Veterans Affairs Graduate Medical Education Expansion Addresses U.S. Physician Workforce Needs

Abstract

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.

With a backdrop of inadequate physician services in primary care and mental health disciplines in many parts of the United States, along with documented critical need in other specialties, in 2014, Congress directed and provided funding for the Veterans Health Administration, Department of Veterans Affairs (VA) to expand graduate medical education (GME) by 1,500 positions. The goal of this expansion was to address the physician postgraduate training gaps by targeting training to specific specialties and high-need locations.

The common pathway for all physician training is GME. Through federal GME support, mostly funded by the Centers for Medicare and Medicaid Services (CMS), the United States has developed a highly skilled physician workforce. Yet, of the federal government’s nearly $20 billion annual investment, ¹ funds are rarely targeted to support specific physician specialties or locations. Federal GME subsidies are concentrated in urban academic environments where the focus is on subspecialty training, often with the interests of the sponsoring institutions as a priority. ² With few exceptions, such as the Teaching Health Center Graduate Medical Education (THCGME) program, administered by the Health Resources and Services Administration, ³ GME funding is not contingent on training physicians in high-need specialties or underserved locations. The location of residency completion often affects where physicians practice. ⁴ Factors strongly associated with localizing primary care physicians in underserved areas include investing in proven curricula, special training programs, financial incentives, and personal characteristics of trainees. ⁵ Though there have been calls for national strategic planning to align GME with national needs from several organizations, including the Institute of Medicine (now the National Academy of Medicine), ⁶ the U.S. Government Accountability Office, ⁷ and the Council on Graduate Medical Education, ⁸ a national plan has yet to be created.

The VA’s Role as the Nation’s Most Extensive Clinical Training Platform

The VA, the largest integrated health care system in the nation, provides comprehensive care at 1,255 health care sites for over 9 million veterans ⁹ who, as a group, have more chronic illnesses than nonveterans. ¹⁰ Further, rural veterans as a population are older, have less formal education, and are more likely to have a disability and to be out of the labor market than rural nonveterans. ¹¹ These factors all contribute to increased health risks.

One of the VA’s 4 statutory missions is providing health professional education and training programs for both the VA and the nation. ¹² Since 1946, when 16 million U.S. veterans were returning from World War II service and medical schools needed clinical training opportunities for their students, VA and medical school partnerships have been a model of successful collaboration. ¹³ Almost every medical school in the United States has an affiliation with a VA facility. Currently, the VA provides training for approximately 45,000 residents annually, rotating through over 11,000 funded full-time equivalent (FTE) positions as part of the nation’s largest clinical training platform, second only to CMS in funding GME nationally. The VA supports over 120,000 trainees and students annually from over 40 different health professions, including GME. The VA affiliates with GME programs sponsored by medical schools and university and community hospitals in many locations, of various sizes, and with different specialties, as well as independent entities. Except for a few legacy programs, the VA no longer sponsors physician residency programs but works with over 250 GME institutional sponsors of over 8,000 programs to offer clinical rotations to residents and other learners as part of their overall training experience. ¹⁴ A typical resident’s VA experience may include from one-quarter to one-third of their annual clinical rotations, for example, 3 or 4 month-long block rotations. One FTE position will generally engage 3 or 4 trainees. If, for example, 1 trainee rotates to a facility for 3 one-month rotations over a year, the FTE effort is calculated as 0.25 FTE.

The VA health care professional workforce gaps include physicians, nurses, and psychologists, among others. Shortages have led to widely publicized problems in providing timely access to care for veterans in various locations across the nation. The VA physician specialty shortages mirror those of the national health care system in which rural areas have the most acute needs. Psychiatry and primary care have been cited as the most needed physician specialists for several years. ¹⁵ The 2014 congressional authorization of funding for GME specified specialty and location targets with the goal of improving access to care for VA patients.

Implications of Legislation for Development of VA Clinical Education

The Veterans Access, Choice, and Accountability Act (the Choice Act or VACAA) of 2014, section 301(b), ¹⁶ provides funds to expand GME by 1,500 positions, which, in 2014, was a 15% increase in VA-supported GME FTE positions. In contrast to most other federal appropriations for GME, which do not designate priorities, appropriations in this act give priority to medical specialties with the largest staffing shortages: “programs in primary care, mental health, and any other specialty that the Secretary [of VA] determines appropriate.” ¹⁶ Statutory language also directed that the number of positions should be increased at VA facilities experiencing clinician shortages that did not support residency positions at the time of enactment and in communities designated as health professions shortage areas. Primary care, for these purposes, includes the specialties of family medicine, internal medicine, and geriatric medicine. Mental health includes all the specialties of psychiatry and addiction medicine.

Though the VA has a significant footprint in providing clinical training, it was recognized that the 5-year period imposed by the original act could not be met because GME requires time for developing infrastructure capable of supporting high-quality clinical education and patient safety, including skilled faculty, teaching accommodations, patient panels, and workspace appropriate for residency education. In rural and smaller VA facilities with a lower level of complexity than larger facilities, educational infrastructure needs are typically greater than at larger urban locations that have established academic activities. The distance between rural VA facilities and academic programs presents travel challenges that add to both the length of time and number of resources required to establish new GME. In light of these circumstances, Congress extended the time frame to 10 years, culminating in 2024, ¹⁷ when about 4,500 additional individual residents will have had clinical experiences at VA facilities (3 residents typically rotate through each FTE position).

With VA assurance that the VACAA federal funding would be stable, this initiative is an incentive for academic affiliates to expand their programs and take advantage of the rich clinical experiences the VA provides for affiliates, such as research programs, libraries, and technological resources.

Sponsoring institutions must have a stable, long-term source of funding to plan recruitment and curricular oversight and to adjust resources, including infrastructure, personnel, faculty, and other critical aspects necessary to ensure ongoing, high-quality training and financial feasibility.

Medical literature is replete with evidence that clinicians with teaching roles have improved career satisfaction. ^18–21 Greater career satisfaction has the potential to increase longevity, thus decreasing turnover with its associated shortages and costs. This trend is reflected in the results of the VA’s 2020 annual All Employee Survey, which indicate that VA clinicians with teaching responsibilities are more satisfied with their jobs and report that they are less likely to be considering leaving the VA than nonteaching clinicians. ²² The annual Trainee Satisfaction Survey is administered by the VA Office of Academic Affiliations (OAA). Physician residents consistently respond they have a more positive opinion regarding a career at the VA after completing their rotations, with over half (55%) responding they would consider a career at a VA medical center. ²³ These findings provide some evidence that training in a VA facility may predispose early career professionals to VA employment.

The need to train and retain primary care and mental health providers in underserved areas is not unique to VA facilities and has been well documented in medical education literature. ^24–26 Establishing GME in locations without current residency education requires interventions at multiple levels, including modifying the institution’s mission and culture, hiring personnel capable of implementing the programs, recruiting new faculty, and preparing current faculty to teach residents.

VA GME Expansion Planning, Approach, and Implementation

OAA was charged with implementing the GME expansion mandated by VACAA. Creating new residency positions on a national level that conform to the legislation required OAA to assess allocations and strategically increase the numbers of positions based on needed specialties, high-need locations, and—importantly—facility readiness. Early in the assessment process, it was clear that the mandate to create new GME positions in underserved locations was challenged by the lack of infrastructure required to establish and support the positions in the required specialties.

All VA facilities were analyzed according to applicable criteria specified in the legislation. Fifty-eight (now 55 due to mergers) smaller facilities—typically outside large metropolitan locations—with either low (fewer than 20 positions) or no GME activity were targeted for development. OAA took a 5-pronged approach based on the office’s experience in expanding specialty-specific training (e.g., the mental health education expansion initiative) ²⁷ and location-based training (e.g., VA GME enhancement initiative, 2006–2011). ²⁸ Two problems in prior expansion programs were the lack of indirect funding (funding in addition to trainee salary and benefits) to support educational programs and the lack of qualified supervisory faculty. With that background, along with the experience in expansion of educational programs in similar settings, the following 5 specific solutions were developed to address these concerns.

• Hired physician leadership with expertise in GME to assist limited GME VA facilities and their prospective affiliates. The outreach program included educating targeted contacts, information campaigns at national academic meetings, and support and mentorship of individual education leaders.

• Implemented a request for proposal (RFP) process for planning grants ($250,000 with a 2-year spending period). These grants were available to the targeted VA facilities with no or limited GME activity. Successful applicants were mentored over the 2-year grant period, anticipating a timeline of 2 to 4 years to request and fill the positions. These were primarily capacity-building grants to establish educational leadership, hire staff, and develop readiness for educational programs.

• Implemented an RFP process open to all participating VA medical centers to apply for funding to plan and equip sites for GME trainees. Infrastructure grants (from $100,000 to $2,000,000) were offered as bridge funds after facilities were awarded GME positions. These funds could be requested and issued in any combination of 3 budget lines: faculty support (clinical dollars), including development programs and salaries for faculty time; support staff (funded from administrative dollars); and clinical learning environment improvement (funded from facilities dollars). Small VA facilities were encouraged to apply in anticipation of these additional resources.

• Allocated GME positions by using an annual RFP process (funding rounds) that allowed facilities to apply for primary care, mental health, or critical need positions. Critical need applications required access metrics, prioritization if more than 1 specialty position was requested, and authorization from regional leadership. Larger facilities and their affiliated academic institutions were invited to apply for positions, though smaller, more rural sites were prioritized. Small, rural affiliates that usually sponsor fewer training programs, yet produce a higher percentage of primary care physicians than larger facilities, ²⁹ were sought out to establish new VA affiliations.

• Established a faculty development program to support clinical faculty inclusive of multiple professions to create high-quality, flexible interprofessional clinical learning environments. We defined faculty development as increasing the competence and confidence of the selected VA preceptors. The Rural Interprofessional Faculty Development Initiative, a 2-year program, focuses on expanding and deepening teaching skills; expanding clinical educational activities; creating intra- and interfacility peer networks; enhancing leadership skills; and encouraging interprofessional, team-based education and patient care. This program was created mainly because small facilities reported that they could not expand educational programming without qualified faculty supervisors. The Rural Interprofessional Faculty Development Initiative is a virtual course that includes monthly webinars and facilitated peer group meetings along with conferences, workshops, and self-paced online learning modules.

Educational integrity of the residency program

Applications were accepted only for new or existing positions approved by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association. Facilities requesting positions in the critical need category were required to provide data demonstrating an inability to meet established VA standards for patient care access in the requested specialty area and an explanation of how additional trainees could help achieve access goals. VA clinical training conforms to all Accreditation Council for Graduate Medical Education institutional requirements. VA internal policies and regulations are well established, with delineated responsibilities for administration of residency training at VA facilities and payment for residents’ time and benefits to the program’s sponsoring institution, the affiliate. Resident supervision is essential for the quality, safety, and success of the educational experience. All residents at VA facilities are supervised by licensed independent physicians who have been credentialed and privileged at the VA facility and are responsible for personal oversight of the clinical care provided by trainees. Supervision is determined by the need and intensity of the care provided and the level of responsibility the resident has earned. ³⁰

Documentation of funding and data sources

OAA maintains a database of allocated GME positions by site, affiliate/sponsor, and specialty/subspecialty going back several decades. Positions in the database can also be retrieved by funding source—either traditional VA-appropriated funding or VACAA-appropriated funding. VACAA-funded positions must be reported to Congress annually as a congressionally mandated report. Allocated GME positions are reported down to the 0.10 FTE level.

The VA’s Fulfillment of the Legislative Mandate

By July 2021, after 8 annual funding rounds, more than 1,490 (99%) of the 1,500 authorized positions had been awarded, as enumerated in Table 1. As shown in Figure 1, primary care specialties (621 positions) and mental health specialties (364 positions) together make up about two-thirds of the congressionally directed priority specialties. The expansion addressed critical need specialties by adding 505 positions in more than 50 medical and surgical specialties. By adding about 150 family medicine positions, the VA more than doubled family medicine residency positions in the VA nationwide. See the list of approved GME residency positions by specialty in Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/B213. Of the 55 targeted sites, 38 have established or increased GME positions and 17 have received planning funds. See the list of residency positions by state (and Puerto Rico), VA medical facility, and academic affiliation in Supplemental Digital Appendix 2 at http://links.lww.com/ACADMED/B213. Distribution of positions among states (and Puerto Rico) is illustrated on the map in Figure 2.

Table 1.

VACAA of 2014 GME Expansion FTE Approved Positions, by Funding Round (2014–2021) and by Category of Specialty

Figure 1.

Approved graduate medical education (GME) residency positions in the categories of primary care (internal medicine, family medicine, and geriatric medicine), mental health (psychiatry and addiction medicine), and critical need specialties. These categories are given priority in the Veterans Access, Choice, and Accountability Act of 2014, which directs the Department of Veterans Affairs (VA) to expand GME in VA facilities.

Figure 2.

Map showing number of approved graduate medical education full-time equivalent (FTE) positions established and funded by the Veterans Access, Choice, and Accountability Act of 2014, per state and in Puerto Rico. (FTE positions are calculated on the basis of the percentage of time residents are assigned to a Veterans Affairs facility.)

The interprofessional faculty development program has enrolled 2 clinical faculty cohorts, comprising 80 participants from 34 facilities across the United States. The 2-year program, to sustain high-quality interprofessional clinical learning and practice environments, is open to all clinical professions. Current enrollees include physicians from a variety of specialties, physician assistants, nurses, nurse practitioners, pharmacists, psychologists, dieticians, podiatrists, a chiropractor, and a clinical education specialist.

Discussion

A prediction of a U.S. physician shortage ³¹ is accompanied by arguments that there is maldistribution of physician services rather than an overall shortage. Not enough physicians are practicing in shortage locations, and there are projections of specialty needs, notably primary care and mental health. ^32,33 The need is particularly acute in rural locations where increased access to physician services would optimize population health and outcomes. ³⁴ Suggested solutions to the shortages and care gaps include training residents in high-need specialties and locations both by redistributing positions and by adding new ones. ³⁵

Several examples show that redistributing existing funded GME positions to high-need locations and specialties has had limited impact. Section 5503 of the Patient Protection and Affordable Care Act (ACA) of 2010 allowed addition and redistribution of GME resident positions to states with resident-to-population ratios in the lowest quartile and to states, territories, or districts with the highest percentage of people living in health professions shortage areas. ³⁶ Similar legislation, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, redistributed nearly 3,000 residency positions. The outcome of the 2003 redistribution resulted in the addition of 12 rural positions, fewer than 3% of all positions redistributed. ³⁷

An important example of targeted GME expansion is the THCGME program, enacted by the ACA. Funded through the Health Resources and Services Administration, it pays residency programs sponsored by ambulatory settings a predetermined, annual amount per resident that includes the traditional CMS direct and indirect payments. ³⁸ In the academic year 2019–2020, the THCGME program supported 738 FTE residency positions, providing funding to 883 individual residents in 56 programs across 25 states. ^3,39 Though the program has been successful in creating new residency positions in rural areas and health professions shortage areas, ⁴⁰ the THCGME programs have been challenged by unstable annual funding allocations, ⁴¹ lacking the $18 billion stable annual entitlement of the CMS portion of the federal GME budget. ^1,42 There is evidence that THCGME residency program graduates and others who train in underserved areas are more likely to return to safety net settings to practice. ^43,44

Recent legislation indicates some effort to align GME funding to address physician workforce needs. The Consolidated Appropriations Act of 2021 ⁴⁵ funds 1,000 additional positions, accompanied by distribution guidelines that prioritize high-need locations, and relaxes certain stringent CMS residency cap criteria, enabling the eligibility of some new and rural programs. It also extends THCGME funding for 2 years. In addition, THCGME programs received a $330 million boost from Congress in the American Rescue Plan Act of 2021. ⁴⁶ As directed by the Coronavirus Aid, Relief, and Economic Security Act of 2020, section 3402, the Department of Health and Human Services, in consultation with the Advisory Committee on Training in Primary Care Medicine and Dentistry and the Council on Graduate Medical Education, recently released a comprehensive and coordinated health care workforce development plan that incorporates health and human services education and training. ^47,48

Because the VA draws its clinicians from the same physician pool as the nation as a whole, the challenges in meeting the VA’s physician workforce needs reflect both the physician shortage ³¹ and the maldistribution of physician services in the United States. Primary care and mental health specialty needs are acute both in the VA ¹⁵ and across the nation ^32,33; these needs are especially evident in rural locations where increased access to physician services would optimize population health and outcomes. ^34,35,49,50 The VA, as mandated by the VACAA of 2014, section 301(b), ¹⁶ expanded the number of new GME positions aligned with demonstrated need in both specialty and location. ⁵¹ The act provided a unique congressional directive with stable, ongoing funding and infrastructure support to expand GME in specific specialties and locations to ameliorate GME overall, as well as targeted shortages. The VA has successfully awarded more than 99% of the allotted positions well ahead of the 2024 congressional deadline to complete the expansion. The VA recognized previously identified barriers to GME expansion that include an inadequate number of faculty or a lack of available supervisory faculty time, insufficient administrative staff, a lack of appropriate educational workspace, and, as noted above, insufficient faculty development. As part of the implementation plan and process, the VA has enhanced infrastructure, clinical learning, and practice environments. The VA has also created an interprofessional faculty development program that provides education, enrichment, and peer support for VA clinicians representing multiple professions engaged in the team-based care of veterans. These changes can improve career satisfaction and longevity, thus decreasing turnover and the resultant associated shortages and costs. Recruitment of recently trained professionals is more likely when they have had positive experiences in the VA system and with veterans as patients.

Limitations

Because this article is an operational analysis of a legislative mandate, not a research study, data were collected and analyzed as part of that statutory requirement, and we did not seek institutional review board approval. Although we see the VACAA GME expansion as a model that could be applicable on a more widespread basis, we realize 1 limitation is the relatively small size of the program. Fifteen hundred is a small number of positions compared with the total number of GME trainees in the United States. In addition, because most of the residents filling these positions are still in training, there are no long-term data demonstrating that they will remain in the rural and underserved areas after training or seek employment at VA facilities. We also recognize that funding internal medicine residents (even those in primary care tracks) does not guarantee that they will devote their future practice to primary care.

Conclusion

Through purposeful federal funding of GME focused on specific, needed specialties; locations; and patient populations, the VA expanded GME training in needed disciplines and locations that have, over the last several decades, been minimalized. The VA GME expansion represents a 15% increase over the previous annual funding of about 10,500 FTE positions, shared by about 45,000 individuals. Though the expansion is modest when compared with the approximately 120,000 GME positions supported each year, the majority of which are funded by CMS, the VA offers a model for future targeted specialty and location training by providing professional oversight, leadership and mentoring, infrastructure support, and faculty development at participating clinical sites.

The VA GME expansion, mandated by Congress through the VACAA of 2014, section 301(b), provides a practical example for expanding training capacity into less populated locations in needed specialties directed toward an underserved population. The expansion also reflects the intention to create the physician workforce the nation needs by increasing clinician retention and recruitment of recent, highly qualified graduates and by shifting residency practice locations and specialties.

Acknowledgments:

The authors wish to thank Edward Salsberg, Fitzhugh Mullan Institute for Health Workforce Equity, George Washington University Milken Institute School of Public Health, for his review and comments on an early draft of this article.