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    Editorial | Graduate medical education at the crossroads


    Dr. Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South Florida, Tampa. He can be reached at [email protected]




    If we want to ensure that future generations of medical students have access to first-rate ob/gyn training, we need to join the growing debate over graduate medical education (GME) funding.

    If you are like me, you had no idea who provided the money to pay your salary as a resident. I just assumed it was my hospital. But the federal government spends more than $15 billion per year on residency and fellowship training, and many are asking why physicians deserve this special largesse denied other professionals.

    A recent Institute of Medicine (IOM) report called for a complete restructuring of federal GME payments to achieve greater transparency and accountability in meeting the nation’s physician workforce needs.1 Critics contend that adopting the IOM recommendations would lead to major cuts in GME funding, threatening the world’s best training programs and jeopardizing patient care.2

    What are the issues behind this debate—and should we be concerned about the viability of future ob/gyn training? 

    Federal support for GME

    Hospitals with accredited GME programs receive $6.8 billion in indirect medical education (IME) and $2.8 billion in direct graduate medical education (DGME) funding from Medicare.1 The former is doled out to hospitals as part of their Medicare prospective payment system remuneration using a complex formula derived from outdated 1980s cost data and designed to cover debatable “indirect” expenses accruing from resident training.

    In contrast, DGME funds are used to directly support the salaries and benefits of residents, program directors, and select faculty. Both IME and DGME payments are dependent on a hospital’s volume of Medicare inpatients, disadvantaging programs with large pediatric, obstetric, and non-elderly adult populations.

    Most states also provide Medicaid GME, matched by the federal government, totaling about $4 billion. The Veterans Health Administration (VA) and the Health Resources and Services Administration (HRSA) supply an additional $1.44 billion and $464 million, respectively, in GME funds. The VA keeps its IME payments and provides DGME funds to affiliated academic GME sponsors, while HRSA funds are used to support children’s hospital residency programs, primary care loan repayment programs, and, more recently, community-based family medicine training programs.

    However, both VA and HRSA funds depend on politically unreliable Congressional discretionary appropriations, rather than Medicare’s mandatory appropriations. The Department of Defense sponsors 200 GME programs with 3200 trainees, but the exact costs of these programs are not available.

    In addition, an unknown level of support is provided by hospitals, physician groups, philanthropy, and even industry, but the preponderance of financial support for GME comes from the federal government.

    Read: Academic medicine: A bubble about to burst?


    Charles J. Lockwood, MD, MHCM
    Dr. Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South ...


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