paperwork for discharges. The effect of this on the education process was recently described in the case of a fairly healthy patient needing a subtotal thyroidectomy (Rabkin, 1984). Not so long ago, the patient would have been admitted to the hospital the day before surgery and would stay several days afterwards. Residents could evaluate the patient before surgery, review the relevant anatomy, physiology and pathology, and then follow the patient's surgery and postoperative course. Traditional hospitalcentered education precludes resident contacts with patients at home, either before or after surgery. Today, the resident's first contact may be in the surgical suite, and the patient may be discharged the following morning, leaving very little time for the resident to appreciate the natural history of the disease, the recovery process and the effect of medical and surgical treatments. Life-supporting Technologies. The ability of well-equipped and welltrained physicians to sustain life in today's hospital settings is widely attested. Nowhere is this ability more evident than in the academic health center hospital, which can bring together the variety of disciplines and state-of-the-art equipment necessary for the task. But these advantages threaten to turn teaching hospitals into overlarge intensive care units, offering excellent experience in care of the very sickest patients, but unbalancing the education of the resident, who is deprived of experience with more customary diagnostic and therapeutic procedures. More Specialized Care. The high-technology expertise in the example above also is perturbing to graduate medical education in another way; it is self-perpetuating as a market strategy. Competing against nearby conuunity hospitals, the teaching hospital offers services that the community hospital cannot. And those services largely involve very specialized care. As a result, residents can be overexposed to patients with problems seldom seen in the usual medical practice. Missing the Action. Hospital residents once were in a position to participate in the full range of diagnoses and pharmacotherapies, because the great majority occurred in the hospital. Today, much in the way of diagnostic imaging, biochemical testing and drug therapy for cardiac dysfunction, metabolic abnormalities and infectious disease is available in ambulatory clinics. Only the more seriously ill patients or those in the end stages of severe chronic disease may be admitted to a hospital and come to the attention of the residents. Even then, the decisions about care may already have been made outside the hospital. And yet, current estimates are that only 10-15 percent of the internal medicine resident's time, and only 20 percent of the pediatric resident's, is spent in out-of-hospital care.* The Issue of High-level commissions, professional associations and knowledgeable educators have predicted that by the year 1990 the ratio of medical specialists to generalists will be out of the proportions needed. (Physicians of the Future, 1976; Gaduate Medical Education National Advisory Committee, 1980; Association of American Medical Colleges. 1981; Petersdorf, 1983.) Although some observers may quarrel about the specific estimates of oversupply in each specialty, few dispute that the predictions have caught the trend. *These estimates do not include federally-supported programs that have more ambulatory care experience. However, in 1984 those progranis accounted for only four percent of afl internal medicine residencies and 12 percent of pediatric residencies. (Primary Care Graduate Medica! Education Branch, 1984). Academic health centers have not faced this problem directly and continue to develop training programs according to service needs, specialty slots and research activities. Aside from small, federally-supported residency programs with a primary care emphasis that exist in some academic health centers, family practice training at the centers is uncommon. Most medical schools sponsor family practice residencies, but the slots are largely in affiliated hospitals, many of them rural. Widespread acknowledgement that specialties are moving into oversupply has not prevented increasing specialization over the past five years. Before this increase is halted, some powerful social, economic and academic forces will have to be dealt with: • Rapid advances in knowledge and its application attract physicians to ever-narrower subspecialities. Physician use of technology-intensive methods of diagnosis and therapy is more financially rewarding than methods of practice employed in primary care. Hospitals gain a market advantage by having specialty services for patient care, abetted by residents in training. • Academic prestige accrues more plentifully to faculty in specialist rather than generalist education. Neither teaching methods nor financial compensation have been developed adequately for graduate medical education in an ambulatory setting that might encourage more primary care training. PRINCIPLES FOR THE FUTURE OF GME The entire health care enterprise is undergoing a change, largely because of increasing costs. As a consequence, each part of the enterprise is being examined anew and none more thoroughly than graduate medical education. Academic health centers, and particularly their teaching hospitals, must work with government, business and industry to come to a better understanding of what teaching hospitals produce. This Task Force report was commissioned to provide a sound basis for fashioning policies that will lead graduate medical education through these times of change to a stable future. This examination has convinced the Task Force that (1) benefits of graduate medical education to society are plentiful and substantial, (2) the costs of such education are relatively small, (3) problems with graduate medical education are related less to cost than to program content, specialty distribution and program control, and (4) emerging economic forces will adjust the future supply of trained physicians that graduate education produces. The Task Force urges that both in the public and private sectors the shapers of policy, who will be considering revisions in the structure and funding of graduate medical education, preserve the benefits of the education, remove its outdated features and ensure that its cost is reasonable. The following four principles can serve as a framework for the public debate and a basis for the Task Force's subsequent descriptions of policy options and recommendations. Principle #1: Support for graduate medical education care by all payers. Graduate medical education benefits our society by ensuring the availability of quality practitioners in whatever numbers are needed. Its support is both a sound investment on the part of society and, when provided by all payers for health care, is consistent with other enterprises in which apprentice training is part of the price to consumers. In health care, the consumers largely are represented by third-party payers-Medicare, Medicaid, Blue Cross, commercial insurers and self-insured businesses. These, then. should also be the payers for graduate medical education; for any one of them to reject participation in its support not only would be unfair, but also would be detrimental to the future quality of medical care in the United States. Graduate medical education is vulnerable to shifts in financial support. because so much of the training is concentrated in so few hospitals. Some 7,000 hospitals of all kinds exist in this country, but nearly half of all graduate physicians are trained in only 100 of them the major teaching hospitals. These hospitals also provide a wealth of special services to patients. serve as the acute care resource for entire regions, and foster the clinical research that ensures continual improvement in care. To jeopardize their support would be against the public interest. Principle #2: Financial support for graduate medical edu- |