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 po licy generally advocates more training in primary care specialties. Objective To describe a program to increase primary care graduate medical e ducation (GME) in a large academic health system-the Veterans Health Admini stration 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. Afte r assessing the impact of the first year of these changes on patient care, the VA implemented modifications aimed at introducing primary care curricul a for training of internal medicine subspecialists, neurologists, and psych iatrists. The change in strategy was in response to the call for better ali gnment of GME with local patient care and training needs to provide coordin ated, continuous care for seriously and chronically ill patients. Setting The VA health system, including 172 hospitals, 773 ambulatory and c ommunity-based clinics, 206 counseling centers, and 132 nursing homes. Part icipants A total of 8900 VA residency training positions affiliated with 10 7 medical schools. Main Outcome Measure Proportion of residents in primary care training durin g 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 interna l medicine subspecialties, neurology, and psychiatry. Conclusion In this case study of GME realignment, national policy was drive n more by local patient care issues than by a perceived national need for p rimary care or specialty positions.