• Diane R Rittenhouse, Alexandra S Ament, and Kevin Grumbach.
• Mathematica, Oakland, CA.
• Fam Med. 2020 Sep 1; 52 (8): 551-556.

Background And ObjectivesGraduate medical education (GME) determines the composition and distribution of the physician workforce in the United States. Federal and state governments heavily subsidize GME but in most cases do not tie subsidies to national or state physician workforce goals. As a result, GME sponsoring institutions (eg, teaching hospitals, schools of medicine, federally qualified health centers) decide how many and what type of physicians to train. The objective of this study was to better understand the factors that influence decision-making by sponsoring institutions.MethodsBetween May and December 2018, we interviewed 35 national or state GME policy leaders and an additional 26 GME leaders from a purposive sample of four sponsoring institutions. We analyzed interviews following a conventional content analysis approach to identify emergent themes.ResultsWhen considering investing in GME, we found that sponsoring institutions do not consider national or statewide workforce recommendations. Instead, they weigh multiple factors of concern to their institution, including public GME subsidies, market competition, potential clinical revenues, academic stature, local workforce demands, as well as their own organization's mission/culture, staffing, financial reserves, educational leadership, teaching resources, and size.ConclusionsUnless and until the incentives for sponsoring institutions are strongly aligned with national and state physician workforce priorities based on public need, progress on creating a more balanced physician workforce will not occur.

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