“One thing that’s inherent with trainees is that they’re trainees,” she says. “They’re not as efficient or as effective as someone who’s an expert, right? That’s why it’s training.”
Dr. Parekh, who also serves as chair of the SHM Academic Hospitalist Committee, agrees that finding the right outcome measures could be tough. “It gets very dicey, because how do you define who’s a good doctor?” he says. Currently, residents often are assessed via the reputation and history of the training program. “People say, ‘I know that the people coming out of that program are good because they’ve always been good, and it’s a reputable program and has a big name.’ But it’s not objective data,” he says.
Dr. Sears, of Sound Physicians, notes that it’s also often difficult to attribute patients to specific providers.
“Many times in graduate medical education, patients are going in and out of the program or in and out of the hospital, and how do you attribute?” he says. “I think it becomes very complex.”
A New Take on Transformation
Another IOM recommendation would create a single GME fund with two subsidiaries: an operational fund for ongoing support and a transformation fund. The latter fund would finance four new initiatives to:
- Develop and evaluate innovative GME programs;
- Determine and validate appropriate performance measures;
- Establish pilot projects to test out alternative payment methods; and
- Award new training positions based on priority disciplines—such as primary care—and underserved geographic areas.
A related recommendation seeks to modernize the GME payment methodology. For example, the committee urged Medicare to combine the indirect and direct funding streams into one payment based on a national per-resident amount and adjusted according to each location. In addition, the report endorsed performance-based payments based on the results of pilots launched under the transformation fund.
Dr. Sears says he appreciates the report’s effort to address shortfalls in primary care providers relative to specialists. “That’s not to say that specialty medicine isn’t incredibly important, because it is,” he says. “But I think incentivizing or reallocating spots to ensure that we have adequate primary care physician coverage throughout the country will have tremendous impact on the ability to care for an aging population in the United States, at least.”
I have had physicians tell me that they do not understand why our report said that there was not a physician shortage, and I try to point out that we did NOT say that. Rather, the report [and the committee] said that we could not find compelling evidence of an impending physician shortage and that physician workforce projections had been and are quite unreliable. —Deborah Powell, MD, dean emerita, University of Minnesota Medical School, IOM committee member
Shifting some of our [medical] education to match what Medicare is trying to drive out in the real world, I think, is long overdue. —Scott Sears, MD, FACP, MBA, chief clinical officer, Sound Physicians, Tacoma, Wash.
Dr. Parekh agrees, at least in part.
“Fundamentally, the idea is not a bad one, to say that programs that were more aligned with national needs and priorities in terms of how they train physicians would get more funding, and those that did not wouldn’t,” he says. “I think the challenge is that the devil’s in the details of how you do that.”
A priority-based GME system, he continues, could potentially influence what type of physicians are trained.
“In my mind, it’s not irrational to think that if GME funding was more targeted around expanding slots in certain specialties and not expanding slots in other specialties, that there would be some ability to influence the workforce,” Dr. Parekh says. Influencing where residents go may be more difficult, though a growing mismatch between medical graduates and available residency slots might add a new wrinkle to that debate, as well.