Graduate Medical Education Should Not Be A Commodity

Illustration by Brett Ryder

Hahnemann University Hospital was an academic medical center associated with Drexel University that had served as a clinical patient care hub in Philadelphia, Pennsylvania, since 1848. Hahnemann’s heritage was significant: One in seventy-two physicians currently practicing in the US graduated from or trained within Drexel University or its legacy schools, Hahnemann University and the Woman’s Medical College of Pennsylvania, later named the Medical College of Pennsylvania when men were admitted in 1970. Although Hahnemann University Hospital served as a safety-net institution for underserved people while influencing health care in the Philadelphia area for generations, it is now remembered as the epicenter of the largest graduate medical education (GME) disaster to date. In June 2019 the hospital’s new ownership declared bankruptcy, and within two months—after having provided health care to the region for more than 170 years—Hahnemann University Hospital abruptly closed its doors.

The closure made national news for several reasons. The bankruptcy affected the lives of more than 2,500 employees in the city and displaced more than 550 physician trainees. The hospital’s underserved, ethnically diverse patient population was left to redistribute their own care around the city. Speculation about whether the intentions behind the acquisition of Hahnemann by a private equity group in January 2018 had been well-meaning or whether it was a dubious real estate ploy caught the public eye and received significant political and media attention. Amid stories of injustice and greed, the new ownership announced the hospital’s impending closure less than eighteen months later. During the brief time of ownership, the assets—namely, the hospital itself, its malpractice company, and the center-city property footprint—were split into different corporations. The hospital and malpractice company filed for bankruptcy with millions in unpaid debts, and the owner retained the property lot for future sale.

Amid the ongoing coronavirus disease 2019 (COVID-19) pandemic, the anniversary of Hahnemann’s closure came and went with little fanfare. Here I tell the story of the health care teams that worked and cared for patients at Hahnemann. Hopefully, we can learn from its demise.

‘Rightsizing’ Graduate Medical Education

I have spent my entire career in academic medicine, training the next generations of health care providers. I enjoy teaching others to care for patients even more than I enjoy doing it myself. One of the most memorable compliments I have received is that I have a talent for “turning knuckleheads into great clinicians.”

During my time as a physician at Hahnemann, I became the institution’s first and only female professor of emergency medicine. I then assumed a leadership role as the associate dean of graduate medical education. In that role, I and my team were asked to identify opportunities to improve the tenuous financial situation of the institution by maximizing GME revenue.

Graduate medical education—the additional years of specialized training for physicians after medical school—is substantially funded by the US federal government. I became a scholar of the complexities of GME financing, a mind-boggling, formulaic, and complex process in which significant federal dollars are allocated to support physician training. Specifically, I was tasked with planning to “rightsize” our residency programs. At the time I had a woefully inadequate appreciation of the magnitude of this challenge. It is the schism between balancing a budget and balancing a future health care workforce. What would achieving the right size of a residency program mean? Would the measure of success be the number of physicians we trained who stayed in the region to provide care to the community? Was the right size a balance of comprehensive training programs to support a tertiary care hospital practice and serve as the academic affiliate of a medical school?

What the right size meant to the new hospital ownership was keeping the residency programs that improved the financial bottom line and decreasing or eliminating those that did not. If we eliminated GME positions that weren’t as profitable, the owners asked, how many nurse practitioners or physician assistants would it take to replace the doctors-in-training?

Years of longitudinal planning are required to properly expand or contract the size of physician training programs. Our leadership team invested exorbitant time evaluating training program requirements, regulations, academic affiliation agreements, contracts, and budgets. The complex endeavor stalled in the din of legal disputes and mudslinging.

Then Hahnemann ran out of time.

As the hospital entered bankruptcy court, a judge in Delaware allowed the hospital’s GME physician trainee positions to be auctioned off for $55 million to help repay the owner’s debtors. These trainees and their GME spots became a commodity to be bought and sold, and the spots were auctioned to the highest bidder. Thankfully, the Pennsylvania Medical Society, Association of American Medical Colleges, Accreditation Council for Graduate Medical Education (ACGME), and Centers for Medicare and Medicaid Services (CMS) all appeared in court to object to the auction. A federal judge halted the proceedings, and the spots now are being redistributed according to CMS policy.

An Administrative Decision

The concept of rightsizing residency programs is not unique to Hahnemann. The same financial pressures and conversations are happening around the country in other academic medical centers, whether for-profit or nonprofit health care institutions, and it honestly terrifies me. The competition within the market among for-profit and nonprofit organizations is fierce. It is horrifying to realize that there is little to no protection or anticipatory plan for the greater good of the public.

Family medicine programs are often the first to go in the course of rightsizing financial decisions. Attempts to levy GME funding to support primary care training have occurred, but primary care does not generate high revenue compared with inpatient or procedurally oriented specialties. To a hospital executive under extreme pressure to cut costs, a family medicine resident may add little to no value to the bottom line. Recently, a prominent institution in New York City was going to abolish its family medicine program. As I understand it, the family medicine physicians and trainees at this institution redeployed themselves in every way possible to assist on the front lines of health care during the COVID-19 pandemic, and the decision to eliminate the program is being reconsidered.

Policy makers need to understand that the fate of the pipeline of the future physician workforce often defaults to the decision-making power of a hospital CEO. As health care finance becomes increasingly strained, a hospital executive is not likely to be able to prioritize the greater good and the future physician pipeline over the need to cut a budget. Alarmingly, more and more residency training positions are falling out of the grasp of doctors-training-doctors and into the hands of administrators and for-profit financial organizations.

At Hahnemann University Hospital, for example, the accredited GME training programs were supposed to report up through the hospital board. However, the board was not empowered as a fiduciary or advisory entity, and shortly after the transfer of Hahnemann to the new ownership, the entire hospital board resigned. The fate of the residency programs lay in the hands of one individual holding the purse strings.

The trend of centralized power shifting to administrators is happening everywhere in the United States. How will this influence the physician health care workforce in the future? Decisions made now will affect the next generations of health care access. Is the corporate practice of medicine going to decide how many and what kind of residency and fellowship programs this country needs? Are hospital executives going to decide how many primary care physicians, surgeons, and specialists this country needs? These are enormous, pivotal policy issues. Frankly, the future of health care and the well-being of the nation are in the balance. The situation demands that people begin to pay attention.

Hahnemann wasn’t the only teaching hospital to close its doors and orphan doctors-in-training in 2019. Providence Hospital in Washington, D.C., and Ohio Valley Medical Center in Wheeling, West Virginia, also succumbed to economic collapse within months of the Hahnemann University Hospital disaster but did not garner the same national media attention.

Since the Affordable Care Act legislated the process for permanent redistribution of residency slots from closed institutions in 2010, more than 1,500 physician trainee Direct Graduate Medical Education slots have been redistributed around the country, according to the CMS Section 5506 residency slot distribution process. This number does not include the additional 650 Direct Graduate Medical Education residency slots from the Hahnemann, Providence, and Ohio Valley Medical Center closures in 2019.

A Plea For Reform

There are a multitude of policy issues surrounding the funding and training of the next generation of physicians in the United States. It can be overwhelming to even begin to look for reform.

The financial constraints of the US health care system have led to prioritizing institutional survival over the welfare of the workforce. Under the current structure, sponsoring institutions wield the power to decide internally which programs to expand and contract. Certainly, conditions for adequate training must be met via accreditation. Yet if a sponsoring institution follows the rules to develop a new program with the appropriate accrediting agency, it can then expand or contract to rightsize at the micro level. Even though a large proportion of GME funding is supported by federal dollars, there is no mechanism for overall oversight to ensure that this funding is ultimately meeting the health care needs of the American public.

What happened to Hahnemann will happen again. For more than two decades, leaders, policy makers, educators, consumers, and learners from within and outside the medical education and health care industries have been calling for GME reform. In 2017 the Council on Graduate Medical Education (COGME) concluded that “a national strategic plan for GME is needed to build a dynamic and agile GME system that better addresses the nation’s physician workforce needs, evolving processes in medical education and practice, and healthcare transformation.”

It should not be possible for a venture capitalist to buy a hospital and divide up its parts, file for bankruptcy, try to sell GME positions to the highest bidder, and still stand to gain millions of dollars in profit on the sale of the property. Many patients with disadvantaged social circumstances had to scramble to relocate their health care, and thousands of dedicated health care professionals and support staff lost their jobs. There was no oversight for the overall health and well-being of our population.

It is magical thinking to believe that a profit-based health care system without oversight and a more robust system of checks and balances is going to value the high-quality education of the next generations of clinicians and the health care outcomes of the community over profit. As Thomas Nasca, the leader of the ACGME, and coauthors articulated in Academic Medicine: “[Hahnemann University Hospital]’s closure is emblematic of the moral and ethical dilemmas associated with the rapidly changing US health care environment.”

Physicians and academic medical centers continue to lose educational oversight and business autonomy. Health care quality continues to decline while costs continue to rise. The rub is that attempts by physicians to manage the pipeline of trainees within their specialty—or even to organize—may be construed as a violation of antitrust law. Ironically, US antitrust laws were established to protect the public from failures of the free market. Although physicians probably have the greatest insight into the country’s future potential health care needs, our hands are bound, and we are hamstrung trying to prepare for the future.

Admittedly, the process of becoming a physician certainly doesn’t ensure business savvy, eliminate conflict of interest, or make doctors immune from greed or corruption. In fact, many for-profit organizations that control physician practices were developed by physicians.

Hahnemann’s End

On July 29, 2019, the sky was a picturesque, perfect blue. It was a flawless summer day. Five tumultuous weeks after the announcement of the hospital’s bankruptcy, the residents and fellows were released from Hahnemann to complete their residency training elsewhere. Each day of those five weeks felt like a painful eternity. The rapid unraveling of the institution left many of us going through our stages of loss: shock, denial, anger, bargaining, depression, testing, and acceptance. There was so much loss, yet for me the day had the feeling of a joyous wake. We chose to celebrate our accomplishments in “doing more with less every day.”

That night I had one of the most haunting and vivid nightmares of my life. I dreamt that I pronounced a very healthy-looking man in his forties dead. “Time of death, 07:07.” Then, after a thoughtful moment of silence and mourning with the health care team, the man shot straight up in bed, his gaze pierced straight into my eyes, and he yelled furiously, “How could you let me die?! Why didn’t you do enough to save me?!” It was at this point that I realized that my subconscious hadn’t let me off the hook yet. I know I am not alone in wishing that the result would have been different. Many lessons have been learned. Much has been written about the aftermath of the tragedy. I accept that there is nothing that I, as an individual, could have done to stop the demise of Hahnemann. But I still can’t shake the injustice.

Physicians and academic medical centers continue to lose educational oversight and business autonomy. Health care quality continues to decline while costs continue to rise.

At Hahnemann’s end, I, like everyone else, was caught in the intersection of organizations that blamed one another for their problems and couldn’t forge a trusting relationship or economic deal for the greater good.

I admitted the last patient to Hahnemann University Hospital and worked the overnight shift to close the emergency department down on August 16, 2019. I had worked in the emergency department at Hahnemann for twelve years, and many clinicians there had longer ties to the hospital than mine. I remain honored to have worked shoulder to shoulder with an outstanding team of individuals from nursing, environmental services, and everyone who made the organization a functionally dysfunctional place to care for our community. I have great pride in the contributions to patient care, physician education, and interprofessional teamwork that I made over those twelve years. A piece of me died with its closure.

How many more moral and ethical dilemmas associated with the rapidly changing US health care environment must happen to prompt systemic reform? In my opinion, Hahnemann’s demise is a blatant example of the free market failing the public. As a physician, educator, health care consumer, and Hahnemann survivor, I can’t condone the way the business of health care is going.