Innovation in medical education.

O July 29, 2014, the Institute of Medicine (IOM) released its report on the governance and financing of graduate medical education (GME).1 An important incidental finding of the IOM’s study was that the evidence base available to inform future directions for the substance, organization, and financing of GME is quite limited. The limited evidence reflects a systematic lack of research investment in an area of health care that we believe deserves better. Our nation’s lack of research in medical education contrasts starkly with the large and essential commitment to biomedical research funded by industry, philanthropic organizations, and the public. No one questions the need for sustained support for research in cancer, heart disease, or dementia. But despite medical education’s central role in creating a workforce capable of delivering the resulting biomedical advances — and despite the $15 billion in annual public investment in the medical education enterprise — funding for medical education research is conspicuously absent. As a result, we lack evidence that is essential for guiding improvements in the clinical workforce. The current duration, settings, and organization of GME are more the product of tradition than of evidence and have changed little in the face of substantial changes in the health needs of patients and the systems for delivering care.2 We face questions about the most appropriate structure and content for GME, along with questions that extend beyond GME: What should change in undergraduate medical education, and how should we ensure the continued competence of physicians 20 to 30 years into practice? We also face active debate and a lack of evidence about how to better distribute financial support for GME, whether and how to support the education of other clinicians (in addition to physicians), and to what extent federal GME funding is an effective or appropriate tool for addressing imbalances in the geographic or specialty distribution of health care providers. The research that could answer these questions requires funding and organization that don’t currently exist. The Centers for Medicare and Medicaid Services pays about $10 billion a year toward GME but has neither a researchand-development budget to ensure that this investment is achieving its objectives nor even a clear definition of what those objectives are. Overall, the United States spends nearly $3 trillion a year on health care, nearly all of it delivered through clinicians, with no organized research investment directed at improving the way those clinicians are produced. The IOM committee has proposed a “Transformation Fund” to fill this void. The fund would be directed toward research and innovation in the substance of GME as well as its organization and financing, and the proposal echoes the recommendations of other consensus reports.2 The committee also proposed a governance mechanism to set research priorities and coordinate large-scale efforts such as multiinstitutional studies or nationwide pilot programs. We propose the following approach. First, valid and feasible measures of training success need to be defined. The fundamental goal of medical training is the production of a workforce capable of delivering economically sustainable care that will improve the health of patients and populations in a changing environment. Our system of medical education should be judged against those goals.3 Medical education is currently assessed through process measures (whether residents get enough cases, enough lectures, enough sleep) or intermediate outcomes such as exam performance. Although competency assessment is receiving increased attention, the connections between resident competency and patient outcomes are assumed rather than demonstrated. In order to evaluate alternative processes of medical education, we need systems for routinely assessing meaningful outcomes: the quality, distribution, and cost of care delivered by the graduates of our schools and training programs. Outcomes-driven approaches have the additional advantage of fostering innovation, because when success is determined by outcomes, alternative processes can be tried as ways to get there.4 Second, we need to examine