A broad panel of leaders representing health care, academic medicine, and physician education today called for sweeping reforms in the content and format of U.S. graduate medical education (GME) to ensure that physicians are trained more effectively and efficiently to meet public needs.
The recommendations are part of a package of proposals for overhauling the training of newly minted physicians - "residents" and "fellows" - in the United States promulgated by the Josiah Macy Jr. Foundation, the only national foundation that focuses on improving health professions education. The current proposal was generated from a May 2011 conference; earlier this year, another group of diverse leaders convened by Macy called for major changes in the way the nearly $10 billion GME program is financed and governed.
The recommendations seek to make GME more publically accountable by pro-actively engaging consumers in its design; more efficient by moving to a system that is focused on competency rather than on years of training; and more flexible and diverse by exposing residents to experiences that are less hospital-based and focused on competencies and skills needed for contemporary practice.
Better Meeting Society's Needs
"The public expects the GME system to produce a physician workforce of sufficient size, specialty mix, and skill to meet society's needs. Many observers from both public and professional vantage points feel it is currently falling short in each of these dimensions," the group says. "It is no longer sufficient to say that producing competent physicians meets GME's responsibility to the public. The GME system must also be a responsible steward of public funds and ensure that the process of education is efficient, cost-effective, and evidence based."
Macy President George Thibault, MD, says the purpose of this report is to spur teaching institutions to move more quickly and decisively to reform the well-entrenched U.S. system of GME. A number of factors are stimulating this call to action: changing demographics and disease burdens, a fast-evolving health care system, the explosive growth of technology and focus on efficiency and safety, and an unsustainable rate of increase in health care costs.
"Unless we in academic medicine are self-critical and show a willingness to change, the political and public support for graduate medical education will disappear," he warns. "This is a huge enterprise built on tradition, but the system has to change to be more responsive to public needs."
"Leaders in academic medicine already realize that we cannot and should not maintain the status quo," says Conference Chair Debra Weinstein, MD, Vice President for Graduate Medical Education at the Partners Healthcare System in Boston MA. "Our recommendations offer a blueprint for moving graduate medical education forward. If we don't define a new path, our system for training physicians will become increasingly less effective because of well-intended regulations, inadequate resources, and the rapidly evolving demands of health care delivery."
Highlights of Recommendations
"Ensuring an Effective Physician Workforce for the United States: Recommendations for Reforming Graduate Medical Education to Meet the Needs of the Public," includes a set of six major conclusions with accompanying recommendations and an overarching rationale for each. Here are highlights of what the group recommends:
- Make graduate medical education more accountable to the public. Because it is financed with public dollars, GME needs to create and maintain an ongoing exchange with the public. The group says boards and committees of institutions that sponsor GME and the organizations that oversee it (such as the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties) should have public members at the table. "The voice of the public would help ensure that GME's goals are continually reaffirmed and that the programs are designed to achieve those goals," the panel says.
- Replace time-based training with outcomes-based standards that link graduation to readiness for unsupervised practice. The group says that the current system of training all residents for a fixed duration "fails to recognize or accommodate" the reality that residents vary in how quickly they achieve competency. The panel recommends moving from measuring months and years of training to a system based on an individual's readiness for independent practice. "Routinely aligning the duration of training to individual residents' achievement of competence would yield a more consistent level of skills among physicians entering unsupervised practice, more efficient delivery of competent practitioners to the public, and more responsible use of public funding supporting resident education," the group says.
- Expand the content and sites of training to reflect current and future patient needs. The group sees an urgency to more effectively deliver an updated curriculum, in part by diversifying the training sites for GME (including federally qualified health centers and school-based health centers, for example) to provide a breadth of clinical experience beyond traditional teaching hospitals and to expand content related to professionalism, population medicine, and team-based practice. The group says ACGME's core competencies must be better integrated with clinical performance since they "remain poorly standardized and incompletely assessed and are too often taught and evaluated outside the context of patient care."
- Encourage collaborative education. The group advocates for the elimination of historical professional boundaries so that inter-specialty and inter-professional education become a consistent element of physician training. The group says all residents should have the opportunity to learn with and from physician colleagues in other specialties and other health professionals. This will require revising regulations that now prevent supervision across specialties or professions.
The group also is seeking creation of a National Institute of Health Professions Education to fund and coordinate research efforts across multiple sites and health professions. The group thinks this will result in more productive and cost-effective research, urgently needed to guide improvements in physician and health professions training.
The recommendations are aimed at medical educators, leaders of institutions that train residents, and at groups that set the standards such as the Accreditation Council for Graduate Medical Education and American Board of Medical Specialties.