Physiatric Patient Care, Graduate Medical Education Training, and Graduate Medical Education Funding: A Call for Alignment

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Physiatrists are physicians who specialize in the field of physical medicine and rehabilitation; they provide comprehensive care for the millions of Americans, both adults and children, with functional and cognitive deficits due to injuries, illnesses, and disabilities in conditions such as spinal cord injury, traumatic brain injury, stroke, neurodegenerative disorders, bone, muscle, nerve and joint disorders, chronic pain, amputation, spasticity, and postoperative care. Physiatrists go through extensive education to promote quality of life in patients with acute and chronic disability.
Physiatry training requires 4 yrs of medical school followed by 4 yrs of residency.1 Residency is a graduate medical education (GME) training program providing specialized training in a specific field. Residency programs in physiatry are vital to the creation of physiatrists, who can effectively care for the expanding population of Americans with chronic disease. Americans live longer2 than ever before and one in five Americans experience a chronic disabling condition.3 Rehabilitation of patients experiencing stroke has again and again shown to improve the quality of life.4 In addition, higher functional and cognitive gains after inpatient rehabilitation has been associated with lower admission rates.5 With our national focus heavily biased toward disease “cure” versus the long-term management of chronic disabling conditions, this underserved population is not only growing but also largely neglected. It is crucial that as a nation, the United States continues to train medical students and residents to become physiatrists to care for this growing population.
The Association of American Medical Colleges has projected a shortage of between 61,700 and 94,700 physicians by 2025.6 Medical schools are doing their part and have expanded their census in the past decade. Since 2002, medical schools have increased the number of first-year students by 21.6%.7 The ability for these students to obtain a residency position, a necessary training requirement before practice as a physician, however, is being stifled because residency positions have not grown at the same pace at medical school enrollments: GME growth has been constrained because of the Balanced Budget Act of 1997, which placed a cap on Medicare support for residency programs.8
The federal government, through Medicare, is the largest funder of GME; each year, it contributes approximately US $9.5 billion in Medicare funds and approximately US $2 billion in Medicaid dollars to help pay for GME.9 Congress stated, “Educational activities enhance the quality of care in an institution and it is intended, until the community undertakes to bear such education costs in some other way, that a part of the net cost of such activities (including stipends of trainees as well as compensation of teachers and other costs) should be considered as an element in the cost of patient care to be borne to an appropriate extent by the hospital insurance program.”10 Medicare funding is essential in creating a strong physician workforce and a healthy nation. An increase in GME positions of 17.5% from 2003 to 201211 has been mostly due to increasing rates of subspecialization, leading residents to remain in training longer,12 and is not necessarily a reflection of an increase in resident matriculation in GME programs. Graduate medical education growth in physiatry, in particular, has been remarkably small, with growth less than half that of other GME programs: 7.08% growth in physical medicine and rehabilitation GME positions from 2007–2008 (1199 residents) to 2015–2016 (1293 residents) compared with a 15.4% growth in GME positions across all specialties from 2007 (107,851 residents) to 2016 (124,409 residents).
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