The AAOS staff and the AAOS Washington Health Policy Fellows designed a survey regarding funding for orthopaedic graduate medical education and the impact of industry support in funding graduate medical education activities (see Appendix). A web-based survey was developed and administered to orthopaedic residency program directors or chairs in the AAOS database. Questions were formatted and the data collection tool was developed by the Department of Research and Scientific Affairs of the AAOS to ensure proper survey format and to minimize response bias11-13.
In August 2008, residency program directors or chairs were contacted to apprise them of the survey. One week after the announcement, the survey link was distributed to 149 residency program directors or chairs (one contact per residency program). Three reminder e-mails were subsequently sent over the next month. Data collection was concluded four weeks after the survey initiation. The respondents were required to provide their e-mail address as part of the survey to verify participation and eliminate duplicate program submissions, but they were assured of the confidentiality of their responses. At all times, the survey results were maintained with strict confidentiality. After verification, the identifiers were removed so that no responses could be tracked to the respondent. The data were coded, tabulated, and analyzed for accuracy by the Department of Research and Scientific Affairs of the AAOS, and the percentages of the responses to items and the mean ratings were calculated when applicable.
The invitation to participate in the web-based survey and the survey link were distributed to program directors or chairs of all orthopaedic residency programs for a total of 149 surveys. Eighty (54%) of the 149 invited survey participants responded. Of these, fifty-nine were program directors and twenty-one were program chairs. Responding programs had, on the average, twenty-four residents (range, three to seventy-two residents) in their programs. Of the respondents, 78% were university-based, 18% were community-based, and 5% were military-based programs.
Of the responding programs, 86% provided research funding to residents and 90% of the programs provided a funding source (a so-called book fund), which residents could use to purchase books, travel to meetings or courses, or buy equipment such as loupes. Contributors to the book fund were the faculty (38%), the institution (30%), and industry (19%), with other sources (alumni donations and endowments) contributing the remaining 13% of the funding.
Textbooks were purchased or obtained directly for the residents by the residency program for 64% of the programs and by industry for 28% of the programs. Furthermore, resident educational course expenses were directly subsidized (either partially or entirely) by the residency program for 75% of the respondents, whereas course expenses were subsidized by industry for 27% and by other funding sources, including faculty and the residents themselves, for 17% of the respondents.
Over half of the program directors or chairpersons (57%) believed that resident interaction with industry was a beneficial educational experience, whereas 20% did not share this sentiment. When asked specifically about the financial support given for graduate medical education activities by industry, 88% of responding programs stated that industry financial support paid for books at their programs, 83% of the programs had held industry-supported sawbones courses for the residents, 67% of the programs had received industry funding for courses and meetings off campus for their residents, and 65% of the programs had journal club sponsored by industry.
If industry financial support for resident education were substantially reduced or entirely eliminated, nearly one-half (45%) of the respondents indicated that their program would not be able to maintain its current level of educational offerings without interruption. However, if given time to acquire additional resources and financial support, 56% of the respondents believed that their residency program would be able to once again provide residents with the current level of books, educational courses, and other educational resources. Nearly one-quarter (24%) of the respondents did not believe that they could provide educational resources at their current levels without the financial support of industry.
If industry support were to be reduced or eliminated, the respondents cited faculty contributions (24%), private donations to a residency foundation (20%), hospital or institutional support (18%), resident contributions (11%), increased government support (9%), and a departmental educational "tax" on revenue generated (9%) as potential sources for increasing financial support for resident educational endeavors (Fig. 1).
As financial support for graduate medical education continues to decline, finding alternative sources of funding for orthopaedic residency education is becoming a major concern for many training programs. The federal government is the major source of funding for graduate medical education in the United States, with Medicare providing $8.8 billion to teaching hospitals in 2007 and Medicaid providing $3.2 billion to its respective states in 20059. The 2009 budget of the Bush administration sought to reduce the funding for Medicare by $182.7 billion over five years9. One of the proposals was to cut by 60%, over three years, the add-on payments that Medicare makes to teaching hospitals for medical education9. These indirect payments for medical education by Medicare totaled $5.8 billion, and lowering the add-on payments as proposed would save Medicare $12.9 billion over five years9. Furthermore, in a recent proposed regulation, the Bush administration sought to prevent state Medicaid programs from using any of their federal matching dollars to fund graduate medical education9.
State Medicaid funding for graduate medical education is also in jeopardy. A recent report noted that state tax revenues declined an average of 5.9% in the months from July to September 200814. As most states are required to balance their budgets annually, many states need to either raise taxes or cut expenses such as Medicaid funding. Furthermore, some states are reevaluating how Medicaid funds will be used for graduate medical education. Recently, the U.S. Department of Health and Human Services recommended that the New York State Health Department modify its Medicaid rate-setting process for graduate medical education funding in order to permit a more targeted allocation of graduate medical education payments to certain hospitals15. This proposed modification could lead to further cuts in graduate medical education funding to some institutions.
Another source of funding for graduate medical education has been industry financial support. Industry support of medical education includes funding for research and continuing medical education, sponsorship of educational meetings, and providing books and other educational materials to resident physicians2,3,8,16. Although the total support for graduate medical education from industry is not fully known, it has been estimated that nearly 50% of all continuing medical education in all medical specialties is supported by industry3,16. The relationship between industry and orthopaedic surgery has come under scrutiny as questions regarding conflicts of interest have been raised. As a result, the American Medical Association and the Association of American Medical Colleges have recently published reports and guidelines for the interaction between industry and physicians2,16. These reports state that the relationship between industry and physicians may lead to biases that can influence the objectivity and integrity of academic teaching, learning, and practice, and they recommend decreasing, if not completely eliminating, industry funding2,3,16. It should be stated that neither of the reports, however, proposed any other sources of funding for the critical areas currently being supported by industry2,3,16. Some pharmaceutical and implant companies have banned gifts to physicians and have decreased funding sources for continuing medical education and research in an attempt to address the conflict-of-interest issues3,17. The relationship between orthopaedic surgeons and industry has also been impacted with the recent settlement between the U.S. Department of Justice and five major orthopaedic implant manufacturers. As a consequence, funding for orthopaedic research may decrease, and funding for other important educational resources may also17. Even funding for community service projects such as the AAOS annual playground building program has been affected with decreased industry financial support17.
This study explores the perceptions of residency program directors and chairs about the financial support for their residency programs from industry. Although in this study only the funding available from industry for a specific portion of graduate medical education expenses for orthopaedic residents could be quantified, we believe that the effects of the cessation of industry funding for the resident book fund and for residents to attend educational courses can serve as an example of the impact that decreased funding may have on overall graduate medical education. One of the limitations of this study is that we did not quantify the amount of funding provided by industry to residency programs or quantify the amount necessary for all educational activities within orthopaedic graduate medical education. However, the potential impact of industry may go beyond funding. For example, the Accreditation Council for Graduate Medical Education now mandates the use of simulation and skills laboratories as part of surgery residency training18. For some institutions that have built simulation and skills laboratories or surgical simulation centers, the expense of establishing and maintaining these training centers has been mitigated at least in part through cooperative leasing arrangements with industry to conduct workshops and training courses. Such arrangements may not be possible in the future, possibly placing these centers in jeopardy.
Nearly half of the respondents believed that, if industry funding were decreased or eliminated without any other funding to replace the current level of financial support, their programs would be unable to provide their residents with the current level of educational resources. This response clearly demonstrates the importance of industry financial support for many of these institutions, although industry support of the book fund and resident courses contributed to only a small portion of the overall expenses. In the face of decreasing resources, one consideration may be to conduct an objective evaluation and perform a needs assessment of the educational tools currently used by orthopaedic training programs.
Potential sources for increasing funding, according to the respondents, focused on financial contributions by the faculty, alumni, and/or a departmental residency foundation, while only a small percentage (9%) believed that government support would be increased. Thus, when industry funding is no longer available for graduate medical education, a greater proportion of the responsibility to fund resident education may fall on the shoulders of faculty who already donate their time and likely contribute some of their income to a university or dean's tax. The potential also exists for cannibalization of research funding, private donations, or endowments for capital improvement. This may result in less faculty participation in residency training and less research funding.
In conclusion, with decreases in industry funding for graduate medical education, it is imperative that industry and academic programs continue to work toward a common methodology so that funding from industry can still occur, and yet remain ethical and transparent. Furthermore, it is equally important that the federal government, in health-care reform legislation, address and increase graduate medical education funding in order to ensure that future orthopaedic residents have high-quality educational opportunities and are able to deliver quality patient care.
The survey used in this study is available with the electronic versions of this article, on our web site at (go to the article citation and click on "Supplementary Material") and on our quarterly CD/DVD (call our subscription department, at 781-449-9780, to order the CD or DVD).
Note: The authors thank Heidi Schmalz of the AAOS Department of Research and Scientific Affairs for her help with the statistical analysis, survey format, and management of the collected data. They also thank Jeanie Kennedy with the AAOS Washington office for assistance in designing the survey and the preparation of the manuscript.