Walking toward a new venture & away from burnout

Burnout is more than an academic topic. Providers are taking action & exiting clinical care. Where they end up and what they leave behind are necessary but neglected considerations.

Let’s unpack the decision to exit residency training. Here are *some* considerations from my perspective as a former Nephrology Program Director.

Brief Primer on Medicare, GMEs, and Trainees

Medicare pays training institutions to train residents/fellows. The amount Medicare gives to each graduate medical education (GME) program will depend on the percentage of Medicare patients that are served by that institution. In other words, Medicare doesn’t pay the GME program for the entire cost of resident training - only the portion that pertains to the care of Medicare beneficiaries.

A GME program (for physicians) is one that has obtained accreditation from the ACGME or the AOA.

DGME is the direct costs that Medicare will pay to a GME program. These costs are calculated based on 5 factors. In the olden days, these costs were actual costs. That is, the hospitals would accrue all the direct costs for a resident, transmit that value to Medicare, and Medicare would send it a check to cover that amount. Pretty soon, Medicare decided to make the cost a calculated one so that there is predictability in how much must be spent.

Adjusted rolling average FTE count: big name that basically means how many FTEs (trainees) a GME program has. This is a fixed number that is assigned to each GME program by Medicare. GME programs can shift these FTEs around from one site to another, but the total must always equal that which Medicare has allotted to that program.

Per-resident amount: A set amount that Medicare will pay per resident trained.

The remainder of the formula adjusts (lowers) the payment based on the Medicare patient load and siphons some money away from physician training and towards nursing training. Yes….resident training, in part, funds nursing training.

Indirect payments reflect the additional costs that a hospital incurs because resident care is considered “inefficient” care. More tests, longer length-of-stays are characteristics of resident-driven care and add more costs to the GME program. This indirect payment is *not* calculated through an ABC system. The calculation is done in a rudimentary manner: it is a percentage of the total cost of a Medicare beneficiary’s inpatient stay.

Resident “Cap” (FTE cap)

Medicare sets the number of residents that a GME program can have. That number was established in the great year of 1996 and last updated in 2020.

1996 was the first year that more emails were sent than postal mail. It was also the year of the very first USB cable. It was also the year that CSS was developed. It was also the year….well, you get my point…it was a long long time ago.

Per resident amount:

Medicare will determine how much it will pay per resident trained.

What else does Medicare "set"?

The IRP: initial residency period — a/k/a: a trainee’s “eligibility”. This is the number of years you need to complete your training and become board eligible/certified (BE/BC), based on ACGME guidelines, in the very first residency that you chose. The limit is set based on your initial residency selection, and can be no greater than 5 years. It resets if you choose a fellowship.

Back to our resident. S/he wants to exist from his/her residency program. S/he may be considering another specialty - one that fits better with his/her interests/lifestyle/expectations/new future plans. Unfortunately, changing specialties is not the same as changing a college major. S/he has only x years of 100% funding by Medicare - a number that is “set in stone” based on the residency s/he chose. If s/he chose Internal Medicine, Medicare will commit to paying for his/her training for 3 years and no more.

If s/he exceeds 3 years, the maximum a GME program can get from Medicare is 50% per year. A GME program would rather recruit a resident who is at the start of his/her IRP than one who has switched. So leaving one’s residency for another specialty won’t allow the new program to receive the maximum payment for training you.

Consideration 3: Your “love for medicine” has eroded because of the specialty itself and you’re ready to move into the non-clinical world.

Hopefully, you’re searching for a non-clinical role because you want to enter it and not exit the clinical world (i.e., running to the former instead of away from the latter). We will discuss non-clinical roles in another exposition. For now, just know that it is a legitimate option but won’t work out if you consider it a “reconciliation” prize.