Value, Social Contracts, and Medical Education
Authors: Catherine R. Lucey, Robert M. Golub
Journal: JAMA (2014)

In July 2014, the Institute of Medicine released a report recommendingasubstantial redesignof federal funding forgraduate medical education (GME), suggesting that the public deserves better stewardship of the $20 billion it contributes annually to the education of physicians in the United States.1 While in absolute dollars this contribution is significant and vitally important to the institutions that sponsor residencyprograms, in relative terms this amount represents less than 1% of the total annualUShealth care expenditures. Thus, the IOM recommendations suggest a new fundingmodel for GME not as a strategy to decrease overall health care expenditures but as an opportunity to increase the value of medical education to the public. The report details concerns that, to date, federal and state investment in residency training has not produced the right types of physicians (too few primary care physicians), in the right areas of the country (too few inWest andMidwest rural areas, too many in the urban East), and with the right set of skills (insufficient attention toquality, safety, cost, patient centeredness, teamwork, ambulatory practice, chronic disease management, and patient experience). The report proposes a newmodel of federal funding that increases accountability for the only relevant return on taxpayer investment in medical education: achieving the triple aimof improved individual experience of care, improved health of populations, and reduced per capita costs of health care.2 In part, the IOM proposal, which would require substantial legislative changes to implement, calls for the establishment of a GME transformation fund to support educational innovations designed to accelerate thedevelopment of the ideal 21st-centuryhealth care workforce.Therecommendations fromtheIOMhavebeencontroversial and have been endorsed by few professional societies, but they should be discussed and debated. Whether implementation is possible at a time of great change in theUS health care system is uncertain. This Medical Education theme issue of JAMA brings together a series of articles that advance current understanding of the effect of innovations in and interventions directed toward medical education on the ability to achieve safe, highquality, evidence-based, high-value, patient-centered care for all. In aggregate, these studies illustrate the complexity of the challengeoutlined in the IOMreport andprovide insights into future directions that medical education might take to fulfill the profession’s social contract. Two articles in this issue of JAMA assess the association of residency trainingwith costs of care. Inone report, Pitts and colleagues3 conducted a cross-sectional studyof resourceutilization in emergency department visits managed by attending physicians supervising residents (n = 3374 visits) comparedwith attendingphysicians alone (n = 25 808visits). The intentof thestudywastoexplore theassumptionthat the training of residents increases resource utilization. Controlling for patient and institutional variables known to increase resource utilization, supervised visits were significantly associatedwithmorefrequenthospitaladmission(21%vs14%;odds ratio [OR], 1.42; 95%CI, 1.09-1.85) andadvanced imaging (28% vs 21%;OR, 1.27; 95%CI, 1.06-1.51) anda longer emergencydepartment stay (median, 226 vs 153minutes; adjusted geometricmean ratio, 1.32; 95%CI, 1.19-1.45), but notwith blood testing (53% vs 45%; OR, 1.18; 95% CI, 0.96-1.46). Moreover, in secondary analyses the differences seemed to be primarily drivenbyminor teaching institutions (definedas residentsparticipating in ≤50%of the visits). One hypothesis that could be generated from the findings reported by Pitts et al is that the practice patterns of attending physicians change when residents are present and that future educational interventions should teach attending physicians how to supervise residents while modeling a focus on cost-conscious care. The importance of ensuring that attendingphysicians are prepared to model the type of medical practices that will achieve the triple aim is evident in the study by Chen and colleagues.4 This study adds to an emerging literature demonstrating that the environment in which residents train can have an enduring effect on their ability to practice safe, highquality, and cost-conscious care.5,6 The study analyzed data on 2851 physicians providing care to 491 948 Medicare beneficiaries in 2011. It identified a positive association between health care expenditure rates in the region in which a family medicine or internal medicine residency program was situated and the expenditures associated with the care provided by their program graduates. For example, among physicians practicing in high-spending regions, the mean spending per beneficiary per year for those who trained in high-spending regions exceeded those who trained in low-spending regions by $1926. An important additional finding is that this associationwanedwith greater years in practice, and differences became nonsignificant after 16 to 19 years. These 2 articles lend credence to the recent strategyof the Accreditation Council for Graduate Medical Education (ACGME) to evaluate the learning environment as part of the GMEaccreditationprocessandsuggest thatan institution’sability to deliver high-value, cost-conscious care be added to the list of key indicators of institutional readiness for quality residency education.7 Achieving this ideal environment will require educational interventionsdirected towardnotonlyGME traineesbut also the faculty andpracticingphysicianswhosupervise andmentor residents and fellows. Institutions that sponsor residency and fellowship training programs must fulfill the obligation to society for the education of physicians to be conducted in an environment that minimizes risk to patients. Although GME training programs have enthusiastically embraced the need to change their curricula and explicitly teach their residents how to contribute to a culture that strives to eliminate preventable medical error, implementation of duty hours reform to address the assumption that resident fatigue contributes to Editorial Opinion