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University of Medicine and Dentistry of New Jersey Newark, NJ 07102
WEB—This is a Web exclusive article.
However, one point professed by Larson and Saket [1] bears comment. Referring to the rescheduling of the certifying examination from the 12th month of the 4th year of residency to 3 months after the completion of the 5th year beyond internship, they state "residents against the delay have argued that since resident labor is essentially free to the training hospitals (their salaries and administrative costs are offset by reimbursement by government and other entities), it is not unreasonable for residents to finish the last few months of training rounding out their education." This argument, articulated euphemistically, is in several ways factually incorrect and is also politically invidious and should not be propounded or promoted. Rather it must be repudiated to prevent our specialty from becoming susceptible to a public relations debacle.
Most hospitals receive compensation from Medicare for housestaff salaries through funds designated for direct and indirect graduate medical education, the amounts of which are transferred according to the number of approved training positions irrespective of the type of residency. The formula for reimbursement depends on the percentage of care provided to Medicare patients at that hospital. Some facilities have done very well by this formula. Others, such as mine, which serves a largely innercity clientele of predominately young and middle-aged patients, get less than 20% of each trainee's salary from Medicare because the patient population treated contains only a small percentage of elderly individuals. These institutions must therefore directly pay most of residents' salary and benefits expenses. They do not get a gift from the government to cover all or even most of the costs.
The Balanced Budget Act of 1997 placed a cap on the number of trainees for which Medicare will reimburse hospitals. That cap has not been changed in 11 years [2, 3]. It is conceivable that a radiology program could cadge additional positions from some other residency program without exceeding the cap, but that is unlikely inasmuch as nearly all program directors wish to gain additional trainees and will not give away positions they already have. In 1997, there were 3,754 radiology residents in the United States. In 2008, there are now 4,559 individuals in our training programs [4, 5]. So the additional 805 trainees, a 22% increase, are not being compensated through an augmented infusion of Medicare funds. They have to be paid from other sources. If the funding source is the hospital itself, its financial officers probably would not countenance providing support to "round out a trainee's education" because they would know that phrase for what it is—a smokescreen for the performance of no clinical work.
Moreover, Medicare has reaffirmed recently that payment is made for resident salaries on the basis of clinical work done daily, not for learning, studying, or rounding out an education. In a directive issued in 2006, Medicare announced, and recent audits have confirmed, that a day spent by a resident with no documentation of a clinical encounter for which a charge could be generated is a day without payment to the facility for that trainee's service [6].
The rationale reported by Larson and Saket [1], if believed and asserted, puts radiology in an unnecessarily untenable position. At present, no other specialty conducts its certifying examination during residency, and no other specialty has sought to legitimate a several-month "study hall" in preparation for the examination. It is unreasonable for radiologists to maintain a position validating several months of preparation for an examination at others' expense. Like everything else, nothing is free, although it may seem so to the immediate beneficiaries.
There is no justification beyond self-centeredness to claim, under the guise that the hospital does not pay for it, that radiology residents can act according to a unique schedule of privilege available to no other residents. Ultimately Medicare and the American public do pay for most of residency salaries. And for others, a transaction must take place contributed by some other payor. Thus, the assertion that there is "free time" is indefensible and inimical. We must remember that radiology has an enduring problem with the image it projects to others in medicine and also to the general public as a result of our seeming clinical separateness and our physical remoteness. We will not earn their empathy by pleading that we deserve to maintain a special exemption from other duties to prepare for a test. From a public policy perspective, why make things worse by adding antipathy to anomie?
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