Internships and hospital-based medical education preceded by more than 40 years the beginnings of a medical school in Washington State. Just after the turn of the 20th century, a few internships were begun by hospitals in Seattle and Spokane to help with the care of their sicker patients in the tradition of Eastern teaching hospitals. In the 1920s and 1930s, the number of hospitals with internship programs grew steadily as part of a nationwide effort at hospital standardization. Experiences in developing these programs and problems with intern recruitment contributed to the beginning of the University of Washington School of Medicine after World War II. Since the 1960s, intern and resident training has progressively become a cooperative effort of the school with many hospitals and clinics in Washington, Alaska, Montana, and Idaho contributing to the development of graduate medical education in this region.
OBJECTIVE. This study identifies predictors of young physicians practicing specialties for which they did not report having graduate medical education. DATA SOURCE. A secondary analysis was conducted using a nationally representative survey of young physicians, Practice Patterns of Young Physicians, 1987 (United States). Physicians were under 40 years of age and in uninterrupted practice more than one but fewer than six complete years. STUDY DESIGN. Young physicians who practiced specialties without prior graduate medical education (GME) in these specialties were compared to young physicians who practiced only the specialties for which they reported GME. Comparisons were made on sociodemographic characteristics, international medical graduate status, number and types of GME specialties, year completed GME, and preference for a practice position that was not offered. DATA EXTRACTION METHODS. Sample size was 4,440, including 345 (7.8 percent) physicians who practiced specialties without prior GME. Logistic regression analysis was used to identify predictors of young physicians practicing specialties without prior GME. PRINCIPAL FINDINGS. Physicians who practiced specialties without prior GME more likely were younger, members of minorities other than Black...
There is a perception that the career options open to medical school graduates who are members of minority groups are restricted. This perception relates especially to those postgraduate medical training programs that have not traditionally encouraged or had significant minority participation. Data were therefore sought to determine whether this perception was well founded. Recent reports show the strikingly low numbers of minorities on medical school faculties and in administrative positions in spite of efforts to fill such positions. Information on the specialties of practicing minority physicians is limited, but accurate figures are available on the participation of minorities in various specialty postgraduate training programs. For instance, during recent years, 50 to 60 percent of all black residents have been trained in internal medicine, pediatrics, general surgery, and obstetrics and gynecology. Further studies are needed to document or disprove the conception that minority physicians have less access than other physicians to certain careers in the delivery of health care and education. In the interim, efforts should be continued to encourage minority physicians not only to seek preparation for community primary care practice...
Until the last few years, graduate medical education (GME) positions were so plentiful in the United States that even with a heavy influx of both U.S. and alien graduates of foreign medical schools, many positions remained unfilled. In the future, however, it is unlikely that all those planning to enter GME in the United States will be able to do so. Applicants for U.S. GME positions increased from 15,000 in 1980 to 20,000 in 1983, while the positions offered declined to fewer than 18,000. Increasing financial pressure may cause some U.S. hospitals to cut back on their GME positions. Recent Federal regulations require them to isolate the cost of education from patient care costs, and community hospitals may no longer with to provide GME if they can no longer recover educational costs. On the other hand, State legislatures may react to pressures to provide GME positions for U.S. citizens graduating from foreign medical schools. Another factor increasing the demand for GME positions is the greater number of U.S.-citizen graduates from foreign medical schools in the Caribbean. The Caribbean schools generally lack the facilities to provide clinical training, so that efforts are made to provide such training for U.S. citizens in the United States. For example...
The past decade has seen ongoing debate regarding federal support of graduate medical education, with numerous proposals for reform. Several critical problems with the current mechanism are evident on reviewing graduate medical education (GME) funding issues from the perspectives of key stakeholders. These problems include the following: substantial interinstitutional and interspecialty variations in per-resident payment amounts; teaching costs that have not been recalibrated since 1983; no consistent control by physician educators over direct medical education (DME) funds; and institutional DME payments unrelated to actual expenditures for resident education or to program outcomes. None of the current GME reform proposals adequately address all of these issues. Accordingly, we recommend several fundamental changes in Medicare GME support. We propose a re-analysis of the true direct costs of resident training (with appropriate adjustment for local market factors) to rectify the myriad problems with per-resident payments. We propose that Medicare DME funds go to the physician organization providing resident instruction, keeping DME payments separate from the operating revenues of teaching hospitals. To ensure financial accountability...
Increasingly, graduate medical education (residency training) is being proposed as a policy instrument to reform the traditional manpower problems of distribution of physicians. This article suggests why graduate medical education has become the latest policy device in the decades-old effort to rectify physician imbalances, and it discusses the potential for reform contained in this approach. It then presents a number of problems that will probably hinder the effective implementation of such policy and concludes that future federal policy directives are uncertain.
The last major change in medical education was the Flexner Report, over a century ago. Since that time, iterative improvements have occurred to the question-and-answer and “see one, do one, teach one” educational environment. However, multiple external forces—from the 80-hour work week to the emphasis on patient safety to competing demands on student and faculty time—have raised calls for a fundamental revamping of the entire medical educational process. Fortunately, new methods, curricula, and processes, such as Accreditation Council for Graduate Medical Education competencies or Objective Structured Assessment of Technical Skills, as well as innovative technologies such as web-based learning and simulation, have provided opportunities to support the revolution in medical education that will be responsive to national priorities, the public concern, and, most of all, to patient safety.
Declining reimbursement for graduate medical education (GME) as well as increasing hospital competition has placed the cost of GME in the spotlight of institutional administrators. Traditional hospital-generated cost center profit and loss statements fail to accurately reflect the full economic impact of training programs on the institution as well as the larger community. A more complete analysis would take into consideration the direct, indirect, and “intangible” benefits of GME programs. The GME programs usually have a favorable impact on the trainees themselves, the sponsoring institution, the local community, university sponsors and affiliates, and the greater community, and all of these areas need to be considered in the economic analysis. Complete analyses of programs often demonstrate very positive benefits to their sponsoring institutions that would not be recognized on simple cost center profit and loss reports. Studies in the literature that quantify the net economic benefits of GME programs are consistent in their favorable findings.
Although enhancing professionalism and ensuring compliance with duty hour regulations both represent important priorities of current graduate medical education, tension in reconciling these goals has been expressed. The term tyranny of the OR has been coined to express the assumption of dichotomous thinking, that is, that we assume we must choose between seemingly competing goals. In contrast, because there is powerful creative value in adopting a bridging mindset, an alternative state called the genius of the AND has been defined to express the benefits of reconciling perceived competing goals.
We explore the history behind the current structure of graduate medical education funding and the problems with continuing along the current funding path. We then offer suggestions for change that could potentially manage this health care spill. Some of these changes include attracting more students into primary care, aligning federal graduate medical education spending with future workforce needs, and training physicians with skills they will require to practice in systems of the future.
While video is a powerful teaching and learning tool because it can influence knowledge, skills, and attitude formation effectively and reach learners with various learning and communication styles, there are pedagogical, technical, and copyright considerations. Instructors must know sources of appropriate videos, select effective video segments, apply various strategies for incorporating video triggers into the overall educational process, refine the message, overcome technological obstacles, and comply with copyright laws. One might ask, “Is using video triggers to improve your teaching worth it?” “Yes!” Numerous studies demonstrate that using video in many medical education settings supports and enhances learning and offers a bigger advantage in contrast with traditional methods.
The German graduate medical education system is going through an important phase of changes. Besides the ongoing reform of the national guidelines for graduate medical education (Musterweiterbildungsordnung), other factors like societal and demographic changes, health and research policy reforms also play a central role for the future and competitiveness of graduate medical education.
The Patient Protection and Affordable Care Act (ACA) of 2010 created the Teaching Health Center Graduate Medical Education (THCGME) program to provide graduate medical education (GME) funding directly to community-based health centers that expand or establish new primary care residency programs. The THCGME program was the legislation’s only new investment in GME, and it represents a significant departure from the Medicare GME funding system. It provides payments to ambulatory care centers for both direct and indirect GME expenses and mandates a level of reporting from recipients that is not required for Medicare GME support. This initial look at the 11 inaugural teaching health centers (THCs) shows they are training primary care residents in relevant delivery models (e.g., interprofessional teams, patient-centered medical homes), developing educational initiatives that address primary care practice in underserved areas, and transforming organizational and funding structures to support community-based training. The THCs plan to evaluate and report resident performance, patient quality of care, and graduate outcomes. The work of the first THCs has implications for primary care training, the GME system, and future policies and legislation aimed at strengthening the health care workforce.
Graduate medical education (GME) defines the overall number, specialty make-up and geographic distribution of the U.S. physician workforce. Medicare GME payments represent the largest single public investment in health workforce development but it is an inflexible system that is drawing scrutiny for its rationale, effectiveness and balance. We analyzed Medicare hospital cost reports for teaching hospitals and found large state level differences in the number of Medicare sponsored residents per population, total Medicare GME payments, payments per person (ranging from $1.94 to $103.63 per person in Montana and New York, respectively), and average payments per trainee (ranging from $63,811 to $155,135 per trainee in Louisiana and Connecticut, respectively). Options to address these imbalances include ensuring those states that receive less Medicare GME are prioritized or protected in the case of increases or decreases in funding and the re-examination of the Medicare GME formulas. The state level variation highlights that the GME system badly needs flexibility and the capability to deliberate and make policy about public investments in graduate medical education.
Internal medicine residents today face significant challenges in caring for an increasingly complex patient population within ever-changing education and health care environments. As a result, medical educators, health care system leaders, payers, and patients are demanding change and accountability in graduate medical education (GME). A 2012 Society of General Internal Medicine (SGIM) retreat identified medical education as an area for collaboration between internal medicine and geriatric medicine. The authors first determined a short-term research agenda for resident education by mapping selected internal medicine reporting milestones to geriatrics competencies, and listing available sample learner assessment tools. Next, the authors proposed a strategy for long-term collaboration in three priority areas in clinical medicine that are challenging for residents today: (1) team-based care, (2) transitions and readmissions, and (3) multi-morbidity. The short-term agenda focuses on learner assessment, while the long-term agenda allows for program evaluation and improvement. This model of collaboration in medical education combines the resources and expertise of internal medicine and geriatric medicine educators with the goal of increasing innovation and improving outcomes in GME targeting the needs of our residents and their patients.