I am writing to inform the readership of the Annals of a change in graduate medical education reimbursement that will have a significant impact on internal medicine residency training. Specifically, I am referring to a serious threat to the medical chief residency. Over the years, the internal medicine chief residency at many institutions has evolved as a postgraduate year (PGY) 4 (or later) experience that is tailored to the needs of the program and the individual person filling the position. The chief medical resident often fulfills that vitally important role of a supervisor-colleague for housestaff who is able to bridge the gap between residents and faculty. This respected teacher is part housestaff leader, part educational resource, part cheerleader, and part counselor. Further, the chief often embodies the spirit of a residency, which is critical for housestaff morale. Finally, the chief residency itself has often been a fertile training ground for future academic physicians.

Our institution has recently been informed by Blue Cross of Rhode Island, our Medicare intermediary, that chief medical residents in their fourth year of training will no longer qualify as residents for the purposes of graduate medical finance. This means that hospitals in our region will not receive graduate medical education reimbursement from Medicare for such residents. Under the regulations, an approved medical residency program must meet one of the following requirements: 1) It must be approved by one of the national organizations recognized by Medicare; 2) it must count toward certification of the participant in a specialty or subspecialty, as listed in the directory of graduate medical education programs published by the American Medical Association or the Annual Report and Reference Handbook, published by the American Board of Medical Specialties; or 3) it must be approved by the Accreditation Council for Graduate Medical Education as a fellowship program in geriatric medicine. It is the contention of our Medicare intermediary that the chief medical residency meets none of these requirements. It is not in a general internal medicine program because internal medicine is only a 3-year program, it is not in any type of subspecialty fellowship, and it is not in a geriatric medicine program. Certainly, the chief residency can be reinvented as a PGY-3 experience, and indeed this has been done at numerous institutions. We, however, strongly feel that this is ill advised and acts to the detriment of an individual's training by denying him or her a traditional senior resident experience.

Clearly, this change in reimbursement will not be limited to Rhode Island and may have a widespread effect on internal medicine residency training across the United States. It may further affect fellowships in general internal medicine that are currently not accredited by the Council for Graduate Medical Education. We hope that the Annals readership shares our concern over this potential loss and that as internists we will voice our collective concern through our specialty organizations to save the medical chief residency.