Graduate medical education (GME) in the United States needs an overhaul if it is to have any hope of keeping up with an aging population and a rapidly changing health care system, according to a recently released report from the Council on Graduate Medical Education (COGME). Ensuring value for dollars spent is high on the list of recommendations from the council.
The report's authors point out that the nation faces serious challenges in ensuring that Americans have access to "the very best physician workforce in the world." Medical education has not evolved as rapidly as changes in the health care delivery system, they say.
The report, Improving Value in Graduate Medical Education(www.hrsa.gov), proposes a number of recommendations that address topics ranging from funding, recruiting criteria and curricula issues to the need for medical education research.
Defining the Problems
According to COGME, past unsolved problems, including poor geographic distribution of the physician workforce and accelerating subspecialization at the expense of primary care, have collided with new challenges to create a crisis in medical education. "GME is responsible for developing the future physician workforce but falls short in several areas," say the authors. "Training program size and specialty mix are sometimes at odds with the nation's health workforce requirements."
- Authors of a recently released COGME report say U.S. graduate medical education (GME) needs an overhaul if it is to keep up with health system reform and an aging American population.
- The report says that GME, which is responsible for ensuring the nation's future physician workforce, falls short in areas such as training program size and specialty mix.
- The report outlines six specific recommendations that deal with funding, recruiting criteria, curricula issues and medical education research.
Many training hospitals have not adequately focused on primary care training, and the curriculum often is lacking in important areas, such as population health, care coordination and team-based care. "National accreditation organizations have been slow to lead these necessary changes," says the report.
In addition, for 15 years, Congress has resisted funding GME with additional public monies. "The Balanced Budget Act's imposition of a funding cap on the number of Medicare-funded positions slowed expansion (of residency slots), except under limited circumstance," says the report. "Without additional funding, the number of training positions continued to grow slowly, but largely in subspecialties."
Stan Kozakowski, M.D., director of the AAFP Division of Medical Education, calls the report "groundbreaking" in its assertion that the country's medical education system must prove its value. After all, he notes, public tax dollars provide more than $13 billion in funding each year.
He points out that GME funding has been buffeted by the weak economy, as well as by congressional sequestration measures that slashed money from the federal budget. "The report implies that we need to be more strategic in how we train physicians because there is not a limitless pot of money," says Kozakowski. "Clearly, the way to attain workforce reform in medicine is to purposely address the GME environment, and that includes appropriately aligning accreditation forces."
The COGME report outlines six principal recommendations regarding GME:
- increase and broaden GME funding;
- prioritize funding to quickly align the physician workforce with population and health delivery needs;
- work to improve training efficiency;
- align medical student recruitment efforts with population health care needs;
- realign clinical learning and curricula to reflect patient-centered, safe and effective care; and
- invest in medical education research to improve GME quality and physician competencies.
In terms of GME funding, the report recommends that Congress continue funding current GME positions, increase funding for additional positions, aim to graduate 3,000 more physicians per year and look at funding sources other than Medicare. "COGME also recommends that training be expanded and prioritized to meet specific needs of a U.S. population that is growing and aging as an increasing proportion of physicians reach retirement age," says the report.
In addition, GME funding increases should be directed to high-priority specialties -- family medicine, geriatrics, general internal medicine, general surgery, high-priority pediatric subspecialties and psychiatry -- and training programs should emphasize new competencies. "Training in nonhospital-based outpatient and office-based practices needs to be incorporated into any new GME approach to reflect the shift of medical care to outpatient settings," says the report.
Eliminating transitional postgraduate year positions could improve efficiencies and reduce waste, according to the report, which also urges accreditation and licensing organizations to "permit flexibility in certain clinical training in the fourth year of medical school to be credited toward residency training."
Report authors also call for a revision in medical student recruitment criteria to help craft a physician workforce that meets population needs. "Recruitment needs to target students with the necessary personal attributes essential to providing patient-centered care," says the report. "Achieving these goals requires changes in the interview process as well as a willingness to accept students from a variety of educational backgrounds."
In addition, Congress should direct HHS to develop and disseminate "innovative faculty development programs to improve GME training across all specialties," says the report. The clinical learning environment of sponsoring institutions should be evaluated to ensure that core competencies set out by the Institute of Medicine -- namely, patient-centered care that is safe, timely, effective, efficient and equitable -- are met. And successful completion of each phase of medical education should be based on an assessment of competence rather than on the amount of time spent in training.
Lastly, the authors urge the nation to invest in medical education research to improve the quality of GME and the competencies of the physician workforce. Specifically, the report asks Congress to authorize and finance an entity dubbed the National Institute for Health Professions Education that would "support innovative medical education research that improves both learner and patient-care outcomes."
Although not perfect, many of the COGME report recommendations dovetail with the AAFP's own roadmap for change in the nation's GME system, according to Kozakowski. He calls GME funding an "investment for the country" and notes that funding should not be cut but strategically expanded.
COGME report findings that align with AAFP priorities include
- funding GME and aligning it with workforce priorities,
- eliminating waste in the system,
- getting the right people in the medical education pipeline,
- setting priorities around competencies, and
- creating a research agenda to ensure the right steps are being taken.
"The 21st COGME report is important because it drives federal policy," says Kozakowski. "The information in this report will be a touchstone for others. Those in the accreditation world will have a hard time ignoring these recommendations."
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