Graduate Medical Education
That Meets the Nation’s Health Needs
Committee on the Governance and Financing of
Graduate Medical Education
Board on Health Care Services
Jill Eden, Donald Berwick, and Gail Wilensky, Editors
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by Contract No. 101053-0009 between the National Academy of Sciences and ABIM Foundation; Contract No. 101053-0013 Aetna Foundation; Contract No. 101053-0014 The California Endowment; Contract No. 101053-0002 California HealthCare Foundation; Contract No. 101053-0003 The Commonwealth Fund; Contract No. 101053-0012 East Bay Community Foundation; Contract No. 101053-0010 Health Resources and Services Administration; Contract No. 101053-0006 Jewish Healthcare Foundation; Contract No. 101053-0001 Josiah Macy Jr. Foundation; Contract No. 101053-0007 Kaiser Permanente Institute for Health Policy; Contract No. 101053-0005 The Missouri Foundation for Health; Contract No. 101053-0004 Robert Wood Johnson Foundation; Contract No. 101053-0008 UnitedHealth Group Foundation; and Contract No. 101053-0011 U.S. Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project.
International Standard Book Number-13: 978-0-309-30355-2
International Standard Book Number-10: 0-309-30355-9
Library of Congress Control Number: 2014950457
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Suggested citation: IOM (Institute of Medicine). 2014. Graduate medical education that meets the nation’s health needs. Washington, DC: The National Academies Press.
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Victor J. Dzau is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council.
COMMITTEE ON THE GOVERNANCE AND FINANCING OF GRADUATE MEDICAL EDUCATION
DONALD M. BERWICK (Co-chair), Former President and CEO, Institute for Healthcare Improvement
GAIL R. WILENSKY (Co-chair), Senior Fellow, Project Hope
BRIAN ALEXANDER, Director, Neuro-radiation Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Harvard Medical School
DAVID A. ASCH, Executive Director, Penn Medicine Center for Health Care Innovation, University of Pennsylvania and Philadelphia VA Medical Center
DAVID ASPREY, Professor and Chair, Department of Physician Assistant Studies; Assistant Dean, Office of Student Affairs and Curriculum, University of Iowa Carver College of Medicine
ALFRED O. BERG, Professor, Department of Family Medicine, University of Washington School of Medicine
PETER BUERHAUS, Valere Potter Distinguished Professor of Nursing and Director, Center for Interdisciplinary Health Workforce Studies, Institute for Medicine and Public Health, Vanderbilt University Medical Center
AMITABH CHANDRA, Director of Health Policy Research, Kennedy School of Government, Harvard University
DENICE CORA-BRAMBLE, Chief Medical Officer and Executive Vice President, Ambulatory and Community Health Services, Children’s National Health System
MICHAEL J. DOWLING, President and CEO, North Shore–Long Island Jewish Health System
KATHLEEN A. DRACUP, Dean Emeritus, University of California San Francisco School of Nursing
ANTHONY E. KECK, Director, South Carolina Department of Health and Human Services
OCTAVIO N. MARTINEZ, JR., Executive Director, Hogg Foundation for Mental Health
FITZHUGH MULLAN, Murdock Head Professor of Medicine and Health Policy, Department of Health Policy, The George Washington University
ROGER PLUMMER, Retired Telecommunications Industry Executive
DEBORAH E. POWELL, Dean Emeritus and Professor of Laboratory Medicine and Pathology, University of Minnesota Medical School
BARBARA ROSS-LEE, Vice President for Health Sciences and Medical Affairs, New York Institute of Technology
GLENN D. STEELE, JR., President and CEO, Geisinger Health System
GAIL L. WARDEN, President Emeritus, Henry Ford Health System
DEBRA WEINSTEIN, Vice President for GME, Partners Healthcare System
BARBARA O. WYNN, Senior Policy Analyst, The RAND Corporation
JILL EDEN, Study Director
CHERYL ULMER, Co-Study Director (through May 2013)
STEPHANIE PINCUS, IOM Scholar-in-Residence
CHELSEA FRAKES, Research Assistant (through April 2013)
HANNAN BRAUN, Research Assistant (through June 2013)
HANNAH DURING, Senior Program Assistant (starting June 2013)
KAYLA WATKINS, Research Assistant (starting October 2013)
SARA THARAKAN, Research Assistant (starting November 2013)
ADAM SCHICKEDANZ, Chief Resident in Pediatrics, University of California San Francisco School of Medicine (July 2012)
DOUG JACOBS, Medical Student, UCSF Pathways Explore Summer Fellow (2012)
ROGER HERDMAN, Director, Board on Health Care Services (through June 2014)
SHARYL NASS, Interim Director, Board on Health Care Services (starting June 2014)
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
TIMI AGAR BARWICK, Physician Assistant Education Association
PAUL BATALDEN, Institute for Health Policy and Clinical Practice, Dartmouth College Geisel School of Medicine
FLOYD E. BLOOM, Bloom Scientific Associates Inc.
ELIZABETH BROWN, University of Pennsylvania Perelman School of Medicine
DEBORAH WATKINS BRUNER, Nell Hodgson Woodruff School of Nursing and Winship Cancer Institute, Emory University
BENJAMIN CHU, Kaiser Permanente Southern California and Hawaii Regions
TIMOTHY C. FLYNN, University of Florida College of Medicine and UF Health Shands Hospital
DAVID GOODMAN, Center for Health Policy Research, Dartmouth Institute for Health Policy and Clinical Practice
STUART GUTERMAN, The Commonwealth Fund
RICHARD KNAPP, American Association of Medical Colleges (retired)
RALPH MULLER, University of Pennsylvania Health System
KAREN J. NICHOLS, Chicago College of Osteopathic Medicine, Midwestern University
ROBERT L. PHILLIPS, American Board of Family Medicine
THOMAS C. RICKETTS, University of North Carolina Gillings School of Global Public Health
DAVID SKLAR, University of New Mexico
KATE WALSH, Boston Medical Center
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Neal Vanselow, Chancellor-Emeritus, Tulane University Health Sciences Center, and Georges Benjamin, Executive Director, American Public Health Association. Appointed by the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
As the U.S. population ages and diversifies and the Affordable Care Act extends health coverage to more Americans than ever before, it has never been more critical for the nation’s graduate medical education (GME) system to produce a physician workforce that meets the evolving health needs of the population.
For decades, Medicare has been the dominant funder of GME programs—contributing almost $10 billion in fiscal year 2012—and this funding, along with support from the Department of Veterans Affairs and the Health Resources and Services Administration, has been extremely valuable to the successful function of teaching hospitals across the country. However, many studies have shown that the current GME program does not produce adequate numbers of physicians prepared to work in needed specialties or geographic areas. Nor does it train physicians to practice in the community-based settings where most Americans seek care. Perhaps most critical, it lacks the oversight and infrastructure to track outcomes, reward performance, and respond nimbly to emerging challenges.
In 2012, an Institute of Medicine (IOM) committee was formed—with the support of 12 private foundations and backing from 11 U.S. senators—to analyze the governance and financing of the GME system. The 21 members of the committee who authored this report brought a range of experience in GME and education for other health professions, academic health centers, clinical medicine, health care financing and administration, and research, among others. I thank this eminent and diverse group of individuals for their contributions to this important task. In particular, on behalf of the IOM, I extend my gratitude to the committee co-chairs,
Donald Berwick and Gail Wilensky, and study director, Jill Eden, as well as her staff, for their leadership and dedication throughout the study process.
The committee’s report, Graduate Medical Education That Meets the Nation’s Health Needs, proposes significant revisions to rectify current shortcomings and create a GME system with greater transparency, accountability, strategic direction, and capacity to innovate. The report adds an important new dimension to the IOM’s previous calls to action to improve the health system—beginning with the publication of Crossing the Quality Chasm in 2001. I hope it will provide useful and principled guidance for policy makers and program administrators alike as we work toward a GME system that better contributes to achieving the nation’s health goals.
Harvey V. Fineberg, M.D., Ph.D.
President, Institute of Medicine (July 2002-June 2014)
The committee and staff are indebted to a number of individuals and organizations for their contributions to this report. The following individuals provided testimony to the committee:
Jonathan Amiel, Assistant Dean for Curricular Affairs, Columbia University College of Physicians & Surgeons; Attending Psychiatrist, New York State Psychiatric Institute’s Washington Heights Community Service
Karl Auerbach, President, American College of Occupational and Environmental Medicine
Paul Batalden, Professor Emeritus of Pediatrics and Community and Family Medicine, Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College Geisel School of Medicine
Nick Bath, Senior Policy Advisor for Health, Senate Health, Education, Labor, and Pensions Committee
Lisa Bellini, Vice Chair for Education, Department of Medicine, Perelman School of Medicine, University of Pennsylvania; Chair of the Board, Alliance for Academic Internal Medicine
Cybele Bjorklund, Minority Staff Director, House Ways and Means Subcommittee on Health
Mark Boom, President and CEO of The Methodist Hospital System
Boyd Buser, Vice President for Health Affairs and Dean, University of Pikeville–Kentucky College of Osteopathic Medicine
Nick Busing, President and CEO, Association of Faculties of Medicine of Canada
Benjamin K. Chu, Group President, Kaiser Permanente Southern California and Hawaii
Malcolm Cox, Former Chief Academic Affiliations Officer, Veterans Health Administration
Charles Cutler, Chair-Elect, Board of Regents, American College of Physicians
Ralph G. Dacey, Jr., President, Society of Neurological Surgeons
Arnold R. Eiser, Vice President, Medical Education, Mercy Health System SEPA; Professor of Medicine and Associate Dean, Drexel University College of Medicine
Dan Elling, Majority Staff Director, House Ways and Means Subcommittee on Health
Karen Fisher, Professional Staff, Senate Finance Committee
Tim Garson, Jr., Director, Institute for Health Policy, University Professor and Professor of Public Health Sciences, University of Virginia
Roland Goertz, CEO, Heart of Texas Community Health Center, Inc.; Vice Chair, Educational Health Center Task Force, National Association of Community Health Centers
Christopher Gonzalez, Vice Chair of Health Policy, American Urological Association
Fern Goodhart, Health/Education Legislative Assistant, Senator Tom Udall
David Goodman, Director, Center for Health Policy Research, Dartmouth Institute for Health Policy and Clinical Practice
Tiffany Groover, National Health Service Corps Scholar, PGY-3, Internal Medicine, Boston Medical Center
Atul Grover, Chief Public Policy Officer, Association of American Medical Colleges
Kristi Guillory, Senior Policy Analyst, American Cancer Society Action Network
Marc Hartstein, Director, Hospital and Ambulatory Policy Group, Center for Medicare, Centers for Medicare & Medicaid Services
Dianne Heffron, Director, Financial Management Group, Center for Medicaid and CHIP Services, Centers for Medicare & Medicaid Services
David Hoyt, Executive Director, American College of Surgeons
John Ingle, Fellow, Department of Otolaryngology, University of Pittsburgh Medical Center; President, Committee of Interns and Residents
Tim Johnson, Senior Vice President and Executive Director of Finance and Graduate Medical Education, Greater New York Hospital Association
Jim Kaufman, Vice President of Public Policy, Children’s Hospital Association
Frank R. Lewis, Executive Director, American Board of Surgery
Raul Mirza, PGY-4, Walter Reed Army Institute of Research, Sequential Preventative Medicine and Occupational & Environmental Medicine Residency
Tom Nasca, Executive Director and CEO, Accreditation Council for Graduate Medical Education
James Pacala, President, American Geriatrics Society
Richard Pan, California Assembly member speaking on behalf of the American Academy of Pediatrics
Judy Pauwels, Associate Professor, University of Washington Department of Family Medicine
Robert Petzel, Under Secretary for Health, U.S. Department of Veterans Affairs
Anne Morris Reid, Senior Professional Staff Member, House Energy and Commerce Subcommittee on Health
David Reines, Vice Chair, COGME; Clerkship Director of Surgery, VCU School of Medicine Inova Campus
Tom Ricketts, Deputy Director, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
Steven M. Safyer, President and CEO of Montefiore
Lewis Sandy, Senior Vice President for Clinical Advancement, UnitedHealth Group
Eric Schoomaker, GEN (Ret.), Former Army Surgeon General, Scholar in Residence, Uniformed Services University of the Health Sciences
Heidi Schumacher, PGY-3, Pediatrics, Children’s National Medical Center
Manisha Sharma, PGY-3, Family Medicine, Montefiore Medical Center
Susan E. Skochelak, Vice President, Medical Education, American Medical Association
David Squire, Former Executive Director, Utah Medical Education Council
Megan Taira, Legislative Assistant, Senator Charles Schumer
George Thibault, President, Josiah Macy Jr. Foundation
Linda Thomas-Hemak, President and CEO, Wright Center for Graduate Medical Education
Mary Wakefield, Administrator, Health Resources and Services Administration
Steven A. Wartman, President and CEO, Association of Academic Health Centers
Sandra Wilkniss, Senior Legislative Counsel for Health Care, Senator Bingaman
We also extend special thanks to the following individuals who were essential sources of information, generously giving their time and knowledge to further the committee’s efforts:
Robert Baron, Professor of Medicine, Associate Dean for Graduate and Continuing Education, University of California, San Francisco
David Battinelli, Senior Vice President for Academic Affairs, North Shore–Long Island Jewish Health System and Dean for Medical Education, Betsy Cushing Whitney Professor of Medicine, Hofstra North Shore–Long Island Jewish School of Medicine
Andrew Bindman, Senior Advisor and Assistant Secretary for Planning and Evaluation, Office of Health Policy, U.S. Department of Health and Human Services
Christine K. Cassel, President and CEO, National Quality Forum
Barbara Chang, Director, Medical & Dental Education, Office of Academic Affiliations, Veterans Health Administration
Renate Dombrowski, Health Insurance Specialist, Division of Acute Care, Centers for Medicare & Medicaid Services
Linda Famiglio, Chief Academic Officer, Geisinger Health System
Erin Fraher, Director, North Carolina Health Professions Data System, Cecil G. Sheps Center for Health Services Research
Victor Fuchs, Henry J. Kaiser, Jr., Professor of Economics and of Health Research and Policy, Emeritus; FSI Senior Fellow and CHP/PCOR Core Faculty Member, Stanford University
David Godfrey, State Medicaid Director, Minnesota Department of Human Services
Marc Hahn, President and CEO, Kansas City University of Medicine and Biosciences
Tim Henderson, Health Workforce Consultant
Michael Johns, Professor of Medicine and Public Health, Emory University
T. Michael Kashner, Research Professor of Medicine and Associate Vice Chair for Education Research, Department of Medicine, Loma Linda University School of Medicine, VA Healthcare System
Mary Kauper, System Administrative Director of Medical Education, Henry Ford Health System
Kathleen Klink, Former Director, Division of Medicine and Dentistry, Bureau of Health Professions, Health Resources and Services Administration
Richard Kronick, Director, Agency for Healthcare Research and Quality
Mark E. Miller, Executive Director, Medicare Payment Advisory Commission
Cathryn Nation, Associate Vice President, Health Sciences University of California, Office of the President
Robert Phillips, Vice President for Research and Policy, American Board of Family Medicine
Marla Salmon, IOM Nurse Scholar-in-Residence
Edward Salsberg, Former Director, National Center for Health Workforce Analysis, Health Resources and Services Administration
Kenneth Shine, Former Executive Vice Chancellor for Health Affairs, University of Texas System
Robert Young, Henry Ford Health System
Funding for this study was provided by ABIM Foundation, Aetna Foundation, The California Endowment, California HealthCare Foundation, The Commonwealth Fund, East Bay Community Foundation, Health Resources and Services Administration, Jewish Healthcare Foundation, Josiah Macy Jr. Foundation, Kaiser Permanente Institute for Health Policy, The Missouri Foundation for Health, Robert Wood Johnson Foundation, UnitedHealth Group Foundation, and U.S. Department of Veterans Affairs. The committee appreciates the opportunity and support extended by the sponsors for the development of this report.
Finally, many within the Institute of Medicine were helpful to the study staff. We would like to thank Clyde Behney, Laura DeStefano, Chelsea Aston Frakes, Molly Galvin, Greta Gorman, and Abbey Meltzer.
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Boxes, Figures, and Tables