Seminars in Nephrology

VOL. V, NO. 3                                                       SEPTEMBER 1985


Financing Fellowship Training

Walter Lacquer, a penetrating scholar of German history and politics, feels that one of the most distinctive characteristics of the German people is a tendency to too much. This appears to be a trait not limited to Teutons. With respect to medicine, we seem to have too little or too much care, too few or too many doctors. The same people, or their clones, who 20 years ago decried the shortage of physicians now have dis­covered that we are up to our endoscopes in doc­tors. This realization is likely to have interesting effects on the training of nephrologists.

Senators Dole, Durenberger, and Bentsen have just introduced an amendment (S. 1158) to the So­cial Security Act which, if passed, will have a pro­found effect on the funding of all graduate medical education. Among the bill’s provisions are a limit on the number of years of residency training that Medicare will support and an end to the funding of training of alien (excluding Canadian) graduates of foreign medical schools.

The bill would provide a maximum of five years of residency training, but no more than the mini­mum number of years necessary to satisfy initial Board eligibility. In other words, three years for a medical resident and five for a prospective sur­geon. The thinking of the senators is instructive and not entirely logical. (By the logic of politics, it is totally coherent.) The following quotations are all from the Congressional Record of May 16, 1985, beginning page S 6337:

Open-ended funding of medical education cannot continue.

The contraction of subspecialty slots likely to result should shift emphasis more to Primary care training. In this way, more physicians in training will choose to end their graduate medi­cal training at the still-needed first contact spe­cialties.

It does not appear to continue to make sense to use Medicare Trust Fund dollars to underwrite AFMG (alien foreign medical graduate) train­ing. The aliens who train here frequently plan to stay and ultimately also contribute to this na­tion’s over supply of physicians.

Though I (Bentsen) am pleased to be an origi­nal cosponsor of the pending bill, I am not yet satisfied that the question of funding graduate fellowships has been properly addressed, partic­ularly as it relates to internal medicine residen­cies.

Many might agree that it does not make a lot of sense to have graduate medical education open ended. S.1158 proposes to address the problem by training less specialists and more primary care physicians. What it does, however, is support the training of urologists at the expense of nephrolo­gists, of orthopedic surgeons in preference to rheumatologists. This anomaly results from the different board structure of surgical and medical subspecialties: a single board in the case of urol­ogy; two boards in that of nephrology. The bill will support training only to the point where a trainee is first able to sit for a board examination.

The Association of Professors of Medicine has recommended the compromise of funding a fourth (but not a fifth) year of training in internal medi­cine. This proposal is, of course, an admission of insecurity because it still leaves intact the inequal­ity between medical and surgical specialties. The Professors feel that one year is all they can hope for and that one is better than two. Their logic is as impeccable as their standing with the Congress is weak. Why our position with our legislators is so fragile is not clear. Senator Bentsen, at least, ap­pears to be aware of the inherent unfairness of the proposal.

The issue of foreign medical graduates is sheer politics. Aliens do not vote. American graduates of foreign medical schools do, and so do their families. Therefore, the senate is unwilling to fund alien graduates of foreign medical schools while it is content to support American graduates of the same institutions. The concern of our solons about open-ended subsidies is nowhere to be seen on this issue. Foreign medical schools can accommodate as many of our citizens as they can squeeze in, and the federal government will subsidize their gradu­ate education. In effect, this bill cedes to institu­tions beyond our jurisdiction the right to determine how many residency slots the government will un­derwrite.

Of course, the bill is not yet law. It still may not be when this appears. There still is time to present arguments for its modification. Two reasonable changes are to treat medical and surgical residents the same and to limit the number of foreign gradu­ates, regardless of citizenship, we will subsidize. We could change our board structure to match that of surgery and perhaps obtain funding for fourth and fifth year residents, but that would be a law­yer’s trick and not an educationally sound reason for modifying what has proved to be a satisfactory system of certification.

Finally, why the preference for Canadians over Mexicans? Canadian graduates of Canadian schools who take residency training in the United States will continue to be supported by Medicare, whereas Mexicans will not. Surely, it cannot be because the Senate thinks Canadian schools are better than Mexican. If that were so, they would not be willing to fund American graduates of Mexican medical schools.

Originally published:

Kurtzman NA (ed): Financing fellowship training.  Sem Nephrol 5:155-156, 1985.