Undergraduate training in medicine is supported by a variety of mechanisms, including tuition, guaranteed federal and state loans, and a variety of scholarships. Medical school education provides some experiences in population health through such classes as statistics and epidemiology. In addition, electives in some of the clinical disciplines of public health practice are available through elective rotations in preventive medicine, community medicine, and occupational health. Although this exposure does provide medical students with some understanding of population-based health, it is not at the level that many believe is necessary for all physicians to achieve a basic competency in public health.
For more than 30 years, the federal government has provided some degree of funding for postgraduate training of physicians. Acting jointly or as a primary funder, the government has influenced the structure of health professions education and training that is needed by funding several programs through the various departments of the federal government. These programs have often served as the primary means for physicians to acquire training in public health and to prepare them to enter the public health workforce, but few data exist on the number of physicians trained and the amount of funds allocated to their training.
The financing of postgraduate education for most physicians is primarily supported through Medicare Graduate Medical Education (GME). GME has two specific payment mechanisms that offer payments for education in the clinical environment: a direct GME payment that partially compensates the teaching institution for the cost of residency training and an indirect GME payment that partially compensates the teaching institution for the higher patient care cost because of the presence of medical residents. As the largest explicit contributor of GME, the Medicare program spent nearly $8 billion in fiscal year (FY) 2004 for residency education and training (GAO, 2006).
Preventive medicine residency programs (costing an average of $108,000 per resident/year [ACPM, 2005a]) typically do not receive Medicare GME funds, as most programs do not qualify for direct medical education reimbursement because preventive medicine residency training tends to occur in nonhospital settings, for example, in state and local health departments, leaving such nonclinical programs to scramble for resources. Direct medical education costs usually include salaries and fringe benefits for residents, compensation for the faculty who supervise the residents, program administration costs, and allocated institutional overhead costs associated with graduate medical education (Bruccoleri,