Sweeping Overhaul of Content, Format Is Needed to Ensure Future of GME

A document recently released by the Josiah Macy Jr. Foundation reinforces the AAFP's long-held views on needed reforms in graduate medical education, or GME. The report, which was released by a GME workgroup convened by the Macy Foundation in May, calls for major reforms in the content and format of GME education in the United States.

According to Stanley Kozakowski, M.D., director of the Academy's Medical Education Division and chair of the Council of Academic Family Medicine, the report is a call to action to the broad community of GME stakeholders. "It puts into words the things that we as educators have known and been attempting to articulate for some time."

As GME evolves, he added, "A document like this becomes a touchstone for all to use."

The report, Ensuring an Effective Physician Workforce for the United States: Recommendations for Reforming Graduate Medical Education to Meet the Needs of the Public, (16-page PDF; About PDFs) summarizes recommendations made with input from 49 Macy Foundation workgroup participants. It complements a Macy report released in March that focused on changing the way GME is financed and governed.

"Unless we in academic medicine are self-critical and show a willingness to change, the political and public support for graduate medical education will disappear. This is a huge enterprise built on tradition, but the system has to change to be more responsive to public needs," said Macy Foundation President George Thibault, M.D., in a statement.

Report authors note that a new way of doing business is imperative. "Physicians in training must understand the financial implication of their patient management decisions, and their training must include new and efficient models of care so that they will be prepared to practice cost-effective medicine and be responsible stewards of resources while providing high-quality patient care."

The report estimates that the nation could face a shortage of 100,000 primary care physicians by the middle of the next decade. "The public expects the GME system to produce a physician workforce of sufficient size, specialty mix and skill to meet society's needs," says the report. Conclusions are made about the current state of GME, and recommendations are offered in six specific areas. They are

In terms of accountability, "GME must meet the needs of -- and be accountable to -- the public," says the report. GME must include and engage communities in feedback, analysis and planning, and the evaluation of GME at all levels must be transparent.

Those recommendations are consistent with Global Consensus for Social Accountability of Medical Schools, (16-page PDF; About PDFs) a report created with input from more than 130 organizations and individuals from around the world that has been promulgated by the World Health Organization, according to Kozakowski.

The Macy Foundation report also concludes that high-quality GME can be achieved only via a physician's experience with a diverse mix of patients and clinical problems. "Special attention should be paid to nonhospital training sites. GME sites should incorporate established and emerging models of health care delivery (such as medical homes), provide meaningful experience in team-based care and population health, and incorporate new technologies, such as electronic health records and telemedicine."

The heart of patient-centered care lies in a physician's ability to provide patients with the right care at the right time in whatever setting is appropriate, said Kozakowski. "We, as a society, need to recognize that education must take place in a variety of settings and that funding models need to reflect that."

In addition, education should "occur across historic professional boundaries," so that residents have the opportunity to learn from physicians in other specialties, a move that would require an overhaul of certain regulations and billing requirements, says the report.

The report authors also note that a focus on increased efficiency in the GME system will enhance the quality of training and help address physician workforce shortages. "The length of GME should be determined by an individual's readiness for independent practice, demonstrated by fulfillment of nationally endorsed, specialty-specific standards rather than tied to a GME program of fixed duration."

Steps taken to increase educational efficiency have the potential to free up residency positions within the GME cap, and those positions could be redirected to address workforce needs. Furthermore, say the authors, "We endorse the funding of a national workforce commission to guide the allocation of residency positions by specialty and geography to meet societal needs."

Kozakowski agreed. "Let's form an independent body to look at this," he said. There needs to be an unbiased nationwide review of how to get the kind of physicians we need to serve people," he noted. "Our current system does not ensure that."

The report further recommends that medical education follow a continuum of lifelong learning. In particular, flexibility in the final year of medical school would help ensure that individuals can successfully transition into GME. Students often use their final year of medical school to interview for residency programs and pursue electives rather than to "strengthen their medical education or deepen their learning in a given area," say the authors.

Although research is lacking, "Residency program directors will tell you that, in their experience, many medical students are not as well prepared to enter residency today as they were in the past," said Kozakowski, who just ended a 15-year run as director of the Hunterdon Medical Center Family Medicine Residency Program in Flemington, N.J. He agreed that there needs to be a lifelong learning continuum.

In addition, GME must have support at both institutional and national levels, says the report. Programs must be well designed and flexible enough to achieve optimal outcomes. One-size-fits-all GME "inhibits the development of individual or program-based areas of expertise."

"This is consistent with the idea that a single, rigid educational system does not lend itself to consistently producing competent physicians to practice in the settings where they may be needed," Kozakowski observed.

The report's final recommendation on research calls for the creation of an organization it dubs the "National Institute of Health Professions Education." The creation of such a body would "best leverage the large public investment in medical education for the greatest good to society," say the authors. The national institute could coordinate, prioritize and fund research on health professions education, with a substantial focus on GME.

"GME reform is imperative if we are to have a more robust, reliable and efficient health care delivery system," say the report's authors. They note that the report provides a blueprint for doing so, but there are barriers that must be overcome, as well, including national planning, regulatory changes and faculty development.

However, the authors say they believe that reform is vital to the future of GME and can be accomplished. "We have the tools, talent and commitment to accomplish reform of the GME system and must seize this moment to ensure that current and future patients get the care they need and deserve."