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Tectonic Shifts Are Needed in Graduate Medical Education to Ensure Today’s Trainees Are Prepared to Practice as Tomorrow’s Physicians

Phillips, Robert L. Jr MD, MSPH; Bitton, Asaf MD, MPH

doi: 10.1097/ACM.0000000000000477
Responses to the 2014 Question of the Year
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Dr. Phillips is vice president for research and policy, American Board of Family Medicine, Lexington, Kentucky. He is also professor of family medicine, Georgetown University School of Medicine, Washington, DC, and clinical professor of family and population health, Virginia Commonwealth University School of Medicine, Richmond, Virginia.

Dr. Bitton is assistant professor of medicine, Division of General Medicine, Brigham and Women’s Hospital, and assistant professor of health care policy, Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.

Other disclosures: Dr. Phillips has received funding from the Josiah Macy Jr. Foundation to support research on graduate medical education outcomes and accountability; he has also received support from Title VII funding (Health Resources and Services Administration). In addition, he has received funding from the Commonwealth Fund (for patient-centered medical home/Medicaid evaluation), the U.S. Agency for Healthcare Research and Quality (quality/safety research and electronic health record–related research), and the Fulbright Scholar Program as a Specialist to the Netherlands. Dr. Bitton is a core faculty member of the Harvard Medical School Center for Primary Care, and associate program director at Ariadne Labs, a joint center for health systems innovation at Brigham and Women’s Hospital and the Harvard School of Public Health. Dr. Bitton has received funding for work on primary care redesign, team-based care, and patient-centered medical home research from the Commonwealth Fund, the Controlled Risk Insurance Company Risk Management Foundation, the Center for Integration of Medicine and Innovative Technology, the National Institute for Health Care Management Foundation, the National Cancer Institute, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, and the Gates Foundation.

Dr. Phillips is an advisor to a Macy Foundation-supported study on GME outcomes, and he is a former vice chair of the Council on Graduate Medical Education. Dr. Bitton serves on the Practice Assessment Committee of the American Board of Internal Medicine and is a member of the Executive Council of the Association of Chiefs and Leaders in General Internal Medicine. He also serves as a senior advisor to the Comprehensive Primary Care Initiative at the Center for Medicare and Medicaid Innovation (CMMI).

Ethical approval: Reported as not applicable.

Disclaimer: The ideas expressed in this article are solely those of the authors and do not represent official positions of CMMI or any other organization for which they work or advise.

Correspondence should be addressed to Dr. Phillips, American Board of Family Medicine, 1133 Connecticut Ave. NW, Suite 1100, Washington, DC 20036; telephone: (859) 269-5626 ext. 1253; e-mail: bphillips@theabfm.org.

Most U.S. institutions that sponsor graduate medical education (GME) programs are struggling to commit to a non-volume-based care business model while, at the same time, working to sustain or expand a fee-for-service status quo.1 The Association of Academic Health Centers and some of its member institutions contend that there is a viable business case to be made for a population-based care model that seeks to resolve environmental, social, and behavioral determinants of health. As teaching hospitals struggle with these tectonic shifts in their business models and social contracts, they are also contending with how to prepare young physicians for practice in the resulting new models of care. Here, we offer key steps that academic health centers (AHCs) can take to position their GME programs at the leading edge of change.

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Make GME your mission

Most training institutions do not have a uniquely stated GME mission. Without a clear GME mission statement, GME training and output commonly devolve to reflect the hospital’s dominant business strategy.2 As AHCs reform their business models and social contracts, it makes sense to also enunciate a new GME mission that clarifies whom GME serves as well as the competencies and capacities of graduates.

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Develop new training models

For more than 25 years, the Institute of Medicine and the Council on Graduate Medical Education have advocated for moving training out of hospitals and acute care settings.2 There is ample evidence that community-based training increases migration of the physician workforce into rural and underserved settings and that it produces more generalist physicians than does hospital-based training.2 Population-based business models shift care out of hospital and acute care settings, taking advantage of robust generalist teams that can provide comprehensive, complex, proactive, relationship-rich care. These new care models should underpin new GME training models. Training institutions could make training sites the leading edge of clinical innovation for the institution, preparing a physician workforce that is not only familiar with new care models but also comfortable with change. Although there are some early examples of collaborative care models, much institutional skepticism exists around them—especially those models that break down disciplinary walls and engage patients meaningfully.3 As many GME institutions continue to remain stuck in old training models, we expect that we will increasingly hear that graduates are not prepared when they begin to practice.

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Train the trainers

GME educators cannot teach what they do not know. Moving to a population-based health care model will require retrofitting the existing workforce, so why not train educators as the first wave? Yet, at the very time we need to train the trainers to teach in new care models, most philanthropic organizations and federal agencies are eliminating faculty development support. GME institutions should be loud in expressing this dire need for faculty training and support to funders.

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Emphasize accreditation and certification

The Accreditation Council for Graduate Medical Education created the Next Accreditation System in order to produce doctors whose competency is measured in performing the tasks essential for clinical practice in the 21st century. Some certifying boards have signaled a willingness to carry this intent past completion of training. Accreditation and certification can help ensure preparation by clarifying expectations for training and practice and by measuring outcomes.

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Seek opportunities for new federal partnership

Medicare’s GME funding system remains largely unchanged since its inception 50 years ago, and most state GME support is similarly still anchored in teaching hospitals. This 13 billion dollars’ worth of pressure to maintain the status quo could instead become a massive funding stream for reforming GME. Forty years ago, Title VII funding fueled growth and innovation in GME, but it has become so small and is threatened so regularly that most of the training community lacks faith that it will last. It could, however, once again become the federal research/development mechanism for support of new training models. Title VII could lead the way and inform modifications to Medicare GME funding. The Teaching Health Center GME program is a shining example of what this could look like.

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Be accountable

Ensuring that GME will prepare trainees for practice in new systems of care requires a new social contract with accountability for both training sponsors and funders. Training sponsors will need to be accountable to trainees for training them to practice in these new models, to the public for producing the needed workforce, and to their communities for improving health. Payers—for care and for training—need to be accountable to training sponsors for support of new training models, for breaking anachronistic payment models, and for making GME training sites a priority for clinical innovation. Funders of GME should consider GME payment transitions that reduce reliance on hospital-based systems and increase institutions’ willingness to experiment with training models.

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In sum

The same tectonic shifts that are reshaping the U.S. health care system should also change the GME landscape in the United States. This GME metamorphosis has many features but one goal: to ensure that tomorrow’s physicians are prepared to practice in new systems of care delivery.

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References

1. Parmar A. Healthcare industry suffering with “institutional schizophrenia” as business model shifts. MEDCITY News. Published August 28, 2012. http://medcitynews.com/2012/08/institutional-schizophrenia-occurring-in-healthcare-industry-as-they-ponder-business-model-shift/. Accessed April 30, 2014
2. Council on Graduate Medical Education. 20th Report: Advancing Primary Care. 2010 Rockville, MD Department of Health and Human Services http://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/Reports/twentiethreport.pdf. Accessed May 8, 2013
3. Bitton A, Ellner E, Pabo E, et al. Launching the Harvard Medical School Academic Innovations Collaborative: Transforming primary care practice and education. Acad Med. 2014;89:1239–1244
© 2014 by the Association of American Medical Colleges