Graduate Medical Education Positions Research Articles

New Opportunities for Expanding Rural Graduate Medical Education to Improve Rural Health Outcomes: Implications of the Consolidated Appropriations Act of 2021.

Evidence shows that those living in rural communities experience consistently worse health outcomes than their urban and suburban counterparts. One proven strategy to address this disparity is to increase the physician supply in rural areas through graduate medical education (GME) training. However, rural hospitals have faced challenges developing training programs in these underserved areas, largely due to inadequate federal funding for rural GME. The Consolidated Appropriations Act of 2021 (CAA) contains multiple provisions that seek to address disparities in Medicare funding for rural GME, including funding for an increase in rural GME positions or "slots" (Section 126), expansion of rural training opportunities (Section 127), and relief for hospitals that have very low resident payments and/or caps (Section 131). In this Invited Commentary, the authors describe historical factors that have impeded the growth of training programs in rural areas, summarize the implications of each CAA provision for rural GME, and provide guidance for institutions seeking to avail themselves of the opportunities presented by the CAA. These policy changes create new opportunities for rural hospitals and partnering urban medical centers to bolster rural GME training, and consequently the physician workforce in underserved communities.

Rural Residency Training as a Strategy to Address Rural Health Disparities: Barriers to Expansion and Possible Solutions.

Rural Residency Training as a Strategy to Address Rural Health Disparities: Barriers to Expansion and Possible Solutions.

The Single Accreditation System: Risks to the Osteopathic Profession.

In August 2014, the American Osteopathic Association (AOA) and the American Association of Colleges of Osteopathic Medicine (AACOM) signed a memorandum of understanding with the Accreditation Council for Graduate Medical Education (ACGME) to create the Single Accreditation System (SAS) for graduate medical education (GME) in the United States. The AOA made the decision that it would close its GME accreditation system in response to dramatic growth in colleges of osteopathic medicine, a shortfall in osteopathic GME positions with increasing dependence on the ACGME system, ACGME policy decisions that adversely impacted osteopathic students, and declining osteopathic student interest in primary care. Osteopathic teaching institutions bore responsibility for meeting ACGME accreditation standards between 2015 and 2020, including determining institutional sponsorship, which program applications to submit, program size, educational leadership, and whether to pursue Osteopathic Recognition. Approximately 692 of 954 (72.5%) eligible osteopathic GME programs in 2014-2015 obtained ACGME accreditation by June 1, 2020. There were sharp reductions in surgical and subspecialty programs and a significant drop of DOs in educational leadership positions. A low percentage of ACGME-accredited programs applied for Osteopathic Recognition. In closing its GME accreditation system and joining the ACGME, the AOA gave up control of its direct relationship with osteopathic residents, fellows, and teaching institutions to gain critical GME opportunities. In this article, the author considers whether this gain will offset the risks taken by the AOA, including decreased DO leadership opportunities and role models, lower than expected interest in Osteopathic Recognition, and possible decreased DO interest in osteopathic organizations and osteopathic specialty board certification. Time and the choices of current and future DO trainees in ACGME programs will determine the future of the osteopathic profession-and whether these risks were worth taking.

US Primary Care vs Specialty Care Trainee Positions and Physician Incomes: Trends From 2001 to 2019.

Much of the Affordable Care Act (ACA) and subsequent US health care policies were designed to address deficiencies in health care access and enhance primary care services. How residency positions and physician incomes have changed in the post-ACA era is not well characterized. We evaluated the growth of US trainee positions and physician income, in the pre- vs post-ACA environment by specialty and among primary care vs specialty care. Total resident complement by specialty and year was extracted from the National Graduate Medical Education (GME) Census and stratified into primary care vs specialty care. Median incomes were extracted from Medical Group Management Association surveys. Piecewise linear regression with interaction terms (pre-ACA, 2001-2010, vs post-ACA, 2011-2019) assessed growth rate by specialty and growth rate differences between primary care and specialty care. Sensitivity analyses were performed by focusing on family medicine and excluding additional GME positions contributed by the introduction of the 2015 single GME accreditation system. Resident complements increased for primary care (+0.16%/year pre-ACA to +2.06%/year post-ACA, P < .001) and specialty care (+1.49%/year to +2.07%/year, P = .005). Specialty care growth outpaced primary care pre-ACA (P < .001) but not post-ACA (P = .10). Family medicine had the largest increase in the pre- vs post-ACA era (-0.77%/year vs +2.09%/year, P < .001). Excluding positions contributed by the single GME accreditation system transition did not result in any statistically significant changes to the findings. Income growth increased for primary care (+0.84%/year to +1.37%/year, P = .044), but decreased for specialty care (+1.44%/year to +0.49%/year, P = .011). Specialty care income growth outpaced primary care pre-ACA (P < .001), but not post-ACA (P = .22). We found significant growth differences in resident complement and income among primary care versus specialty care in the pre-/post-ACA eras.

Addiction Medicine After COVID-19: The Imperative of a Trained Workforce

Addiction Medicine After COVID-19: The Imperative of a Trained Workforce

Analysis of Preclinical Academic Performance Compared to Matched Residency

IntroductionAs medical school enrollment has risen, the number of graduate medical education positions remains relatively unchanged. With this increased disparity, residency selection committees place heavy emphasis on USMLE Step 1 scores, clerkship grades, class rankings, and Alpha‐Omega‐Alpha membership when extending interviews and ranking applicants. The preclinical years are often overlooked in their relevance to potential residency matches but may play an important role in choosing and ultimate acceptance into a particular specialty. The purpose of this study was to assess how preclinical performance of Medical College of Georgia (MCG) graduates compared to their residency match. We hypothesized there would be academic performance differences in preclinical content areas that are typically associated with a student's residency choice.MethodsPreclinical academic performance from MCG Classes of 2017 and 2018 (n=321 students) were compared to matched residency. Residencies were categorized by relative competitiveness based on residency U.S. graduate fill rates (Highly Competitive/HC: Plastic Surgery, Orthopaedic Surgery, Otolaryngology, Ophthalmology, Radiology, Radiation Oncology, and Neurosurgery; Competitive/C: Emergency Medicine, Urology, Dermatology, General Surgery, Anesthesiology, Pediatrics, OB/Gyn.; Less Competitive/LC: Psychiatry, Pathology, Physical Medicine and Rehabilitation, Internal Medicine, Neurology, Family Medicine). ANOVA and t‐tests were used for analyses.ResultsStudents matching into highly competitive residencies performed significantly better in all preclinical courses compared to those going into competitive or less competitive residencies (p&lt;0.05). As expected, USMLE Step 1 scores were also significantly higher for students matching in highly competitive residencies (243.7 ± 13.0) compared to other residencies (C: 231.0 ± 15.9; LC: 230.8 ± 16.3; p&lt;0.05). Students who matched into Surgical or Radiology specialties performed significantly better in Anatomy (84.4 ± 5.6) compared to those in other specialties (82.9 ± 5.5; p&lt;0.05). Students matching into Orthopaedic Surgery scored significantly higher than the class average for the Year 1 Tissue and Musculoskeletal System (88.9 ± 3.6 vs. 85.3 ± 5.4; p&lt;0.01) and Year 2 Skin and Musculoskeletal System Courses (95.8 ± 1.5 vs. 92.7 ± 3.9; p&lt;0.01). Students matching into Dermatology scored significantly higher than the class average in Pathology (92.1 ± 3.5 vs. 88.0 ± 5.4; p&lt;0.01).ConclusionsStudents who match into highly competitive residencies need a firm foundation in the basic sciences in order to perform well on USMLE Step 1 and in the clerkships. While residencies may not look specifically at preclinical grades, more competitive programs such as Surgery specialties and Radiology place greater emphasis on class rank and overall grades, which incorporate preclinical grades. Our previous research has shown that content and performance in the preclinical curriculum do influence residency choice early in medical school. Subsequent studies will further examine how these factors are involved in residency choice.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

The American Board of Family Medicine: New Tools to Assist Program Directors and Graduates Achieve Success.

In this commentary we review the improvements in the pass rates for first-time American Board of Family Medicine (ABFM) Certification Examination test takers in the context of new tools and resources for program directors against the backdrop of a changing accreditation system and increased competition for a relatively fixed number of graduate medical education positions in family medicine. While causality cannot be established between the strategic initiatives of the ABFM and higher pass rates, we can all celebrate the new tools and resources provided to residents and program directors, and the improved performance of family medicine graduates on the certification examination.

State of the Plastic Surgery Workforce and the Impact of Graduate Medical Education Reform on Training of Plastic Surgeons.

Although recent estimates predict a large impending shortage of plastic surgeons, graduate medical education funding through the Centers for Medicare and Medicaid Services remains capped by the 1997 Balanced Budget Act. The authors' aim was to develop a plan to stimulate legislative action. The authors reviewed responses of the American Society of Plastic Surgeons, American College of Surgeons, and American Medical Association from January of 2015 to a House Energy & Commerce Committee request for input on graduate medical education funding. In addition, all program directors in plastic surgery were surveyed through the American Council of Academic Plastic Surgeons to determine their graduate medical education funding sources. All three organizations agree that current graduate medical education funding is inadequate to meet workforce needs, and this has a significant impact on specialty selection and distribution for residency training. All agreed that funding should be tied to the resident rather than to the institution, but disagreed on whether funds should be divided between direct (allocated to residency training) and indirect (allocated to patient care) pools, as is currently practiced. Program directors' survey responses indicated that only 38 percent of graduate medical education funds comes from the Centers for Medicare and Medicaid Services. Organized medicine is at risk of losing critically needed graduate medical education funding. Specific legislation to support additional graduate medical education positions and funding (House Resolutions 1180 and 4282) has been proposed but has not been universally endorsed, in part because of a lack of collaboration in organized medicine. Collaboration among major organizations can reinvigorate these measures and implement real change in funding.

Considerations for Medical Students and Advisors After an Unsuccessful Match.

Increasing numbers of graduating U.S. medical students are not securing a graduate medical education (GME) position, even after participating in the National Resident Matching Program (also known as "the Match") and the Supplemental Offer and Acceptance Program. The reasons for an unsuccessful Match include increasing numbers of applicants compared with nearly unchanging numbers of available GME positions, academic problems or professionalism lapses, and a poor fit between applicants and their first-choice specialty.In this Perspective, the authors (1) examine the current Match landscape; (2) discuss the environmental factors that affect that Match landscape such as increasing medical school enrollment without a corresponding increase in GME positions; (3) review historical data on unmatched MD students; (4) discuss medical schools' responsibilities to unmatched students and to society; (5) explore controversial issues related to unmatched students, including graduation delays and altering the Medical Student Performance Evaluation for subsequent Match applications; and (6) outline various pathways for unmatched students to secure a GME position in the future or to pursue an alternative, nonclinical position. Finally, they share guidelines for advising unmatched students in the weeks and months following an unsuccessful Match. These recommendations aim to clarify what options exist, and are practical, for unmatched students, with the hope that further study will enable the development of best practices in this area.

World medical schools: The sum also rises.

ObjectiveThere is a worldwide shortage of doctors, which is true in most countries and on most continents. To enumerate the number of medical schools in the world at two different times, showing the trends and relating this to population is a beginning. The number is actually going up and has done so for some time; this has increased the supply of physicians and broadened healthcare delivery.DesignThe number to count for geographic and regional information about the medical schools relates directly to the supply of doctors. Regions were chosen from WHO and Foundation for the Advancement of International Medical Education and Research data to illustrate geographic distributions, physicians per patient and kinetics.SettingThe number of medical schools has consistently been rising around the world. However, world order is reverting to disorder, considering wars, disease and beleaguered stand-offs.ParticipantsNone.Main outcome measuresEight countries contain 40% of medical schools; however, several locations are rising faster than the rest. Some regions are stable, but sub-Saharan Africa, the Caribbean, South Asia and South America have increased the most in percentage recently, but not uniformly.ResultsMedical schools are related not only by geography, political boundaries and population but are concentrated in some regions. Graduate Medical Education positions appear to be short on a worldwide basis, as well as in some regions and countries.ConclusionsThe number of medical schools is increasing worldwide and the identification of rapidly rising geographic areas is useful in exploring, planning and comparing regions. Controversy continues in a variety of locations, especially concerning Graduate Medical Education. In addition to funding, faculty candidates and accreditation, new schools are confronting a variety of choices in standards and quality, sizing and regional concerns.

A Methodology for Using Workforce Data to Decide Which Specialties and States to Target for Graduate Medical Education Expansion.

To outline a methodology for allocating graduate medical education (GME) training positions based on data from a workforce projection model. Demand for visits is derived from the Medical Expenditure PanelSurvey and Census data. Physician supply, retirements, and geographic mobility are estimated using concatenated AMA Masterfiles and ABMS certification data. The number and specialization behaviors of residents are derived from the AAMC's GMETrack survey. We show how the methodology could be used to allocate 3,000 new GME slots over 5years-15,000 total positions-by state and specialty to address workforce shortages in 2026. We use the model to identify shortages for 19 types of health care services provided by 35 specialties in 50 states. The new GME slots are allocated to nearly all specialties, but nine states and the District of Columbia do not receive any new positions. This analysis illustrates an objective, evidence-based methodology for allocating GME positions that could be used as the starting point for discussions about GME expansion or redistribution.

Financing Graduate Medical Education to Meet the Needs of Children and the Future Pediatrician Workforce.

The American Academy of Pediatrics (AAP) believes that an appropriately financed graduate medical education (GME) system is critical to ensuring that sufficient numbers of trained pediatricians are available to provide optimal health care to all children. A shortage of pediatric medical subspecialists and pediatric surgical specialists currently exists in the United States, and this shortage is likely to intensify because of the growing numbers of children with chronic health problems and special health care needs. It is equally important to maintain the supply of primary care pediatricians. The AAP, therefore, recommends that children's hospital GME positions funded by the Health Resources and Services Administration be increased to address this escalating demand for pediatric health services. The AAP also recommends that GME funding for pediatric physician training provide full financial support for all years of training necessary to meet program requirements. In addition, all other entities that gain from GME training should participate in its funding in a manner that does not influence curriculum, requirements, or outcomes. Furthermore, the AAP supports funding for training innovations that improve the health of children. Finally, the AAP recommends that all institutional recipients of GME funding allocate these funds directly to the settings where training occurs in a transparent manner.

Transforming Medical Education is the Key to Meeting North Carolina's Physician Workforce Needs.

To meet the needs of the population of North Carolina, an epic transformation is under way in health care. This transformation requires that we find new ways to educate and train physicians and other health care professionals. In this commentary, we propose that the success of the Brody School of Medicine in preparing a primary care physician workforce can serve as a model for meeting the state's future physician workforce needs. Other considerations include increasing graduate medical education positions through state funding and providing incentives for medical students who stay in North Carolina.

In Reply to Rasouli and Willson.

In Reply to Rasouli and Willson.

Is the Physician Shortage Real? Implications for the Recommendations of the Institute of Medicine Committee on the Governance and Financing of Graduate Medical Education.

In July 2014, the Institute of Medicine (IOM) Committee on the Governance and Financing of Graduate Medical Education released its report calling for a major overhaul of the financing of graduate medical education (GME). Several national organizations with an interest in GME faulted the report on the basis that the IOM Committee recommendations would worsen physician shortages. However, this conclusion is based on two questionable assumptions: first, that the nation is already facing a general physician shortage; and second, that the IOM Committee recommendations would make shortages worse. The author argues that although some communities and specialties do face shortages, currently and in the future a general national physician shortage is unlikely. Reasons cited include changes in the delivery system with an increased focus on efficiency and effectiveness; the increased use of interprofessional teams facilitated by the increasing supply of nurse practitioners, physician assistants and other health professionals; and technological advances.The author concludes that the IOM Committee recommendations would support an increase in GME positions in locations and specialties where there is a documented need, in effect removing the current cap on Medicare-funded GME positions. Given the current fiscal environment, the approach recommended by the IOM Committee--steady funding levels but improved targeting to meet documented needs--may be the best strategy for maintaining GME funds and meeting the nation's physician workforce needs.

The Veterans Access, Choice, and Accountability Act of 2014: Examining Graduate Medical Education Enhancement in the Department of Veterans Affairs.

From 2006 to 2011, the Department of Veterans Affairs (VA) introduced the Graduate Medical Education (GME) Enhancement initiative to increase residency positions at VA training sites. VA once again has an opportunity to fund new residency positions through the Veterans Access, Choice, and Accountability Act of 2014 (VACAA). Congressional requirements under VACAA give priority to positions in primary care, mental health, and other specialties that the Secretary of Veterans Affairs deems appropriate. Moreover, facilities meeting the following criteria will be awarded priority for expansion: no prior GME activities, a shortage of physicians, rural locations, areas with a "high concentration of veterans," or located in Health Professional Shortage Areas as defined by the Health Resources and Services Administration. The authors of this Commentary discuss the implications of the new legislation, reviewing the past VA GME Enhancement efforts to examine the potential impact of further expansion of VA GME positions. Understanding the intent of the legislation and its provisions will allow qualified existing and potentially new affiliates to successfully pursue new residency positions during the five-year period of VA GME expansion under VACAA.

Commentaries on health services research

Commentaries on health services research

Aligning expansion of graduate medical education with recent recommendations for reform.

Federal funds support graduate medical education positions, but expansion is needed in urban and rural areas that experience shortages in health professionals. This commentary discusses the need fo...

Addressing the nation's physician workforce needs: The Society of General Internal Medicine (SGIM) recommendations on graduate medical education reform.

The Graduate Medical Education (GME) system in the United States (US) has garnered worldwide respect, graduating over 25,000 new physicians from over 8,000 residency and fellowship programs annually. GME is the portal of entry to medical practice and licensure in the US, and the pathway through which resident physicians develop the competence to practice independently and further develop their career plans. The number and specialty distribution of available GME positions shapes the overall composition of our national workforce; however, GME is failing to provide appropriate programs that support the delivery of our society's system of healthcare. This paper, prepared by the Health Policy Education Subcommittee of the Society of General Internal Medicine (SGIM) and unanimously endorsed by SGIM's Council, outlines a set of recommendations on how to reform the GME system to best prepare a physician workforce that can provide high quality, high value, population-based, and patient-centered health care, aligned with the dynamic needs of our nation's healthcare delivery system. These recommendations include: accurate workforce needs assessment, broadened GME funding sources, increased transparency of the use of GME dollars, and implementation of incentives to increase the accountability of GME-funded programs for the preparation and specialty selection of their program graduates.

Fixing the Primary Care Pipeline: The Role of Teaching Health Centers

Fixing the Primary Care Pipeline: The Role of Teaching Health Centers