Stephen C. Shannon, DO, MPH
President

Let’s Not Lose Sight of GME in the Health Reform Process

As we enter the 2009-2010 academic year, I have been reflecting on osteopathic medical education’s extraordinary growth (in size, stature and impact) over the past decade, and thinking also about what the next ten years will bring. Certainly, we face enormous challenges, but we also have much to celebrate and upon which to build in the years ahead.

Since 2000, nine new colleges of osteopathic medicine have opened their doors to students, and several remote teaching sites have been established as well. Total enrollment has surged, from 10,871 in 2000-01 to 16,893 in 2008-09. Applications to the colleges have grown as well. Only 7,708 potential medical students applied to colleges of osteopathic medicine in 2000. More than 12,800 applied for the 2009-10 academic year.  Today, nearly 20 percent of U.S. medical students are studying at an osteopathic medical college.

This growth, along with the nation’s increased focus on the primary care workforce, has afforded us a stronger voice in the current dialogue on health care reform efforts, particularly with regard to these efforts’ implications for medical education. It has become increasingly clear that much of osteopathic medicine’s traditional focus on patient-centered and preventive care are being heralded as central features of the kind of health care system that the reform effort aims to implement. In other words, osteopathic medical schools are educating the kind of physicians this country needs, and that fact is being increasingly recognized throughout the nation.

There are new twists in this effort that promise the potential of greater effectiveness, but require rethinking traditional approaches and innovation to implement. For example, the full utilization of health information technology, interprofessional education and practice, patient-centered, prevention-focused care---all are advocated by those calling for reform, regardless of partisan roots. These foci are not generally present in medical education venues or clinical practice to the extent needed, but whether or not reform is successful, the call for these changes will continue.

The challenges are greatest in clinical education venues. At the pre-doctoral training level, clinical educators and academic health delivery systems already are stressed because of the economic forces impacting health care delivery and the downturn in government support for medical education. As a result, osteopathic medical schools are increasingly focusing their resources on the development and maintenance of their clinical education systems.

Graduating from medical school does not make one a physician; it equips one for the next stage in education leading to specialization, licensure and practice via graduate medical education (GME). So regardless of the number of graduates and the pre-doctoral curriculum they enjoyed, without growth and innovation in residency training programs, it is hard to see how the graduate medical educational needs for the country’s next generation of physicians will be met.

The complexity of the mostly CMS-financed GME system, coupled with the existing accreditation model and specialty certification processes, point to incremental change at best. In fact, the current CMS GME financing system creates barriers to growth (via the ‘cap’) and innovation, and directly inhibits progress in recognized areas of need, such as development of the “Patient-Centered Primary Care Medical Home” models for clinical training.

Given GME’s federal financing model, it is hard to imagine national health care reform success without attention to issues related to GME. Current legislative efforts address some aspects of medical education and physician training (for example, through growth and support for the National Health Service Corps and Title VII funding to address primary care educational needs). But these efforts, while important, do not offer institutions the means to be transformative. Still, many osteopathic medical colleges are building on their traditional patient-centered, preventive focus to innovate, implement Interprofessional training curriculum and integrate information technology within their curriculum.

As the nation’s policy makers wrestle with how to expand health care access to the population, increase quality and lower cost, the need to address key issues impacting the physician workforce is not being adequately addressed. AACOM is supporting some proposals on GME that have been introduced into health reform legislation (see  http://publish.aacom.org/advocacy/topics/Pages/GradMedEd.aspx  and  http://capwiz.com/aacom/callalert/index.tt?alertid=13780071), but in the traditional CMS-financing model for GME, the price tag for new GME positions is limiting these proposals’ traction with lawmakers. However, there are aspects of these proposals that would enable innovation and fix some of the current disincentives that current regulations create for needed changes in how GME is conducted (e.g., see the “Teaching Health Center Proposal” developed by Fitzhugh Mullan, MD, and colleagues at the Medical Education Futures Study with Senator Bingaman (NM), and the ‘out-of-hospital’ aspects of Resident Physician Shortage Reduction Act of 2009--S. 973/H.R 2251).

From where I sit, “inside the beltway,” I am concerned that needed changes in graduate medical education will be lost or minimized in the health care reform process. Thus, an important opportunity to improve prospects for education of the physician component of the health care workforce may be missed. AACOM is advocating in this key area, and is working with other organizations in our profession to influence relevant proposals. Please join us in conveying the message to lawmakers that graduate medical education should not be given short-shrift in this historic process.