AMIA Board: specification of core competencies in Biomedical Informatics

In 1998 I launched a website called "<b>Medical Informatics and Leadership of Clinical Computing</b>" (now entitled "<b>Contemporary Issues in Medical Informatics- Common Examples of Healthcare Information Technology Difficulties</b>" at <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">this link</a>).<br /><br />Its theme was that leadership of IT in healthcare was severely lacking in the formal competencies needed to reach any measure of success, and in fact the lack of informatics competencies in the usual IT actors was causing wasted resources and patient harm.<br /><br />I had also commented that the term "Medical Informatics" itself was being misappropriated by anyone claiming to do anything with computers in medicine, even the creation of trivial and/or low-value programs.<br /><br />Sadly, little has changed in that regard since 1998; in fact things are much worse.  The meaning of the term "Medical Informatics" itself has become severely blurred, and job listings that use the term are largely misguided.  They often seek a nurse (most common) or doctor (less common) without formal education in the domain, who's dabbled with hospital IT systems, to lead clinical IT projects.  This is a totally inappropriate and even dangerous approach (example <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=leadership" target="_blank">here</a>).<br /><br />The American Medical Informatics Association has released a paper "<b>AMIA Board white paper: definition of biomedical informatics and specification of core competencies for graduate education in the discipline</b>" that is long, long overdue.  As of this writing, full text is available a this link:  <a href="http://jamia.bmj.com/content/early/2012/06/07/amiajnl-2012-001053.full">http://jamia.bmj.com/content/early/2012/06/07/amiajnl-2012-001053.full</a>.<br /><br />This paper certainly provides a robust affirmation of ONC's recommendations on healthcare IT leadership roles that I wrote of in my Oct. 2009 post "<a href="http://hcrenewal.blogspot.com/2009/12/onc-defines-taxonomy-of-health-it.html" target="_blank">ONC Defines a Taxonomy of Robust Healthcare IT Leadership</a>."<br /><br />Some highlights of the new AMIA paper:<br /><br /><blockquote class="tr_bq"><b>Abstract</b><br /><br /><div id="p-2">The AMIA <b>biomedical informatics (BMI)</b> core competencies have been designed to support and guide graduate education in BMI, <b>the core scientific discipline underlying the breadth of the field's research, practice, and education.</b> The core definition of BMI adopted by AMIA specifies that BMI is ‘the interdisciplinary field that studies and pursues the effective uses of biomedical data, information, and knowledge for scientific inquiry, problem solving and decision making, motivated by efforts to improve human health.’ Application areas range from bioinformatics to clinical and public health informatics and span the spectrum from the molecular to population levels of health and biomedicine. <b>The shared core informatics competencies of BMI draw on the practical experience of many specific informatics sub-disciplines. </b>The AMIA BMI analysis highlights the central shared set of competencies that should guide curriculum design and that graduate students should be expected to master. </div></blockquote><br />Note that Biomedical Informatics, which the Board feels is a broader term encompassing all of the information-science disciplines in healthcare and biomedical research, is defined as "a core scientific discipline underlying the breadth of the field's research, practice, and education."  <b>One does not acquire expertise in a scientific discipline without first rigorously studying that discipline, e.g., as is done in medical school</b> to gain optimal understanding of clinical medicine.<br /><br /><blockquote class="tr_bq">... The present articulation of BMI core competencies is intended to support AMIA and its members in promoting the discipline as a career choice, and to provide guidance to students and curriculum developers when choosing, designing (and implementing), or re-designing graduate-level academic BMI programs.</blockquote><br />(Who needs graduate education in Biomedical Informatics when all that seems to be needed is a little on-the-job dabbling?)<br /><br /><blockquote class="tr_bq">... Defining BMI as the scientific core of a discipline that has broad applications across health and biomedicine <b>highlights its foundational role and refutes the kind of reductionism that superficially explains BMI simply as the application of information technology (IT) to biomedical and health problems.</b></blockquote><br />I termed that phenomenon "Medical Instamatics" on that late 1990's site.  Unfortunately, the "reductionism" is all too prevalent today.  People whose BMI education and skill levels (which I define as the ability to apply deep knowledge and experience to successfully manage the unexpected, not just manage traditional activities via a book of "process"), are often at the amateur level -- in the same sense that I am a <a href="http://www.arrl.org/" target="_blank">radio amateur</a>, not a telecommunications/engineering professional -- or worse.  This wreaks havoc (as <a href="http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html" target="_blank">here</a>) in health IT, especially when led by senior management also incognizant of the issues. <br /><br /><blockquote class="tr_bq"><div id="p-11"><b>Definition</b>: Biomedical informatics (BMI) is the interdisciplinary field that studies and pursues the effective uses of biomedical data, information, and knowledge for scientific inquiry, problem solving, and decision making, driven by efforts to improve human health. </div></blockquote><blockquote><blockquote class="tr_bq"><div id="p-12"><b>Scope and breadth of discipline:</b> BMI investigates and supports <b>reasoning, modeling, simulation, experimentation, and translation </b>across the spectrum from molecules to individuals and to populations, from biological to social systems, bridging basic and clinical research and practice and the healthcare enterprise. </div></blockquote></blockquote><blockquote><blockquote><div id="p-13"><b>Theory and methodology:</b> BMI <b>develops, studies, and applies theories</b>, methods, and processes for the generation, storage, retrieval, use, management, and sharing of biomedical data, information, and knowledge. </div></blockquote></blockquote><blockquote><blockquote><div id="p-14"><b>Technological approach:</b> BMI <b>builds on and contributes to computer, telecommunication, and information sciences and technologies</b>, emphasizing their application in biomedicine. </div></blockquote></blockquote><blockquote><blockquote><div id="p-15"><b>Human and social context:</b> BMI, recognizing that people are the ultimate users of biomedical information, <b>draws upon the social and behavioral sciences</b> to inform the design and evaluation of technical solutions, policies, and the evolution of economic, ethical, social, educational, and organizational systems. </div></blockquote></blockquote><br />There is also a call for experts to:<br /><br /><ul class="list-unord" id="list-3"><li id="list-item-6"> <div id="p-24"><b><i>Acquire professional perspective:</i></b> <i>Understand and analyze the history and values of the discipline and its relationship to other fields while demonstrating an ability to read, interpret, and critique the core literature.</i></div></li></ul><br />In effect, health IT amateurs, including those in traditional business computing, have little to no formal education or experience in reasoning, modeling, simulation, experimentation, and translation; developing, studying, and applying theories; building on and contributing to computer, telecommunication, and information sciences and technologies; and drawing upon the social and behavioral sciences to inform design of these complex systems.<br /><b><br /></b><br /><blockquote class="tr_bq">BMI is the core scientific discipline that supports applied research and practice in several biomedical disciplines, including <i>health informatics</i>, which is composed of <i>clinical informatics</i> (including subfields such as medical, nursing, and dental informatics) and <i>public health informatics</i> (sometimes referred to more broadly as <i>population informatics</i> to capture its inclusion of <i>global health informatics</i>). There are related notions, such as <i>consumer health informatics</i>, which involves elements of both clinical and public health informatics. BMI in turn draws on the practical experience of the applied subspecialties, and works in the context of clinical and public health systems and organizations to develop experiments, interventions, and approaches that will have scalable impact in solving health informatics problems. However, it is the <i>depth of informatics methods, shared across the spectrum from the molecular to the population levels</i><a class="xref-bibr" href="http://jamia.bmj.com/content/early/2012/06/07/amiajnl-2012-001053.full#ref-3" id="xref-ref-3-2"></a> that defines the core discipline of BMI and provides its coherence and its professional foundation for defining a common set of core competencies.</blockquote><br />Here is the diagrammatic represention of the above in the full article:<br /><br /><br /><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiX0WhgzQnpXO8Sql66EOfWJVSqULu2qvMhhkceeEnMfmVzwyYi4C_q3RTsX3ET_IucsBpfwlghcZdLrPFR8fAGmIzTHdsIut9g_tdM8_0ngC16xdZAyUqsYWzdqPb-qx2WJ0FRSGXGOIC8/s1600/F1.large.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="220" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiX0WhgzQnpXO8Sql66EOfWJVSqULu2qvMhhkceeEnMfmVzwyYi4C_q3RTsX3ET_IucsBpfwlghcZdLrPFR8fAGmIzTHdsIut9g_tdM8_0ngC16xdZAyUqsYWzdqPb-qx2WJ0FRSGXGOIC8/s320/F1.large.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Biomedical informatics and its areas of application and practice, spanning the range from molecules to populations and society</td><td class="tr-caption" style="text-align: center;"></td><td class="tr-caption" style="text-align: center;"></td></tr></tbody></table><br />Finally, excerpts from the meat of the article on <b><i>Prerequisite knowledge and skills.  </i></b>This depth and breadth of knowledge does not come from studying business computing, dabbling with systems by nurses or physicians lacking formal domain education at the graduate level or beyond, or by guessing by the seat of one's pants:<br /><ul class="list-unord" id="list-2"><li id="list-item-14"><ul class="list-unord" id="list-4"><li id="list-item-16"> <div id="p-34"><b><i>Fundamental knowledge:</i></b> <i>Understand the fundamentals of the field in the context of the effective use of biomedical data, information, and knowledge. For example:</i></div><ul class="list-unord" id="list-5"><li id="list-item-19"> <div id="p-37"><i>... Healthcare: screening, diagnosis (diagnoses, test results), prognosis, treatment (medications, procedures), prevention, billing, healthcare teams, quality assurance, safety, error reduction, comparative effectiveness, medical records, personalized medicine, health economics, information security and privacy.</i></div></li></ul></li><li id="list-item-22"> <div id="p-40"><b><i>Procedural knowledge and skills:</i></b> <i>For substantive problems related to scientific inquiry, problem solving, and decision making, apply, analyze, evaluate, and create solutions based on biomedical informatics approaches.</i></div><ul class="list-unord" id="list-6"><li id="list-item-23"> <div id="p-41"><i>Understand and analyze complex biomedical informatics problems in terms of data, information, and knowledge.</i></div></li><li id="list-item-24"> <div id="p-42"><i>Apply, analyze, evaluate, and create biomedical informatics methods that solve substantive problems within and across biomedical domains.</i></div></li><li id="list-item-25"> <div id="p-43"><i>Relate such knowledge and methods to other problems within and across levels of the biomedical spectrum.</i></div></li></ul></li></ul></li><li id="list-item-26"> <div id="p-44"><b>Theory and methodology</b>: BMI develops, studies, and applies theories, methods, and processes for the generation, storage, retrieval, use, management, and sharing of biomedical data, information, and knowledge. All involve the ability to reason and relate to biomedical information, concepts, and models spanning molecules to individuals to populations: </div><ul class="list-unord" id="list-7"><li id="list-item-27"> <div id="p-45"><b><i>Theories:</i></b> <i>Understand and apply syntactic, semantic, cognitive, social, and pragmatic theories as they are used in biomedical informatics</i>. </div></li><li id="list-item-28"> <div id="p-46"><b><i>Typology:</i></b> <i>Understand, and analyze the types and nature of biomedical data, information, and knowledge.</i></div></li><li id="list-item-29"> <div id="p-47"><b><i>Frameworks:</i></b> <i>Understand, and apply the common conceptual frameworks that are used in biomedical informatics.</i></div><ul class="list-unord" id="list-8"><li id="list-item-30"> <div id="p-48"><i>A framework is a modeling approach (eg, belief networks), programming approach (eg, object-oriented programming), representational scheme (eg, problem space models), or an architectural design (eg, web services).</i></div></li></ul></li><li id="list-item-31"> <div id="p-49"><b><i>Knowledge representation:</i></b> <i>Understand and apply representations and models that are applicable to biomedical data, information, and knowledge.</i></div><ul class="list-unord" id="list-9"><li id="list-item-32"> <div id="p-50"><i>A knowledge representation is a method of encoding concepts and relationships in a domain using definitions that are computable (eg, first order logics).</i></div></li></ul></li><li id="list-item-33"> <div id="p-51"><b><i>Methods and processes:</i></b> <i>Understand and apply existing methods (eg, simulated annealing) and processes (eg, goal-oriented reasoning) used in different contexts of biomedical informatics.</i></div></li></ul></li><li id="list-item-34"> <div id="p-52"><b>Technological approach</b>: BMI builds on and contributes to computer, telecommunication, and information sciences and technologies, emphasizing their application in biomedicine. </div><ul class="list-unord" id="list-10"><li id="list-item-35"> <div id="p-53"><b><i>Prerequisite knowledge and skills:</i></b> <i>Assumes familiarity with data structures, algorithms, programming, mathematics, statistics.</i></div></li><li id="list-item-36"> <div id="p-54"><b><i>Fundamental knowledge:</i></b> <i>Understand and apply technological approaches in the context of biomedical problems. For example:</i></div><ul class="list-unord" id="list-11"><li id="list-item-37"> <div id="p-55"><i>Imaging and signal analysis.</i></div></li><li id="list-item-38"> <div id="p-56"><i>Information documentation, storage, and retrieval.</i></div></li><li id="list-item-39"> <div id="p-57"><i>Machine learning, including data mining.</i></div></li><li id="list-item-40"> <div id="p-58"><i>Networking, security, databases.</i></div></li><li id="list-item-41"> <div id="p-59"><i>Natural language processing, semantic technologies.</i></div></li><li id="list-item-42"> <div id="p-60"><i>Representation of logical and probabilistic knowledge and reasoning.</i></div></li><li id="list-item-43"> <div id="p-61"><i>Simulation and modeling.</i></div></li><li id="list-item-44"> <div id="p-62"><i>Software engineering.</i></div></li></ul></li><li id="list-item-45"> <div id="p-63"><b><i>Procedural knowledge and skills:</i></b> <i>For substantive problems, understand and apply methods of inquiry and criteria for selecting and utilizing algorithms, techniques, and methods.</i></div></li></ul></li><li id="list-item-49"> <div id="p-67"><b>Human and social context</b>: BMI, recognizing that people are the ultimate users of biomedical information, draws upon the social and behavioral sciences to inform the design and evaluation of technical solutions, policies, and the evolution of economic, ethical, social, educational, and organizational systems. </div><ul class="list-unord" id="list-13"><li id="list-item-50"> <div id="p-68"><b><i>Prerequisite knowledge and skills:</i></b> <i>Familiarity with fundamentals of social, organizational, cognitive, and decision sciences.</i></div></li><li id="list-item-51"> <div id="p-69"><b><i>Fundamental knowledge:</i></b> <i>Understand and apply knowledge in the following areas:</i></div><ul class="list-unord" id="list-14"><li id="list-item-52"> <div id="p-70"><i>Design: for example, human-centered design, usability, human factors, cognitive and ergonomic sciences and engineering.</i></div></li><li id="list-item-53"> <div id="p-71"><i>Evaluation:</i> <i>for example, study design, controlled trials, observational studies, hypothesis testing, ethnographic methods, field observational methods, qualitative methods, mixed methods.</i></div></li><li id="list-item-54"> <div id="p-72"><i>Social, behavioral, communication, and organizational sciences: for example, computer supported cooperative work, social networks, change management, human factors engineering, cognitive task analysis, project management.</i></div></li><li id="list-item-55"> <div id="p-73"><i>Ethical, legal, social issues: for example, human subjects, HIPAA, informed consent, secondary use of data, confidentiality, privacy.</i></div></li><li id="list-item-56"> <div id="p-74"><i>Economic, social and organizational context of biomedical research, pharmaceutical and biotechnology industries, medical instrumentation, healthcare, and public health.</i></div><div id="p-74"><br /></div><div id="p-74"><br /></div></li></ul></li></ul></li></ul>While nobody is an expert in all of these areas, skills in many of them are essential for successful and <b>safety-promoting </b>leadership in the health IT domain.<br /><br />I repeat, this depth and breadth of knowledge does not come from studying business computing, dabbling with health IT, or by guessing by the seat of one's pants.  It comes about from rigorous education and experience in the appropriate domains at the graduate and (especially) post-doctoral levels.<br /><br />Amateurs mistakenly put in leadership positions, and their organizations, are going to increasingly find themselves in legal hot water over mistakes in design and implementation that result in patient harm, security breaches, overbilling and other issues.<br /><br />That is probably what it will take to have hospitals manage health IT talent more appropriately.<br /><br />Finally, I plead guilty to tooting my own profession's horn.<br /><br />Somebody needs to when the stakes are so high for patients.<br /><br />-- SS

AMIA Board: specification of core competencies in Biomedical Informatics

In 1998 I launched a website called "Medical Informatics and Leadership of Clinical Computing" (now entitled "Contemporary Issues in Medical Informatics- Common Examples of Healthcare Information Tech…

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The Case of the Vanishing Graduate Medical Education Funds

While primary care falters in the US, those who teach it seem to feel increasingly poverty stricken.  Now it appears that one reason for this is an amazing example of multiple failures of transparency and accountability.  Let me work through it, begging your pardon for a little bit of "inside baseball," medical education style.  The results suggest how we desperately need some medical disciples of Sherlock Holmes.<br /><br /><strong>Background</strong><br /><br />My personal experience and increasing data suggests that most medical school faculty believe that their teaching is not valued by their institutions because teaching brings in no external funds.  In 2004, Dr Catherine DeAngelis, then the editor of JAMA, wrote "few medical schools provide adequate, if any, reimbursement for teaching time."(1)  (See<a href="http://hcrenewal.blogspot.com/2005/01/medical-schools-charge-more-for.html"> this 2005 post</a>.)   This seems absurd on its face, since what are medical schools for if it is not to provide teaching.  <br /><br />However, there is evidence of this mission-hostile behavior.  In 2007, we <a href="http://hcrenewal.blogspot.com/2007/04/medical-schools-to-faculty-show-me.html">quoted </a>from a revealing interview with Dr Lee Goldman, Executive Vice President for Health and Biomedical Sciences at Columbia University,(2) who stated that "taxpayers," faculty who "generate more [money] than they cost," are valued most, and implied that faculty who focus on teaching are regarded as "welfare recipients," who bring in less external funding, and are valued least.  In 2010, we <a href="http://hcrenewal.blogspot.com/2010/12/american-medical-schools-are-only-in-it.html">noted</a> the results of a large-scale survey presented by Dr Linda Pololi in which 51% of faculty felt that the administration only valued them for the money that they brought in, and half felt that their institutions did not value teaching.(3)<br /><br />Yet while faculty seem to believe that educational institutions receive little if any money to pay for teaching, it is not clear why the believe something so counter intuitive, and it is less clear what money actually goes to pay for medical education.<br /><br /><strong>US Government Funding for Graduate Medical Education</strong><br /><br />However, several recent publications affirm that actually a lot of money goes towards one important form of medical education, yet the specifics of the money flows are shrouded in secrecy.  In the May, 2012, SGIM Forum, Dr Mark Liebow and colleagues summarized some of what is known about federal support of graduate medical education, that is, education of interns, residents, and other house officers.(4)  There are two streams of money that flow from Medicare to US hospitals:<br /><blockquote><em>Direct GME (DGME) payments help hospitals pay the salaries of residents, teaching faculty, and support staff</em>. DGME is the product of three numbers: a per resident amount that varies by hospital, adjusted annually for inflation; the number of residents in the hospital (capped for each hospital at 1997 levels); and the fraction of discharges from the hospital that are Medicare beneficiaries. <em>The Indirect Medical Education (IME) payment is a percentage amount added on to each DRG payment</em>. The percentage is calculated via a complex formula (the only US statute containing an exponent!), where the key factor is the ratio of interns/residents to beds (IRB ratio).</blockquote><br />These two streams are of considerable size:<br /><blockquote>Of the <em><strong>$9.2 billion</strong> Medicare paid for GME in 2010, <strong>$3 billion</strong> was for DGME and <strong>$6.2 billion </strong>for IME.</em> The money is <em>paid to hospitals sponsoring training programs</em> rather than to the training programs or other hospitals where training occurs. While about 1,100 hospitals receive GME payments, <em>66% goes to the 200 hospitals that have the largest numbers of residents.</em></blockquote><br />So, the 200 largest hospitals get about $2 billion in direct GME money (and presumably about another $4 billion in indirect money). This averages then to about $10 million DGME and $20 million indirect GME per hospital. <br /><br />Thus, teaching, at least the teaching of interns, residents, and other house-staff does pay, and much more than trivial amounts. (Note that these amounts are not for teaching of medical students, which ought to be supported by other funding streams.) <br /><br />Why then do faculty think that teaching does not bring in any money?<br /><br /><strong>The GME Money Vanishes</strong><br /><br />An article by Dr Saima I Chaudhry and colleagues in the American Journal of Medicine begins to explain, although the explanations are found between the lines.(5)<br /><br />First of all, while the graduate medical education money is paid by the government to the hospitals, the government does not publish what it pays to individual hospitals:<br /><blockquote>It has been previously reported that<em> the amount of GME funding individual hospitals receive is not publicly reported </em>by the Centers for Medicare and Medicaid Services,.... </blockquote><br />The government also does not hold the hospitals accountable for how they spend this money, nor for the quantity or quality of education they supply in exchange for it.<br /><br />Remarkably, Chaudhry et al imply that that the people who run graduate medical education teaching programs also may not know how much money their hospitals receive from the government to fund their programs. The introduction to their article noted:<br /><blockquote><em>It is unclear how much program directors know about the amount and flow of DME funds to their programs</em>. Program directors' beliefs about the transparency of funding to their programs, or their desire to influence how funds are distributed to them, also are unknown.</blockquote><br />The article reported on a survey of internal medicine residency program directors which asked about "their knowledge of D[G]ME funding for their programs, the transparency with which funds are distributed to them, and their desire to influence this disbursement." The researchers sent surveys to 372 member programs, representing 97.1% of all US internal medicine residencies. They got 268 responses, a 72.0% response rate. <br /><br />The main results were that <em>only 159/268 (59.3%) of program directors had tried to find out how much DGME money their programs received, and of those, only 84 (52.8% of those enquiring, but <strong>only 31.3% of all respondents</strong>)<strong> actually knew how much money their programs got</strong>.</em> <br /><br />Of the 92 program directors who did not even try to discover how much money their programs received, approximately <em>21% said that "no one would tell me," 21% said that the "information would be inaccurate," 14% said they "don't know who to ask," and 2% were "afraid to ask." </em><br /><br /><strong>Summary</strong><br /><br />US medical school faculty, especially those in primary care, increasingly feel pressured to perform activities that they perceive brings in money from external sources. They tend to believe that their own teaching somehow does not bring in any money, and that their careers will fail if they do not put more emphasis on other activities that the institution views as more profitable.<br /><br />However, literally billions of US government dollars go to support the education of house staff, including the salaries of faculty who teach interns and residents, who probably are the majority of physician faculty. Faculty probably do not know this, because the government does not publish the amounts given to individual hospitals, nor demand of the hospitals any accountability for how they spend the money they receive.<br /><br />Presumably, the top executives of each hospital know how much money the government gives them. Nonetheless, the majority of physician leaders of residency programs are never told these amounts, apparently because their hospital executives kept the amounts secret. Many of those educators who have tried to find out the figures were unsuccessful. Some did not even try to find out based on beliefs that their attempts would be unsuccessful, any amounts they discovered would be inaccurate, the people who knew the amounts were hidden, or that it would be dangerous to their careers to even try.<br /><br />Thus billions of dollars of money flowing from the government to fund graduate medical education seems to have vanished in an amazing example of widespread deficiencies in accountability and transparency.<br /><br />There are many people who blame government for many social ills. In this case, one can blame the US Congress for not writing a law that makes the money flows transparent and hospitals accountable for providing good educational value for the money provided. One can also blame the executive branch, particularly the Center for Medicare and Medicaid Services (CMS) of the US Department of Health and Human Services (DHHS) for not making the money flows and the values received for them transparent.<br /><br />There are a few people, including this author, who also blame the leadership of health care organizations for many of the problems besetting health care. In this case, one can blame top leadership, presumably CEOs and chief financial officers (CFOs) of hospitals for hiding the amounts of money they receive from Medicare to finance graduate medical education. One can also blame the physician leaders of residency programs for not insisting that they know the true sources of financial support for their programs, obtain budgets that reflect this support, and recognition that their faculty really do bring in external funds for their teaching of house staff (and are thus valuable "taxpayers" in Dr Goldman's parlance.)<br /><br />It is amazing that such amounts of money have been flowing for years mostly in secret. The secrecy has fueled incorrect, and in retrospect, bizarre ideas about the funding of medical education, and the value of medical educators to their institutions. This secrecy, in turn, has helped suppress the morale of medical educators, support the control of managers of health care professionals, and distort the flow of money within academic institutions and to compensation for certain favored individuals.<br /><br />Would our dysfunctional health care system not be better off if we demanded transparency and accountability from its leaders?  In particular, the US government should make payments to hospitals for graduate medical education completely transparent, and develop a system to hold these hospitals accountable for how they spend the money.  Meanwhile, top leaders of hospitals receiving this money should make the amounts transparent, first to the people who are supposed to be doing the education that the money pays for, and to the public at large.  This would allow those running the relevant educational programs to develop reasonable and realistic budgets, to treat their faculty with respect, and to demonstrate what value they provide for the money received.  <br />The ongoing anechoic effect, and related deception and secrecy fostered by leaders in health care are major reasons our health care system is so dysfunctional, that costs are so high, and access and quality so poor.  True health care reform would ensure health care leaders put the mission before their personal enrichment, and act ethically with accountability, transparency, and honesty. <br /><strong>References</strong><br />1.   DeAngelis CD. Professors not professing. JAMA 2004; 292: 1060-1.  Link <a href="http://jama.ama-assn.org/cgi/content/extract/292/9/1060">here</a>.<br />2.  Goldman L, Halm EA.  A view from the top: general internal medicine from the perspective of a chair and dean.  SGIM Forum, April, 2007.  Link <a href="http://www.sgim.org/userfiles/file/Forum/2007/Forum200704.pdf">here</a>.<br />3.  Pololi L, Ash A, Krupat E.  Faculty Values in the Culture of Academic Medicine: Findings of a National Faculty Survey. Link <a href="https://www.aamc.org/download/154216/data/your_career_is_more_than_your_specialty_-_246.pdf">here</a>.<br />4.  Liebow M, Jaeger J, Schwartz MD. How does Medicare pay for graduate medical education? SGIM Forum, May, 2012.  Link <a href="http://www.sgim.org/userfiles/file/May%202012%20Forum/May2012-09.pdf">here</a>. <br />5. Chaudhry SI, Khanijo S, Halvorsen AJ, McDonald FS,Patel K. Accountability and transparency in graduate medical education expenditures. Am J Med 2012; 125: 517-522. Link <a href="http://www.amjmed.com/article/S0002-9343%2812%2900071-X/fulltext">here</a>.

The Case of the Vanishing Graduate Medical Education Funds

While primary care falters in the US, those who teach it seem to feel increasingly poverty stricken.  Now it appears that one reason for this is an amazing example of multiple failures of transparency…

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