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.