Discussion: State of the Plastic Surgery Workforce and the Impact of Graduate Medical Education Reform on Training of Plastic Surgeons

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The authors, as members of the Issues Committee of the American Council of Academic Plastic Surgeons and the Academic Affairs Committee of the American Society of Plastic Surgeons, have provided us with the historical background of graduate medical education, finances, and associated plastic surgery workforce issues and the current climate of efforts toward graduate medical education funding reform.1 To place in relief the effect of the funding crunch on plastic surgery, the authors cite the results of an American Council of Academic Plastic Surgeons survey of training program directors. Of the respondents, less than 40 percent of resident graduate medical education funds were derived from Medicare (with or without Veterans Administration), and the balance were derived from the hospital, clinical revenue, or industry. Because federal (Medicare) funds will pay for only 0.5 of a full-time equivalent beyond primary board certification, of interest would be those results for the independent residency positions alone. An additional adverse funding effect for independent programs on efforts to convert to the integrated model is a necessity to secure funding at the level of two per year (on average) or a total of 12 positions instead of six, certainly a dampening influence on those efforts. Regardless, the necessity to pursue funding from other sources makes the program beholden to entities perhaps with other oxen to gore than resident education. The authors conclude the topic with a set of recommendations. Before a discussion of those recommendations, perhaps some emphasis and perspectives on some particular background aspects may be of benefit.
The issue of the increase over time of the numbers of medical school graduates and static numbers of graduate medical education physicians (the result of the 1997 Balanced Budget Reconciliation Act) represents the disconnect of interests between the American Association of Medical Colleges (the “Deans Group”) and the Accreditation Council for Graduate Medical Education, although the former has a seat on the latter. Because of this mismatch and because of international medical graduates, including the U.S. graduates of offshore medical schools traditionally matched into those graduate medical education positions not filled by graduates of U.S. medical schools, a shrinking number of those positions will be available to international medical graduates.2 The graduate medical education of the United States has always been viewed as the “land of opportunity” for international medical graduates, and they tend to practice in underserved areas, encouraged to do so by some visa requirements. Thus, certainly the ramifications of the Balanced Budget Refinement Act go well beyond the confines and interest of plastic surgery.
Much of the discussion in this article and the literature on this topic revolves around workforce projections. Historically, as the authors describe, the cycle of such projections is one of a zenith of surplus and a nadir of shortage (or the reverse), but the crucial period for any discussion of this topic was the early 1990s. The advent of managed care provided the foundation for estimates of the necessity of plastic surgery care of patient-to-surgeon ratios drastically higher than those that existed at that time. Those estimates compounded by dwindling reimbursement rates culminated in recommendations by an American Society of Plastic Surgeons task force (of which this writer was a member) of a significant reduction in plastic surgery graduate medical education positions (Fig. 1). More broadly, similar projections articulated in the entire arena of graduate medical education resulted in the Balanced Budget Refinement Act legislation of 1999.3 A number of authors (again including myself),4,5 after viewing these data, articulated concerns about the necessity for a thoughtful approach to the issue of the future plastic surgery workforce.
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