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首页> 外文期刊>The Journal of Graduate Medical Education >Establishing the First Residency Program in a New Sponsoring Institution: Addressing Regional Physician Workforce Needs
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Establishing the First Residency Program in a New Sponsoring Institution: Addressing Regional Physician Workforce Needs

机译：在新的赞助机构中建立第一个住院医师培训计划：解决区域医师的劳动力需求

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There is no road map for starting graduate medical education (GME) at an institution new to resident education, especially in a rural, sparsely populated region. This Perspective describes the key steps we followed from 2012 to 2016, and the considerations we learned from our initial experience of starting an internal medicine residency.;How Can New Residency Programs Address Regional Workforce Needs? Thoughtful observers dispute the adequacy of residency positions, and whether a sufficient number of physicians are being trained to meet the nation's health care needs.1,2 However, there is little controversy that our current workforce is misaligned geographically and by specialty.3 According to the Institute of Medicine,4 “under the current terms of GME financing, there is a striking absence of transparency and accountability for producing the types of physicians that today's health care system requires.” The 20th century saw American medicine evolving from generalist to specialist care, and from community- to hospital-based physicians.5 The focus on subspecialization in many GME programs limits the training of generalist physicians for careers in underserved communities, especially in rural and frontier areas. Retraining and redistributing the present physician workforce is impractical. In 2011, Medicare cost reports from teaching hospitals found large state-level differences in Medicare-sponsored residents per 100?000 population (1.63 in Montana to 77.13 in New York); total Medicare GME payments ($1.64 million in Wyoming to $2 billion in New York); payments per person ($1.94 in Montana to $103.63 in New York); and average funding per resident ($63,811 in Louisiana to $155,135 in Connecticut).3 Proposals to address these imbalances are conceptually straightforward, but politically arduous.2 Primary care and community-based training models represent a small minority of GME positions; yet primary care physicians generally perform better in domains of value, hospitalization rates, and patient-centeredness.6–8 Physicians in frontier regions, such as Montana, are aged (average age 55 to 60),9 as are their patients. Attracting and retaining health care professionals in these communities will require purposeful training and positive role models with sustainable and rewarding careers. Montana's first family medicine residency, established in 1996, has placed more than 70% of its graduates in the region. Competence is context specific.10 Experience during training becomes imprinted and affects clinical behavior for decades.11 Creating programs to train physicians where they are needed will require establishing innovative programs in interested (but unprepared) sponsoring organizations. Therefore, rapid cycle improvement and innovation in GME may need to precede geographic and specialty redistribution. Care in rural, underserved, and hard-to-serve settings is often particularly fragmented and poorly coordinated. For team-based, interprofessional collaboration to be modeled, it must first be established. Imperatives to reduce cost and improve access will lead institutions to consider filling specialist and subspecialist gaps with skilled generalists. Even in urban, integrated delivery systems, the choice of delegation of care, from generalists to consultants, shows early and wastefully low-threshold referral as the norm.12 Preparation of generalist physicians for service in sparsely populated, underserved regions requires a higher standard of responsible self-reliance and collaboration than most role models or residency continuity practices provide.;Building a New Sponsoring Institution Institutional Culture Health care delivery systems new to GME will be unaccustomed to the regulatory environment, and will likely lack administrative and management experience with GME and experienced individuals who can serve as program directors, as required by the Accreditation Council for Graduate Medical Education (ACGME). The Centers for Medicare &
机译：没有针对居民教育的机构，特别是在人口稀少的农村地区，开展研究生医学教育（GME）的路线图。该观点描述了我们从2012年到2016年所采取的关键步骤，以及我们从建立内科住院医师的最初经验中学到的考虑因素;新的住院医师培训计划如何解决区域劳动力需求？体贴入微的观察员对居留权的适当性以及是否接受过足够数量的医生的培训以满足国家的医疗保健需求提出质疑。1,2然而，关于我们目前的劳动力在地理位置和专业方面均存在失调的争议很少。3医学研究所，4“根据目前的GME资助条款，在产生当今卫生保健系统所需的医生类型方面，缺乏透明度和问责制非常明显。” 20世纪，美国医学从全科医生发展到专科医生护理，从社区医生转变为医院医生。5在许多GME项目中，对亚专业化的关注限制了在服务不足的社区（尤其是在农村和边远地区）对通才医生的职业培训。 。再培训和重新分配当前的医生劳动力是不切实际的。 2011年，来自教学医院的Medicare成本报告发现，每10万人口中，Medicare资助的居民的州级差异很大（蒙大纳州为1.63，纽约州为77.13）; Medicare GME总付款额（怀俄明州为164万美元，纽约为20亿美元）;每人付款（蒙大拿州为1.94美元，纽约州为103.63美元）; 3解决这些失衡的建议在概念上很简单，但在政治上却很艰辛。2初级保健和基于社区的培训模式仅占GME职位的一小部分;以及平均每位居民的资金（路易斯安那州的63,811美元到康涅狄格的155,135美元）。然而，初级保健医生通常在价值，住院率和以患者为中心方面表现更好。6-8边远地区（例如蒙大拿州）的内科医生与他们的患者一样年龄较大（平均年龄为55至60岁），9。在这些社区中吸引和留住医疗保健专业人员将需要有针对性的培训和积极的榜样，并需要可持续的和有意义的职业。蒙大拿州的首个家庭医学居所始建于1996年，已将其毕业生的70％以上放在该地区。能力是因地制宜的。10培训期间的经验被烙印并影响数十年的临床行为。11创建计划以培训需要的医师，将需要在感兴趣（但没有准备）的赞助组织中建立创新计划。因此，GME的快速周期改进和创新可能需要先于地理和专业重新分配。在农村，服务欠缺且难以服务的地区，医疗服务通常特别分散，协调不力。对于要建模的基于团队的专业间协作，必须首先建立。迫切需要降低成本和改善获取机会，这将导致机构考虑与熟练的通才填补空白。即使在城市综合交付系统中，从全科医生到顾问的委派选择也显示了将早期和浪费低门槛转诊为规范。12为在人口稀少，服务不足的地区提供服务的普通医生的准备工作要求更高的标准。负责任的自力更生和协作，这比大多数榜样或居留权连续性实践所提供的要好。;建立新的赞助机构制度文化GME所不具备的医疗保健提供系统将不习惯监管环境，并且可能缺乏GME和根据研究生医学教育认可委员会（ACGME）的要求，可以担任计划主管的经验丰富的个人。医疗保险中心

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