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Measuring Graduate Medical Education Outcomes: Q&A with Dr. Candice Chen

This month, Academic Medicine published the Macy-funded study “Toward Graduate Medical Education Accountability: Measuring the Outcomes of GME Institutions.” We interviewed lead author Candice Chen, MD, MPH about her research.

Your recent study concludes that medical institutions are still not producing enough primary care doctors or doctors who practice in rural parts of the U.S.  What does your analysis tell us that we don’t already know?
We looked at the overall percentage of people that went into primary care and rural care over three years. Those numbers were shockingly low. Just 25.2 percent of graduates went into primary care. Our primary care workforce is at about 32-33 percent right now and the Council on Graduate Medical Education says it needs to be at 40 percent to meet the country’s health care needs, so that’s a huge gap.

Our study also found that just 4.8 percent of graduates are going into rural areas, whereas the current workforce is at 10 percent and 20 percent of the US population lives in rural areas.

When you see those numbers, it makes it very clear that we are facing a big problem: our GME system is not even going to help us maintain the current workforce.

What do you think makes the top producers of rural and primary care practitioners so effective?  What could other institutions learn from them?

It’s mission. Typically, the mission of these top programs is to produce primary care doctors or produce doctors for underserved areas. Once they make it part of their mission, they can develop pipeline programs, design mission-driven experiences that give trainees the skills and drive to practice in these settings, and recruit students from rural areas who are more likely to return to those communities to work. It’s the hard fight right now but these programs have decided to do it and have shaped their programs to do it.

Just the existence of a family medicine program can influence the number of graduates that practice primary care. But the way the current GME system is set up it doesn’t incentivize new family medicine programs. Payment systems are changing – with ACOs, shared savings and so on. GME has to match that change if we are going to maximize our efforts and get the outcomes that we want.

The bottom producers of primary care practitioners, according to the study, are some of the most prestigious health care institutions in the country.  Should these institutions be worried that they aren’t meeting a primary care mission?
If our workforce was perfect in meeting the country’s health care needs, I would say these institutions could and should continue what they do. But we have shortages. Absolutely specialists are needed—I don’t want Hopkins and Harvard to stop producing some of the best researchers and specialists in the country. But if those doctors go back to Baltimore and Boston and ignore the health problems in their communities, they are doing a disservice to America. If these institutions made the decision to produce the best primary care doctors, I believe they could do it, and they have the resources to do it. We have to be good at doing what we do and at responding to the health and workforce needs of our communities.

With Medicare GME targeted for cuts and assessed for accountability, what it the biggest take-away for policymakers based on these findings?
Our study shows that measuring workforce outcomes is possible. We can look program by program and develop an accountability system that is focused on outcomes. When you look at our findings—the outcomes and how programs are so different—you can see that accountability is long overdue.

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