Velasquez et al. start an important discussion about the role of for-profit training sites in graduate medical education (GME); they outline possible costs and benefits, and conclude that additional academic investigation is needed. Further research, however, would require accepting the role of profit in our health system. To counter, I argue that GME in for-profit training sites is harmful for trainees and patients, so does not merit continued pursuit.

I echo the critiques identified by the authors, but only as starting points. First, the authors fail to mention that the already published literature investigating the impact of for-profit training sites has already drawn some important conclusions. Though not comprehensive, for-profit training sites correlate with lower board pass rates among pediatrics residents and lower pay for emergency medicine residents compared to their academic colleagues.1,2

Second, the authors acknowledge “training environments significantly shape physician behavior.” This means clinicians absorb not just the clinical practice patterns, but also the values and norms of their training environment. This risks producing physicians who have normalized the health system as is — including its inequities and prioritization of profit. Learning in explicitly for-profit training sites will worsen this normalization, and could be harmful for trainee mental health. A growing body of literature shows that working within, and upholding, a care system that does not reflect trainee values results in moral injury, which is subsequently associated with burnout, decreased career satisfaction, and departure from clinical medicine.3

Lastly, as the authors concede, some literature suggests worse outcomes for patients in the for-profit care setting. One recently published study found increased rates of adverse events at private equity acquired hospitals,4 while another found increased mortality for elderly patients with heart disease at for-profit hospitals.5 Thinking beyond these isolated studies, we know spending does not correlate with improved patient outcomes: years of data show the American health system spends more, but has worse outcomes than peer countries that de-platform profit. Accordingly, I fear further investment in for-profit training sites is not evidence-based and risks harming patients.

Taken together — I agree wholeheartedly with the author’s calls for a radical and creative reimagination of GME. I disagree, however, with a reimagined vision that perpetuates the delivery of for-profit care. Academic inquiry into the role of for-profit training sites in GME will only serve to further entrench profit in American healthcare, and thereby ultimately harm patients and trainees.