APRIL 11, 2011

5 Questions: Chamberlain on saving pediatric residency funds


Renee Reijo Pera

Lisa Chamberlain

President Obama’s proposed 2012 budget eliminates all funding for Children’s Hospitals Graduate Medical Education — a federal program of roughly $318 million that helps to fund pediatricians’ residency training. Lisa Chamberlain, MD, an assistant professor of pediatrics at the School of Medicine, conducts research on pediatric health-care policy and children’s health. She and other health-care professionals are organizing grassroots efforts, including a rally at Lucile Packard Children’s Hospital on April 27, to urge federal legislators to reinstate CHGME funding in the 2012 budget. She discussed the issue with Inside Stanford Medicine writer Erin Digitale.

Q: What exactly does the CHGME program do?

Chamberlain: The government pays for graduate medical education — the cost of physicians’ residency training — via Medicare, the federal health insurance program that primarily covers people older than 65. But stand-alone children’s hospitals such as Lucile Packard Children’s Hospital generally don’t take care of Medicare patients, which means they are not eligible for the main pool of GME funds. When GME was established, legislators realized this hole existed. They created CHGME 11 years ago to fill the gap. It’s important for people to understand that the insurance and Medicaid reimbursements that children’s hospitals receive for caring for kids don’t cover the costs of training residents.

There are great metrics to show what an impact CHGME has had — it has significantly increased the number of pediatric subspecialists, for instance. We still have a shortage of subspecialists in many areas of pediatrics, but this program has gone a long way toward reducing the shortages.

The Medicare GME program still provides funds for pediatric residency programs that are part of non-freestanding children’s hospitals, such as where there is a pediatric floor in a larger hospital. But we rely on CHGME funds to train all the residents at freestanding children’s hospitals — that’s 40 percent of general pediatricians and 43 percent of pediatric subspecialists across the country.

Q: How could elimination of CHGME affect the ability of U.S. kids to get the medical care they need?

Chamberlain: It’s already impacting our kids. The level of funding we have had in the past has not been adequate — CHGME has never been fully funded. As a result, we already have shortages of pediatric specialists in fields like rheumatology, orthopedics and nephrology. There are many large regions of the country, even in California, where it’s hard to find a doctor who can take care of a child’s specific condition. These are really sick kids, and they need to travel hours and hours to receive care, or be treated by an adult doctor who lacks the right expertise.

Nationwide, there are more and more kids who have serious, chronic illnesses. We have an increasing ability, with new technology and better capability in neonatal intensive care units, to save babies who would not have survived infancy in the past. We’re better at getting older children through medical crises, too. But many of those survivors are seriously, chronically ill. These kids need specialized care not found in small community settings.

Because of this change, we need more pediatric specialists — pediatric cardiologists, rheumatologists, nephrologists and so on — not fewer. Training pediatric subspecialists is a resource-intensive endeavor; they have to be trained at centers that have a lot of patients with specialized needs, which is what CHGME helps support.

If CHGME is not funded, it’s going to really hurt the ability of freestanding children’s hospitals to continue to train the physicians that kids need. Would we feel the effects of the change the next day? No. Would we feel it five years from now? Absolutely. We’ll see the same sort of physician shortages we see now, but across an even broader range of specialties.

Q: There clearly are problems with the way we fund health care in this country, but we have to make cuts somewhere. If everyone says “not this area,” then we’ll never get any change. Where should the federal government cut back?

Chamberlain: I “get” that there are finite resources available for health care, and I agree that we need to economize and use CHGME dollars wisely. We’ve already been doing that — it’s worth noting that this program has never been funded to the level we believe is needed. I think it boils down to an issue of priority. This is not an area to deprioritize. Our pediatric training system is already incredibly fragile, and children’s lives are in the balance.

Q: Why do kids need their own physicians?

Chamberlain: Children aren’t just small adults. There are three main ways that kids are quite different. First, their diseases differ. Pediatric specialists handle many diseases that adult doctors are not trained to handle. This is partly because, in the past, children with diseases such as cystic fibrosis or congenital heart defects never reached adulthood, so they were treated only by pediatricians.

Second, children’s bodies respond differently to treatment. A great example is in cancer therapy. Children’s hearts and kidneys can withstand more chemotherapy than adults’ organs, so pediatric oncologists push chemotherapy much harder than an adult oncologist would. When children with cancer are treated by adult oncologists, their survival rates are worse. If all you do is treat children, you get very good at providing the treatment that works best for them.

Third, pediatricians know where children are developmentally, which is an important part of helping them cope with treatment for chronic illness. For instance, pediatricians pay attention to issues of schooling, relationships with siblings and the dynamics of the patient’s family. It’s quite different from adult medicine, in which the patient is a legally independent individual, making his or her own decisions.

Q: Is it possible to save the program?

Chamberlain: U.S. Secretary of Health and Human Services Kathleen Sebelius was recently questioned about CHGME while testifying in Congress. Rep. Frank Pallone, D-N.J., asked her why the proposed budget zeroed out CHGME. She said, in essence, “We really regret it; in another budgetary year this would never have happened. ” It’s possible that Pallone now could be the House author on a bill to reintroduce the funding. And I’ve heard that the Senate may be a little ahead of the House in terms of proposing legislation to reinstate this funding, but it’s still not clear whether the program will be saved. That’s why we need to act now.

We are planning a national day of action, called Stand for Kids: Protect Children’s Health Care, for April 26 and 27. We will say that CHGME funding is important and needs to be continued. We’ll be holding a series of rallies and debates, call-ins and visits with legislative representatives to raise awareness about the value of children’s hospitals and the important contribution that training these pediatric subspecialists makes to our communities. There will be a rally at Packard Children’s, tentatively scheduled for April 27 at noon.  

Stanford Medicine integrates research, medical education and patient care at its three institutions - Stanford University School of Medicine, Stanford Hospital & Clinics and Lucile Packard Children's Hospital Stanford. For more information, please visit the Office of Communication & Public Affairs site at http://mednews.stanford.edu/.

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