Resident tuition could boost academic departments

April 1, 2005

New Orleans — Undergraduates are accustomed to paying for their education. Why not dermatology residents?

That's the proposal being investigated by Noah S. Scheinfeld, M.D., assistant attending physician at St. Luke's Roosevelt Hospital Center and assistant clinical professor of dermatology at Columbia University.

"I would like to explore whether or not it might be possible that, in the same way people pay for college, they might pay for their training. And if they pay for their training, this might allow us to pay higher salaries for academic dermatologists, to fund more research and to fund more positions in general," Dr. Scheinfeld tells Dermatology Times.

At the same time, the apparent dearth of dermatologists in many U.S. markets demands an increase in the number of dermatology residency positions offered nationwide. Both pharmaceutical companies and the American Academy of Dermatology (AAD) are attempting to address this shortfall through grant programs now in pilot stages.

Such programs would be supplemented, rather than replaced, by Dr. Scheinfeld's proposition. To gauge its acceptance rate, he has surveyed approximately 30 dermatology applicants, to date, on the subject.

"Almost all of them have said that if they had to pay tuition to be a dermatology resident, they would prefer doing that rather than being paid a salary in some other specialty if they were faced with that choice," he says.

"In addition, about 75 percent of the people who are applying say they really think of dermatology residents as being more students than physicians. This is an important point to highlight, in that if one views residents as physicians who are providing a service, then salaries are in order. But if one sees dermatology residents as being more of students who are being guided in their education, then a tuition-based system makes more sense."

Proposal barrier One barrier that such a proposal ultimately would need to surmount is the Accreditation Council for Graduate Medical Education's (ACGME) requirement that residents receive salaries, a point that the handful of colleagues to whom Dr. Scheinfeld has vetted his idea are quick to note.

"But the ACGME is not providing a mechanism whereby academic dermatology can fund itself. Additionally, 75 percent to 80 percent of our applicants said that they found pharmaceutical companies' funding of additional residency slots to be problematic, probably due to concerns for conflicts of interest."

Conflicts of interest won't be a factor under the AAD's initiative, which pools contributions so no single donor can be identified as the sponsor of a particular grant.

"But it's hard to provide a high-quality, well-rounded education for the amounts of money that are available," Dr. Scheinfeld says.

"In academic departments, one's salary is driven more and more by how much money one generates through clinical practice. But there has to be a way money is designated for teaching, and perhaps the source will be having applicants finance it themselves."

Further impetus for such a proposal stems from the possibility that the federal government might cap Medicaid payments at a flat per-state figure that fails to take states' populations into account, a possibility the President currently is exploring.

"This is going to put additional pressure on academic medicine, so we really need to open up all funding sources. In light of the fact that so many academic positions are open, and that hard research money and academic salaries are lagging behind what's available in the private sector, we must be creative in the way we approach funding," he says.

Going forward, he plans to gather more data to determine if enough applicants would accept his proposal before addressing legal issues such as the one posed by the ACGME.