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Graduate Medical Education and the Institute of Medicine Report

Sklar, David P. MD

doi: 10.1097/ACM.0000000000000532
From the Editor

Editor’s Note: The opinions expressed in this editorial do not necessarily reflect the opinions of the AAMC or its members.

June and July are months of great contrast in the graduate medical education (GME) world. In June, those residents completing their most recent year of training have developed confidence and easy familiarity with their roles. Although they may appear battle-weary, they approach problems in a relatively predictable way. Communications between residents and nurses occur seamlessly on a first-name basis nurtured by a year of shared coffee, pizza, and donuts in the break room and by social events on weekends. The attendings know which residents to continue to watch closely and which can now be entrusted with increasingly significant responsibilities of independent patient care.

In July everything changes as the new interns arrive, their fresh faces shining with eagerness as they ask how to use the computers, and showing wide-eyed stares as they respond to routine questions about patient presentations. The contrast between them and those who were interns a year ago is breathtaking in its scope and reminds me of the remarkable transformations that occur during each year of residency. I know that some very important learning has happened during this time and that most of that has occurred during clinical care experiences and the reflections that follow those experiences. But it is difficult to identify exactly when the learning occurred or what was most critical for its success. Still, I have a sense that the system of GME training is generally working and that I can be confident of the readiness of our graduating residents for independent practice. Also, I wonder about how any new physician or other provider could be considered competent to practice independently without residency training, based on the enormous transformations I have observed in residents.

Another new arrival in July 2014 was the Institute of Medicine’s (IOM’s) report Graduate Medical Education That Meets the Nation’s Health Needs.1 The purpose of the report was to develop recommendations to improve GME, giving specific consideration to the

current financing and governance structures of GME, the residency pipeline, the geographic distribution of generalist and specialist clinicians; types of training sites; relevant federal statutes and regulations; and the respective roles of safety net providers, community health/teaching health centers, and academic health centers.1

This charge to the committee that wrote the report evolved partly from the first recommendation of a conference on the physician workforce sponsored by the Josiah Macy Jr. Foundation in October 2010 that asked for “an independent external review of the governance of the GME system.”2 The recommendation went on to ask that members of Congress should charge the IOM to perform the review; the foundation provided partial funding for the work of the IOM committee.

Why did the Macy Foundation make this recommendation and fund the IOM study? In their report,2 the Macy committee concluded that GME is a public good, financed by public dollars and responsible for meeting the public’s needs for an appropriate workforce to provide access to high-quality medical care, and that there should be an independent review of GME finance and governance to provide better accountability for the public support of GME. Since the IOM has conducted numerous studies to advise Congress about health care issues and has endeavored to provide nonpartisan, authoritative advice, it was an appropriate choice to conduct the review.

After the publication of the Macy proceedings, several senators wrote letters urging the IOM to undertake a review of GME, emphasizing concerns about the supply and distribution of the physician workforce, its impact on access to care, the alignment of current training with needed skills to address future health needs, and accreditation and reimbursement policies.1 The IOM committee was formed in July 2012 and was cochaired by Donald Berwick, MD, former administrator of the Centers for Medicare and Medicaid Services (CMS), and Gail Wilensky, PhD, also a former administrator of CMS, which was then called the Health Care Financing Administration. On July 29, 2014, approximately two years after the committee was named, it presented its findings.1 In the rest of this editorial, I highlight some of those findings and offer my interpretations of them.

As I reviewed the IOM report I identified the following issues:

Workforce adequacy. This is a critical issue that drives the other recommendations related to funding. The IOM report takes a neutral position about future workforce adequacy, citing previous incorrect projections and conflicting testimony and data from experts. The IOM committee was not persuaded by data from the Association of American Medical Colleges3 or the Health Resources and Services Administration4 projecting a future physician workforce shortage, and instead noted that there were opposing views (e.g., see Bodenheimer and Smith5 and Auerbach et al6) concerning the impact of increases in nurse practitioners, physician assistants, and other providers, as well as changes in the delivery and payment systems, all of which created uncertainty about current projections. In the December 2013 issue of Academic Medicine, several articles7–11 addressed future workforce projections. Although proposing different solutions, the predominant opinion expressed in those articles was that in spite of the important contributions of nurse practitioners, physician assistants, and delivery system reform, a significant physician shortage will develop. It is also notable that most projections of workforce shortages occurred before the Affordable Care Act had been passed. It is likely that with increased insurance and Medicaid coverage, patient demand will be far greater than those projections indicate.

Governance. The IOM committee recommended two new entities. A GME policy committee would be appointed to work in the Department of Health and Human Services (HHS) and develop a strategic plan for GME financing, workforce, distribution of funds, collaboration between agencies, and creation of annual reports. Another entity would be a GME center within CMS to manage GME operations and funds in accord with guidance from the policy committee.

Funding. The report recommends that funding of GME remain at the current levels but that there be changes in the way funds are allocated. The Indirect Medical Education and Direct Medical Education funds would disappear, and a new per-resident amount would be determined based on current funds and numbers of residents. The funds would be directed to the organizations sponsoring GME rather than to the hospitals. The funding would also be split into two separate streams. One would provide continued support to currently funded programs at a reduced rate. The other would fund innovations and new programs using a portion of the funds that had been previously used for ongoing GME support.

Transition. To reduce the impact of the changes in funding and governance, the changes would be gradually phased in over a 10-year period.

What are we to make of these recommendations?

My first reaction concerns the failure of the committee to address the physician workforce shortages that have previously been projected.3,4 While workforce projections have been notoriously difficult and inaccurate in the past, there is still a compelling need to make the best guess possible. A shortage of physicians would likely reduce access to needed care, reduce quality, and increase costs. Those most affected would likely be the most vulnerable members of the public.

Unfortunately, the report does not clearly describe how the IOM’s analysis of the workforce data and the testimony of experts occurred or how the committee reached its conclusions. The IOM report cited various articles (e.g., see Bodenheimer and Smith5 and Auerbach et al6) that focus on ways to improve efficiency and improve care delivery to reduce the need for additional physicians. However, those articles do not present a comprehensive analysis of the workforce with an examination of the effects of each change in delivery and its effect on meeting patient demand. Unfortunately, the recommendations about funding in the rest of the report are based on assumptions that no important GME funding increases would be needed to ensure future workforce adequacy. Should these be in error, the funding recommendations would likely be inadequate.

Since workforce adequacy is such a critical issue in the entire report, I was surprised that the report did not recommend that there be an annual development of workforce projections and models that would take into account the most up-to-date information and thinking about all aspects of workforce supply and demand. Such projections would help us adjust our workforce priorities based on the latest data. The federal government provides such projections for Medicare and Social Security annually.

My second reaction concerns the new governance structures of a policy committee in HHS and a CMS operations and management center. Having watched the difficulties of funding the National Health Care Workforce Commission, which would have done many of the same things suggested for the policy committee, I am not confident that the political bridges could be built to find support for funding the policy committee. Nevertheless, there would likely be benefits to creating expertise at HHS in the workforce area that would extend to other areas of health care delivery and finance and that would help HHS provide guidance and oversight of GME funding. The CMS center makes good sense. I am not sure why CMS could not internally reorganize to create such a center immediately.

My third reaction relates to the changes in funding. While overall levels of funding would remain unchanged from current ones, there would be a shifting of up to 30% of GME funding away from ongoing obligations to a transformation fund. This could disrupt current training obligations. All programs would have to compete for the transformation funds, which would likely not be distributed equally. This could lead to underfunding of current residency slots, leading to elimination of positions and programs. Another way to encourage innovation might be to add new financial support to the transformation fund with the same goals. This would encourage innovation while maintaining current necessary training support. Other recommendations concerning flows of funds to sponsoring organizations would likely change some power dynamics between GME offices and hospitals but could, in some cases, ultimately provide the flexibility needed to encourage more ambulatory and community rotations and strengthen primary care training.

Academic Medicine has addressed GME recently in our 2014 Question of the Year12; we also will publish a special group of articles on GME in the coming year. Many of these articles, as well as many of the responses to the 2014 Question of the Year published in last month’s journal, involve issues related to GME that were not covered in the IOM report, such as changes in curriculum, evaluation of residents, and new teaching methods. The Macy Foundation sponsored a conference in May 2011 concerning the content and format of GME13 that did review many of these areas and described the rich and complex role of GME in the overall continuum of medical education that goes beyond the areas of focus of the IOM report. That Macy report can serve as an excellent reference for addressing the many areas of needed improvement in GME not covered in the IOM report. Kenneth Ludmerer has also recently published a wonderful new book, Let Me Heal,14 which traces and interprets the history of GME and provides context for our current discussions.

As we consider the IOM report and its recommendations, we should recognize the many strengths of our current system: the stability of funding, the delicate balance of learning under supervision and delivery of safe and high-quality care, the interplay of research and education, and the commitment of mentors to the professional development of students. Although the system is robust in many ways, it is also fragile. The recent passage of legislation in Missouri to allow recently graduated medical students who did not enter or complete residencies to be licensed and to independently practice medicine after completing one month of physician-supervised work15 is an example of the types of solutions we can expect in a physician shortage environment. Although I have sympathy for medical school graduates who do not receive any or enough residency training, the solution is not to turn them loose for independent practice after a month of supervision. In this case, the cure may truly be worse than the disease.

As I mentioned at the outset of this editorial, June and July are two months that allow us to take notice of all that occurs gradually during each year of GME leading to an almost miraculous transformation of our students into fully formed physicians. I encourage all of our community to provide their expertise and experience to policy makers who will be grappling with the IOM recommendations and to help them understand the remarkable growth and development that occurs in our current GME system and why it needs to be supported and protected from radical change. We also need to understand and update the projections concerning physician shortages and be able to emphasize the impact on our population of not having an adequate workforce. Finally, we need to continue to support our faculty and students as they attempt to maintain their focus on teaching, learning, and caring for their patients as these ideas for changes swirl about them.

David P. Sklar, MD

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1. Institute of Medicine. Graduate Medical Education That Meets the Nation’s Health Needs. 2014 Washington, DC National Academies Press
2. Johns MME chair.. Ensuring an Effective Physician Workforce for America. Recommendations for an Accountable Graduate Medical Education System. 2010 New York, NY Josiah Macy Jr. Foundation
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    © 2014 by the Association of American Medical Colleges