A prescription to advocate for graduate medical education reform.

Training the next generation of physicians in a system wrought with funding disparities has left many residency program directors wondering if there is hope for change—and what role they might play in bringing about change. The current state of graduate medical education (GME) financing is based on outdated statutory formulas that are focused on cost-based reimbursements in the hospital setting. The consequences of this imbalanced funding are significant: the formula impacts access to care, contributes to physician workforce shortages, and ultimately fails to meet the health care needs in the United States. Between 1998 and 2008, there was an increase in the number of residency slots in specialties known for competitive incomes and appealing lifestyles (radiology, ophthalmology, anesthesia, and dermatology) and a decrease in primary care slots (family medicine, pediatrics, and internal medicine). Despite the increasing need for primary care physicians across the country, research indicates that hospitals largely favor higher revenue-generating specialty training, as there is a direct correlation between specialty income and GME slots offered.1 In response to the failures of the Centers for Medicare and Medicaid Services (CMS) to meet the health care needs of the public, the Institute of Medicine (IOM) issued a report calling for dramatic changes in GME funding and governance.2 Specifically, the report recommends providing funding directly to sponsoring institutions, thereby promoting more training at community-based sites. In addition, the report supports the creation of an oversight council to track performance outcomes and lead policy development. Shortly after the IOM report was released, the American Academy of Family Physicians (AAFP) also took a stand emphasizing the need to expand primary care GME by instilling accountability in a budget-neutral manner. The AAFP proposed that CMS limit direct graduate medical education and indirect medical education payments to the training of first-certificate residency programs. They also proposed that CMS require all sponsoring institutions and teaching hospitals seeking new Medicare and/or Medicaid-financed GME positions meet minimum primary care training thresholds as a condition of their expansion. This change could fund an additional 7,000 new residency training spots with a minimum of 50% going to primary care specialties. In addition, AAFP’s proposal would require hospitals and sponsoring institutions to demonstrate a commitment to primary care through the establishment of thresholds and maintenance of effort requirements applicable to all institutions currently receiving GME financing. This is to ensure that institutions truly support training the primary care physicians this country needs. These collective GME refinancing recommendations would result in positive changes for the future of family medicine training. We anticipate a more robust workforce in a variety of geographic and practice settings. The larger impact would be shifting the focus of health care away from acute illness and toward population health and preventative care. The medical organizations that represent teaching hospitals are opposed to these changes, however. As family physicians, we must start educating our colleagues in other specialties on why the current system is unsustainable and harmful to patients and physicians alike, emphasizing that better health outcomes occur when primary care is available and affordable. Second, we must collaborate with other primary care specialties in order to speak to the value of primary care with a unified voice. Program directors carry a strong influence in their communities. Our call to action: contact your representatives and ask them to sponsor or support a bill that includes the AAFP’s proposal for GME reform. Use the AAFP’s resources (http://www.aafp.org/advocacy/informed/workforce/gme.html) to educate your legislators on this very important topic. Encourage your residents, faculty, and patients to do the same. Change comes when we speak with one voice on an issue that affects every American. It’s time to fix this broken system.