MJ Group (India)

To the Editor: Chen et al1 offer a fascinating outline of the current reforms to graduate medical education found in the Teaching Health Center Graduate Medical Education (THCGME) program, part of the Patient Protection and Affordable Care Act. However, Christakis2 states that “reforms such as increasing generalist training, increasing ambulatory care exposure, providing social science courses, teaching lifelong and self-learning skills, rewarding teaching, clarifying the school mission, and centralizing curriculum control have appeared almost continuously since 1910.” It is interesting to consider how many reforms have been set out even since Christakis’ statement in 1995, and uncanny how similar the reforms of the THCGME are to those of the past century. Will the current reforms stand the test of time? There are some reasons for confidence. First of all, as Chen et al1 point out, the new program introduces more accountability into the funding system. Payments are being linked to outcomes, such as having more primary care doctors working in community settings. Second is the strong prima facie case that this new method of training graduates will be less expensive and that it will ultimately produce doctors who can deliver less expensive and more affordable care. However, the above statements are largely hypotheses and have yet to be proven. Proof will require long-term evaluation, so the fact that funding is guaranteed for only five years is a worry. After five years, only a small cohort of primary care professionals will have finished their training and will have spent at most only two years in primary care settings. This is not long enough to measure the sustainability of any changes brought about by the new program. The program’s plans to evaluate further outcomes such as patient outcomes during and after the new residencies is laudable; however, it remains to be seen how rigorous these evaluations will be. Ideally, the program’s new approaches would be subject to cost utility studies. Accounting for and costing the components that make up the new training approaches of the THCGME will be a body of work in itself, but the real work will start when many different outcomes are measured. For example, interprofessional education may be shown to be an effective and low-cost way of improving the coordination of care; technology-enhanced learning may prove to be a medium-cost but highly effective way of improving residents’ applied knowledge. How will we make decisions on what aspects of the program are most worthwhile based on the complex data obtained? The short answer is by looking at the utility of alternatives. Stakeholders may place greater “weighting” on, for example, educational interventions that can improve the coordination of care than on other interventions that can effect other outcomes. I state this realizing that it is a simplification; multiattribute utility theory will ultimately need to guide the analysis of more complex interventions. Kieran Walsh, FRCPI Editor, BMJ Learning, the medical education service of the BMJ Group; [email protected]

Health systems need to use resources to their maximum effect. This naturally leads them towards evidence based medicine, since those interventions that have been shown in well conducted (randomised) studies to be most effective should usually be prioritised over those where high quality evidence is lacking. Problems arise where systems have to juggle alternative choices where the …