Proposed Performance-Based Metrics for the Future Funding of Graduate Medical Education: Starting the Conversation.

Graduate medical education (GME) in the United States is financed by contributions from both federal and state entities that total over $15 billion annually. Within institutions, these funds are distributed with limited transparency to achieve ill-defined outcomes. To address this, the Institute of Medicine convened a committee on the governance and financing of GME to recommend finance reform that would promote a physician training system that meets society's current and future needs. The resulting report provided several recommendations regarding the oversight and mechanisms of GME funding, including implementation of performance-based GME payments, but did not provide specific details about the content and development of metrics for these payments. To initiate a national conversation about performance-based GME funding, the authors asked: What should GME be held accountable for in exchange for public funding? In answer to this question, the authors propose 17 potential performance-based metrics for GME funding that could inform future funding decisions. Eight of the metrics are described as exemplars to add context and to help readers obtain a deeper understanding of the inherent complexities of performance-based GME funding. The authors also describe considerations and precautions for metric implementation.

US Internal Medicine Program Director Perceptions of Alignment of Graduate Medical Education and Institutional Resources for Engaging Residents in Quality and Safety.

Alignment between institutions and graduate medical education (GME) regarding quality and safety initiatives (QI) has not been measured. The objective was to determine US internal medicine residency program directors' (IM PDs) perceived resourcing for QI and alignment between GME and their institutions. A national survey of IM PDs was conducted in the Fall of 2013. Multivariable linear regression was used to test association between a novel Integration Score (IS) measuring alignment between GME and the institution via PD perceptions. The response rate was 72.6% (265/365). According to PDs, residents were highly engaged in QI (82%), but adequate funding (14%) and support personnel (37% to 61%) were lower. Higher IS correlated to reports of funding for QI (76.3% vs 54.5%, P = .012), QI personnel (67.3% vs 41.1%, P < .001), research experts (70.5% vs 50.0%, P < .001), and computer experts (69.0% vs 45.8%, P < .001) for QI assistance. Apparent mismatch between GME and institutional resources exists, and the IS may be useful in measuring GME-institutional leadership alignment in QI.

Financing U.S. Graduate Medical Education: A Policy Position Paper of the Alliance for Academic Internal Medicine and the American College of Physicians.

In this position paper, the Alliance for Academic Internal Medicine and the American College of Physicians examine the state of graduate medical education (GME) financing in the United States and recent proposals to reform GME funding. They make a series of recommendations to reform the current funding system to better align GME with the needs of the nation's health care workforce. These recommendations include using Medicare GME funds to meet policy goals and to ensure an adequate supply of physicians, a proper specialty mix, and appropriate training sites; spreading the costs of financing GME across the health care system; evaluating the true cost of training a resident and establishing a single per-resident amount; increasing transparency and innovation; and ensuring that primary care residents receive training in well-functioning ambulatory settings that are financially supported for their training roles.

What Are We Telling Our Students? A National Survey of Clerkship Directors' Advice for Students Applying to Internal Medicine Residency.

BACKGROUND: Little is known about the advice fourth-year medical students receive from their advisors as they prepare to apply for residency training. OBJECTIVE: We collected information on recommendations given to medical students preparing to apply to internal medicine residencies regarding fourth-year schedules and application strategies. METHODS: Clerkship Directors in Internal Medicine conducted its annual member survey in June 2013. We analyzed responses on student advising using descriptive and comparative statistics, and free-text responses using content analysis. RESULTS: Of 124 members, 94 (76%) responded, and 83 (88%) advised fourth-year medical students. Nearly half (45%) advised an average of more than 20 students a year. Advisors encouraged students to take a medicine subinternship (Likert scale mean 4.84 [1, strongly discourage, to 5, strongly encourage], SD = 0.61); a critical care rotation (4.38, SD = 0.79); and a medicine specialty clinical rotation (4.01, SD = 0.80). Advisors reported they thought fourth-year students should spend a mean of 6.5 months doing clinical rotations (range 1-10, SD = 1.91). They recommended highest academic quartile students apply to a median of 10 programs (range 1-30) and lowest quartile students apply to 15 programs (range 3-100). Top recommendations involved maximizing student competitiveness, valuing program fit over reputation, and recognizing key decision points in the application process. CONCLUSIONS: Undergraduate medical advisors recommended specific strategies to enhance students' competitiveness in the Match and to prepare them for residency. The results can inform program directors and encourage dialogue between undergraduate medical education and graduate medical education on how to best utilize the fourth year.

Ambulatory training for primary care general internists: innovation with the affordable care act in mind.

BACKGROUND: Although primary care general internists (PCGIs) are essential to the physician workforce and the success of the Affordable Care Act, they are becoming an endangered species. OBJECTIVE: We describe an expanded program to educate PCGIs to meet the needs of a reformed health care system and detail the competencies PCGIs will need for their roles in team-based care. INTERVENTION: We recommended 5 initiatives to stabilize and expand the PCGI workforce: (1) caring for a defined patient population, (2) leading and serving as members of multidisciplinary health care teams, (3) participating in a medical neighborhood, (4) improving capacity for serving complex patients in group practices and accountable care organizations, and (5) finding an academic role for PCGIs, including clinical, population health, and health services research. A revamped approach to PCGI education based in teaching health centers formed by community health center and academic medical center partnerships would facilitate these curricular innovations. ANTICIPATED OUTCOMES: New approaches to primary care education would include multispecialty group practices facilitated by electronic consultation and clinical decision-support systems provided by the academic medical center partner. Multiprofessional and multidisciplinary education would prepare PCGI trainees with relevant skills for 21st century practice. The centers would also serve as sites for state and federal Medicaid graduate medical education (GME) expansion funding, making this funding more accountable to national health workforce priorities. CONCLUSIONS: The proposed innovative approach to PCGI training would provide an innovative educational environment, enhance general internist recruitment, provide team-based care for underserved patients, and ensure accountability of GME funds.

Threats to graduate medical education funding and the need for a rational approach: a statement from the alliance for academic internal medicine.

With the current focus on reducing the federal budget deficit, funding for graduate medical education (GME) has come under scrutiny, particularly those monies labeled as indirect medical education payments; these are intended to cover ill-defined costs inherent to training programs, such as increased lengths of stay, additional testing, and patients with more complex conditions. Although there are cogent arguments that indirect medical education expenses have decreased over the past 25 years, there is also a reasonable expectation that direct medical education expenses, such as those related to resident salaries, faculty involvement, administration of programs, and overhead costs, have increased. Our current system of GME financing is complex and cumbersome and relies almost exclusively on government support. This article examines the adequacy of current funding, focusing on the economics of the entire system rather than individual hospitals, states, or regions. It also recommends reexamining GME financing and considering options that ensure appropriate levels of government support and participation of other health care insurers to adequately fund GME.