The history of calls for reform in graduate medical education and why we are still waiting for the right kind of change

The author reviews the history of calls for reform of graduate medical education (GME), beginning with the Rappleye report of 1940, the first report on GME. Several continuities emerge. First, the reports have regularly called for GME to serve the "health needs of society." However, these perceived "needs" have continually been shifting as medicine and society evolve, thereby presenting GME a moving target. Second, the reports have regularly called for GME to focus more on education and less on service in order to avoid exploiting residents and compromising their training. Third, GME is a multifaceted subject. Reports on GME have typically addressed one part or another but not the subject as a whole. In their selectivity, the reports have reflected the particular perspective of the sponsoring groups. What the reports have generally not discussed, but what is underscored by calls for reform, is that GME is expensive, and any effort to improve its quality will be costly in terms of money, faculty time, or both. Thus, the profession has become complicit in maintaining the status quo. Any successful effort toward reform must acknowledge that GME functions as part of the larger health care delivery system, whose fate will ultimately determine the quality and robustness of GME in America.