Residency (GME) Positions: Addressing the Nation's Healthcare Needs

I’ll start this post with full disclosure: I am a medical educator, and have spent a good portion of my professional life educating trainees (residents) to prepare for independent practice.  My specialty is combined internal medicine-pediatrics, or “Med-Peds” for short, and my personal clinical practice is primary care for the underserved.

I have been very interested in what the future health care environment will look like, and thus follow updates from agencies that comment on the future of health care, as well as the supply of physicians and other health care providers.

There are some facts about which very few disagree, and there are others where interpretations are very different.  We do know that many new medical schools have opened up within the past few years, and also that many existing medical schools have increased matriculation. 

From this, it would seem as if the supply of physicians to care for future generations is being addressed.  But remember that, to be a physician practicing independently, one must graduate medical school, and also complete residency training.  It is this part, the percentage of residency training positions, which has NOT increased as much as the medical school matriculation.  The actual number of positions has increased, but not at the same rate as medical school graduates (see Figure 1).  In short, the “bottleneck” for US students to become practicing physicians is indeed US residency positions, known as GME, or graduate medical education.  The National Residency Match Program (NRMP) does state that there are enough GME positions for all US graduates, but there are other graduates (from international medical schools) applying for these same positions.

This was a busy week for such projections.  The AAMC came out with a roadmap earlier this week describing plans for how to address this situation.  The Commonwealth Fund, however, delivered another interpretation of the situation, stating that the current healthcare situation can handle the influx of new patients as a result of the Affordable Care Act.  This follows on the heels of the IOM report last year addressing the GME issue and recommending no additional funding for new residency positions, among other things. 

So who is correct?  I admit my biases on this topic, in that a) I am an educator, and attend the AAMC meetings, and b) I practice in a state where even the Commonwealth Fund writes that there are fewer primary care docs.  For the record, our Med-Peds residency program is the largest one in the country, and has been for at least 20 years.  About 40-45% of our graduates choose primary care as their ultimate specialty, higher than either hospital medicine or further fellowship subspecialty training.  This percentage of graduates choosing primary care was higher in the 1990s.

I’m curious what readers of this blog think about the situation.  Is there a doctor shortage, and is there a shortage of primary care physicians?  Will patients be able to get access to health care given the influx of new patients into the health care system?  What else should be done besides the roadmap outlined by the AAMC?

Thanks for reading; I’m curious to hear differing opinions.

GME Funding: A New Recommendation and Discussion

Today, the Institute of Medicine (IOM) presented a recommendation report on the future of GME funding to meet the health care needs of the population.  

In this report, the IOM experts suggested a 35% drop in the amount of current payments to teaching hospitals for GME.  Among other things, five principles for reform were described: accountability, meeting the needs of the public, innovation, stability in the funding, and aligning education and clinical care.  They also discussed the creation of a GME Policy Council within HHS to help develop a strategic plan for a physician workforce, and phasing out direct and indirect medical education in favor of a global operational fund.

Other constituencies quickly provided comments voicing their concern over the IOM’s specific recommendations.  The AAMC’s comments were titled “IOM’s Vision of GME Will Not Meet Real-World Patient Needs”, and stated: “ …the IOM’s proposal to radically overhaul GME and make major cuts to patient care would threaten the world’s best training programs for health professionals and jeopardize patients, particularly those who are the most medical vulnerable.”  

In addition, the American Hospital Association noted: “Today’s report on GME is the wrong prescription for training tomorrow’s physicians.  We are especially disappointed that the report proposes phasing out the current Medicare GME funding provided to hospitals and offering it to other entities that do not treat Medicare patients.”  

So what do I think?  This is a very complex issue, first of all.  I do believe that GME funding needs to change because, fundamentally, we (the health care system and the training of future physicians within that system) need to meet the future health care needs of the population.  I believe that we do need more physicians, not fewer.  While reform is likely important, it is costly to educate residents.  Just look at colleges, and how much it costs to educate undergraduate students.  The same is true for residents.

So where do we go from here?  I am not sure, but as a residency educator, I hope that today’s recommendations do not jeopardize the fine training program that I have the privilege of overseeing and other outstanding educators across the country also oversee.  I hope that educators who do the day-to-day work to train the physicians of tomorrow are listened to.  I hope that residents who are currently in the training programs can have their voices heard too.  Let’s advocate for GME to continue to train competent residents who will leave and be ready for independent practice, and for funding that can accomplish that.  After all, THAT is why we are here, to provide much needed health care to the patients.  In all of the discussions and counterarguments, that needs to be the essential core.  As Francis Peabody stated in JAMA in 1927: “The secret in caring for the patient is to care for the patient.” 

GME Funding

A recent post from the NY Times discusses the issue of the physician workforce of the future.  I believe it accurately describes some of the concerns about GME training.  Yes, GME training is indeed the bottleneck by which new physicians come into the workforce.  Yes, we need new physicians (and other health care professionals) to care for an aging population.  We especially need primary care physicians for this, but we also need general surgeons, many types of subspecialists, and we need physicians to go into underserved areas, particularly rural areas.

There are bills that, if passed, could help fund more GME slots.  Dr. Atul Grover from the AAMCdescribes them well here in this post.  Residency programs accredited by the ACGME take new graduates from medical school, and appropriately train them to go out and practice medicine independently.  I also personally disagree with a proposal from Missouri that advocates for "assistantphysicians".  Simply put, these graduates need adequate training (a minimum of 3-4 years for most residency programs, with some like neurosurgery taking as long as 7-8 years), and that is what GME provides.

Please advocate for future GME funding: it is the best way to begin to create a physician workforce that will help care for our society.