp
, & St (9)
peptic
Dis (29)
Malig
neoplasm
l (20)
Acute
LRI
(10)
Dep/
Anx (5)
DJD (16)
diabetes
mell~tus
(15)
acute
URI
(2)
general
medical
exam
(1)
.
schemlc
heart
disease
(8)
hyper
tension
(4)
acute
URI
(2)
general
medical
exam
(1)
general
medical
exam
(1)
Pre and
Post
natal
care
(3)
1 ~
general
practice
and
family
practice
internal general obstetrics
medicine pediatrics and
gynecology
breast
Dis (58)
hvper
tension
(4)
Acute
Sp & St
(9)
peri
rectal
(39)
hernia
(57)
acute
URI (2)
Malig
neoplasm
(20)
benign
neoplasm
(23)
general
medical
exam
(1)
soft
tissue
. . .
Injuries
(6)
medical
and
surgical
after
care
(7)
medical
and
surgical
after
care
(7)
acute
sprains
and
strains
(9)
frac
tures
and
dislo
cations
(13)
general ortho
surgery pedics
arrhyth
mias
(54)
hyper
tension
(4)
.
schemlc
heart
disease
(8)
derma
titis
and
eczema
(12)
acne and
related
condi
tions
(18)
depres
sion
and
anxiety
(5)
cardi- derma- psychi
atry
ology tology
Source: Rosenblatt, Roger A., and Daniel C. Cherkin, Ronald Schneeweiss and L.
Gary Hart. 1983. The Content of Ambulatory Medical Care in the United States.
The New England Journal of Medicine. 309~15~:892-897.
Reprinted by permission of The New England Journal of Medicine.
17
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physicians still pronde the majority of care for these 15 diagnostic clusters, and
that these clusters still represent a substantial portion of primary care practice.
Certainly the primary care experience differs radically from the inpatient
experience, where admissions increasingly are for specific, invasive procedures.
To the extent that it is desirable that the settings and experiences of
residency training replicate those that will be found in practice, it is clear that not
all ambulatory settings are of equal quality. The primary care practitioner most
often practices in a physiciants office--a site that is underemphasized in todays
training. By one estimate, family practice residents spend roughly 40 percent of
their time on inpatient services, 30 percent in ambulatory clinics including those
of other specialties such as dermatology and ophthalmology, and 30 percent of
their residency time in continuity practice where the residents provide primary
care for families over an extended period of time and follow patients who are
admitted to the hospital (Colwill, 1989). Many sites that are used for ambulatory
care training of primary care residents do not meet the description of the recently
approved Special Requirements for Residency Training Programs in Internal
Medicine, which state that "the conditions under which ambulatory patients are
managed should be similar to those of office practicet' (Accreditation Council for
Graduate Medical Education, 1988~.
The Association of Program Directors in Internal Medicine (1987)
investigated both the duration and sites of ambulatory care experiences of internal
medicine residents in 1985. Ninety-five percent of the programs surveyed stated
that residents had at least two years with continuity experience. For more than
95 percent of these programs the experience consisted of a half day per week.
For most residents this experience was in hospital service clinics which differ in
many ways from office based experience. The indigent case load is high and
advanced disease and multiple conditions are more frequently observed; patients
are likely to show evidence of a poor socio-economic environment. Few internal
medicine residents spent much time in office-style settings. Only 11 percent of
programs offered experience in HMOs and 40 percent offered experience in private
offices. Moreover, of those programs that offered these sites only 4.! percent and
14.9 percent of residents respectively trained there. In addition, only 22.6 percent
of programs indicated that they also offered ambulatory care block time--an
experience that is not interrupted by inpatient duty. Furthermore, despite
suggestions that more time be devoted to ambulatory care, change appears to be
slow. Data from the National Study of Internal Medicine Manpower (which
surveys all accredited internal medicine programs), indicate that between 1976 and
1987 no significant change took place in the proportion of residency time devoted
to ambulatory care. However, over that period the site of ambulatory training
shifted, with an increase in training away from the hospital campus (Anderson et
al., 1989). One indication that the slow rate of change is due in part to the
18
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difficulties in financing and in coping with logistical problems is found in the
reaction to a proposal by the Residency Renew Committee in Internal Medicine.
In 1988 the committee proposed special requirements for internal medicine
training that mandated a minimum of 25 percent of the three-year training
program be spent in ambulatory settings. Despite support from such groups as
the Association of Program Directors in Internal Medicine, and a general
acknowledgement that the change is necessary, the difficulties in implementing the
change are enormous. Cost and logistical problems are causing programs to
request, at least, a delay in implementation (Cohen, 19891.
The pediatric residency experience resembles internal medicine in its lack of
similarity to subsequent practice (Schroeder et al., 19861. Charney (1989) notes
that a considerable amount of the pediatric resident's ambulatory experience is in
acute illness clinics or emergency departments. The climate in an emergency
room is in many respects unlike a primary care setting: patients are not likely to
be known to the physician, there is little ability to observe over time, and there is
pressure to make swift diagnoses. The sites for continuity experience are also
criticized. Charney surmises that one of the problems with the continuity clinic is
that it is an artificial construct, designed for teaching purposes, where residents
do not observe role models for future practice. Better experiences can sometimes
be found in neighborhood health centers and private offices. However, only about
30 percent of pediatric residents spend time in those settings.
Thus, despite mounting concern about the amount of ambulatory care
training, and the quality of training in the most frequently used ambulatory care
sites, change has been slow to occur. The ways in which current financing
mechanisms make the transition difficult is the subject of Chapter 2.
Primary Care Physicians and Cost Containment
The concept of the physician as gatekeeper--a designated health professional
who serves as the patient's primary physician and refers patients to specialist
services, as needed--is not new (Somers, 1983~. Today the emphasis is on the role
of the primary care physician as a gatekeeper or case manager, often in managed
care systems, with responsibility for balancing cost and quality considerations and
ensuring that patients receive good, cost effective, care.
The question of whether primary care physicians are the most appropriate
gatekeepers was answered in the affirmative by Somers (1983), with limitations.
In some circumstances a subspecialist might be appropriate--for instance for a
patient with end-stage-renal disease the nephrologist might function as gatekeeper.
In practice it appears that, at least in HMOs, primary care physicians do perform
19
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the gatekeeper role. Of 91 HMOs that responded to a survey and used patient
care managers/gatekeepers, 79 percent always used physicians for that function.
Family practice, internal medicine, and pediatrics were the three most frequently
used specialties (American Medical Care and Review Association, 19881.
In addition to these formal roles, primary care physicians can play major
roles in containing health care costs in less formal ways. Even in traditional solo
practice or group fee-for-service practices, the primary care physician makes
decisions concerning testing and referral that have major cost implications. In
addition, some of the attributes emphasized in primary care, such as preventive
care, health education and counseling are thought to be useful in forestalling more
costly episodes of illness. Eisenberg (1986) reviewed the literature on differences
in behavior among specialties. He notes that, in general, the literature suggests
that the more specialized physicians provide more intensive care than do
generalists even when controlling for case mix and severity. Eisenberg also notes
that residents learn decision-making styles during their residency training. Thus,
the nature of the residency experience can be a powerful influence on the ability
of the physician to provide cost effective care--an ability that is increasingly
valuable in today's environment. As one examination of the need for teaching in
the ambulatory setting noted, organized forms of medical care find that the more
tightly they control care to emphasize primary care, the more likely they are to be
financially viable. Therefore primary care physicians, even more than other
physicians, need clinical training in ambulatory-care settings (Perkoff, 1986).
Other Policy Issues Relating to Financing Primary Care GME
The following sections discuss two areas that may be affected by changes in
the support of GME for primary care physicians--the supply of primary care
physicians and access to care for indigent people.
PrimarY Care Manpower Two issues in primary care manpower are pertinent to
the committee's deliberations. The first is whether the educational system is
producing enough primary care physicians to meet the nation's needs, or to put it
another way, whether the proportion of primary care physicians and specialists
being produced matches future needs. The second issue is linked to the answer to
the first. If there is a desire to sustain the rate of production of primary care
physicians, or perhaps increase the rate of production, will a sufficient number of
physicians choose primary care specialties and fill available residency slots?
The question of the balance between the demand for and supply of physicians
has been debated for a long time. Major uncertainties result from difficulties in
20
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estimating demand, which is affected by many variables such as health care
financing, the organization of services, technological change, disease patterns,
demographics, and economics. The supply of physicians is theoretically easier to
project, yet it too is fraught with difficulties, as evidenced by the recent debate
about the supply, as well as the demand, forecasts of the Graduate Medical
Education Advisory Council.
Also debatable is the appropriate supply of primary care physicians. Such
groups as a 1978 Institute of Medicine committee have affirmed the key role of
primary care physicians in the nation's health care system (Institute of Medicine,
1978). The limited data that are available contain elements that are causing
concern about the adequacy of the future supply of primary care physicians. A
major study for the Federated Council for Internal Medicine (1987) found that
although there will be a slight excess of internal medicine physicians through
2020, there will be shortages of general internists. Taking into account such
variables as the ratio of physicians to population, the Council on Graduate Medical
Education (COGME) concluded that there is a current or impending undersupply
of family practice and general internal medicine physicians, but there is likely to
be an oversupply of pediatricians. However, COGME points out that its
conclusion is based on an assumption of no change in the demand for pediatric
services, which may be invalid; adolescent morbidities are increasing and between
12 and 16 million children are uninsured. Expansion of insurance coverage would
cause a major increase in demand for pediatric services (Council on Graduate
Medical Education, 1988). Table 1.1 indicates that between 1981 and 1987 the
three specialties with which this report is concerned -- general internal medicine,
general pediatrics, and family medicine -- experienced growth rates close to, or
substantially in excess of, the growth rate of all physicians. However, in 1987,
these three groups together represented less than 26 percent of all active
physicians. Table 1.2 shows the projections to the year 2020 of the Bureau of
Health Professions, indicating that in future years the three primary care
specialties together are expected to grow at a slower rate than the supply of all
physicians. The Bureau attributes the slow rate of growth in part to loss of older
physicians who will not be replaced in sufficient numbers (Department of Health
and Human Services, 1988).
Growth in the supply of primary care physicians in the near future must
come from the pool of physicians doing their residency training. Table 1.3
indicates the relatively meager growth between 1985 and 1988 in the number of
residents in the three primary care specialties compared with the total growth in
21
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Table 1.1
Supply of Active Physicians in Family Practice, General Pediatrics and
General Internal Medicine, 1981 - 1987
1981
1987
1981-87
Percent
Change
20.7
Specialty No.
% of
All MDs
485,123 100.0 585,597
No. % of
All MDs
100.0
Total
Physicians
Family 31,195 6.4 44,944 7.7 44.1
Practice
General 28,027 5.8 34,669 5.9 23.6
Pediatrics
General 60,118 12.4 72,038 12.3 19.8
Internal
Medicine
Total
119,340 24.6 151,165 25.8 26.7
Source: American Medical Association, Physician Characteristics and
Distribution, 1982 Edition and Forthcoming 1988 Edition.
22
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Table 1.2
Projected Change in Number of Professionally Active Physicians, General
and Family Practice, General Internal Medicine and General Pediatrics
1986, 2000 and 2020
Percent Percent
Change Change
Specialty 1986 2000 2020 1986-2000 1986-2020
All 521,780 667,370 757,130 27.9 45.1
Physicians
General 71,320 81,660 95,100 14.5 33.3
and Family
Practice
General
Internal
Medicine
76,260 91,440 105,930 19.9 38.9
General 34,530 46,040 51,520 33.3 49.2
Pediatrics
Primary Care 182,110
Physicians
219,140 252,550 20.3 38.7
U.S. Department of Health and Human Services, Sixth Report to the
President and Congress on the Status of Health Personnel in the
United States. DHHS Publication No. HRS-P-OD-88-1. June 1988.
23
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OCR for page 25
residents.) It must be remembered that close to two thirds of internal medicine
residents enter subspecialty training (Department of Health and Human Services,
1988). Some analysts interpret data from the National Resident Matching
Program as cause for alarm (see for example Colwill, 1988). Table 1.4 illustrates
the four-year trend in United States seniors entering primary care residency
programs. Each of the three specialties experienced a downward trend of some
magnitude. These data, together with indications from an annual survey of
graduating medical students, underlie the concerns about the supply of
primary care physicians. Data from this survey (Table 1.5) show declines in the
proportion of medical students, who each year represent the most recent entrants
into the residency pipeline, choosing primary care specialties. Data from the
National Resident Matching Program also highlight the fact that the number of
available primacy care residencies is not necessarily the determinant of the
number of primary care physicians that enter the workforce. Between 1983 and
1989, the number of residency positions in primary care offered to physicians in
their first year after medical school increased faster than the positions were filled.
Thus, family practice positions offered increased by 4.4 percent and the proportion
filled by U.S. graduates fell from 71.4 percent to 59.8 percent. Including foreign
graduates the proportion filled fell from 80.6 percent to 71.1 percent. Internal
medicine first year positions offered grew by 19 percent between 1983 and 1989,
while the fill rate dropped from 71.9 percent to 63.5 percent and 86.3 percent to
80.4 percent respectively for U.S. graduates and in total. The pediatric experience
was similar. Positions increased 15.2 percent and the fill rate dropped from 65.8
percent to 60.7 percent and 84.6 percent to 80.0 percent respectively for U.S.
graduates and in total (National Resident Matching Program, 1989). However,
there are indications that the number of U.S. graduates filling residencies is
higher than indicated by data from the National Resident Matching Program.
~ Data from the American Board of Pediatrics indicate that the number and
growth rate of pediatric residents may be somewhat higher than indicated by the
data in Table 1.3 According to data derived from the number of residents taking
the Board's annual in-training exam and a follow-up survey of programs, the
number of general pediatric residents grew from 6,695 in 1985 to 6,942 in 1988.
(Personal Communication, Thomas K. Oliver, Senior Vice President, American
Board of Pediatrics, October 2, 1989). This growth of 3.6 percent exceeds the 2.9
percent shown by data from the American Medical Association, but is nevertheless
substantially below the 9.2 percent growth for all residents between 1985 and
1988 shown by the same data set of the American Medical Association.
25
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Table 1.4
National Resident Matching Program
Positions Matched by U.S. Seniors
Percent
Change
Specialty 1986 1987 1988 1989 1986-89
Internal 4,067 3,750 3,668 3,432 - 15.7
Medicine*
Family 1,680 1,729 1,493 1,468 - 12.6
Practice
Pediatrics 1,367 1,366 1,313 1,256 - 8.1
* Excludes preliminary programs because a high proportion of that group
enters other specialties.
Sources: Jack M. Colwill. 1988. Primary Care Education: A Shortage of
Positions and Applicants. Family Medicine 20~41:250-254; National
Resident Matching Program, Evanston, Illinois.
26
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Table 1.5
Specialty Choice of Medical School Graduates 1981 - 1988
Percent of All Graduates with Definite Choice
General
Internal General Family
Medicine Pediatrics Practice
198112.7% 7.3% 17.3~o
198213.9 6.8 18.2
198312.7 6.5 17.7
198410.4 6.6 17.0
198510.3 5.6 15.9
19868.3 5.4 17.0
19876.8 5.2 18.3
19887.3 4.9 13.6
Source: Association of American Medical Colleges. Graduation
Questionnaire 1981 - 1988. Washington, D.C.: Association
of American Medical Colleges.
27
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Such indications are found in data collected by the American Medical Association
and frequent anecdotes of positions unfilled by the match being filled by U.S.
graduates after the match has been completed.
Behind these numbers lie the factors that cause physicians to select
specialties. The extent to which financial factors determine choice is not
completely clear. Only 0.7 percent of graduating medical students in 1988 stated
that income relative to other specialties was the most important factor in the
choice of specialty (Association of American Medical Colleges, 1988). However,
survey data on such a topic may contain distortions because of reluctance to admit
to being influenced by financial factors. Nevertheless, rational economic decision-
making would steer physicians away from primary care specialties; the return on
the educational investment is lower for the primary care specialties than for all
other specialties except psychiatry (Marder, 1988); the incomes of primary care
specialties are low compared with other specialties, and the income differential
between the highest-paid specialties and the lowest-paid specialties (pediatricians,
general and family practitioners, and psychiatrists) is growing. Between 1977 and
1987, the real mean net income (after expenses and before taxes) of general and
family practice physicians fell by 0.3 percent; for pediatricians the drop was 0.6
percent and for internal medicine physicians there was an increase of 0.7 percent.
Other specialists did better. The real net income of the average physician
increased by 1.5 percent over the same period; 3.3 percent for surgeons and 2.8
percent for anesthesiologists. The actual net income differentials were also
considerable in 1987. Pediatricians, general and family practitioners and internal
medicine physicians had net incomes of $85,300, $91,5000 and $121,800
respectively, compared with net earnings of over $163~000 for
obstetrician/gynecologists and anesthesiologists, and over $180,000 for surgeons
and radiologists (Gonzalez, 1988). Some economic analyses indicate that future
earnings do have a small impact on specialty choice (Sloan, 1980 and Hadley, 1977
cited in Yoder, 1983). One empirical analysis using sophisticated econometric
techniques indicates that expected lifetime earnings have a statistically significant
but small effect overall on the specialty choice of United States medical school
graduates. It is, however, interesting to note that this finding does not hold for
women physicians (Marder, 1988).
Primary Care and the Problems of indigent Care The committee felt strongly
that any policies that increase the support of primary care ambulatory residencies
should be analyzed in terms of their impact on access to care for medically
indigent patients--both to ensure that access is not imperiled and if possible to
increase the availability of services for disadvantaged populations.
28
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The interaction between care for indigent patients and primary care resident
financing is complex. On the one hand, primary care training in ambulatory
settings is hard to finance, in part because these settings customarily provide care
for substantial numbers of medically indigent patients. On the other hand, as can
be seen from numerous examples (Walkington, 1989), primary care ambulatory
residency programs can be used by state and local governments to provide needed
care for indigent residents. When state or local governments pay for such care,
the financial difficulties of the programs can be eased. Such a proposal is spelled
out by Reiselbach (19861:
" a linkage between the funding of graduate medical education and care
of the indigent may be an effective means of accomplishing the changes
in clinical education and indigent care necessitated by major problems in
these areas".
The natural affinity that has developed between GME and hospital care can be
extended to primary care settings resulting in benefits to education as well as
patients.
Another aspect of the relationship between primary care physicians and care
for indigent people is the role of primary care in the prevention of hospitalization
and serious illness. This role is made clear by the following data: a survey of
uninsured patients admitted to Washington, D.C. hospitals indicated that nearly
40 percent had no usual source of primary or outpatient care. When evaluated by
hospital quality assurance staff it was discovered that more than one-third of
uninsured, non-obstetric, non-trauma patients could have avoided the admission of
they had received timely primary care. In addition, analysis revealed that
admission rates for diagnoses that are well suited to management in an outpatient
setting were much higher in poorer areas of the city, where the proportion of
uninsured residents is highest (Barch, 1989). These data again indicate that
access to primary care can be a cost effective and humane health system response
to the problem of medical indigency.
Finally, residents are important in enabling teaching hospitals to provide
significant amounts of uncompensated care. The fear is that if primary care
residents substantially reduce their inpatient service time, the costs of replacing
residents with other personnel will reduce the financial ability of the hospitals to
sustain their uncompensated care load. This could, in some localities, have a
serious impact on access to hospital care for medically indigent people. The role
of teaching hospitals in the provision of uncompensated care is quite substantial.
In 1986, 369 teaching hospitals (members of the Council of Teaching Hospitals)
provided a disproportionate amount of the uncompensated care (deductions for
charity care and bad debt) provided by short term non-federal hospitals. These
29
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369 hospitals provided 40 percent of uncompensated care and received only 29
percent of net patient revenues (Association of American Medical Colleges, 1988b).
30
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REFERENCES
Accreditation Council for Graduate Medical Education. 1988. Special Requirements
for Residency Training Programs in Internal Medicine. Chicago: Accreditation
Council for Graduate Medical Education.
American Medical Care and Review Association, Council of Medical Specialty
Societies. 1988. Patient Care Managers and Gatekeepers: A Status Report.
Bethesda, Maryland: American Medical Care Review Association.
Anderson, Ronald M., Christopher Lyttle, Claire Kohrman, Gerald Levey, and
Catherine Glen. 1989. National Study of Internal Medicine Manpower: XV. A
Decade of Change in Residency Training in Internal Medicine. Annals of
Internal Medicine. Il0~111:922-929.
Association of American Medical Colleges. l98Sa. 1988 Graduation Questionnaire
Results. Washington D.C.: Association of American Medical Colleges.
Association of American Medical Colleges. 1988b. Bad debt and charity deductions
for short-term non-federal hospitals by membership in the Council of
Teaching Hospitals. Based on data from the American Hospital Association
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34
Representative terms from entire chapter:
medical education
