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Forum Speakers Call for Fundamental Changes in Graduate Medical Education
Programs Need to Meet Nation's Needs, Say Speakers
By James Arvantes • Washington, D.C.
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.
- Speakers at a recent primary care forum called for changes in graduate medical education, or GME, programs.
- Current programs are failing to meet the nation's physician workforce needs, said speakers.
- GME programs should change to better reflect changing patient populations, changing delivery systems and the changing needs of patient populations.
The Black Box
"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.
"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."
Macy Foundation Report
Sweeping Overhaul of Content, Format is Needed to Ensure Future of GME
Fundamental Changes Needed in Medical Education, Say Speakers