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In 1997, President Bill Clinton was coming off a convincing reelection effort and presiding over a booming economy. Tax revenues were surging, and the federal budget deficit was falling. During the preceding two years, the annual deficit had shrunk from $164 billion to just $22 billion. For the first time in a generation, a federal budget surplus seemed like a real possibility.
Against this backdrop, Clinton and a Republican-controlled Congress negotiated the Balanced Budget Act of 1997, which aimed to balance the federal ledgers by 2002. The act created the State Children’s Health Insurance Program, which provided health insurance to children from low income families, and enacted a number of reforms aimed at squeezing cost savings from Medicare.
One of these provisions sought to cap the number of medical school graduates apprenticing as residents in U.S. teaching hospitals. Then as now, Medicare reimbursed hospitals for a significant share of residents’ salaries. The Balanced Budget Act established limits on those reimbursements, effectively fixing the number of funded residents at 1996 levels. (In 1999 Congress amended the limit for rural hospitals only, increasing the numbers of funded residents at those hospitals to 130 percent of 1996 levels.) Essentially, the law stipulated that if a hospital wanted to expand its pool of residents, Medicare would not pay for it.
How could such a provision make it through Congress? Lawmakers received cover from the American Medical Association (AMA), the Association of American Medical Colleges, and other major stakeholders in American medicine who endorsed caps on funding for residents and other graduate medical education programs. In March 1997, months before the Balanced Budget Act was enacted, the AMA even suggested reducing the number of U.S. residency positions by approximately 25 percent — from 25,000 to fewer than 19,000. “The United States is on the verge of a serious oversupply of physicians,” said the AMA and other physicians’ groups in a joint statement. Since most states require at least some residency training for medical licensure, reducing the number of residency positions would curtail the supply of doctors in the U.S.
Fast forward two decades, and what once seemed like a glut now looks like a shortage. The growth in the number of residency positions — and thus the number of doctors — slowed after the passage of the Balanced Budget Act. From 1997 to 2002, the number of residents in the U.S. increased by just 0.1 percent. Although the number of positions has increased since then, each year thousands of residency applicants fail to secure a position. Factor in an aging population and a projected increase in demand for health care services, and the U.S. is now forecasted to experience a shortage of 46,900 to 121,900 physicians by 2032. Absent a meaningful response from Congress, it will be doctors — particularly residents — and their patients who pay the price.
American medicine is already experiencing a devastating crisis within its workforce. In a recent Medscape survey, 44 percent of American physicians reported feeling burned out, 15 percent reported feeling depressed, and 14 percent reported thoughts of suicide. Between 300 and 400 doctors kill themselves every year, a rate more than double that of the general population. And the crisis may be getting worse.
Physician burnout has serious consequences for patients, providers, and the medical system at-large. A 2018 study found that physicians who reported at least one symptom of burnout were more than twice as likely to report having committed a serious medical error within the preceding three months. Burned out physicians are more likely to suffer from anxiety, depression, and exhaustion. A recent study estimated that burnout costs the American health care system $4.6 billion annually.
Residents are most vulnerable to burnout. They work brutal hours, get insufficient sleep, and lack control over their schedules. It’s little surprise that nearly 30 percent of residents experience depression or depressive symptoms.
Many causes underlie the physician burnout crisis. For instance, the increasing corporatization of American medicine has burdened physicians with excessive non-medical tasks, or “scut work,” and diminished the power of their voices. Also, excessive paperwork requirements and the proliferation of electronic medical records have forced physicians to spend more time in front of computers and less meaningful time with their patients. And long work hours, historically a hallmark of an American medical career, leave them little time to wind down and maintain crucial relationships outside of the clinic or hospital. The outdated funding caps established by the Balanced Budget Act now threaten to exacerbate the crisis.
This augurs poorly for the welfare of American physicians. My worst days as a medical intern came when I was carrying a full patient load. During a day shift, that meant managing 10 patients at a time: spending time with them, examining them, entering all necessary medical orders, and filling out dozens of associated medical documents. During night shifts, sometimes as many as 40 patients were under my care. These shifts were often challenging, chaotic, and stressful; if even a single patient developed complications, the shifts could quickly become unbearable.
To prevent these nightmare scenarios from becoming the new norms, Congress must, at the minimum, lift the graduate medical education funding caps implemented by Mr. Clinton’s 1997 law. An even better response would be to increase Medicare funding to create more residency positions.
Time is of the essence: It takes four years to complete medical school and an additional three to seven years to complete residency in the U.S. With a physician shortage looming, Congress must act as soon as possible. Bills to create more residency positions have been introduced in both the House and Senate in 2019, but they’ve stalled. They deserve a vote.
Increasing federal funding for medical residents will not solve the burnout crisis in America. But it would go a long way toward mitigating the effects of impending demographic changes. After two decades of inaction on this issue, it’s time for legislators to act.
Kunal Sindhu is a resident physician in New York City. You can follow him on Twitter @sindhu_kunal.