The recent release of a study on graduate medical education (GME) funding by the AAFP's Robert Graham Center for Policy Studies and The George Washington University School of Public Health has focused renewed attention on the nation's investment in GME funding and whether that investment is producing the physician workforce the country needs.
Fitzhugh Mullan, M.D., co-author of a report on graduate medical education, discusses factors that influence a medical school student's decision to pursue a career in primary care.
"This (study) is really examining an important question: Are Medicare investments, which are quite substantial, producing the clinicians that we need?" said Cristina Boccuti, M.P.P., a senior associate at the Kaiser Family Foundation and one of several speakers to address a July 16 Capitol Hill primary care forum on the study. "Other research has looked at whether clinicians have the skills that we need for a reformed delivery system," said Boccuti. "This (study) starts to look at the specific workforce, and it addresses whether that workforce -- particularly primary care -- goes into the geographic areas where it is needed to care for underserved and disadvantaged populations."
The study, "Toward Graduate Medical Education Accountability: Measuring the Outcomes of GME Institutions"(journals.lww.com) was published in Academic Medicine. It points out that the American taxpayer largely is responsible for funding GME training in this country through Medicare ($10 billion) and Medicaid ($3 billion). Yet, the U.S. medical education system fails to produce enough primary care physicians to meet the country's health care needs and does not produce an adequate number of physicians to work in rural and underserved areas, according to a press release on the study(www.graham-center.org).
- The AAFPs Robert Graham Center for Policy Studies held a July 16 primary care forum on Capitol Hill that called for changes and more accountability in how the nation funds graduate medical education (GME).
- Speakers at the forum said current GME investments are not producing enough primary care physicians to meet the nation's needs.
- Most physician residency training occurs in teaching hospitals, and hospitals depend on higher-paying subspecialties for income, said speakers.
We are not furnishing enough of the type of students we need or in the areas where we need them, said Robert Phillips Jr., M.D., M.S.P.H., one of the authors of the study. This trend is largely a result of fundamental flaws in the nation's GME system, he added, echoing the findings of the study.
Most physician residency training occurs in teaching hospitals, and many hospital business plans depend on higher-paying subspecialties for income, giving hospitals an incentive to train more subspecialists, said Phillips, vice president for research and policy at the American Board of Family Medicine. Teaching hospitals are not held accountable for creating and sustaining GME slots that meet the country's workforce needs, said Phillips. "In the absence of accountability, GME funding will bend to the teaching hospital's business plan. It is not nefarious. It is good business. If there is no accounting for how you receive $13 billion, you are going to use it in a way that is most effective for your business model."
The study looked at 759 academic health center institutions and found that 158 produced no primary care graduates, and 198 did not produce a single rural physician between 2006 and 2008. Another 479 institutions did not produce any National Health Service Corps participants, and 283 produced no physicians who practice in clinics designed as federally qualified health centers or rural health clinics.
These findings make it increasingly difficult to justify GME funding without accountability, Phillips said.
The Graham Center published a study earlier this year that says the United States needs about 52,000 more primary care physicians by 2025 as a result of an aging population, changing demographics and more people obtaining health insurance. In 2014, the United States will need at least 8,000 more physicians to meet increased patient demand, according to Phillips. "We can't sustain what we have, much less meet those coming needs," he said.
However, he added, GME can "reshape" the workforce. "We know that family medicine programs that have a rural training track put out two and half times as many rural physicians as those that don't," Phillips said. There is strong evidence that how and where you teach people can have a major influence on workforce trends.
Fitzhugh Mullan, M.D., co-author of the report and the Murdock Head Professor of Medicine and Health Policy at The George Washington University School of Medicine, addressed that issue, saying that several factors can influence a medical student's decision to pursue a career in primary care. These include the structure and content of the medical school curriculum and how much of the clinical experience occurs outside of the hospital.
Mullan also presented data on how medical schools perform based on a defined social mission that includes the number of graduates who practice primary care and in rural areas, as well as the number of minority graduates. Many of the nation's top medical schools are failing to address major and long-term problems in American medicine based on that criteria, said Mullan.
He stressed the importance of GME in determining the composition of the nation's physician workforce. GME is a "final common pathway" and a "definer of our workforce in terms of its predilections, its geography, and ultimately, how it integrates with health care in the country," said Mullan.