Institute of Medicine Recommends Changes in Graduate Medical Education

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Questions, concerns and spirited debate have surrounded the Graduate Medical Education (GME) system for decades. The program that trains nearly 120,000 physicians per year is under constant scrutiny.¹ Changes to the political landscape, combined with ongoing efforts by health industry payers and regulators to squeeze inefficiency out of the system, have kept the GME in the spotlight.

Key issues tied to the GME program—the future of the physician workforce, patient access to primary and specialty care, teaching physician compensation, Baby Boomers and growing patient volumes—are just as important to rheumatologists as they are to legislators, administrators and economists.

“The current system is flawed in that it doesn’t incentivize high-quality programs or allow for developing programs to address future needs,” says Kristine Lohr, MD, MS, professor of medicine, interim chief of the Division of Rheumatology, and director of the Rheumatology Training Program at the University of Kentucky School of Medicine in Lexington. The current system favors procedure-based specialties and subspecialties. There are more training slots for surgery, GI, cardiology, pulmonary and critical care, than for the cognitive subspecialties, such as rheumatology, endocrinology and infectious diseases.

Dr. Lohr

“The cap system lacks flexibility and, thus, fails to address workforce projections,” says Dr. Lohr.

To address some of the nation’s issues with physician training, the Institute of Medicine (IOM) in July 2014 released a seminal report on GME programs and funding. Titled Graduate Medical Education That Meets the Nation’s Health Needs, the report called for “significant changes” to the GME system and produced five recommendations for reform, along with suggested goals and next steps (see Table 1).

Led by former CMS Administrator Don Berwick, MD, and inclusive of more than 20 leaders in medicine and business, the IOM committee’s examination found the financing and administration of the GME program had a “striking absence of transparency and accountability.” Some $15 billion a year in funding, according to the report, isn’t the problem.

“More government money isn’t the issue. What is important is spending it smarter,” says Gail Wilensky, an economist, former Medicare administrator, and chair of the IOM’s Committee on the Governance and Financing of Graduate Medical Education. “It is an unusual role the federal government has taken here, and it should continue on the ground if it can become more focused on meeting this goal of hoping to transform a workforce for the 21st century—and do so in a way that is more transparent and accountable for achieving its goals, which we think it has not done in the past.”