K.A. Klink was chief, Health Professions Education, and acting chief officer and senior advisor, Office of Academic Affiliations, Veterans Health Administration, Department of Veterans Affairs, Washington, DC, at the time of writing. The author is now a special lecturer, Center for Family and Community Medicine, Columbia University Irving Medical Center, New York, New York.
A.P. Albanese is chief of medicine, Department of Veterans Affairs Northern California Healthcare System, and clinical professor of medicine, University of California Davis School of Medicine, Sacramento, California.
Acad Med. 2022 Aug 1;97(8):1144-1150. doi: 10.1097/ACM.0000000000004545. Epub 2022 Jul 21.
The United States has a well-trained, highly specialized physician workforce yet continues to have care gaps across the nation. Deficiencies in primary care and mental health specialties are most frequently cited, though critical shortages in multiple disciplines exist, particularly in rural areas. Sponsoring institutions of physician graduate medical education (GME) have created rural residency tracks with modest federal funding and minimal incentives, though efforts targeting shortages in these specialties and geographic locations have been limited. In response to access problems in the Veterans Health Administration, Department of Veterans Affairs (VA), the second largest federal funder of GME with the most expansive clinical education platform, Congress passed the Veterans Access, Choice, and Accountability Act of 2014. This act directed the VA and provided funding to establish 1,500 new positions, a 15% expansion of VA-funded positions at the time. Priority for position selection was given to primary care, mental health, and any other specialties the secretary of VA determined appropriate. Importantly, priority was also given to VA facilities with documented physician shortages, those that did not have GME training programs, those in communities with high concentrations of veterans, and those in health profession shortage areas. Many rural facilities match this profile and were targeted for this initiative. At the conclusion of fiscal year 2021, 1,490 positions had been authorized, and 21 of the 22 VA medical centers previously without GME activity had added residents or were planning to soon. Of the authorized positions, 42% are in primary care, 24% in mental health, and 34% in critically needed additional specialties. Targeted GME expansion in the VA, the largest integrated health care system in the nation, has been successful in addressing physician GME training that aligns with physician shortages and may serve as a model to address national physician specialty and geographic workforce needs.
美国拥有一支训练有素、高度专业化的医生队伍，但全国仍存在医疗服务缺口。初级保健和精神健康专业的不足是最常被提及的，但实际上多个学科都存在严重短缺，尤其是在农村地区。医师研究生医学教育（GME）的主办机构已经利用少量联邦资金和最低激励措施设立了农村住院医师培训课程，尽管针对这些专业和地理位置的短缺问题已经开展了一些工作，但收效甚微。为了解决退伍军人健康管理局（VHA）的服务获取问题，作为第二大 GME 资助者、拥有最广泛临床教育平台的退伍军人事务部，国会通过了 2014 年《退伍军人选择和问责法案》。该法案指示退伍军人事务部提供资金，设立 1500 个新职位，这是当时退伍军人事务部资助职位数量的 15%的扩充。职位选择的优先顺序是初级保健、精神健康以及退伍军人事务部部长认为合适的任何其他专业。重要的是，优先考虑有文件证明医生短缺的退伍军人事务部设施、没有 GME 培训计划的设施、退伍军人集中的社区的设施以及卫生专业人员短缺地区的设施。许多农村设施符合这一要求，成为该计划的目标。截至 2021 财年末，已授权 1490 个职位，以前没有 GME 活动的 22 个退伍军人事务部医疗中心中有 21 个已经增加了住院医师或计划很快增加。在授权的职位中，42%是初级保健，24%是精神健康，34%是急需的其他专业。退伍军人事务部作为全美最大的综合性医疗保健系统，其 GME 扩张计划取得了成功，满足了与医生短缺相匹配的医生 GME 培训需求，可能成为解决全国医生专业和地理劳动力需求的典范。
