Graduate Medical Education: Issues and Options

by Frank C. Wilson, MD

March 22nd, 2010

Graduate medical education, still in the process of being born, was not mentioned in Flexner’s 1910 landmark treatise on medical education.  The existence now of 8500 residency programs and 127 specialties and subspecialities would, a century ago, have seemed preposterous.

Movement in GME prior to 1985 was largely academic and specialty specific. Curriculum, accreditation and certification, and duration of training were issues for resolution within the house of medicine.  Since the mid-1980s, influences outside of medicine, fueled by explosive population growth, technologic innovation, and social concerns have become dominant players, threatening the foundations of the educational bridge between student and practitioner.  An expanding and aging population and a panoply of therapeutic options have created overriding problems of access and expense.

Among the major challenges facing contemporary graduate medical education are issues related to teaching and learning, evaluation, professionalism, supervision, research training, funding, and manpower.  This book considers the issues in these areas and offers options for their resolution.

Following are excerpts from a few of these topics:

Teaching and Learning

“The search for ways to improve medical education should include a re-examination of the values underlying the profession.  Values shape the world; they should hold pride of place in the intellectual community and drive the educational enterprise.  Unfortunately the ethos that determined them in the past has been blurred by contravening trends of the present.  Propelled by the explosive escalation of knowledge and technology, too little attention has been given to the humanistic values that should determine their use.”


“Among the core competencies, professionalism is the most critical and among the most difficult to quantify. It is the competency which, possessed in full measure, gives rise to the others.  A professional possesses and maintains a unique body of medical knowledge and uses it to provide effective, safe, compassionate and ethical patient care, including the communication skills necessary to help patients navigate through a complex health care system.”

… “professionalism is founded on the pillars of science and service, upon possession of a specialized body of knowledge and skills, and the obligation to use that expertise to serve others before self.”  … “at the heart of this obligation is ethics, and at the heart of ethics is the welfare of the patient.”

“Professionalism is not just a philosophical ideal, nor can it be marginalized by the need for efficiency or productivity. It should be defined according to its characteristic traits, its cognitive base made clear, and opportunities provided to gain experience in its application to daily medical care.”

Manpower: Supply and Distribution

“With specialty choices determined largely by issues of income and lifestyle, fewer students are choosing careers in primary care.  High-tech specialities offer exciting opportunities for cure; but older patients having chronic conditions, are often more in need of care than cure – for someone to be there to guide them through the complex world of health care and to manage multiple diseases and depression. Despite the fact that most of the problems for which a physician is consulted can be handled by generalists, they have become an endangered species.”

“Medical care for the aged drives and will continue to drive, health care in the U.S. for the foreseeable future. By 2020, some 20% of Americans will be over 65, and people over 85 constitute the most rapidly expanding segment of the population, for which all physicians must be prepared.”

“Population trends must be studied, and planning for anticipated growth closely coordinated with the capacity of the U.S. health care system for expansion.  Since resources are finite, and expansion of the physician pool is very costly and time consuming, joint planning…is essential to meet short- and long- term needs for medical services.”


 In his Foreword to the book, David C. Leach, Executive Director Emeritus of the ACGME, said: “This is an important book about this most formative time in a physician’s life, the history of graduate medical education, the key issues that consume present interests of medical educators, and the options that the profession and society have for going forward.  It is timely.  Workforce shortages, financial constraints, new knowledge and technologies, and dramatically changing demographic patterns in society pose challenges.  Changes are needed; will wisdom or reflex actions inform the changes?”

 Dr. Wilson is Kenan Professor and  Chief Emeritus of Orthopaedics at UNC.  He is a past President of the American Orthopaedic Association, the American Board of Orthopaedic Surgery, the Association of Orthopaedic Chairmen and the Thomas Wolfe Society.  He received the Thomas Jefferson Award from UNC, and the Distinguished Clinician-Educator Award from the American Orthopaedic Association.  His bookGraduate Medical Education:  Issues and Options, can be found  on