THE

COMMONWEALTH

FUND

REPORT OF THE TASK FORCE
ON ACADEMIC HEALTH CENTERS

GRADUATE
MEDICAL

EDUCATION

PROGRAMS
IN THE

UNITED STATES

ACKNOWLEDGEMENTS

This report was commissioned by The Commonwealth Fund Task Force on Academic Health Centers and is one in a series of Task Force reports on issues facing academic health centers. The report was prepared under the direction of a committee of the Task Force chaired by Merlin K. DuVal, M.D. Other menibers included David R. Challoner, M.D.; Arthur J. Donovan, M.D.; Clifton R. Gaus, Sc.D., and Katherine W. Vestal, R.N., Ph.D.

The Task Force acknowledges the assistance and consultation of Steven A. Schroeder, M.D.; Barbara Gerbert, Ph.D., and staff at The Institute for Health Policy Studies, University of California, San Francisco, in the research used in preparation of this report.

Special thanks are also extended to Barbara Culliton and Wallace Waterfall for their expert and skillful writing and editing assistance.

In all cases, the statements made and the views expressed are those of The Commonwealth Fund Task Force on Academic Health Centers and do not necessarily entirely reflect those of individual Task Force members, The Commonwealth Fund, Dr. Schroeder or The Institute for Health Policy Studies.

High costs, high technology and high expectations have created pressures to change and restructure the American health care system.

The Commonwealth Fund Task Force on Academic Health Centers was formed to help the nation's leading medical institutions find ways to accomplish the changes needed in these times of rising costs; declining public support for medical services, education and research, and a growing supply of medical personnel and facilities. As part of its effort, the Task Force is issuing reports that examine the effects of public policy decisions on the performance of academic health centers.

An academic health center consists of a medical school and a teaching hospital as its main components and may also include schools of nursing. dentistry and other health professions. The teaching hospital is the principal site of graduate medical education.

Medical education in the United States today begins in medical school and continues intensively for as many as eight years of graduate medical training. In medical school, future physicians study the basic biologie seiences and have their first contact with patients. But not until the new M.D.s enter a program of graduate medical education, a "residency," is their training for the care of patients fully under way.

Most states require one year of graduate medical education (the year that formerly was called an internship but now is part of the residency) before licensing a physician. The medical profession regards three years of graduate (residency) training as the minimum needed to practice medicine.

The physician in graduate medical education not only learns the skills needed by a practitioner; but also takes care of patients, serves as an instructor for medical students and conducts clinical research. These multi

ple functions of the education process are indispensible to quality health care in this country. However, now they are threatened from both outside and within the system.

Externally, a widespread and growing concern over the cost of health care has attracted unprecedented scrutiny of graduate medical education. Internally, fraginented organizational influences have diffused controls of the education process to a point that the functions of such education can be preserved only by decisive action.

The cost of graduate medical education is quite small in comparison with total health care expenditures-hardly two percent. In the present national mood of economy, however, every component of health care costs is subject to close examination, and the training of new physicians is no exception.

The problem of funding graduate medical education offers an opportunity to correct the problem of its disjointed organizational structure. The creation of a successful funding mechanism should force the various auspices under which the education is conducted to realign themselves and assume appropriate shares of responsibility for the enterprise.

This Task Force report views the size, content and cost of graduate medical education. The report presents principles, policy options and recommendations that the Task Force believes can set a direction for constructive and significant change in the academic health center. Among the questions facing medical educators and public policymakers are whether

we are training too many or too few doctors for the services most needed, such as primary care. The Task Force makes these suggestions consonant with its view that graduate medical education is a national resource that must be supported by all payers for health care.

It suggests that limits be set on numbers of residencies or length of training. It recommends that formal connections be established between the organizations that have decision-making powers over residencies and the hospitals who, with revenues from patient care, support residency training. It recommends that training be broadened to include more exposure to ambulatory outpatients. And it recommends a voucher system for more equitable distribution of funds for graduate medical education.