I fully agree with Dr. Walsh’s comments that cost is an essential element of public accountability for graduate medical education (GME). This is especially true since public money is used to fund GME programs. In fact, most discussions of GME accountability have been driven by proposals to decrease public funding of GME. The creation of accurate and reliable accountability measures as discussed in my commentary would in large part be used to drive a portion of public funding to programs and institutions that meet desired training outcomes.
As Dr. Walsh underscores, measuring the costs of GME is not completely straightforward. Some costs, such as the “direct” teaching costs reported on annual Medicare cost reports, are easier to define. These include a portion of trainee and faculty salaries and benefits and a portion of teaching-related overhead costs. Much more challenging is the calculation of “indirect” costs, the additional costs of teaching institutions ascribed to the involvement of residents and fellows in patient care. Most challenging, however, is the measurement of the increased (or decreased) revenue received by health care institutions and providers due to the patient care provided by resident and fellows.
Despite the challenges, I agree that more careful cost analyses of GME are both feasible and necessary. The key, however, will be to ensure that all costs and all revenues are captured. In the meantime, GME measures focusing on competence, the learning environment, and workforce outcomes can be initiated immediately to incentivize better GME outcomes and provide public accountability.
Robert B. Baron, MD, MS
Professor of medicine and associate dean for
graduate and continuing medical education,
Division of General Internal Medicine, Department
of Medicine, University of California, San Francisco,
School of Medicine, San Francisco, California;