Results of a nationwide veterans affairs initiative to align graduate medical education and patient care

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 medical schools. 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.