Less (sub)special

In every decade for the past 50 years, there have been many calls for reform of the system that finances graduate medical education in the U.S. But those calls have not led to substantive change.

With implementation of the Patient Protection and Affordable Care Act well under way and increasing clarity on where the gaps are in terms of the mix of physicians and skill sets needed for practice, it's time for action. We need substantive reforms in the governance and financing of GME, and we need them now.

That's why a GME Policy Workgroup, sponsored by the Josiah Macy Jr. Foundation and the Association of Academic Health Centers, last month issued a set of five major recommendations for reforming GME policy. (The work group's report is available at macyfoundation.org.) The work group, made up of leaders in academic medicine and healthcare, recognized after study and expert testimony that the impending shortage of physicians, particularly in primary care and some specialties, as well as a need to better meet the population's changing needs for care, required immediate action.

The work group's recommendations are based on four major tenets:

• GME is a public good.
• Because it is largely publicly financed, it must be accountable to the public.
• We need to ensure an adequate supply of physicians.
• We need an independent external review of how GME is governed and financed.

Our call for reform should come as no surprise. All providers are increasingly being asked to become accountable for providing high-quality, safe, cost-effective care to a diverse population of patients. We should apply the same standard for how we train residents.

Why should academic medicine meet that standard? Unlike undergraduate medical education, graduate medical education—the period when we train interns and residents for practice—is largely financed with public money, mostly through Medicare and Medicaid. Medicare is the single largest payer, at approximately $9.5 billion annually; Medicaid pays an additional $3.5 billion. Nevertheless, the public has had little to say in how these dollars are spent.

We believe that has to change. The GME enterprise is largely responsible for the composition of the physician workforce in this country. It only seems appropriate that the payers that support residency training should work with the professions to make sure its dollars are producing physicians with the right skills and competencies, who are trained in settings where patients get care, and who represent the right mix of needed specialties.

One of our key recommendations is determining how best to restructure the GME system to increase physician supply in the specialties where there are shortages. Over the past decade, the number of those training in subspecialties has grown at five times the rate of those training in core specialties. We believe there will not be an increase in the number of practicing physicians in needed specialties unless we allow the number of residency positions in core specialties to grow.

To address that, we recommend a one-time increase of 3,000 entry-level GME positions in three specialties: adult primary care (family practice and general internal medicine), general surgery and psychiatry. Our recommendation is comparable to what the Council on Graduate Medical Education seeks but differs from those of the Medicare Payment Advisory Commission, which believes Congress should not fund additional GME slots without further study. We also call for a targeted increase, largely funded by reallocating some existing positions. Because of the inherent uncertainties in making projections in a changing healthcare system, the recommendations must be reassessed at least every five years.

We also seek an independent external review of the governance and financing of GME to help the accreditation processes function in a way that best serves the public, the training programs and the trainees. Congress should charge the Institute of Medicine to perform the review and make recommendations on the structure and function of the Accreditation Council for Graduate Medical Education, as well as the number of residency positions needed, appropriate training sites and optimal funding mechanisms.

Creating innovative training approaches and alternative sites to give trainees the skills and competencies they need is another critical GME reform we seek. In addition to current sponsoring institutions, we need sponsorship by healthcare systems, accountable care organizations, teaching health centers and other new organizations that are fostering patient-centered, coordinated, interprofessional and interdisciplinary care. A first step would be to establish a specific funding mechanism to provide incentives to work toward this goal.

None of us is saying the GME system is producing incompetent doctors. The U.S. system for educating physicians is still a beacon to the world. But if it is going to meet contemporary needs and continue to lead, it needs to be less subspecialty-centric and fragmented and more oriented toward team-based care.

We have joined a growing chorus seeking to fix a system that is no longer optimally configured. We may not all agree on how to get there. But all of us are aiming for the same goal. Let's not let another decade pass without taking the steps we know are necessary.

Dr. George Thibault is president of the Josiah Macy Jr. Foundation in New York. Dr. Michael Johns is chancellor of Emory University, Atlanta, and chair of the GME Policy Workgroup.