To complete requirements under the Veterans Access, Choice, and Accountability Act of 2014 (Choice Act), VHA through its Office of Academic Affiliations must place 1,500 new Graduate Medical Education (GME) resident slots, or approximately 4,500 new residents, into VA medical centers within the next five years, focusing on primary care, mental health, and other underserved specialties. VA must also report on their progress, describe why if any they are unable to fill these new positions, and report if new residents are willing to consider VA for futue employment. GME is important to VA since presently one-third of all U.S. physician residents rotate through a VA medical center and are involved in 37% of VA's physician services while caring annually for 2.5 million veterans. Presently, VA clinical training programs are VA's best means to recruit medical staff, as nearly 60% of VA staff physicians rotated through a VA medical center as part of their GME training. In FY 2005-2010, OAA increased the number of residents by 1,200 positions involving 3,600 residents as part of a GME Enhancement Program 2005-2010. However, there is grave concern that VA may not have sufficient medical staff or space to accommodate these new Choice residents. Our purpose is to determine if, and how, VA/OAA can accommodate 4,500 new Choice Act residents across medical centers and how Choice residents will contribute to GME education outcomes in the face of potentially rising resident to staff ratios. GME education outcomes include clinical opportunities provided to residents to gain meaningful patient care experience, satisfaction over the clinical learning experience, and likelihood residents will consider their clinical host for future employment. Our objective is to determine at present staffing and resident levels do trainees add to clinical workload net of supervision costs. We also assess whether the exogenous GME Enhancement Program 2005-2010 resulted in expanding VA clinical opportunities, rising satisfaction rates with VA's clinical learning environment, and ultimately on increasing residents' employability, or their willingness to consider VA for future employment. By studying GME Enhancement of FY 2005-2010, OAA can forecast potential GME education outcomes for the new Choice Act for FY 2015-2019. Data are obtained from CDW through VA's Allocation Resource Center, OAA's paid slot file, survey of Designated Learning Officers, and Learners' Perceptions Survey of VA trainees, plus VHA's All Employee Survey data for FY 2001 through FY 2015. Cross-nested, multilevel models will be selected using a Best Approximating Model Method to measure the impact of exogenous increases in GME Enhancement 2005-2010 residents on clinical workload, and on GME education outcomes (clinical opportunities, satisfaction, employability), by specialty (primary care, psychiatry, and other specialties), and a a function of characteristics of the medical center, residents, and clinical staff, among others. The performance of the final workload and outcome models will be assessed, and applied to simulation studies to determine how different allocations of Choice positions across VA medical centers will impact national GME education outcomes planned for FY2016-2020. Finally, timing of the study, with on-going relationships with OAA, will enable investigators a unique opportunity to test some of its predictions and assess overall performance of estimated predictive models, with corrective actions, if necessary, planned.