Department of Veterans Affairs, Office of Academic Affiliations, Washington, DC.
Loma Linda University Medical School, Loma Linda, CA.
Med Care. 2022 Sep 1;60(9):709-717. doi: 10.1097/MLR.0000000000001752. Epub 2022 Jul 28.
Graduate medical education is centered in hospitals despite a care system where patients mostly receive their care in an outpatient setting. Such gaps may exist because of inadequate funding for residency positions in community and hospital-based clinics.
Determine if physician residents' contribution to outpatient workload offsets their costs for supervision, salary, and fringe benefits as residents acquire skills to become independent practitioners.
VA's electronic patient records from 2005 through 2018 were analyzed using generalized linear mixed models to estimate resident and staff contributions to workload in relative value units.
Resident participation rate is resident contributed workload net of supervision as a percent of total clinic workload. Productivity is per diem resident workload as a percent of per diem staff workload. Efficiency is per dollar resident workload as a percent of per dollar staff workload. Progressive independence is annual rate of change in resident productivity.
Average participation rates varied by specialty from 6% to 22%, with 11% (primary care) and 13% (psychiatry). Productivity rates ranged from 21% to 94%, with 57% (primary care) and 61% (psychiatry). Efficiency rates varied from 0.63 to 3.81, with 1.69 (primary care), 1.89 (psychiatry). Progressive independence rates varied from 2.7%/year (psychiatry) to 39.7%/year (specialty care).
Although residents rotating through most VA clinics generate revenue to cover their direct costs as they learn, some federal subsidies may be necessary to encourage hospital- and community-based clinics to accept residents from the less profitable primary care and mental health specialties.
尽管医疗体系中患者主要在门诊接受治疗，但住院医师的医学继续教育仍以医院为中心。这种差距可能是由于社区和医院诊所的住院医师职位资金不足造成的。
确定住院医师对门诊工作量的贡献是否足以抵消其监督、工资和福利成本，因为住院医师在获得独立执业技能的同时也在增加工作量。
利用 VA 的电子病历记录（2005 年至 2018 年），通过广义线性混合模型，估算住院医师和工作人员在相对价值单位中的工作量贡献。
住院医师参与率为住院医师净工作量与监督工作的比例（占总诊所工作量的百分比）。生产力为每位住院医师的日工作量与每位工作人员的日工作量的百分比。效率为每位住院医师的工作量成本与每位工作人员的工作量成本的百分比。渐进独立性是住院医师生产力的年变化率。
平均参与率因专业而异，从 6%到 22%不等，其中 11%（初级保健）和 13%（精神病学）。生产力率从 21%到 94%不等，其中 57%（初级保健）和 61%（精神病学）。效率率从 0.63 到 3.81 不等，其中 1.69（初级保健），1.89（精神病学）。渐进独立性率从每年 2.7%（精神病学）到每年 39.7%（专科护理）不等。
尽管在 VA 的大多数诊所轮转的住院医师在学习过程中产生收入来支付其直接成本，但为了鼓励医院和社区诊所接受来自利润较低的初级保健和精神卫生专业的住院医师，可能需要一些联邦补贴。
