Time to Start Growing Graduate Medical Education

Now that the Medical Center has received legislative approval to start building a new medical school, we can begin implementing our plans to expand our class size from 135 to 165 students per class, on a path that coincides with completion of the project.  A new building with greatly expanded simulation capabilities and classrooms better suited to interactive team-based learning is a must for us to train more doctors for a state that ranks last in physicians per capita.

But while we’re making plans to grow the class size, we can’t lose sight of a related need that is in some ways just as important.  We also need to increase the number of residency positions we offer to accommodate this growth in class size.  After all, to produce more M.D. graduates without adequate graduate medical education (GME) opportunities in place to accommodate them would make us an “exporter” of well-prepared physician graduates to other states.

The mismatch of medical school seats to residency slots is already a challenge in other places.  For the past decade, spurred by concerns about our country’s aging population, states have established new medical schools and expanded enrollment at existing schools.  Yet the number of residency training slots has not kept pace with this explosive growth. 

We’ve seen evidence of this disequilibrium during Match Day the last few years.  On a national level, there are simply too many graduates seeking too few residency positions.  When all the dust settled, our graduates have done fine.  But this is a trend that will grow worse over time.

What’s holding back the growth of residency slots?  If you guessed money, you’d be right.  Medicare has traditionally funded residency training in the United States.  But the number of Medicare-funded slots has essentially been frozen since the Clinton administration.  Despite this freeze, GME programs have experienced modest growth by turning to alternative sources of funding.  Teaching hospitals, medical school departments, physician group practices and even state legislatures have chipped in to fund resident and fellowship slots.  But this modest growth in GME slots has not been nearly enough to match the growth in medical school enrollment.

Now there’s discussion in Washington, D.C., of even cutting back on Medicare funding for GME, out of concern for the federal budget deficit.  I think everyone in medical education agrees that this exactly the wrong time to be considering such actions.  If anything, we need to expand federal support for GME. 

In Mississippi, we’re keeping a close watch on these developments.  We’re fortunate to be co-located with a VA Medical Center, which supports the training of about 80 of our residents.  Our hospital system is also a major underwriter of GME, contributing about $5 million each year to this effort.

Historically, we’ve tried to keep our total number of UMMC residency positions at about 110 percent of the size of our medical school class.  Why is that the magic number?  Well, about 55 to 60 percent of our graduates stay in the state to complete their training.   And we find that we can fill approximately one-half our residency slots with quality out-of-state trainees.  So the 110 percent ratio gives us the flexibility we need to accommodate our own graduates and to “import” graduates that want to come here from other states, many of whom remain in Mississippi to practice.

You might ask, why not reserve ALL of our residency slots for our own graduates?  To put it simply, there are forces at work that take them away from us – like family tradition, access to training programs we don’t provide, or just a desire to see the world beyond Mississippi.  Even with this out-migration, we retain more of our graduates in-state than almost any other medical school.  And many of our graduates eventually do return, and we welcome them with open arms.

What do the numbers look like for the future?  Right now we have about 560 residency slots and next year we will reach our full complement of 135 students per class, for a total of 540 for all four years.  That will give us a ratio of residents to students of about 104 percent – a little less than we’re comfortable with, but with a few new slots coming on line to give us some wiggle room.

It will really get interesting when our new medical school comes on line.  When we finally grow the class size to its full complement of 165, or 660 students for all four years, then theoretically we will need 726 residency positions to accommodate them.  That’s 166 more than we offer today!  We’ll have to be awfully creative to identify the funding and the clinical teaching material to accommodate such growth.  Certainly one of our options will be to turn to community-based hospitals to partner with us in this critical piece of our education mission.

We’re fortunate that we have wonderful leadership of our residency programs from Dr. Shirley Schlessinger, associate dean for GME, and the directors of our 51 accredited residency and fellowship programs.  We also have a well-conceived plan for gradual, quality growth of our residency and fellowship programs, in areas that speak to the state’s needs. This is one of those cases where failure is not an option!  Mississippi needs more doctors, and we’re going to deliver.