Medical education in a changing world: thoughts from California.

Medical education has been buffeted by the frenetic changes in our health care delivery system. This commentary focuses on six major issues facing family practice training programs caring for underserved populations in California: 1) The patient base for training programs is eroding. 2) There is no or limited funding for graduate medical education (GME) in Medicaid managed care programs. 3) There are barriers to using residents in managed care systems. 4) Disproportionate share funding from Medicaid for hospitals caring for poor and underserved patients does not support medical education. 5) Capitated Medicare and Medicaid programs are siphoning off dollars meant for GME. 6) Consolidation in the health care market is threatening medical education training sites. To address these issues, primary care GME programs should work with community-based sites so both can increase patient care, educational activities, and revenue in this managed care era. At the same time, community-based training sites in primary care GME programs must redesign their delivery systems to provide efficient, cost-effective care. The result will be better access for primary care patients and more appropriate training for our residents. Family medicine educators should become increasingly involved at the local, state, and national levels to ensure that GME funding directly supports training and is not relegated to being a by-product of patient care.