Military Graduate Medical Education: Are the King's Clothes Tattered?

Abstract

Military Graduate Medical Education (GME) has long been considered a cornerstone of the Military Health System (MHS) and comprises 3% of the nation’s GME positions. In these times of fiscal uncertainty, the $9.5 billion the federal government annually contributes to teaching hospitals through Medicare is under significant scrutiny. With MHS consuming 10% of the Department of Defense (DoD) budget, the cost-benefit of military GME is likely to be questioned yet again. As early as 2006, an Office of the Secretary of Defense, Health Affair’s sponsored report stated we must be willing to “admit the rhetoric of needing GME to maintain the force structure as it relates to quality, recruitment, and cost effectiveness may not be true.” This report concluded, “A critical re-look at DoD-sponsored GME is needed today. The King may not be naked—but his clothing is tattered.” As I pondered whether the allure of military GME was more rhetoric than reality, a question crossed my mind. “Why do a number of cost-conscience, quality health care delivery institutions such as Kaiser Permanente (KP), Geisinger Health System, and Intermountain Healthcare engage and value GME?” The President of KP Southern California, after noting a lack of financial incentive, stated their health care system should become even more involved in GME. Are there insights into the value of GME the MHS might gain from health care systems like KP? Further, any significant changes in military GME should be considered in the context of growing challenges in meeting the health care needs of the country, the shifting accreditation emphasis on patient safety and quality improvement, and the impact of residency training on future practice. Senior leaders at KP reported several reasons for being engaged in GME for over 60 years: grounding residents in their culture; growing future leaders; positive impact on faculty recruitment, quality, satisfaction, and retention; workforce contribution; research; and enhancing the image of the organization. They assert “grounding of trainees in the fundamentals of Permanente Medicine virtually ensures a cultural fit.” Given the unique nature of military medicine, the value of MHS acculturation during training should not be underestimated. A military physician’s career may result in movement among five different cultures: academic, clinical, research, administrative, and military-unique operations. During the last decade of conflict, military GME teaching faculty, nurses, support staff, and patients have lived the “raison d’etre,” as the operational culture has been described. They bring this back to the classroom, the health care team, and the bedside. Like KP, we breed our future health care leaders in this training culture. Our military treatment facilities (MTFs) contain key ingredients described by a Nobel Laureate, Robert Fogel, found in a flourishing culture: a common sense of community, purpose, general discipline, and a strong work ethic. Given challenges with military life (deployments, moves, lower career pay), incentives are needed to retain top physicians, who, in turn, recruit our future DoD physicians. Yet recruitment, satisfaction, and retention of highly qualified providers remain vexing problems for the MHS, with 15% to 30% annual turnover. Turnover is expensive, costing one college of medicine with an annual 6.7% turnover an estimated 45 million dollars over 5 years. A significant proportion of the cost was due to orienting to the new practice setting. Perhaps this further explains why KP is willing to finance GME. KP hires 30% of their former residents, who make up 15% of their faculty workforce. The Department of Veterans Affairs (VA), with an annual turnover of 9%, found residents are twice as likely to consider a VA career after their rotations. Office of the Dean, Graduate Medical Education, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234-4504. This article was presented at the Department of Pediatrics Grand Rounds, Uniformed Services University, Bethesda, MD, April 11, 2013. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of the Air Force, Department of the Army, Department of Defense, or the U.S. Government. This work was prepared as part of their official duties and, as such, there is no copyright to be transferred. doi: 10.7205/MILMED-D-13-00283