E D I T O R I A L
Editorial: Debates in Graduate Medical Education: Who Will Care for Us When We Get Older? Stephen R. Hammes, MD, PhD Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Rochester Medical Center, Rochester, NY 14642
or many decades, the government has funded graduate medical education (GME) through Medicare and other sources to the tune of approximately 15 billion dollars per year. These funds were designated to support residency and fellowship programs that were part of academic institutions seeing a higher proportion of Medicare and Medicaid, as well as uninsured, patients. The GME program helped balance the losses that these academic institutions faced when caring for these patients, as well as with the inherent financial losses due to the obvious but necessary inefficiencies that are a part of providing medical care while still emphasizing teaching and research. Although far from a perfect system, GME funding has directly or indirectly supported generations of outstanding physicians, educators, and researchers. However, as the country strives to improve the quality and efficiency, as well as the cost, of health care, a more circumspect look at the GME system has become necessary. On July 29, 2014, the Institute of Medicine’s Committee on the Governance and Financing of GME issued a report describing their findings and recommendations regarding how they felt the federal government should support the future training and education of physicians in the United States (1). This report created quite a stir, because it brought out many important issues that apply to clinicians, educators, and researchers alike, all of whom rely upon and benefit from federal support of medical education and training. As a general starting point for discussion, the report emphasized that our health system is in flux, as we move toward creating better delivery systems that focus on patient-centered care, population health, and low-cost. The report went on to point out that we currently do not have the ability to analyze
these issues in a meaningful way, and therefore, it is difficult to know exactly how GME support should be used in the future. Finally, the committee commented that they were not convinced that a shortage of physicians was imminent; thus, efforts should be focused on improving GME rather than increasing GME resources. The authors of this report then went on to make 5 major recommendations.
ISSN Print 0888-8809 ISSN Online 1944-9917 Printed in U.S.A. Copyright © 2014 by the Endocrine Society Received September 30, 2014. Accepted September 30, 2014.
Abbreviations: GME, graduate medical education.
F
doi: 10.1210/me.2014-1311
1) Medicare and other government organizations need to continue to support GME, because it plays a critical role in maintaining our medical workforce. However, the amount of GME support should be held steady at approximately 15 billion dollars per year (adjusting for inflation). 2) A new GME policy council needs to be created to develop and then implement a strategic plan that will address how the nation should best train and support our future physician workforce. 3) With regard to Medicare GME, although some funds should continue to directly support residency training, an unspecified percentage of GME resources should be siphoned away from the general fund into a Transformation Fund. This new fund will be used to develop innovative GME programs that will focus on health care delivery with the ultimate goal of developing useful parameters that can be used to measure the future success of residency training programs. 4) Efforts should be made to simplify Medicare payments for GME and to create performance-based payment strategies. 5) Decisions regarding Medicaid payments for GME should remain with individual states.
Mol Endocrinol, November 2014, 28(11):1753–1755
mend.endojournals.org
The Endocrine Society. Downloaded from press.endocrine.org by [${individualUser.displayName}] on 27 October 2015. at 22:15 For personal use only. No other uses without permission. . All rights reserved.
1753
1754
Hammes
Debates in Graduate Education
Mol Endocrinol, November 2014, 28(11):1753–1755
In general, the concepts brought forth in this report training and putting them into the Transformation Fund, have garnered support, because most organizations and direct GME support for resident/fellow training will acacademic institutions understand and applaud efforts to tually decrease. Interestingly, at the same time that this streamline and improve the way that GME is funded and report has come out, the Creating Access to Residency implemented. Specifically, many organizations and indi- Education Act of 2014 (H.R. 4282) is making its way viduals dedicated toward improving research in medical through Congress. This bill proposes to actually increase education and delivery of care were enthusiastic about the GME funding for primary care training by allowing new Transformation Fund, which, in principle, would allow grants or contracts from Medicare/Medicaid to support GME dollars to go toward developing better methods of new residency slots in regions where there are fewer than implementing and tracking the success of our medical 25 medical residents per 100 000 population. These very education system (2). There is little doubt that, as the different interpretations of the future of our medical committee pointed out, medical education and residency workforce are understandably concerning, and clearly training are struggling to keep up with the rapid advances more analyses and discourse need to occur before moving in medical therapies, the added complexities of the elec- forward with any recommendations or plans. Assuming tronic medical record, and the increasing need to cut costs that there will be no shortage of physicians and then being and improve efficiency. In short, the concept that some- proven wrong could be devastating, as such a mistake thing new needs to be done with GME was highly could take decades to reverse. In addition to the concerns about our future workforce supported. However, many medical organizations, such as the numbers, academic medical centers are equally worried American Medical Association and the American Col- about losing the financial stability necessary to run medical lege of Physicians, have expressed concerns about this education programs. GME support of medical education plan (3, 4). These concerns primarily focus on one ma- is one of the foundations that holds our entire medical jor point of contention: whether or not our country is education and research system afloat, because it allows facing a physician shortage in the near future. Both the academic medical centers to cover the financial losses associated with treating American Medical Association Medicare/Medicaid paand American College of Phy- “Are we confident that the quality tients, as well as with sicians point out that several and quantity of our future training new doctors. studies by reputable groups physician and research work force With reimbursement estimate that our country al- will be sufficient as we get older?” rates dropping, and unready has a significant shortage of primary care physician and that, by 2020, this certainties surrounding the Affordable Care Act, a loss of shortage may reach the level of approximately 45 000 GME funding for the training of residents and fellows at primary care physicians. Notably, this anticipated short- this point could be financially devastating. Finally, the impact that stagnant or decreased GME age does not just concern primary care and, in fact, hits close to home for the Endocrine Society. In a study of the support toward residents and fellows will have on mediclinical endocrinology workforce published in The Jour- cal research bears mentioning. As stated recently in an nal of Clinical Endocrinology and Metabolism in 2014 editorial in Molecular Endocrinology (6), pressures from (5), a highly respected group of endocrinology educa- decreased National Institutes of Health funding and intors performed a careful analysis of the endocrine creased student loan burden are effectively draining the workforce in the United States, pointing out that our pool of potential future physician scientists. GME funding country already faces a significant shortage of endocri- allows academic medical centers to use other resources to nologist, with a physician-to-patient gap of nearly support basic and clinical research training of these indi1500 physicians. Moreover, this shortage is only going viduals. If GME funding does not keep up, or is siphoned to get worse, with a potential gap of up to 2700 adult elsewhere, then medical centers may be forced to take endocrinologist over the next decade if the number of funds from research to support medical education and training; thus endangering the long-term future of mediendocrinology fellows is not increased. Despite these sober predictions by several independent cal research. With all this in mind, what can we do to address these groups, the Institute of Medicine report does not acknowledge these studies as credible. Therefore, the report issues surrounding GME? Unfortunately, there are no does not recommend increasing the amount of GME dol- sure-fire answers. However, the authors of the Journal lars and slots to ensure that the demands of the future can of Clinical Endocrinology and Metabolism article make be adequately met. In fact, by taking funds away from some excellent suggestions. For example, they propose
The Endocrine Society. Downloaded from press.endocrine.org by [${individualUser.displayName}] on 27 October 2015. at 22:15 For personal use only. No other uses without permission. . All rights reserved.
doi: 10.1210/me.2014-1311
decreasing the number of medicine residency years for subspecialists from 3 to 2. This has proven to be effective, because many physician scientists (such as myself) were successful with this approach. In fact, 2-year Research Pathway residencies are commonplace now, and physicians from these programs appear to pass the boards and move forward without difficulty. This tactic could be extended to primary care physicians as well, where extensive inpatient training during residency may no longer serve a purpose. Using such an approach, it may be possible to use the same number of GME slots but still increase the number of future physicians. In summary, the question that we, as members of the academic medical community, need to ask ourselves is: are we confident that the quality and quantity of our future physician and research workforce will be sufficient as we get older? If the answer is “no,” or even “maybe,” then we need to work together both privately and publically to ensure that our tax dollars are put to good use. Stephen R. Hammes, MD, PhD Editor-in-Chief, Molecular Endocrinology
mend.endojournals.org
1755
Acknowledgments Address all correspondence and requests for reprints to: Rebecca Kelly, Managing Editor, Endocrine Society, Publications Department, 2055 L Street NW, Suite 600, Washington, DC 20036. E-mail: [email protected]. Disclosure Summary: The author has nothing to disclose.
References 1. Wilensky GR, Berwick DM. Reforming the financing and governance of GME. N Engl J Med. 2014;371:792–793. 2. Asch DA, Weinstein DF. Innovation in medical education. N Engl J Med. 2014;371:794 –795. 3. American Medical Association. AMA Press Release, July 29, 2014. Available from http://www.ama-assn.org/ama/pub/news/news/ 2014/2014-07-29-support-graduate-medical-education-funding. page [last accessed October 15, 2014]. 4. American College of Physicians. ACP Press Release, July 31, 2014. Available from http://www.acponline.org/pressroom/iom_statement.htm? hp [last accessed October 15, 2014]. 5. Vigersky RA, Fish L, Hogan P, et al. The clinical endocrinology workforce: current status and future projections of supply and demand. J Clin Endocrinol Metab. 2014;99:3112–3121. 6. Mirmira RG. Editorial: the vulnerable physician-scientist. Mol Endocrinol. 2014;28:603– 606.
The Endocrine Society. Downloaded from press.endocrine.org by [${individualUser.displayName}] on 27 October 2015. at 22:15 For personal use only. No other uses without permission. . All rights reserved.
Editorial: Debates in Graduate Medical Education: Who Will Care for Us When We Get Older? Stephen R. Hammes, MD, PhD Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Rochester Medical Center, Rochester, NY 14642
or many decades, the government has funded graduate medical education (GME) through Medicare and other sources to the tune of approximately 15 billion dollars per year. These funds were designated to support residency and fellowship programs that were part of academic institutions seeing a higher proportion of Medicare and Medicaid, as well as uninsured, patients. The GME program helped balance the losses that these academic institutions faced when caring for these patients, as well as with the inherent financial losses due to the obvious but necessary inefficiencies that are a part of providing medical care while still emphasizing teaching and research. Although far from a perfect system, GME funding has directly or indirectly supported generations of outstanding physicians, educators, and researchers. However, as the country strives to improve the quality and efficiency, as well as the cost, of health care, a more circumspect look at the GME system has become necessary. On July 29, 2014, the Institute of Medicine’s Committee on the Governance and Financing of GME issued a report describing their findings and recommendations regarding how they felt the federal government should support the future training and education of physicians in the United States (1). This report created quite a stir, because it brought out many important issues that apply to clinicians, educators, and researchers alike, all of whom rely upon and benefit from federal support of medical education and training. As a general starting point for discussion, the report emphasized that our health system is in flux, as we move toward creating better delivery systems that focus on patient-centered care, population health, and low-cost. The report went on to point out that we currently do not have the ability to analyze
these issues in a meaningful way, and therefore, it is difficult to know exactly how GME support should be used in the future. Finally, the committee commented that they were not convinced that a shortage of physicians was imminent; thus, efforts should be focused on improving GME rather than increasing GME resources. The authors of this report then went on to make 5 major recommendations.
ISSN Print 0888-8809 ISSN Online 1944-9917 Printed in U.S.A. Copyright © 2014 by the Endocrine Society Received September 30, 2014. Accepted September 30, 2014.
Abbreviations: GME, graduate medical education.
F
doi: 10.1210/me.2014-1311
1) Medicare and other government organizations need to continue to support GME, because it plays a critical role in maintaining our medical workforce. However, the amount of GME support should be held steady at approximately 15 billion dollars per year (adjusting for inflation). 2) A new GME policy council needs to be created to develop and then implement a strategic plan that will address how the nation should best train and support our future physician workforce. 3) With regard to Medicare GME, although some funds should continue to directly support residency training, an unspecified percentage of GME resources should be siphoned away from the general fund into a Transformation Fund. This new fund will be used to develop innovative GME programs that will focus on health care delivery with the ultimate goal of developing useful parameters that can be used to measure the future success of residency training programs. 4) Efforts should be made to simplify Medicare payments for GME and to create performance-based payment strategies. 5) Decisions regarding Medicaid payments for GME should remain with individual states.
Mol Endocrinol, November 2014, 28(11):1753–1755
mend.endojournals.org
The Endocrine Society. Downloaded from press.endocrine.org by [${individualUser.displayName}] on 27 October 2015. at 22:15 For personal use only. No other uses without permission. . All rights reserved.
1753
1754
Hammes
Debates in Graduate Education
Mol Endocrinol, November 2014, 28(11):1753–1755
In general, the concepts brought forth in this report training and putting them into the Transformation Fund, have garnered support, because most organizations and direct GME support for resident/fellow training will acacademic institutions understand and applaud efforts to tually decrease. Interestingly, at the same time that this streamline and improve the way that GME is funded and report has come out, the Creating Access to Residency implemented. Specifically, many organizations and indi- Education Act of 2014 (H.R. 4282) is making its way viduals dedicated toward improving research in medical through Congress. This bill proposes to actually increase education and delivery of care were enthusiastic about the GME funding for primary care training by allowing new Transformation Fund, which, in principle, would allow grants or contracts from Medicare/Medicaid to support GME dollars to go toward developing better methods of new residency slots in regions where there are fewer than implementing and tracking the success of our medical 25 medical residents per 100 000 population. These very education system (2). There is little doubt that, as the different interpretations of the future of our medical committee pointed out, medical education and residency workforce are understandably concerning, and clearly training are struggling to keep up with the rapid advances more analyses and discourse need to occur before moving in medical therapies, the added complexities of the elec- forward with any recommendations or plans. Assuming tronic medical record, and the increasing need to cut costs that there will be no shortage of physicians and then being and improve efficiency. In short, the concept that some- proven wrong could be devastating, as such a mistake thing new needs to be done with GME was highly could take decades to reverse. In addition to the concerns about our future workforce supported. However, many medical organizations, such as the numbers, academic medical centers are equally worried American Medical Association and the American Col- about losing the financial stability necessary to run medical lege of Physicians, have expressed concerns about this education programs. GME support of medical education plan (3, 4). These concerns primarily focus on one ma- is one of the foundations that holds our entire medical jor point of contention: whether or not our country is education and research system afloat, because it allows facing a physician shortage in the near future. Both the academic medical centers to cover the financial losses associated with treating American Medical Association Medicare/Medicaid paand American College of Phy- “Are we confident that the quality tients, as well as with sicians point out that several and quantity of our future training new doctors. studies by reputable groups physician and research work force With reimbursement estimate that our country al- will be sufficient as we get older?” rates dropping, and unready has a significant shortage of primary care physician and that, by 2020, this certainties surrounding the Affordable Care Act, a loss of shortage may reach the level of approximately 45 000 GME funding for the training of residents and fellows at primary care physicians. Notably, this anticipated short- this point could be financially devastating. Finally, the impact that stagnant or decreased GME age does not just concern primary care and, in fact, hits close to home for the Endocrine Society. In a study of the support toward residents and fellows will have on mediclinical endocrinology workforce published in The Jour- cal research bears mentioning. As stated recently in an nal of Clinical Endocrinology and Metabolism in 2014 editorial in Molecular Endocrinology (6), pressures from (5), a highly respected group of endocrinology educa- decreased National Institutes of Health funding and intors performed a careful analysis of the endocrine creased student loan burden are effectively draining the workforce in the United States, pointing out that our pool of potential future physician scientists. GME funding country already faces a significant shortage of endocri- allows academic medical centers to use other resources to nologist, with a physician-to-patient gap of nearly support basic and clinical research training of these indi1500 physicians. Moreover, this shortage is only going viduals. If GME funding does not keep up, or is siphoned to get worse, with a potential gap of up to 2700 adult elsewhere, then medical centers may be forced to take endocrinologist over the next decade if the number of funds from research to support medical education and training; thus endangering the long-term future of mediendocrinology fellows is not increased. Despite these sober predictions by several independent cal research. With all this in mind, what can we do to address these groups, the Institute of Medicine report does not acknowledge these studies as credible. Therefore, the report issues surrounding GME? Unfortunately, there are no does not recommend increasing the amount of GME dol- sure-fire answers. However, the authors of the Journal lars and slots to ensure that the demands of the future can of Clinical Endocrinology and Metabolism article make be adequately met. In fact, by taking funds away from some excellent suggestions. For example, they propose
The Endocrine Society. Downloaded from press.endocrine.org by [${individualUser.displayName}] on 27 October 2015. at 22:15 For personal use only. No other uses without permission. . All rights reserved.
doi: 10.1210/me.2014-1311
decreasing the number of medicine residency years for subspecialists from 3 to 2. This has proven to be effective, because many physician scientists (such as myself) were successful with this approach. In fact, 2-year Research Pathway residencies are commonplace now, and physicians from these programs appear to pass the boards and move forward without difficulty. This tactic could be extended to primary care physicians as well, where extensive inpatient training during residency may no longer serve a purpose. Using such an approach, it may be possible to use the same number of GME slots but still increase the number of future physicians. In summary, the question that we, as members of the academic medical community, need to ask ourselves is: are we confident that the quality and quantity of our future physician and research workforce will be sufficient as we get older? If the answer is “no,” or even “maybe,” then we need to work together both privately and publically to ensure that our tax dollars are put to good use. Stephen R. Hammes, MD, PhD Editor-in-Chief, Molecular Endocrinology
mend.endojournals.org
1755
Acknowledgments Address all correspondence and requests for reprints to: Rebecca Kelly, Managing Editor, Endocrine Society, Publications Department, 2055 L Street NW, Suite 600, Washington, DC 20036. E-mail: [email protected]. Disclosure Summary: The author has nothing to disclose.
References 1. Wilensky GR, Berwick DM. Reforming the financing and governance of GME. N Engl J Med. 2014;371:792–793. 2. Asch DA, Weinstein DF. Innovation in medical education. N Engl J Med. 2014;371:794 –795. 3. American Medical Association. AMA Press Release, July 29, 2014. Available from http://www.ama-assn.org/ama/pub/news/news/ 2014/2014-07-29-support-graduate-medical-education-funding. page [last accessed October 15, 2014]. 4. American College of Physicians. ACP Press Release, July 31, 2014. Available from http://www.acponline.org/pressroom/iom_statement.htm? hp [last accessed October 15, 2014]. 5. Vigersky RA, Fish L, Hogan P, et al. The clinical endocrinology workforce: current status and future projections of supply and demand. J Clin Endocrinol Metab. 2014;99:3112–3121. 6. Mirmira RG. Editorial: the vulnerable physician-scientist. Mol Endocrinol. 2014;28:603– 606.
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