Reforming Graduate Medical Education in the U.S.

Abstract

The foundation of the U.S. health care system is a workforce of highly competent doctors who are prepared to provide the highest quality health care when they enter practice. However, there is increasing concern that the current system for training doctors following graduation from medical school falls short in terms of producing an adequate workforce to meet the nations changing health care needs. Reforming the graduate medical education system will require accurate data on the true costs of training physicians, greater oversight and accountability, and a transition from the current outdated financing system that is based mainly on federal support to a system that is more equitably distributed among stakeholders and where the funding is controlled by the states and follows the trainee.

The U.S. health care system has some of the most highly qualified, competent doctors in the world, and the care that they provide is generally as good asand in many cases, superior tothat in other nations. However, Americas current system for training doctors after graduation from medical school needs substantial reform.

The primary deficiency is an uncoordinated and outdated financing system that fails to foster the kind of health care workforce needed to keep pace with the changing demographic and epidemiological profile of Americas patient population. The graduate medical education (GME) system falls short in both the number of doctors trained and their distribution by specialty and geography.

The good news is that private accreditation and certification entities are already actively pursuing reforms to basic GME standards and training methodswithout the need for government intervention. Yet, for revised medical education standards and methods to be truly effective, those changes must be accompanied by complementary reforms to GME financing, governance, and accountabilityall of which are still lacking. Federal and state lawmakers need to tackle this second set of issues because government funding heavily influences the basic structure and performance of Americas GME system.

Lawmakers should pursue a reform agenda based on four principles:

Calls for substantial reform of GME are not new. Among others, the Commission on Graduate Medical Education in 1940, the Millis and Coggeshall reports in 1966, the Medicare Payment Advisory Committee in 2010, and, most recently, the Institute of Medicine (IOM) in a report published in July 2014 have called for reform. Given that the past century witnessed significant and rapid advances in medical science, periodic calls to reform medical education to keep pace should not be surprising.

Indeed, the first systemic redesign of American medical education dates back to the reformist era at the turn of the 20th century. In 1904, the American Medical Association (AMA) established the Council on Medical Education, which led to Abraham Flexners extensive survey of medical schools and their educational standards and practices. Flexners report was published in 1910 and became the catalyst for a sweeping transformation and standardization of what is now known as undergraduate medical education (UME), the period of study leading to a medical degree.[1]

Opportunities for postgraduate medical education existed as early as the mid-19th century, although widespread adoption of a period of training in a formal residency program as the preferredand eventually the onlypath to becoming a board-certified doctor was largely a postWorld War II phenomenon. For instance, surgical residency programs existed as early as 1889. However, during most of the first half of the 20th century, the majority of surgeons entered general practice before gaining surgical expertise through informal methods such as apprenticeships, educational opportunities in Europe, short courses, or performing progressively more complex operations on surgical patients in their practices.[2]

In 1913, Pennsylvania was the first state to require a one-year rotating internship after graduation from medical school as a prerequisite for physician licensuresomething that is now a minimum requirement in all states. Physician specialty boards began to proliferate in the 1920s and 1930s, and during World War II, board-certified doctors were given higher rank, better pay, and better assignments in the armed forces.