Among the major issues highlighted in the IOM report:
- The report does not see a shortage of physicians as dire as some groups have suggested, saying that physician assistants, advanced practice registered nurses, care delivery redesigns, telemedicine, electronic communication and other innovations "may ultimately lessen the demand for physicians despite the added pressures of the aging population and coverage expansions."
- The GME system has been producing more physicians—17.5% more per year in 2012 than in 2002—but "has not produced an increasing proportion of physicians who choose to practice primary care, to provide care to the underserved populations, or to locate in rural or other underserved areas."
For example, there is a great need for more primary care physicians but residents choosing that field have dropped "precipitously," from 54% of those in the third year of residency in 1998 to 21% in 2011.
- Nearly all GME training now occurs in hospitals, "in spite of the fact that most physicians will ultimately spend much of their careers in ambulatory, community-based settings."
- There's "worrisome evidence that newly-trained physicians in some specialties have difficulty performing simple office-based procedures and managing routine conditions." The report cited a study that mentioned as examples, "care of minor depression and anxiety, minor chronic pain, basic dermatological conditions, and headaches) and performing simple procedures provided in outpatient settings."
- Today's GME curricula don't sufficiently emphasize "care coordination, team-based care, cost of care, health information technology, cultural competence, and quality improvement."
- Residents and faculty "know little about the costs of diagnostic procedures." And, residents "feel unprepared to provide culturally competent care."
- Though 90% of the $15 billion spent on GME funding comes through the Medicare and Medicaid programs, physicians are not required to provide services to Medicare or Medicaid patients after graduation from a Medicare or Medicare-supported residency program.
- Today's GME system "does not yield useful data on program outcomes and performance" and there is "no mechanism for tying payments to the workforce needs of the healthcare delivery system." The IOM recommends that a system that ties payments to performance be created.