Graduate Medical Education: Trends in Training and Student Debt

The federal government invests significantly in medical education through various programs to help ensure that the anticipated supply of new physicians meets the nation's health care needs. Medicare, the federal health care program for elderly and certain disabled people, subsidizes training for medical school graduates in hospitals and other teaching institutions by helping to support the increased costs associated with postgraduate medical training. These subsidy payments provided hospitals and other teaching institutions with an additional $8.76 billion for postgraduate medical training in fiscal year 2008. In addition, Medicaid, a joint federal and state program that finances health care for certain low-income individuals, provides funding for graduate medical education. In order to pay for medical school tuition and related fees, students often rely on loans to finance their education. The Department of Education (Education) administers loan programs that are available to medical school students. These loans may be made by private lenders and guaranteed by the federal government or made directly by the federal government through a student's school. The Health Resources and Services Administration (HRSA) administers various scholarships, loans, and loan repayment programs for disadvantaged students and those committing to practice in underserved areas or train in specific specialties. In addition, the Department of Veterans Affairs provides funding and training opportunities for new physicians in its medical facilities. Students must complete an undergraduate education and typically 4 years of medical school, at which point they earn a medical degree and become physicians. By their last year of medical school, students typically choose a specialty in which they will undertake required postgraduate medical training, known as residency, in order to practice medicine without supervision. Most specialties can fall into three general categories: primary care, surgical, and procedural. Most students apply for residency through the National Resident Matching Program (NRMP), which matches applicants with residency programs based on the preferences of both parties. However, because more students apply for some specialties than positions are available, some students may not receive a position in their preferred specialty. Residency can last 3 to 5 years, depending on the specialty. After residency, some physicians may decide to pursue further postgraduate medical training, known as a fellowship, in order to become a subspecialist. For example, to become a cardiologist, a medical school graduate must complete an internal medicine residency followed by a cardiology fellowship. In some cases, depending on the specialty or subspecialty, a physician could spend 7 or more years in postgraduate medical training. Congress asked GAO to provide information on graduate medical education. Specifically, we focused on (1) trends in postgraduate medical training, (2) factors that influence medical students' specialty choice, and (3) trends in the amounts of student debt incurred by medical school graduates. Enclosure I contains information on graduate medical education. You also asked us to provide information on trends in postgraduate dental education and student debt and thoracic surgery fellowships; that information can be found at enclosures II and III, respectively.