Graduate medical education that meets the nation's health needs

231 Pages·2014·3.415 MB·English

by  Berwick, Donald Mark, Eden, Jill, Wilensky, Gail R.

Committee on the Governance and Financing of
Graduate Medical Education
Board on Health Care Services
Jill Eden, Donald Berwick, and Gail Wilensky, Editors
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NOTICE: The project that is the subject of this report was approved by the Govern-
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councils of the National Academy of Sciences, the National Academy of Engineer-
ing, and the Institute of Medicine. The members of the committee responsible for
the report were chosen for their special competences and with regard for appropri-
ate 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 Founda-
tion; 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 Founda-
tion 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, conclu-
sions, 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 pro-
vided support for the project.
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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.
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Advising the Nation. Improving Health.
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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
v
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
Study Staff
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)
vi
Reviewers
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
vii
viii REVIEWERS
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 construc-
tive 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 Asso-
ciation. 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 com-
ments were carefully considered. Responsibility for the final content of this
report rests entirely with the authoring committee and the institution.
Foreword
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) sys-
tem 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 administra-
tion, 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,
ix
x FOREWORD
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, account-
ability, 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 Qual-
ity 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)