NEJM: GME Reform

The IOM recently released a report on Graduate Medical Education (GME) financing that has set the medical training world on fire. It’s long, and it’s complicated, and – to be honest – I don’t feel well versed enough in this yet to comment. So I won’t. That said, Gail Wilensky and Don Berwick have a piece in this week’s NEJM that’s hard to ignore. Especially this part:

After reviewing the relevant literature, the committee reached several important conclusions that helped shape its recommendations: forecasts of future physician shortages are variable and have been historically unreliable; increasing the number of physicians is unlikely to resolve specialty and geographic maldistribution; increasing Medicare funding is not essential for increasing the physician workforce — the number of U.S. residency positions has increased by 17.5% in the past decade, despite a cap on the number of Medicare-funded slots; current programs are producing an increasingly specialized workforce that is insufficiently responsive to local and national needs; and many newly trained physicians lack essential office-based skills.

Each of these sentences is a shot in the heart for those who think GME funding increases are the solution for what ails us. Apparently, the IOM committee determined that turning out more physicians won’t fix geographic shortages. Increasing funding isn’t key since even without funding, hospitals have been turning out more residents in the last 10 years. And those spots are turning out specialists, not primary care docs, and they’re not responsive to the needs of this country.


The committee debated at great length whether it is justifiable to continue government funding for GME, through either Medicare or other sources; current government funding is an estimated $15 billion per year. It noted the lack of similar funding for undergraduate medical education and for other health care professions and nonmedical professions that are also important to society and whose workforce may also fall short of demand.

TIE contributors are poring over the report and other documents. I expect that in the coming weeks, we’ll have more to say. But this NEJM Perspective (along with the IOM report) will likely make a lot of medical educators uncomfortable.


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