Graduate medical education downsizing: Perceived effects of participating in the HCFA demonstration project in New York State

Objective: Financial support for graduate medical education (GME) is shrink ing nationally as Medicare cuts GME funds, Thirty-nine hospitals in New Yor k State (NYS) voluntarily participated in a Health Care Financing Administr ation demonstration project (HCFADP)-the goal of which was to reduce total residency training positions by 4-5%/year over a five-year period, while in creasing primary care positions. The objective of this study was to determi ne the effect of downsizing on emergency department (ED) staffing and emerg ency medicine (EM) residency training. Methods: Structured interviews and s urveys of NYS program directors (PDs) were conducted in October-December 19 99. Simple frequencies are reported. Results: One hundred percent of 17 PDs completed the interviews and seven of 12 participants in the HCFADP return ed surveys. Twelve of 17 programs participated in HCFADP and two programs d ownsized outside HCFADP. Seven of 12 participants lost EM positions. Six of 12 programs were forced to exclude outside residents from rotating in thei r ED, leading to a need for one participating program and one non-participa ting program to find alternative sites for trauma. Five of 12 institutions provided resident staffing data, reporting a reduction in ED resident cover age in year 1 of the project of 9-40%. Programs compensated by increasing t he number of shifts worked (4/12), increasing shift length (1/12), decreasi ng pediatric ED shifts (1/12), decreasing elective or research time (2/12), and decreasing off-service rotations (4/12). Six departments hired physici an assistants or nurse practitioners, two hired faculty, and two hired resi dent moonlighters. Six of 12 programs withdrew from HCFADP and returned to previous resident numbers. Eight of 12 PDs thought that they had decreased time for clinical teaching. Conclusions: A 4-5% reduction in residency posi tions was associated with a marked reduction in ED resident staffing and EM residency curriculum changes.