Cheryl Clark, September 12, 2011
The nation's system for training physicians is in dramatic need of a complete overhaul to adequately provide future patient care, says a report from the Josiah Macy Jr. Foundation, which issued 14 recommendations to make that happen.
"Although notable changes have occurred in graduate medical education (GME) over the past decade, including the introduction of a competency-based framework and limitations on duty hours, many people feel that much broader reforms are needed to keep pace," says the 39-member panel that authored the report.
The panel, consisting of physicians and surgeons as well as medical school deans and faculty members, said the nation will be short more than 100,000 doctors by the middle of the next decade, in part because of the current system's entrenched ways of educating and assuring the quality of the physician workforce.
"Unless we in academic medicine are self-critical and show a willingness to change, the political and public support for graduate medical education will disappear," warns Macy President George Thibault, MD, in a statement. "This is a huge enterprise built on tradition, but the system has to change to be more responsive to public needs."
One of panel’s key recommendations is that medical education should shift from gauging competency by months and years of training to actual measurements of individual physicians' readiness for independent practice. This is because medical school residents "vary significantly in how quickly they achieve competency, yet the current system of training all residents for a fixed duration fails to recognize or accommodate this reality."
The panel also prioritizes its recommendation to diversify training sites from traditional teaching hospitals to federally qualified and school-based health centers "and to expand content related to professionalism, population medicine, and team-based practice.”
A third key recommendation is for educational institutions to eliminate historic boundaries so that other health provider professions can learn with their physician colleagues. "This will require revising regulations that now prevent supervision across specialties or professions," the group says.
The panel also wants to require a period of "monitored independence" during GME to confirm each physician's readiness for independent practice. "Program directors and teaching faculty express widespread concern that residents are not given sufficient opportunity to act independently within the present teaching environment and are consequently less well prepared for practice," the statement says.
The report lists four trends that make a major shift in medical training necessary:
1. New approaches to physician practice are necessary to meet the needs of an aging population, as the number of people 65 and older will double by 2020. This population will live longer with more chronic, cognitive, and functional issues and will be more racially and culturally diverse.
2. Care continues to move outside the hospital to the home, clinics, and other community settings, and care providers are assuming new roles to meet these needs. The Affordable Care Act's directives will accelerate this trend, giving 32 million more people health coverage. This influx will require trainees to be "prepared to work in different organizations and sites of care, and in teams of health professionals."
3. Trainees must enter practice trained to use new healthcare technologies safely and efficiently. "Advances in medical diagnostics, therapeutics, and information technology can significantly improve health outcomes. However, we have fallen short in consistently using technology optimally to improve the quality and efficiency of healthcare," the panel writes.
4. The next generation of physicians must help lower costs and be more efficient. "Physicians in training must understand the financial implications of their patient management decisions, and their training must include new and efficient models of care so that they will be prepared to practice cost-effective medicine and be responsible stewards of resources while providing high-quality patient care," the report says.
However, to change the graduate medical system, medical educators face many obstacles, including the growing tension between work-hour restrictions and competition for curricular time and non-educational tasks. Another important obstacle is the difficulty in persuading sufficient numbers of medical students to choose primary care.
"In the past decade, the number of residents in subspecialty training has risen five times faster than the number of residents in the core specialties (those representing primary board certification). The number of residents expected to practice primary care has declined by more than 10%," the report notes.
The panel was chaired by Debra Weinstein, MD, Massachusetts General Hospital, and Vice President for Graduate Medical Education for Partners Healthcare System, Inc.