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Toward GME Accountability

An analysis of over 750 institutions shows that fewer than one-quarter of doctors train as primary care providers.

Dr. Candice Chen and colleagues attempted to assess outcomes of the nearly $10 billion federal Medicare and more than $3 billion federal-state Medicaid annual investments in graduate medical education (GME) in their recent study.

Using multiple data sources including the American Medical Association Masterfile, National Provider Identification file, Medicare claims, and the National Health Service Corps data, the authors identified a cohort of physicians who had completed residency programs between 2006-2008. These data were then analyzed to determine primary care output based on the institution, program, and primary teaching site. For the purposes of this study, primary care was defined as family medicine, general internal medicine, general pediatrics, internal medicine-pediatrics, internal medicine geriatrics and family medicine geriatrics. General surgery, psychiatry, and OB/GYN “output” was also measured.

Among all 759 institutions, 158 trained no primary care graduates, while 184 saw more than 80% of their graduates pursue primary care. Similarly, 198 institutions were identified with no graduates practicing in rural areas, while 10 institutions only produced physicians practicing in rural areas. Significantly more institutions (283) trained no graduates practicing in federally qualified health centers or rural health centers, and even more institutions (479) produced no National Health Service Corps members.

Overall primary care production was estimated to be 25.2%, although the authors noted that this is likely an overestimate. Only 4.8% of GME graduates practiced in rural areas. In internal medicine, an estimated 37.9% pursued primary care (including hospitalists in that count). Among surgeons, an estimated 38.4% of graduates pursued general surgery. Correlation analysis revealed possible positive association of primary care output with: rurality of the program, percentage of female trainees, percentage of osteopathic graduates, percentage of international medical graduates (IMGs), and mean age.


Federal GME funding is increasingly subject to scrutiny in the current fiscal environment just as Affordable Care Act (ACA) implementation expands coverage to millions more Americans. GME funding has been targeted for potential cuts by the Bowles-Simpson Fiscal Commission, the failed Joint Select Committee on Deficit Reduction (“the SuperCommittee”), and MedPAC despite evidence that cuts to GME may have devastating consequences.

Following the social mission medical school rankings, this study represents a novel effort to try to measure GME “outputs” in terms of training a complement of physicians aligned with the country’s needs and with a particular emphasis on specialties and geographic areas with significant physician shortages. However, it is less clear how the results of this study should inform policy. Is it desirable for institutions and programs to be measured by primary care “output?”

It is difficult to fault institutions and programs for following the money. Our current reimbursement system incentivizes institutions to value specialists over primary care physicians. For this reason, it is not surprising that many institutions choose not to train primary care doctors and instead focus on lucrative subspecialty fellowships.

Chen, C, et al. Academic Medicine. 2013; 88 (9): published online.


Elizabeth Wiley, MD, JD, MPH 

Dr. Wiley is the immediate past president of the American Medical Student Association. She currently is a resident at the University of Maryland. Her commentary represents her own views and does not necessarily reflect the views of either AMSA or University of Maryland.

Elizabeth Wiley, MD, JD, MPH
About Elizabeth Wiley, MD, JD, MPH

Dr. Wiley is a resident at the University of Maryland. Contact: Facebook | Twitter | More Posts

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