Response to “Extended Duration of Training, Resident Physician Well-Being, and the Primary Care Physician Shortage: Questions Remaining Following the Length of Training Pilot”

We thank Dr Parente for his thought-provoking editorial, which raises important questions following additional positive findings from the Length of Training Pilot (LoTP). His commentary emphasizes the resident perspective. While critically important, equal consideration must be given to the needs of patients, society, and our social accountability as professionals. The financial and human costs to the public of lesser-trained, reduced-scope family physicians must also be considered.

We see limited evidence that “the findings of the LoTP address more of a shift in family medicine practice rather than an erosion”¹ of preparedness and scope of practice. Although additional competencies have been added to residency curricula, we must also acknowledge what training and competencies have been reduced to accommodate expanding expectations within a 3 year model. Concerns regarding resident finances, well-being, and workforce size with extended training warrant careful analysis.

The potential financial impact analysis relies on assumptions that may not fully reflect real-world practice. Although no longitudinal studies directly demonstrate that broader scope leads to longer careers or fewer reductions in work hours, broader scope is associated with lower burnout and higher job satisfaction.² Burnout, in turn, is associated with reduced work hours³ and earlier retirement.⁴ Graduates of 4 year programs report acquiring a broader scope and unique skill set compared with graduates of 3 year programs.⁵ More comprehensive scope is also associated with lower costs and fewer hospitalizations.⁶ Broader scope may therefore decrease risks of reduced weekly hours and shortened careers with important financial implications.

As clinical reimbursement increasingly incorporates quality indicators and comprehensive care demonstrates cost efficiency, increased reimbursement may occur as the system moves away⁷ from strictly fee-for-service models. It is unlikely that the full compensation differential of a first-year attending would be invested. Realistic recommended savings rates typically range from 10%–20%, depending on debt, taxes, and living expenses. Extended training therefore represents a variable financial opportunity cost that may be mitigated by other, more influential financial factors.

As leaders engaged in redesigning family medicine residency education over the past two decades using real-world, empirical data, we view extended residency training as an investment in a 40 year career rather than a single-year opportunity cost. Four-year residents describe how this investment aligns with their long-term professional goals. Carney and colleagues reported residents’ reflections that added training, experience, and confidence may outweigh short-term financial trade-offs.⁸ Although longer-term analyses would be valuable, heterogeneity in graduates’ practice settings makes this difficult.

We find no substantive evidence that extended training threatens resident well-being; LoTP studies found no differences.⁹ As Dr Mainous notes, prioritizing physician workforce size assumes a physician-dominant system that may no longer exist.¹⁰ The future of family medicine will depend more on workforce quality than quantity.

Eventually, continued calls for additional study enable our discipline to avoid choosing the harder road. We hope that after 20 years of length of training innovation, study, and dialogue, our specialty will look at existing empirical and LoTP evidence and move decisively into action.