Three themes in contemporary medical practice bode ill for physicians who
continue to participate in illegally managed teaching programs. The first is the
growing reluctance of medical malpractice insurers to continue to insure
physicians who have preventable claims against them. If a physician’s insurer
pays off on a case involving an improperly supervised student, the physician
may have difficulty in renewing the policy or in obtaining coverage from
Second, with the demise of charitable immunity and the growth of formal risk
management and quality assurance programs, hospitals are demanding that
physicians supervise the care of their patients personally. Third, outside
pressures are increasing the enforcement of the laws governing the supervision
of nonphysician personnel. The driving force behind this enforcement has been
the Medicare/Medicaid programs. Physicians who bill for work performed by
students and residents violate the federal law against fraud and abuse. Private
insurance companies are increasing their supervision of billing practices
associated with teaching programs. The growing concern among politicians
about the illicit use of drugs will result in more vigorous enforcement of the
rules on who may write prescriptions and dispense drugs.
It is not necessary to deceive patients to persuade them to participate in
teaching programs. Many patients enjoy having students involved in their care.
The students generally have much more time to spend with an individual
patient than do either the residents or the attending physician. Medical schools
that have been forced to adopt rigid policies of disclosure to patients have not
seen the students driven from their hospitals.
In the past, properly supervising medical students and residents was more
expensive than not supervising them. This is changing, however, as the federal
government and third-party payers become more reluctant to pay for student
work. An institution that is subject to an enforcement action for fraud can see
its revenue stream from the federal government frozen for months or years.
The physicians who are personally accused of fraud must expend tens of
thousands of dollars of their own funds on defense lawyers because these
actions are not covered under medical malpractice insurance. If the defense is
not successful, the physician is subject to large fines, loss of licensure, and