A Vision for Graduate Medical Education

When I started my residency years ago, there was no orientation. On that first day the new interns arrived from all parts of the country, all men, some dressed formally in jackets and ties, others in scrubs. We received our patient lists from the tired departing interns, who smiled knowingly about what we were soon to experience. We each met our new resident and faculty attendings, and in my case, I immediately started getting called to work up new patients. One was a patient with leukemia, another had end-stage liver disease, a third had chronic lung disease with an infection. I was on call my first day and would end up in the hospital for 36 hours, picking up several more patients, visiting the intensive care unit to manage a sign-out patient from another team who had developed a fever, and going to the emergency department to assist in the evaluation of a patient who was vomiting blood. I remember these patients as vividly as if I had seen them yesterday. I left the hospital the next day in a daze, exhausted and exhilarated at the flood of stories, people, and experiences I had encountered. I remember thinking that if I could survive the crushing workload, I would learn more in the coming year than I had ever learned in my life.

In fact, that first week I calculated that I spent 126 hours in the hospital. The pager, which initially had been a mark of distinction and pride demonstrating my new status as a doctor, quickly became a persistent and dreaded enemy, interrupting patient conversations, lunch breaks, or educational conferences, even hounding me in the bathroom. The pages often led to questions from nurses that I could not answer and reminded me of how much I had to learn. At the same time, I felt motivated to overcome the gaps in my knowledge by the enormous trust of my faculty supervisor, the other residents, and especially the patients, who imagined I knew far more than I did.

The experience of residency has changed since those days. Gone are the 100-hour workweeks and the limited on-site supervision by faculty. Educational conferences have become more organized, and the learning time is now more protected from interruptions. Evaluation has expanded beyond medical knowledge and patient care to encompass a variety of outcomes that residents should demonstrate. Simulation has provided an alternative venue for exposure to unusual or difficult cases and has augmented procedural learning and evaluation. Faculty now have become more involved in the care of the residents’ patients, writing notes to document their involvement and generating bills that provide substantial income for academic departments. The residents have also changed; there are more women—now the majority in some specialties—and there is greater diversity of race, ethnicity, and class. There are also other providers to share the workload, such as nurse practitioners, physician assistants, pharmacists, and paramedics. Concerns about patient safety, quality improvement, cost of care, and the educational environment have resulted in broadening expectations for residents’ education.

With all of the improvements in graduate medical education (GME), why has it been the subject of numerous studies and reports over the past four years, two sponsored by the Macy Foundation,^1,2 one from the Institute of Medicine (IOM),³ and another from a consortium of organizations in Canada?⁴ What are the problems that have led to concerns? Is there a crisis in GME and, if so, what is its cause and what can we do about it? This month’s special GME issue of Academic Medicine provides some answers to these questions. But first, it is instructive to briefly describe the recent expert reports published about GME.

The Macy Foundation sponsored two conferences of GME leaders in 2010 and 2011. The first conference,¹ chaired by Michael M.E. Johns, MD, recommended a comprehensive review of GME finance and governance by the IOM as well as reexamination of accreditation policies to facilitate GME redesign, the funding of innovation, and an initial expansion of 3,000 entry-level positions and other changes based upon estimates of the future workforce.

The second conference,² chaired by Debra Weinstein, MD, emphasized public accountability of GME, changes in training to anticipate delivery system reform, changes in the curriculum and the learning environment, reexamination of the duration of training and transitions along the continuum of medical education, greater integration of the clinical educational environment with the educational objectives, increased flexibility to allow for innovation, and investment in research in medical education.

The genesis of the recent IOM report on GME³ began on December 21, 2011, when eight U.S. senators sent a letter to the IOM requesting a review of GME. In the letter they noted that “the United States is failing to adequately match the medical training with the medical needs on a national level.”³ The letter went on to mention specific concerns about governance and financing of GME, accreditation, distribution of physicians, care of the underserved, access to health care, skills for the future needs of the health care system, and the distribution of funding across states. These senators were pointing out that GME receives public financing but may not meet the needs of the public if it fails to produce the right number of physicians with the right skills practicing the right specialties in the right areas.

After receiving the request and procuring funding, the IOM convened a group of experts to examine the GME system, focusing mainly on finance and governance concerns. In July 2014 the IOM published its report,³ in which the committee recommended continued Medicare funding of GME, greater transparency for GME funding, and two new committees to oversee the governance of GME. They also recommended changes in the methods of determining amounts and destinations of GME funds, and that there be funds for GME to encourage innovation and accountability. Finally, the committee recommended to continue using Medicaid funds to supplement Medicare funding of GME. Since its release the report has stimulated a mix of reactions about its conclusions and recommendations.⁵

The report of the Future of Medical Education in Canada Postgraduate Project,⁴ from a consortium of four Canadian organizations (the Association of Faculties of Medicine of Canada, le Collège des Médecins du Québec, the College of Family Physicians of Canada, and the Royal College of Physicians and Surgeons of Canada), identified 10 areas of focus for improvement of GME: social accountability, learning and work environments, competency-based curriculum, transitions, assessment systems, clinical teachers, leadership, governance, accreditation, and physician mix and distribution. These areas have considerable overlap with those identified in the Macy Foundation reports.

Unfortunately, the concerns and suggestions made by these committees are not new. Kenneth Ludmerer, in his excellent history of GME, Let Me Heal,⁶ describes the failures of previous commissions and committees to bring about reform. Because our current problems in GME are best understood as the products of historical processes, this month’s special GME issue of Academic Medicine includes three Commentaries^7–9 that focus on the final three chapters in Let Me Heal. The other articles in this special GME issue provide analysis, opinions, and proposals to address many of the concerns raised by the four reports described above.

As I reviewed the four reports, previous GME literature, and the current articles in our special GME issue, I decided to organize the information they present about GME around these key questions:

• Who are the individuals we are training and who are their teachers?
• Why do we train residents?
• How many residents do we need?
• Where should residents be trained?
• What do we want residents to learn and do?
• How should we teach residents?
• When should physicians’ training begin and end?

I used these questions, explored in more detail below, to help create a coherent framework for myself for considering the current challenges in GME and the gaps in our understanding.

Who are the individuals we are training and who are their teachers? Within this double question are subsumed additional questions about selection of students and residents, professional identity formation, diversity, selection and training of faculty, leadership skills, and the creation of teams, including nonphysician providers.

In this issue of the journal, Golden et al¹⁰ write about nurse practitioner training to address the shortage of geriatricians and the implications for geriatrics training. There is much to learn about how nurse practitioners—who follow a different curriculum and a shorter training process—develop patient care skills and knowledge, and how their services compare to those of physicians. Shtasel et al¹¹ consider the community-based primary care workforce and describe innovative fellowship and practitioner programs that identify future community health and primary care leaders. The authors describe the characteristics of a supportive learning environment for primary care with the hope that innovations that can improve the attractiveness of primary care could help community health centers recruit and retain primary care clinicians.

Why do we train residents? This question requires an overall analysis of the purpose of GME, public needs, and accountability. Holmboe and Batalden¹² provide a broad overview of the use of outcomes as a basis for designing the GME curriculum and assessing GME quality. They ask us to reconsider the goals of medical education with reference to the desired outcomes. Aschenbrener et al¹³ envision GME as occupying a central place in the medical education continuum that can connect to the other phases of that continuum through a common set of competencies. They also believe that this approach can improve the transitions between the phases of medical education.

Mihalich-Levin and Cohen¹⁴ describe the current GME funding formulae in this month’s AM Last Page, which illustrates the public’s financial commitment to GME and demonstrates the need for accountability for this funding. Gold et al¹⁵ propose an alternative to current GME finance with an all-payer funding mechanism to better align physician training with the health care needs of the public.

Busing et al¹⁶ share the perspectives of Canadian education leaders about the purposes of GME and describe a unique governance model for Canadian GME that could be a useful model in the United States.

How many residents do we need? Workforce projections have provided a justification for government investment in GME, particularly when such projections suggested impending deficits. However, workforce projections have often been inaccurate and led to wild gyrations in residency applications to specialties based upon concerns of future over- or undersupply. The current workforce projections of a physician deficit were recently disputed in the IOM report³ mentioned earlier. Salsberg¹⁷ considers past physician workforce projections and how to evaluate their limitations; he also discusses implications for workforce policy based upon current data.

Nuss et al¹⁸ describe a program in Georgia in which state funds have been allocated to help start new GME programs in hospitals that had not previously been involved in GME. Such an approach would offset the effect of Medicare caps imposed on hospitals with established GME programs. Chang and Brannen¹⁹ describe a VA expansion in GME training currently under way to address perceived needs to improve access to care for veterans.

Where should residents be trained? There has been a growing concern that hospital-based training does not sufficiently nurture and support residents or prepare them for effective functioning in ambulatory settings. There have also been concerns raised about the connection between residents’ learning environment and the quality of their education. Jennings and Slavin²⁰ discuss the problem of burnout and mental distress of residents during their training and how to improve the learning environment to foster resident wellness. Roemer et al²¹ describe the features of training programs at Kaiser Permanente and how they prepare graduates for work in a managed care environment with skills in population health, which will increasingly be important as health reform evolves. Chen et el²² describe the potential loss of current primary care residency training positions when federal grants end. Such cuts could decrease the opportunities for primary care training to occur in ambulatory settings; training in those settings helps prepare residents to provide efficient care.

What do we want residents to learn and do? Because of changes in the care delivery system, the need for a team and systems approach to medical care, and the patient safety problems in the current system, it is increasingly important to reform the content of medical education to include patient safety, quality improvement, team management, and health policy. Liao et al²³ describe new content in GME that focuses on preparing graduates for a role in improving quality. Bagian²⁴ describes the importance of patient safety training as part of future GME education to reduce unnecessary risks to patients from physician error.

How should we teach residents? There has been a reexamination of how to best provide the educational content and experiences to learners who have a variety of learning styles. Weinstein,² Brady,⁷ and Andolsek⁸ comment upon the changes in educational pedagogy in the recent history of GME and what we can learn from them to improve our future educational approaches. Along with the changes in how to teach are changes in evaluation based upon observation of achievement of competency, discussed by Holmboe and Batalden.¹²

When should physicians’ training begin and end? In an article in JAMA, Emanuel and Fuchs²⁵ raise questions about whether physician training time could be reduced, including transitions from medical school to GME and GME to practice. Yet increasing numbers of residents are pursuing fellowships leading to subspecialization and lengthening of training. Holmboe and Batalden¹² and Aschenbrener et al¹³ discuss the need to move away from a time-based training approach to an outcomes-based approach throughout the continuum of medical education. The latter approach could provide the mechanism for changing the duration of physicians’ training.

Based upon the information and ideas in the articles mentioned above, I perceive threats to GME primarily in three areas: financial, structural, and political.

The financial threats relate partly to a combination of pressure on Medicare from an expanding population of beneficiaries^26,27 and a lack of clarity on future physician workforce projections. This combination of factors could result in decreased government support for GME, since Medicare funds help support the GME system. Recent presidential budgets have included proposed cuts to GME funding. While alternative funding from states, hospitals, and other sources has provided small increases in GME positions over the past 10 years, continued increases may not be possible if hospitals’ clinical revenues flatten or are reduced. States that have supported GME with Medicaid funds in the past will also come under pressure to reduce Medicaid expenditures as the Affordable Care Act shifts funding for Medicaid expansions from the federal government to the states. Also, if clinical revenues to teaching hospitals are reduced as part of an overall reduction in health care spending, the resulting financial pressures may affect the support of clinical faculty who provide most GME training and supervision.

The structural threats include changes in care delivery for which today’s residents are not sufficiently prepared. Such changes will involve more emphasis on team care, population health, chronic care, disease management, patient self-care, quality improvement, data analytics, cultural competence, and implementation sciences.

The political threats involve philosophical and policy differences in the political parties’ attitudes about the role of government in health care. Whether market forces will resolve problems such as projected workforce deficits or whether the problems will be addressed with active government involvement will result in substantially different outcomes for GME.

Based upon these threats, I have the following suggestions:

First, to address the financial and political issues, we need accurate workforce projection data as well as data that describe the value of GME at the state and national levels. Workforce data should be developed by trusted impartial experts on an annual basis and include probability/risk corridors to account for uncertainty. These projections can then guide policy discussions concerning the financing and governance of GME. Data should also be collected that show how Medicare GME funds are being spent, the outcome of GME training related to distribution of graduates, the quality and quantity of services they provide, and how these services have improved the health of the public. A set of agreed-upon data will reduce some of the uncertainty and speculation about future workforce needs that have characterized recent GME policy discussions. The Association of American Medical Colleges recently sponsored an update of workforce projections that is an excellent start to the production of the type of data that are needed.²⁸

Second, to address the structural issues for GME, we should agree upon the purpose of GME. This seems like a simple and straightforward issue; isn’t the purpose of GME to produce physicians? But physicians are a diverse group including generalists, specialists, administrators, teachers, and researchers. Will they meet the needs of our population? How aligned is the current training of our physicians with those needs? I have previously suggested²⁹ that the triple aim of better health, better health care, and lower cost proposed by Berwick et al³⁰ could be adopted as the goal for our medical education system. Such a goal would highlight the practical nature of medical education. While medicine applies scientific methods to the understanding and treatment of disease, it also has a unique social mission of care delivery for which it is accountable. An agreement about the goals of GME would allow for a standardized approach to curriculum design and the prioritization of various competing content areas, so that, for example, education related to quality and safety would become core areas of knowledge rather than a peripheral addition to an already-crowded curriculum. An agreed-upon goal for medical education as a whole would also assist in the transitions between the phases of medical education. The adoption of outcomes, competencies, milestones, and entrustable professional activities could provide a framework to assess whether GME is meeting its intended purpose. Clarification of the goals of GME would affect the selection of students, the desired training environment, the incorporation of teams, the development of faculty, and incorporation of education technology and information systems as part of comprehensive GME reform. Such clarification would also provide justification for governance and funding structures.

Finally, addressing the political, financial, and structural issues will require engagement with the public to make the case for public support of GME. Since financial pressures on Medicare and health care spending in general will likely increase, and there will be competition for limited public funds, there must be a clear rationale for why public funds should support GME that can encompass the diversity of political philosophies and political interests. To accomplish such a task would require a bidirectional exchange between the medical education community and the public about the full spectrum of expectations for the GME system, from what GME should provide to the public to what the public commitment to GME should accomplish. This discussion should lead to agreements about governance and funding that allow for flexibility, innovation, and accountability. The recommendations of the committees I cited earlier^1–4 could guide such conversations. Any agreement would likely include measures of accountability and transparency that could be used to monitor the achievement of agreed-upon goals.

While I am sometimes nostalgic for the days when the goals for residents’ education seemed relatively simple—learning through caring for patients, reading, discussing cases with faculty role models, and surviving the arduous hours of training—I recognize the limitations of those days, both in the lack of educational rigor and the lack of alignment of the GME system with the health needs of the public. The articles in this special issue of Academic Medicine provide exciting new ideas for our consideration to strengthen that rigor and improve that alignment. Through an understanding of the current financial, structural, and political issues confronting GME, we can redesign our future GME system to meet the educational needs of our future physicians and the health care needs of their patients and also can honor the historic public–private commitment to the education of a physician workforce that has served our country well.