Institute Of Medicine aims to boost graduate medical education
As the U.S. population grows, the physician workforce shrinks, and information technology fundamentally changes the way care is delivered, the Institute of Medicine says graduate medical education needs an overhaul.
Last July, IOM published a new report, "Graduate Medical Education That Meets the Nation's Health Needs," that offers a list of recommendations to improve the GME system. Specifically, it seeks ways to increase the capacity of the nation's clinical workforce to ensure high-quality care as the population increases and diversifies.
The study points out that, since the inception of Medicare and Medicaid in 1965, U.S. taxpayers have provided billions of dollars to fund GME, the period of residency and fellowship that is provided to physicians after they receive a medical degree – a "scale of government support for physician training (that) far exceeds that for any other profession," according to IOM.
Still, there's a "striking absence of transparency and accountability" the report argues, when it comes to "producing the types of physicians the nation needs."
The 21-member IOM committee makes the case that a dramatically changing healthcare landscape in the U.S. makes it imperative to take stock of and make changes to the public's investment in GME – addressing current deficiencies and paving the way for a physician workforce that's ready for the future.
In the past half century or so, this funding of medical education – public financing for GME totaled about $15 billion in 2012, roughly $9.7 billion of that from Medicare – has expanded residency opportunities to more people in more specialties, the IOM report shows. There are more women and minorities; working conditions have improved, and "residency training has evolved from an apprenticeship model emphasizing service to a curriculum-based educational experience tied to the achievement of defined competencies."
Still, much of the programing dates from 1965 – "a time when hospitals were the central, if not exclusive, site for physician training," IOM members write.
"Medicare GME payment rules continue to reflect that era despite dramatic changes in the healthcare system," according the report brief. "Although hospital services remain essential, the burden of chronic disease, the need for greater emphasis on preventive care, and modern information technologies (as well as other influences) mean that health care increasingly takes place in community settings and relies on non-physicians and integrated care models."
One group applauding the report was the Surgical Coalition, which noted in a press release that there's a severe physician workforce shortage, "that will only worsen as health insurance coverage is expanded to millions of Americans and the baby boomers continue to reach retirement age."
By 2025, according to the Surgical Coalition, that shortage will approximate 130,600 physicians – 64,800 specialists (including surgeons) and 65,800 primary care physicians.
"The maldistribution rate among surgeons, especially in rural communities, is significant, and in many parts of the country there are no general surgeons, orthopedic surgeons or neurosurgeons," according to the coalition. "Twenty-five percent of all Americans do not live within 60 minutes of a Level I adult trauma center, and even more do not have a Level I or II children's trauma center within their reach."
Time to modernize
An increasing reliance on telemedicine and remote surgery technology may be one way to address this need (as the Department of Veterans affairs may be discovering as it works to address its own shortcomings).
But more broadly speaking, the IOM report points to an approach to medical education that's substantially out-of-step with the times – a system of learning that doesn't just date back 50 years, but, in the case of pre-residency schooling, more than a century.
In a Healthcare IT News cover story this past fall, "Are med schools failing future docs?," we spoke with Marc Triola, MD, associate dean for educational informatics at NYU School of Medicine, who points out that "a lot of the structure and some of the content of medical education is more than 100 years old."
Indeed, the famous Flexner Report, developed by educator Abraham Flexner in 1910, has shaped the way most medical schools have operated ever since.
"It defined what med school should be," says Triola. "It's four year long – two years of classroom-based instruction and two years of clinical. It should be based on the scientific method and scientific reasoning. That's kept medical school programs very similar for a very long time.
"But our reporting showed that even though this new generation of physicians is the most tech-savvy yet, few are making much use of information technology in their med school and even GME training."
One 2012 study from the Alliance for Clinical Education found that just 64 percent of med school programs allowed future physicians any use of electronic records; of those that do, only two-thirds allowed students to actually write notes with in the EHR.
"Schools have a responsibility to graduate students with the expertise and sense of duty in the basics of practice," said Lynn Cleary, MD, president of the ACE, when that report was published. "The EHR is now part of that skill set."
Thankfully, there are programs like the one the American Medical Association launched in 2013, through which it awarded $11 million, to be split among 11 medical schools, to help offer future physicians more advanced and forward-looking medical education.
The Accelerating Change in Medical Education initiative aimed to "close gaps in readiness for practice," Susan Skochelak, MD, group vice president of medical education at AMA, explained to Healthcare IT News. Without it, and ones like it, she said, there was concern that "our graduates are not really ready for the real world of practice. We were a little pessimistic that there would be enough change for what's needed right now."