Context Planning for the US physician workforce is imprecise. Prevailing policy
generally advocates more training in primary care specialties.
Objective To describe a program to increase primary care graduate medical education
(GME) in a large academic health system—the Veterans Health Administration
of the Department of Veterans Affairs (VA).
Design In 1995, a VA advisory panel recommended a 3-year plan to eliminate
1000 specialist training positions and add 750 primary care positions. After
assessing the impact of the first year of these changes on patient care, the
VA implemented modifications aimed at introducing primary care curricula for
training of internal medicine subspecialists, neurologists, and psychiatrists.
The change in strategy was in response to the call for better alignment of
GME with local patient care and training needs to provide coordinated, continuous
care for seriously and chronically ill patients.
Setting The VA health system, including 172 hospitals, 773 ambulatory and community-based
clinics, 206 counseling centers, and 132 nursing homes.
Participants A total of 8900 VA residency training positions affiliated with 107
Main Outcome Measure Proportion of residents in primary care training during the 3-year alignment.
Results Over 3 years, primary care training in the VA increased from 38% to
48% of funded positions. Of this total, 39% of the increase was in internal
medicine subspecialties, neurology, and psychiatry.
Conclusion In this case study of GME realignment, national policy was driven more
by local patient care issues than by a perceived national need for primary
care or specialty positions.