Tuesday May 12, 2015
It’s Time to Revolutionize GME -- Not Simply Reform It
“Social entrepreneurs are not content just to give a fish or teach how to fish. They will not rest until they have revolutionized the fishing industry.”
-- Bill Drayton, founder and chair of Ashoka: Innovators for the Public(www.ashoka.org), a nonprofit organization dedicated to fostering social entrepreneurs worldwide
This post isn’t about fishing or the fishing industry. It's about the ability of each of us, individually and collectively, to drive change or, as the author above stated, “revolutionize” an industry.
Physicians aren’t necessarily the first group that people outside of health care think of when pondering professions that drive innovation, but physicians actually are among the most accomplished drivers of change in the world. And family physicians are at the front of that group. Throughout history, physicians have driven innovation in scientific research, revolutionized the practice of medicine, emphasized public health and dramatically improved the quality of life for millions of people worldwide.
As I examined the impact family medicine has had on revolutionizing the health of our nation, I was struck by just how much change our specialty has made. The AAFP has led the charge against smoking and tobacco, we are at the forefront of the obesity crisis, we were one of the first physician organizations to call for universal access to health care coverage -- recognizing that health insurance was a key indicator of health and wellness -- and we led the national effort to maximize vaccination rates.
Today, we continue this leadership through our efforts to modernize the care delivery system; the promotion of payment models that facilitate comprehensive, continuous and connected patient-centered care; and our efforts to place a higher value on the appropriate use of medical services through our work on the Choosing Wisely campaign. These are just a few examples of our efforts and accomplishments, but they demonstrate the positive impact family physicians and the AAFP can have on the health care system and the health of individuals when we organize our voice and speak loudly for change.
Now it is time for the AAFP to harness our energy and drive change in our graduate medical education system.
Today, family physicians from across the nation are gathering in Washington, D.C., for the AAFP’s 2015 Family Medicine Congressional Conference (FMCC). This event features presentations from notable health policy experts, researchers, a senior member of the Obama Administration, and two members of Congress. However, the most important opportunity FMCC provides is a chance for a group of family physicians to join together to drive change and innovation in health care. This year, we will focus our combined energy on revolutionizing our nation’s graduate medical education system.
Although Medicaid, the Veterans Health Administration and some private sources contribute to the training of our physician workforce, the majority of funding comes from Medicare. We spend more than $16 billion annually to train an estimated 120,000 physicians. The challenge for the country as a whole, and our elected officials, is to determine the return we are getting on this investment.
During the past year, there has been an increased awareness that we, as a nation, need to develop a comprehensive strategy on physician workforce. Our national GME policy was developed in the 1960s and continues to rely primarily on a hospital-based model that places a greater emphasis on training a workforce that reflects the needs of a teaching hospital rather than meeting the needs of its community or state. I am not one to diminish the important role teaching hospitals play and the value they add to our health care system. But we need academic health centers and teaching hospitals to play a role in our GME system rather than playing the leading role.
There are two talking points I use repeatedly to drive home the impact of the legacy hospital-based system. First, since 1965 there has been an increase in the number of recognized medical specialties from 10 to 145. Many of these are subspecialties of internal medicine, pediatrics and surgery, but some are new first-certificate disciplines. Second, 71 percent of all medical residents and fellows train east of the Mississippi River, and 60 percent of all residents and fellows are trained in just 10 states. These statistics demonstrate the economic power of GME and how GME finances have been consolidated to a handful of cities and communities.
To put it kindly, the AAFP believes the GME system is in desperate need of change, so we developed and put forth recommendations. In 2014, the AAFP released a report entitled “Aligning Resources, Increasing Accountability, and Delivering a Primary Care Physician Workforce for America.” This policy is thought-provoking by design, but we felt it was time to revolutionize GME -- not simply reform it around the edges.
Our policy proposal calls for limiting GME finances to first-certificate training -- meaning no more federal funding for fellowship training -- and establishes two levels of primary care accountability that hospitals must meet in order the secure their federal GME financing. Additionally, we create a pathway for more federal GME investment in community settings outside the traditional hospital-based system.
This policy remains the foundation of the AAFP’s advocacy efforts regarding comprehensive GME reform and will be the focal point of FMCC. This will not be an easy journey. GME finances are part of the economic fabric of many hospitals, cities and states, and they will not welcome the reforms we have proposed. We, as family medicine, must also recognize that we have a responsibility to change the GME system for the entire physician workforce, not just family medicine. I hope you will join your colleagues who are attending FMCC and lend your voice to driving innovation. Our country needs family medicine to once again be the catalyst of change.
This week, Atul Gawande, M.D., wrote a compelling article titled “Overkill”(www.newyorker.com) for The New Yorker about the changes that have occurred in McAllen, Texas, since his July 2009 article entitled “The Cost Conundrum.”(www.newyorker.com) Besides being one of the premier medical writers in the world (in my opinion), Dr. Gawande draws some interesting and encouraging conclusions on what has allowed McAllen to go from a high-cost, low-quality health care community to one that is high quality, low-cost. We should be proud of the answer, which is primary care.
I won’t ruin the article for you, but I will tell you my favorite line: “McAllen, in large part because of changes led by primary-care doctors, has gone from a cautionary tale to something more hopeful.”
That's just one more illustration of family medicine as a driver of change.
Posted at 07:00AM May 12, 2015