Graduate Medical Education in State of Flux

Keynote speaker delivers recommendations to preserve GME By Elizabeth Sidney

Addressing the Chicago Medical Society’s grassroots Council, educator Russell Robertson, MD, called for new and aggressive approaches to solving the worsening crisis in GME. Due to Congressional inertia and lack of new funding mechanisms, Medicare-supported teaching programs cannot possibly expand to accommodate the increasing numbers of medical school graduates. Dr. Robertson, who is former dean of the Chicago Medical School and past chair of the College of Graduate Medical Education (COGME), travels the country to discuss health care trends and new education models. His talk before the CMS Council on Nov. 12 drew many students and academic colleagues.

Serving eight teaching institutions and a major public health system, CMS is behind a coalition of local deans and students pushing for new Medicare-funded training positions. Central to this effort is advocacy in Washington, DC, where CMS leaders have personally urged lawmakers to approve one of several proposals before Congress that would add 15,000 slots over three years. But despite sustained efforts by academic groups, and organized medicine, legislators have yet to pass any bill. The dearth of new Medicare-supported slots creates a bottleneck in the training pipeline when allopathic and osteopathic schools are working to boost enrollment 30% by 2016 to meet the needs of a growing and aging population. Almost everyone, from legislators to public policy experts, agrees on the need for accelerated training to address looming physician shortages.

The Association of American Medical Colleges (AAMC) projects a physician shortfall of 90,000 or more by 2020. Yet the robust growth in enrollment will not translate into a single new doctor without additional training slots, the AAMC states. Congress capped the number of Medicare residency positions at 94,000 with the Balanced Budget Act of 1997. Sequestration and other budget cuts also impede the expansion of GME.

Displacement of Residents
Despite modest 6.8% growth in net new GME positions in recent years, “we’re really seeing a net displacement of residency spots,” Dr. Robertson explains. Not only did interventional subspecialties account for almost all this growth, but the new positions were all hospital-funded. The increase also coincided with the closure of many primary care programs. The Health Resources Services Administration added net new positions to existing residency programs, and since 2000, teaching hospitals have entirely self-funded the training of thousands of additional doctors.

The 2012 match signaled trouble ahead. For students not matched initially to a residency position, the NRMP launched the Supplemental Offer and Acceptance Program (SOAP) in 2012. Designed to streamline and automate the process, SOAP replaced the “scramble.” Under this format, unmatched students submit applications for unfilled positions through the AAMC’s electronic residency application service, ERAS.

A record number of students, 256, or 4.6%, failed to land a spot in 2012 after this second round, Dr. Robertson said. Eligible students were “displaced” to the 2013 match, which had the highest participation ever, with an additional 1,000 U.S. seniors competing for positions. By the end of Match Week 2013, 528 students had not matched; many were expected to participate in the 2014 match.

Displacement may also occur when medical schools compensate residency programs for clinical clerkships. This trend has grown increasingly important over the last few years as offshore medical schools began making payments to teaching hospitals in states like New York. In 2012, the AMA called for legislation opposing such limitations on training opportunities for U.S. LCME/COCA students in clinical rotations.

Dr. Robertson predicts that in the years ahead, matching for IMGs will become more difficult. He advises all students to have an alternate plan in the event they are unable to match into their chosen specialty. Students can improve their chances of being matched by ranking a sufficient number of residency training programs and not limiting their rank order lists to highly competitive programs.

With the focus on medical homes and primary care, GME should be moving into ambulatory and community settings, Dr. Robertson said. But funding continues to flow through hospitals although 90% of primary care services are provided in outpatient clinics. Many have called for the delinkage of GME funding from inpatient hospital services.

Dr. Robertson relayed recommendations from the COGME, AAMC, and Macy Foundation, to expand GME. They include:

Independent review by the Institute of Medicine of GME governance and financing.
IOM recommendations on the structure and function of the accreditation process.
Ongoing guidance and assessment by the IOM.
Priority on funding of core residency programs in internal medicine, pediatrics, surgery, family medicine, and ob-gyn.
More GME positions in rural and underserved urban communities.
Shift training to non-hospital and office-based practices.
Self-fund procedural specialties through the income they produce.
In-depth analysis of how teaching hospitals manage their IME funds.
Re-set Medicare funding priorities based on net costs of running residency programs.
New GME funding partners and mechanisms to align with community needs.
Eliminate transitional post-graduate year positions and excess preliminary non-categorical positions.
Flexibility in fourth-year clinical training, crediting some toward residency training.
Reconsider fellowship accreditation guidelines to require fewer years of training for certain specializations.
Reward training innovations that reflect society’s need for physicians who can practice effectively in the changing health care environment.
Loan forgiveness by the National Health Service Corps for applicants who are the sole or primary borrower.

The neglect of GME underscores why the medical profession must stand united as one body when urging lawmakers to address critical issues. With each specialty promoting its own solution and lobbying separately, Congress is less apt to listen, Dr. Robertson emphasized.

Nutrition Standards for Food Banks

CMS’ Council approved a measure from Susan B. Kern, MD, that urges food banks and pantries as well as state agencies to develop nutritional guidelines for the donated foods they dispense. Fresh fruits and vegetables are sorely missing in these facilities due largely to lack of refrigeration and expense.

Funding for initiatives like this will require creative approaches, Dr. Kern said. In California, for example, food pantries partner with farmers’ markets and grocery stores. The participating grocers may offer direct discounts to consumers. In the Chicago area, Metra buses are being repurposed to carry fresh fruits and vegetables into underserved communities, Dr. Kern reported.

The resolution directs the Illinois State Medical Society and American Medical Association to work toward state and national nutritional guidelines for food banks and pantries.

The CMS Council is the starting point in Illinois for new legislative proposals. All members may submit resolutions. For information, please call 312-670-2550 or email esidney@cmsdocs.org.

The next Council meeting is on Tuesday, Feb. 18, 2014, at 7:00 p.m., at Maggiano’s Banquets, in Chicago.