A Mortgage on the House of God

Abstract

No one can deny that managed care has had a profound impact on the US health care system, especially in areas of high penetration. Patients are now referred to as “members,” “covered lives,” or even “units of service.” Physicians are simply “providers.” Few outside the medical education community, how-ever, are even aware of the impact of managed care on physician training programs, especially those based in community hospitals. The impact of managed care on graduate medical education is multidimensional. That is, it affects many very different aspects of a training program. These include the patient base itself, the fiscal status of the training program, the viability of the sponsoring institution and the resources available to support physician clinical education. In some cases, that impact can be positive. In others it is clearly negative. The priorities of contract populations, clinical guidelines and pathways, capitation, outcomes monitoring and information systems often collide with those of continuity of care, clinical problem solving, patient advocacy and professional collaboration. Significantly, the impact of managed care is also temporally unreliable, in that the patient population of hospitals, clinics and other clinical settings are at risk for major change with minimal advance warning. When coupled with the stresses inherent in residency training, for example, this “instability” of the environment can bring with it substantial challenges for both faculty and housestaff.