Editorial  |   April 2012
The Problem With Graduate Medical Education
Author Affiliations & Notes
  • Stephen C. Shannon, DO, MPH
    Dr Shannon is a member of the Editorial Advisory Board for JAOA—The Journal of the American Osteopathic Association. He has served as the guest editor for the JAOA's annual theme issue on osteopathic medical education since 2006
  • Address correspondence to Stephen C. Shannon, DO, MPH, President, American Association of Colleges of Osteopathic Medicine, 5550 Friendship Blvd, Chevy Chase, MD 20815-7213. E-mail:  
Article Information
Medical Education / Graduate Medical Education
Editorial   |   April 2012
The Problem With Graduate Medical Education
The Journal of the American Osteopathic Association, April 2012, Vol. 112, 166-167. doi:
The Journal of the American Osteopathic Association, April 2012, Vol. 112, 166-167. doi:
The number of graduates of the nation's osteopathic and allopathic medical schools does not determine the number of physicians joining the nation's physician workforce. Although medical school education is a necessary part of training, it is not sufficient. In the end, the nation's graduate medical education (GME) system determines the number of osteopathic physicians (ie, DOs) and allopathic physicians (ie, MDs) eligible to practice medicine. Graduate medical education is the last hurdle a physician must surmount to be licensed as a physician in the United States and to be eligible for specialty certification. 
Currently, the nation's GME positions are filled by graduates from US MD and DO schools and international medical graduates. In the 2010-2011 academic year, there were 111,586 residents in programs accredited by the Accreditation Council for Graduate Medical Education (ACGME), of whom 65.3% were US MD school graduates, 27.3% were international medical school graduates, and 7.2% (8066) were US DO school graduates.1 The proportion of these trainees in ACGME programs has been stable for a number of years even as the overall number of positions has marginally grown. The number of DOs reported in AOA-accredited GME programs has increased by more than 50% since the 2005-2006 academic year. As indicated by DeRosier and Lischka2 in this issue of JAOA—The Journal of the American Osteopathic Association, 6322 DOs were training in osteopathic GME (OGME) programs in the 2010-2011 academic year. (It is important to note, however, that more than 20% of AOA-accredited residency positions are dually accredited by both the AOA and the ACGME. The number of DO trainees being counted twice—by both the AOA and the ACGME—is not currently available.) 
The adequacy of the GME system to meet the supply of trained physicians needed by the US health care system has received increasing scrutiny. The growing population of aging Americans (many with chronic diseases like diabetes mellitus) and the potential of the implementation of the Affordable Care Act to add more than 30 million more individuals to the insured population are 2 of the factors triggering concern.3 While osteopathic and allopathic medical school enrollment has grown substantially in an attempt to address the anticipated shortage of physicians (eg, from 2002 to 2015, DO enrollment is expected to have doubled and the combined enrollment is expected to have increased 35%4), the number of first-year GME positions in AOA and ACGME programs has grown only about 0.9% annually during the past decade.5 
The GME system is constrained from supporting physician workforce growth as a result of the Budget Reconciliation Act of 1997, which imposed a cap on the number of funded GME positions. Coupled with the lack of planning for the number and type of positions needed, many policy makers and workforce researchers are concerned that the nation may face a significant shortage of physicians and a resulting problem with its health care system in the coming decades.6 Calls for reform have come from a number of public7-9 and private10 bodies. In addition, a bipartisan group of US Senators recently asked the Institute of Medicine to “conduct an independent review of the governance and financing of our system of graduate medical education.” The letter stated that the group was interested in “an analysis of the governance and financing of GME and potential GME reforms.” Some specific areas of concern were also listed,11 as follows:
    reimbursement policy
    using GME to better predict and ensure adequate workforce supply by type of provider, specialty, and demographic mix
    distribution of physicians
    role of GME in the current care of the underserved
    impact of changes in GME on access to health care
    use of GME to ensure that the workforce possesses the skill sets needed to effectively address current and future health care needs
The OGME system is taking crucial strides to address the GME shortage as an important aspect of the US physician workforce issue. The article in this issue of the JAOA by Oliver W. Hayes III, DO, and colleagues12 is of particular note in that it provides some context and guidance to individuals and institutions attempting to start residency training programs in hospitals that do not fall under the GME cap. Many of the nation's osteopathic medical schools and Osteopathic Postgraduate Training Institutions have developed OGME programs in association with a variety of institutions and funding mechanisms. For example, OGME programs have successfully pursued the establishment of new primary care training residencies as a part of the Teaching Health Center Program, which was funded on a trial, 5-year basis by Congress as a part of the Affordable Care Act.13 Thirteen of the 23 residency programs funded by this program to date are AOA or dually accredited residency programs.14 The AOA's OGME Development Initiative15 is also providing resources and helping to coordinate OGME expansion efforts. 
Ultimately, the physician supply and the funding mechanism to support the education and training of physicians and other health care professionals is a critical policy dilemma for this country. It is essential that the osteopathic medical profession provide leadership in efforts to improve the medical education system in order to maintain and improve the quality, efficiency, and access to health care and preventive services for our nation. The reports and articles in the 2012 osteopathic medical education issue of the JAOA document the work being done by osteopathic medical educators and policy makers in this regard and provide data benchmarks for the evaluation of our effectiveness in these efforts. 
   Financial Disclosures: None reported.
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