Academic medical centers balance dollars with resident education

Medicine has a fraught relationship with money. Dealing as they do with matters of life and death, doctors are loath to assign a dollar value to human life, preferring to avoid the subject altogether and instead provide the care that they deem appropriate no matter the cost. Insurance companies, on the other hand, make their business in rationing health dollars and have no such qualms: the consensus among them is that a human life in this country is worth about $50,000 per year (though new data suggests that number may be closer to $130,000). Controversial though this may be, it has real implications for which treatments are made available to which patients. There is no getting around the fact that illness is expensive, and the return on investment diminishes the more ill you are.

The one exception to this intrusion of financial matters into health care, I would argue, is academic medicine. Residency is, in many ways, an idyllic time (another controversial statement). Residents are free to experiment (within the bounds of patient safety, of course), to order tests that may not be “cost-effective,” to pursue a diagnosis that may be purely academic and may not have any true bearing on the patient’s prognosis or hospital course. This is the luxury of being a resident: You are not yet beholden to a hospital’s bottom line. And nor should you be. The resources of the hospital are at your disposal, all in the service of making you a more judicious clinician. In starting a training program, a hospital is entering into an implicit contract that the resident comes first; that educating the next generation of physicians takes precedence over turning a profit.

And yet there are hints that this is not so. At large urban academic centers, turnover is high, and hospital stays relatively short, such that one barely finishes typing up an admission note before the discharge summary is due. And the hospital is packed to the brims: Where I work, virtually no space is safe from being converted into a patient “room,” including hallways, a day room which was purposed as a space for patients and families to spend time, and a treatment room which was meant to be reserved for procedures.

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