Graduate Medical Education in USA

Li-Cheng Xu, M.D., Ph.D.
Diplomate of the American Board of Internal Medicine,
Fellow of Oncology/Hematology,
Memorial Sloan-Kettering Cancer Center,
New York, NY 10021

Historical Aspects of Graduate Medical Education in the United States

History of medical specialism dated back to post World War II era when specialists were in great demand as the army planned for the treatment of several hundred thousand battle casualties who were returned to the United States at the end of the War.  In order to ensure high-quality medical care for soldiers, many recently discharged medical officers took advantage of the G.I. Bill to be trained in specialty and subspecialty medicine.  However, a rapid advance in medical specialism in the United States occurred as a result of the introduction of Medicare in 1965.  With its liberal funding for graduate medical education, many academic medical centers were rewarded to produce more physicians including specialties/subspecialties.  After 30 years of supporting graduate medical education through open-ended payment policies, the federal government recently curtailed Medicare's generous commitment to subsidize the training of new doctors with provisions contained in the Balanced Budget Act of 1997, a measure designed to erase the federal deficit by 2002.

In the United States, the federal government is the largest single explicit financing source for graduate medical education.  Of the federal programs and agencies that support graduate medical education (Medicare, Medicaid, and the Departments of Defense and Veteran Affairs), Medicare is by far the largest single source of such funds.  Over the past decade, the Reagan, Bush, and Clinton administrations all proposed reducing these educational payments.  Until 1995, however, key congressional committees chaired by legislators who championed the interests of large teaching hospitals repeatedly thwarted those efforts.  In 1995, with newly elected Republican majorities in control of the House and Senate, Congress enacted legislation that would have reduced Medicare's total spending by $270 billion and Medicaid's by $182 billion over seven years, while cutting taxes by $245 billion.  President Clinton vetoed that measure, asserting that the budget cuts were too draconian and that the tax cuts favored the wealthy.

The 1997 budget law altered the formulas by which Medicare subsidizes graduate medical education.  The program recognizes the costs of education in two ways: it provides direct medical-education payments to hospitals that cover a share of residents' stipends, faculty salaries, administrative expenses, and institutional overhead allocated to residency programs; and it provides an indirect medical-education adjustment that reflects the added patient care costs associated with the operation of teaching programs.  Medicare's direct payments for graduate medical education are based on hospital-specific, per-resident amounts that are determined by adjusting audited 1984 costs for inflation.  Medicare pays a portion of this amount that is equal to the proportion of a hospital's inpatient days that is accounted for by Medicare beneficiaries.  Medicare's direct payments for graduate medical education totaled $2.2 billion in fiscal 1997 --47 percent more than in 1990.  The reduction in direct payments over five years is slated to total $700 million.

Medicare's indirect medical-education adjustment is based on the number of full-time-equivalent residents who are being trained in the inpatient and outpatient departments of a teaching hospital.  Generally, the more residents there are, the greater the payments to a hospital will be.  Such payments to teaching hospitals totaled $4.6 billion in 1997 -- 84 percent more than in 1990.  Congress sliced $5.6 billion off Medicare's indirect teaching payments over the next five years by changing the formula to make the payments less generous.  For the first time, Congress imposed a cap on the number of residents the program will support by its direct and indirect teaching payments.  The key factor driving Medicare's educational payments upward was a national increase of 26.4 percent in the number of residents in training between 1989 and 1996 (from 82,789 to 104,609).

Structure and Accreditation of Graduate Medical Education in the United States

The American Graduate Medical Education is highly organized and regulated.  There are a number of specialty boards serving the function of defining qualifications and issuing credentials to assure the public of the specialist's preparation and skill.  Over the past 72 years, 24 such boards have been approved and now issue 31 different types of general specialty certificates and 57 types of subspecialty credentials.  For 50 years, the American Board of Medical Specialties has encouraged a system of recertification to demonstrate that the certified specialist has maintained skill and has incorporated the new knowledge associated with advancing medical science.  Presently, 17 of the 24 boards are committed to time-limited certificates requiring recertification every seven to ten years, and others are currently planning such a process.  New methods of performance assessment are being used for recertification processes.  In addition to recertification, the other major change in specialty credentialing is the number of subspecialty certificates sought and authorized.  The numbers have increased dramatically during the past 20 years and reflect the advances in science as well as new styles of practice.

Member Boards of the American Board of Medical Specialties (Subspecialties not listed) are listed as follows:

American Board of Allergy and Immunology
American Board of Anesthesiology
American Board of Colon and Rectal Surgery
American Board of Dermatology
American Board of Emergency Medicine
American Board of Family Practice
American Board of Internal Medicine
American Board of Medical Genetics
American Board of Neurological Surgery
American Board of Nuclear Medicine
American Board of Obstetrics and Gynecology
American Board of Ophthalmology
American Board of Orthopaedic Surgery
American Board of Otolaryngology
American Board of Pathology
American Board of Pediatrics
American Board of Physical Medicine and Rehabilitation
American Board of Plastic Surgery
American Board of Preventive medicine
American Board of psychiatry and neurology
American Board of Radiology
American Board of Surgery
American Board of Thoracic Surgery
American Board of Urology

The American Board of Internal Medicine (ABIM) was established in 1936.  Certification by the ABIM recognizes excellence in the discipline of internal medicine, its subspecialties, and areas of added qualifications.  In addition to the primary certificate in internal medicine, the Board offers subspecialty certificates and certificates of added qualifications.  Subcertificates are offered in cardiovascular disease; endocrinology, diabetes and metabolism; gastroenterology; hematology; infectious disease; medical oncology; nephrology; pulmonary disease; and rheumatology.  The certificates of added qualifications recognize special expertise in areas that have a fundamental practice-oriented relationship to an underlying discipline, and are offered currently adolescent medicine, clinical cardiac electrophysiology, critical care medicine, clinical and laboratory immunology, geriatric medicine, sports medicine and interventional cardiology.  Training requirements for each subspecialty varies between 2-3 years.

There are almost 7600 programs accredited by the Accreditation Council for Graduate Medical Education (ACGME).  The ACGME is jointly sponsored by the American Board of Medical Specialties, the American Hospital Association, the American Medical Association, the Association of American Medical Colleges, and the Council of Medical Specialty Societies.  Each sponsoring organization appoints four representatives.  The federal government names a representative to serve in a nonvoting capacity and the ACGME chooses two public representatives.  There is also a resident representative, and the chair of the Residency Review Committee Council sits as a nonvoting representative.

The mission of the ACGME is to improve the quality of health in the United States by ensuring and improving the quality of graduate medical education experience for physicians in training.  The ACGME establishes national standards for graduate medical education by which it approves and continually assesses educational programs under its aegis.  It uses the most effective methods available to evaluate the quality of graduate medical education programs.  It strives to develop evaluation methods and processes that are valid, fair, open, and ethical.

In carrying out these activities the ACGME is responsive to change and innovation in education and current practice, promotes the use effective measurement tools to assess resident/fellow physician competency, and encourages educational improvement.  As part of this response, the ACGME recently established the Institutional Review Committee (IRC), which is composed of ten members who are appointed by the Chair of the ACGME in conjunction with the Executive Committee.  This committee reviews institutions sponsoring training programs in graduate medical education for compliance with the Institutional Requirements.

Under the aegis of the ACGME, the accreditation of graduate medical education programs is carried out by review committees with delegated accreditation authority.  An IRC consists of representatives appointed by the American Medical Association, the appropriate specialty board, and, in some cases, a national specialty organization.

Graduate medical education programs are accredited when they are judged to be in substantial compliance with the Essentials of Accredited Residencies in Graduate Medical Education.  The essentials consist of
(a) the Institutional Requirement, which are prepared by the ACGME, approved by its sponsoring organizations, and apply to all programs, and
(b) the Program Requirements, which are prepared by a review committee for its area(s) of competence and approved by the ACGME.

The accreditation review process is set in motion in one of two ways, depending upon whether the program under consideration is seeking initial accreditation, reaccreditation, or continued accreditation.  The review committee reviews the program information detail, evaluates the program, and determines the degree to which it meets the published educational standards (Essentials).  The review committee decides upon an accreditation status for the program and identifies areas of noncompliance with the Essentials.  A review committee may grant full accreditation if
(a) When programs holding provisional accreditation have demonstrated, in accordance with ACGME procedures, that they are functioning on a stable basis in substantial compliance with the Essentials.
(b) When programs holding full accreditation have demonstrated upon review, that they continue to be in substantial compliance with the essentials; and
(c) When programs holding probationary accreditation have demonstrated, upon review, that they are in substantial compliance with the Essentials.

Pros and Cons of the American Graduate Medical Education

It is widely recognized that quality of the American health care is one of the finest in the world.  It is a highly standardized and organized complex health care system.  Rapid advance in medical technology has brought a new era of medicine with more options for the public.  The American Graduate Medical Education has flourished since 1990s with dramatic increase in specialty and subspecialty care.  The public can take advantage of highly specialized care and enjoy benefits of most advanced medical technologies.  However, it has been concerned that consequence of subspecialty proliferation may lead to

(a) fragmentation of medical care,
(b) relative lack of primary care physicians,
(c) uneven geographical distribution of physicians as evidenced by shortage of physicians with fewer subspecialists in underserved areas and
(d) make the costs of health care less affordable/unaffordable for general public.

Recently, the major academic medical centers throughout the country have faced challenges from development of managed care systems.  In return for continued support from federal government, the academic medical centers are mandated to deal with inefficiencies and control their excessive costs.  They will have to minimize the cost of their most complex and specialized care without sacrificing quality.  They must train more primary care physicians and fewer specialists.  There has been more attention to how to use diagnostic tests appropriately, more focus on cost-conscious decision making, more training of generalist physicians in "specialty" medicine.

In summary, the history of the American Graduate Medical Education has proved that investment into health care and medical education is a very complex, long-term process, which requires a close coordination between professional societies, governmental agencies and law makers.  Relationship between demand and supply of medical care professionals including specialists/subspecialists should be constantly evaluated.  Highly structured programs in the graduate medical education can facilitate the training of high-quality health care professionals in a more efficient manner.

Ginzberg E   The shift to specialism in medicine: the U.S. Army in World War II. Acad Med 74: 522-5, 1999

Wilson FC,  Graduate medical education in the United States.  Clin Orthop  306:103-9,  1994

Langsley DG   Medical specialty credentialing in theUnited States.  Clin Orthop 257: 22-8, 1990

Hochbaum SR  The evolution of a medical specialty. Mich Hosp 24: 7, 9-10, 1988

Stevens RA Graduate medical education: a continuing history.   J Med Educ 53: 1-18, 1978

Holden WD   Specialty Board certification as a measure of professional competence. JAMA 213: 1016-8, 1970

1999-2000 Graduate Medical Education Directory  84th edition, by the American Medical Association.

Iglehart JK Health Policy Report -Medicare and graduate medical education. N. Eng. J. Med. 338: 402,1998