Forum Speakers Call for Fundamental Changes in Graduate Medical Education

Teaching hospitals in the United States could do a more effective job of managing the nation's multi-billion-dollar investment in graduate medical education, or GME, by taking steps to produce a physician workforce that better meets the needs of the country. That was one of the central themes to emerge from a primary care forum on GME accountability held here on Oct. 6 that was sponsored by the American Board of Family Medicine and convened by the AAFP's Robert Graham Center.

The United States spends $13 billion annually on GME, according to George Thibault, M.D., president of The Josiah Macy Jr. Foundation, which recently issued two reports that call on teaching hospitals and residency program directors to alter the content of their programs to better reflect changing patient populations, changing delivery systems and the changing needs of patient populations.

Thibault described the U.S. medical educational system as "disjointed," saying it is time for a much better and smoother set of transitions between medical schools and residencies. The fourth year of medical school, in particular, should be "used in a much more rigorous but flexible way to prepare people for residency," he said. This should include the possibility that some medical students could enter residency sooner than after four years of medical school.

In addition, "More of the training should be out of the hospital and in the community," said Thibault, one of three main speakers to address the primary care forum.

Thibault referenced a Macy Foundation report issued in 2010 that addresses the financial and regulatory issues surrounding GME, as well as a second report released in September that focuses on the actual operation of GME programs and how they should be structured to achieve better accountability.

GME training should encompass quality improvement, patient safety and an understanding of medical economics, noted Thibault. Training also should place a greater focus on interdisciplinary and interprofessional methods to prepare residents for working in teams.

Although there have been calls for GME reform since the 1940s, those calls have gone largely unheeded, said Thibault. He is convinced, however, that the "profession is more ready for change than it has been for a long time. Some of that is out of fear, and some of that is out of real genuine interest and change."

According to Candice Chen, M.D., M.P.H., a pediatrician at Children's National Medical Center in Washington and another forum speaker, GME is a "bit of a black box." Data and money go into one end of the box, she said, and physicians emerge from the other end.

"Looking at primary care shortages in the United States, we seem to be missing something in terms of what goes in and in providing the workforce that is needed," said Chen, co-principal investigator of the Graduate Medical Education Accountability Study, which is led by the Graham Center.

Chen discussed preliminary findings from a study funded by the Macy Foundation and conducted by researchers at the Graham Center and the George Washington University Health Policy Research Center that looks at ways of measuring GME accountability. Researchers asked a cross-section of GME stakeholders whether GME constitutes a public good. Those stakeholders basically concluded that GME is a public good and, therefore, should be held socially accountable for producing a physician workforce that meets the needs of the country.

The study also looked at the specialties and subspecialties medical school graduates choose to enter and where they go to practice. Chen presented findings from two programs with the largest number of resident graduates in 2006 and 2008: Mount Sinai School of Medicine and the New York Presbyterian Hospital. The two institutions train a similar number of different specialties -- 66 for Mount Sinai and 67 for New York Presbyterian -- as well as a similar number of residents -- 1,625 for Mount Sinai and 1,586 for New York Presbyterian.

But the outcomes of the two institutions are quite different in terms of producing primary care physicians. Mount Sinai had 430 graduates in primary care fields compared to 137 for New York Presbyterian based on the AMA 2011 Masterfile, said Chen. Although both schools are located in New York, 4.4 percent of Mount Sinai's graduates chose to practice in rural areas compared with just 1.1 percent for graduates from New York Presbyterian between 2006 and 2008, she added.

During his presentation at the forum, family physician Russell Robertson, M.D., dean of the University of Chicago Medical School and chair of the Council on Graduate Medical Education, or COGME, addressed the role of academic health centers in GME. "Academic health centers have done an absolutely terrible job of providing medical students with appropriate context in regard to making specialty choice decisions," said Robertson.

"This is not because of any sort of mal intent, but just simply because of the environment in which their training is unintentionally skewed."

He alluded to a COGME report (66-page PDF; About PDFs) issued last December that calls for proper balance in the physician workforce, alignment of financial and other incentives, coordination and integration of care, and social accountability among health care institutions. The report points to the need for transformational change and calls for more support for primary care and a greater supply of primary care physicians.

According to the COGME report, primary care physicians currently comprise 32 percent of all physicians in the country, but that number should be at least 40 percent, said Robertson. Only 27 percent of medical school graduates in 2008, meanwhile, planned on becoming primary care physicians, he added.

"At a time when we should be on the upswing for primary care physicians, we are still heading in what the council thought was the wrong direction," he said.

Robertson cited income as a major determinant in influencing career choices. "When medical school students are making specialty choices, they are looking at a return on investment in terms of what they think they are going to generate as practitioners," he said. "That is something I really worry about because I don't think the incomes of physicians are going to be sustained at the level they currently are right now."