Medicare reimbursement
Taxpayers, through Medicare, provide substantial financial support for residents in all specialties. That support, however, does not come without twists. For example, if a person decides upon a three-year residency in internal medicine, that individual has made a choice, knowingly or unknowingly, to accept a lifetime limit of three years of Medicare-supported training. Similarly, entry into a five year training program in some other specialty would limit that person to five years of Medicare support. If, after one year, the resident in internal medicine switches to a four-year program in pathology, only two of the original three subsidized years under Medicare are still available. Had that person, however, begun in a five-year specialty, there would still be four of the original five years left for a move to pathology. It is therefore extremely difficult to make a reasoned decision to change specialties, unless one obtains independent financing for the uncovered years. On the one hand, a program may be reluctant to discharge an unsuitable resident who is far into training, knowing that that most of his or her Medicare currency has been spent. Conversely, programs cannot easily accept talented and advanced residents from other disciplines because they, too, would have exhausted their Medicare dollars. I find it hard to imagine a better way of getting square pegs into round holes. The beneficiaries of this Medicare rule are the international graduates because, regardless of the amount of training they will have received abroad, they arrive in the USA with a clean, unsullied Medicare slate. Rare will be the American graduate who enters a pathology residency with a clinical experience that goes beyond the clerkship of a medical student.