Changes and Challenges in Rural Graduate Medical Education: The Family Medicine Spokane Rural Training Track Experience in Colville, Wash.

Rural community-based graduate medical education programs in family practice are considered wise investments in America's future because they generate highly trained physicians who typically settle and practice in rural communities. In recent years, however, federal funding cutbacks and revised accreditation requirements have threatened the viability of these programs. In Colville, Wash., Mount Carmel Hospital has responded by agreeing to continue its collaboration with the Northeast Washington Medical Group to fully fund the cost of the Family Medicine Spokane Rural Training Track family practice residency program.     

Nutrition Academic Award: nutrition education in graduate medical education

The Nutrition Academic Award received by Tufts University School of Medicine strengthened our first-year Nutrition and Medicine course and clearly resulted in more nutrition in third-year clerkships and residency programs. Standardized patient cases in nutrition counseling for cardiovascular disease and weight loss were developed and incorporated into the clerkships and residency programs in internal medicine and family medicine. This was a value-added benefit that provided practice in initiating lifestyle changes and motivational skills, while expanding nutrition education. Eight standardized patient educators were trained in collaboration with physicians in internal and family medicine. Six slide shows on nutrition topics, 1-2 h each, were developed and included clinical cases, dietary analysis, and patient handouts. The Medicine Clerkship included 4 nutrition sessions and the standardized patient experience, whereas the Family Medicine Clerkship included 1 nutrition session and the standardized patient experience. Working with faculty in the Department of Family Medicine, we developed a nutrition mentoring program for the family medicine residents and used 3 nutrition messages that were a modification of the Dietary Approaches to Stop Hypertension (DASH) diet to teach diet evaluation, intervention strategies, feedback from nutrition referrals, and follow-up. Seven sessions on nutrition and chronic disease with cases were offered to the residents in family medicine, which concluded with a nutrition intervention session using standardized patient educators. This expanded nutrition program in internal and family medicine along with the standardized patient experience receives excellent ratings from physicians, residents, and medical students.     

在农村开展全科医学培训的实践与思考

当前开展农村社区卫生服务工作,最大的困难京在于农村基层医务人员缺少困难就在农村基层医务人员缺少全科医学知识,因此,加速培养合格的全科医学人才,以尽快适应开展农村社区卫生服务的需要,就成为农村卫生工作的当务之急,江苏省盐城市卫生局为提高农村卫生从事社区卫生服务的综合能力,有计划地对现有人员进行全科医学培训,１９９８年底在盐盐县大冈镇和射阳县兴桥镇的农樯开展全科医学培训的试点,现就试点地区３年多来在农村开展全科医学培训的实践及其问题的思考简述如下。     

Product-line evaluation of graduate medical education program costs

This article reports the results of an innovative application of traditional multivariate approaches to estimating hospital costs in order to support product-line evaluation of graduate medical education (GME) program costs among the clinical departments and teaching facilities of a nationwide, federal multi-institutional system. Department-level data for 1988, 1989, and 1990 were used to estimate a multiple regression model of total costs per disposition for the specialties of medicine, surgery, obstetrics/gynecology, orthopedics, psychiatry, and pediatrics. Systemwide and facility-specific GME program costs per disposition were estimated for each specialty on the basis of dependent variable scores predicted by the regression model. Measures of case-mix intensity, facility bed size, department staff size, clinical specialty, GME status, teaching intensity, operating efficiency, and regional variation each made statistically significant contributions to the explained variance in total costs per disposition, and yielded an adjusted R2 of .701. Estimates of total costs and GME costs per disposition revealed substantial variation among clinical specialties, both systemwide and within specific facilities. The results of these techniques, their usefulness for enhancing executive ability to evaluate costs of GME programs as product lines, and their implications for public policy regarding hospital payments are discussed.     

Paying for graduate medical education: the debate goes on

The debate over Medicare payments for graduate medical education has been conducted under the premise that such payments cover the added costs of training. Standard economic theory suggests that residents bear the costs of their training, implying that the additional costs of teaching hospitals are not attributable to training per se but to some combination of a different patient care product, unmeasured case-mix differences, and the costs of clinical research. As a result, payment for the additional patient care costs at teaching hospitals should come from the Medicare trust fund; any subsidies for training should come from general revenues.     

Financing graduate medical education in primary care: options for change

The current mechanisms of graduate medical education (GME) financing favor inpatient and procedural care, making the support of primary care programs difficult, as these residencies are oriented toward outpatient evaluation and management. Criteria for evaluating proposals that aim to improve the financial support of primary care programs include the financial, administrative, and educational implications of the options as well as the views of interested stakeholders. Other sources of funding for primary care GME are changes in existing Medicare payments; increased categorical GME funding, ambulatory payment, and grants; commitments from future employers; and redistribution of current funds. Alternatives for spending these funds to aid primary care programs include dividing the sources in three ways: on a per-resident basis, by competitive grants, or by incentives for primary care education. An analysis of the alternatives for changing GME financing shows that several solutions will be needed simultaneously.     

Financing graduate medical education: An update and a suggestion for reform

This article reports data pertinent to three issues in the financing of graduate medical education: sources of funds for house staff support, the financing of faculty salaries for educational activities, and reimbursement bias in favor of care provided in inpatient settings. Using data from a 1979 hospital survey, we estimate that total expenditures for house-staff stipends and fringe benefits were almost $1.6 billion. Eighty-seven percent of these funds were derived from patient care revenues. Faculty salaries for educational activities added another $376 million to the cost of graduate medical education. Teaching hospitals collected 81 percent of their charges for inpatient care, but only 72.8 percent of charges for outpatient care. However, Medicare and Medicaid reimbursed approximately the same proportion of charges in both settings. The article concludes by arguing that a unified-charge system for paying teaching hospitals would eliminate most of the issues currently associated with the financing of graduate medical education as matters of public policy.     

Building and assessing competence: the potential for evidence-based graduate medical education

The Accreditation Council for Graduate Medical Education (ACGME) has recently begun to use educational outcome measures as an accreditation tool. This long-term initiative offers the potential for building knowledge about effective educational interventions and ultimately for using time-variable educational models. This article reviews the progress of the ACGME initiative and plans of the initiative and explores the broader implications of competency. In addition to knowledge and skills the product of a good educational program is a physician who habitually exercises good clinical judgments. Skill sets and accountability proceed along a continuum that is outlined. Crucial is the development of a community committed to discerning and obeying the truth about the effectiveness of educational interventions.     

The impact of graduate medical education on teaching hospital efficiency

This quantitative research study assesses the efficiency of university teaching hospitals in providing hospital services and graduate medical education, identifying areas in which inefficient teaching hospitals differed from their efficient counterparts. The study analyzed American Hospital Association (AHA) data from 2002 in order to examine the efficiency of Council of Teaching Hospital (COTH) hospitals. An efficiency frontier was determined using Data Envelopment Analysis, an effective method of measuring efficiency widely accepted within the health care management literature. The study found that the performance of teaching hospitals increased approximately 6.6 percent when graduate medical education (GME) was included as a key measure of output. Additionally, average excess operating expenses per hospital went from $29,447,581 without residents to $8,321,407 with residents. The average excess full-time employees decreased by 24 percent from 187 without residents to 143 with residents. Conversely, the shortage of outpatient visits increased from an average of 29,461 per hospital without residents to 36,155 with residents. This study clearly documents the need to include GME when benchmarking teaching hospitals. It also shows inefficient COTH hospitals could save approximately $1.6 billion in excess overhead expenses if they emulate the practices of the most efficient members.