Minutes of Meeting,
September 17, 2003
The Council on Graduate Medical
Education (COGME) convened in the Versailles Room I in the Holiday Inn
Select, 8120 Wisconsin Avenue, Bethesda, Maryland, at 8:00 a.m., Dr. Carl
J. Getto, Chairman, presiding. Originally scheduled to meet the next
day, September 18, COGME adjourned following the conclusion of the
current meeting because of the advent of extremely inclement weather
conditions.
Members Present
Carl J. Getto, M.D., Chair
Robert L. Johnson, M.D., Vice Chair
Regina M. Benjamin, M.D., M.B.A, Member
Laurinda L. Calongne, Member
William Ching, Member
Allen Irwin Hyman, M.D., FCCM Member
Rebecca M. Minter, M.D., Member
Lucy Montalvo, M.D., M.P.H., Member
Angela Dee Nossett, M.D., Member
Earl J. Reisdorff, M.D., Member
Russell G. Robertson, M.D., Member
Jerry Alan Royer, M.D., M.B.A., Member
Susan Schooley, M.D., Member
Humphrey Taylor, Member
Donald C. Thomas III, M.D., Member
Douglas L. Wood, D.O., PH.D., Member
Howard Zucker, M.D., Designee of the Deputy Assistant Secretary for Health
Tzvi M. Hefter, Designee of the Centers for Medicare and Medicaid Services
Stephanie H. Pincus, M.D., M.B.A., Designee of the Department of Veterans
Affairs
Staff:
Jerald M. Katzoff, Acting Deputy Executive Secretary
Howard Davis, Ph.D.
Helen Lotsikas, M.S.
Eva Stone
Welcome and Announcements
Dr. Getto welcomed both new and old members and stated that since
there is no pending legislation to reauthorize COGME, he wanted to
accomplish as much as possible at this meeting. He stated that the agenda
would be altered because of pending inclement weather to allow the
workforce paper to be considered in the afternoon rather than the next
day.
After introducing the new members to COGME, the Chair presented Dr. Stan
Bastacky a plaque in recognition for his dedicated service as Acting
Executive Secretary to COGME. Dr. Getto noted that Dr. Bastacky had been
reassigned to the National Health Service Corps, Ready Responder Program.
Dr. Bastacky responded with comments about his service with COGME, noting
the many significant accomplishments during his tenure.
Elizabeth M. Duke, Ph.D., HRSA Administrator, after recognizing Dr.
Bastacky's contribution to COGME, explained changes occurring in HRSA.
She noted the advent of the Ready Responder Corps. She commented on the
strong expansion of health centers, one of the important initiatives of
the President as well as the number of excellent applications HRSA
received for health centers during the first cycle funding in FY2003. She
stated that those applications not able to be funded during the first
cycle will be funded during FY2004 and noted that the establishment of new
health centers was ahead of schedule. Dr. Duke remarked that the National
Health Service Corps, another important initiative of the President, was
well supported during FY2003 and hoped that the full complement of
authorized 3,600 slots could be filled in FY2004. She noted the high
retention rate of National Health Service Corps physicians.
Dr. Duke explained that the goal of the Ready Responder Corps was both to
serve the underserved and to assist underserved areas to compete better
for the National Health Service Corps and other providers. The Corps will
also be mobilized to combat bioterrorism. She explained that the
programNational Hospital Bioterrorism Preparedness Program is State
administered and each State has submitted a preparedness program.
Overcoming several obstacles, the States are beginning to implement the
program. Dr. Duke concluded by stating that HRSA is preparing to do more
with current resources. She also explained the procedures used to improve
the grant making process and noted that the FY2004 grant preview
programHRSA Grant Preview is in placeavailable.
Kerry Nessler, R.N., M.S., Associate Administrator for the Bureau
of Health Professions, welcomed new members and announced staff changes in
BHPr: Ms. Nessler acknowledged the following personnel: David Rutstein ,
Deputy DirectorAssociate Administrator for Health Professions; Carol
Bazell, Director, Division of Medicine and Dentistry and instrumental in
COGME; Roger Straw, Acting Branch Chief, Dental and Special Projects
Branch; Jerry Katzoff, Acting Deputy Executive Secretary, COGME. She
thanked Stan Bastacky for his service to COGME.
Ms. Nessler described the outcomeoutcomes of the International Workforce
Conference in Oxford, England held November 4th and 5th. Issues
discussed at the conference included physician supply and demand and hours
worked by residents. Participants discussed methods to develop common
data elements in order to improve reporting on physician workforce data.
She and Carl Getto were among the attendees. She described the steps
involved in the Bureau's strategic planning process, including inviting
fifty outside organizations to the Bureau to provide input into the
planning process.
Jerald Katzoff, Acting Deputy Executive Secretary, Mr. Katzoff
reviewed the agenda and briefing book materials and acknowledged staff.
Carl Getto noted Dr. Marvin Dunn's death, stating that Dr. Dunn and his
words of wisdom will be greatly missed. Dr. Getto then introduced panel
participants.
Presentations on the Physician Workforce
Elliott Fisher, M.D., M.P.H., Center for Evaluative Studies, Dartmouth
Medical School. Dr. Fisher, discussed his research concerning the
geographic variation in physician supply, explaining that he based his
analysis on Hospital Referral Region data. He shared the findings which
showed that the generalist physician supply grew modestly while the growth
of specialist physician supply was much more rapid. He observed that
there is no evidence that increases in the per capita supply of specialist
physicians and the intensity of their services result in any difference in
health status. Dr. Fisher considers that while more specialist physicians
are not needed, current GME policies exacerbate the disparities in
physician supply and may contribute to a poorer quality of care.
Jonathan Weiner, Dr. P.H., Professor of Health Policy and Management,
The Johns Hopkins University's Bloomberg School of Public Health,
discussed his continued research on managed care staffing patterns. Dr.
Weiner noted the expected publication of his study on staffing patterns of
prepaid group practices. He described the methodology used to derive
physician staffing patterns in prepaid health delivery organizations,
including trends in the staffing patterns of Kaiser Permanente. He
compared the results with comparable data currently existing in the
country. He noted that the demographics of the population served by these
organizations are similar to the general population demographics. The
proportion of primary care physicians ranges from 41% to 46% percent of
the overall physician supply in these organizations. However, specialty
care in these organizations increased at twice the rate (2.4% annually) as
of the national rate (1.2%). National growth in the use of non-physician
providers (NPP) exceeded the growth of NPP, used in Kaiser Permanente,
which occurred mostly in NNP specialists. Dr. Weiner felt that efficient
practice could support fewer physicians than currently exist with good
quality outcomes.
Robert Butler, M.D., President and CEO, International Longevity Center,
discussed the impact of an aging society on physician workforce
requirements. The factors he noted that will influence the projected need
for physicians to care for older persons are changes in demography,
utilization patterns, and physician productivity. He noted the multiple,
complexity, interactive physical and psychosocial pathologies of older
persons, particularly those over the age of 75. This group is also
subject to adverse reactions caused from the use of many different
drugs. Dr. Butler stated that 17% of older patients in hospitals suffered
adverse drug reactions. Since the current medical lexicon is not
sensitive to aging and noting that the marked increase in the proportion
of elderly expected between 2000 and 2050, Dr. Butler stressed the need
for physicians that are trained (geriatricians) to provide appropriate
care for this group of persons.
Impact of Residency Duty Hours Restrictions-Cost and Structural
Adaptations
Danielle Carrier, Program Director for Operations Improvement,
University Health System Consortium (UHC), described the results of
the UHC Benchmarking Project survey. The Project goals were: 1) identify
successful strategies to comply with the new resident work hour
limitations; 2) determine the current level of compliance with the new
ACGME standards; 3) focus on changes n the service delivery process; and
4) provide an opportunity for knowledge sharing among members. Survey
respondents detailed compliance strategies, with scheduling cited as the
most common. Based upon respondents cited cost figures, the medical costs
were $170,000 per program or $4,834 per resident, primarily resulting from
additional labor costs for additional FTEs.
Ms. Sunny Yoder, Association of American Medical Colleges (AAMC),
conveyed the fact that the AAMC was actively involved in research and
initiatives to help members develop coping strategies. The AAMC held an
Educational Conference last September and is to hold one again during the
latter part of this September on the topic dealing with implementing
requirementACGME requirements for resident physician duty hours. She
described some positive as well as adverse results from these
restrictions. Ms. Yoder described possible adaptive responses that may
evolve. She noted that finding a balance between regulatory-style
enforcement and traditional accreditation processes will constitute a
challenge.
Thomas Whalen, M.D., Program Director, General Surgery, Robert Wood
Johnson Medical School, described the accommodation his surgery
program made to the duty hour restrictions. He expressed concern about
the impact of duty hour restrictions on the training, particularly of
surgical residents. He opined that duty hour limitations would cause
residents to lose the opportunity to learn from their mistakes. A major
problem lies in the availability of resources. Administrators will say,
“It is your problem – run with it.”
Brett Robins, M.D., Program Director and Assistant Professor, Med/Peds,
University of Rochester, considers that excessive duty hours
disheartens students and causes them to be cynical. He expressed support
for duty hour restrictions and wondered why there was such a long period
before these restrictions were instituted.
Following the above panel discussion, Dr. Getto introduced Mrs. Ruth
Bletzinger.
University of Michigan Supreme Court Case Ruling
Ms. Ruth Beer Bletzinger, Director, Division of Community and Minority
Programs, AAMC, discussed the implications of the University of
Michigan Supreme Court Case ruling for medical school admission criteria
needed to achieve the goal of educating a diverse physician workforce.
Dr. Getto thanked Ms. Bletzinger for her discussion and then introduced
Mr. Salsberg.
Report on the Physician Workforce
Edward Salsberg, Director of the Center for Health Workforce Studies,
State University of New York, presented a draft copy of his report
“Development of a Framework for Revised COGME Physician Workforce Goals.”
The paper contained findings of probable projected shortages over the next
20 years in the physician workforce in both the primary and non-primary
care sectors, and contained eight recommendations, which called for the
need for (a) phased, modest increases in enrollments in both the
undergraduate and graduate medical education, (b) modest increases in the
number of non-physician providers, (c) systems to track the supply,
demand, and need for physicians, and (d) expanded programs funded by the
Public Health Service that canto help meet expected future physician
workforce needs. The draft recommendations were leftprojected on thea
screen for the benefit of COGME during its discussion.
During the discussion, Mr. Salsberg stated that he had tried to respond to
the comments and concerns expressed at COGME's previous meeting held in
April. He explained that this version of the paper explicated more
clearly the underlying assumptions and included scenarios portraying
different assumptions. He then proceeded to discuss the findings,
background, methodology, and potential recommendations, reiterating
previous caveats concerning the difficulties of forecasting.
The session was opened to discussion. Dr. Royer remarked on comments
concerning the paper submitted by Jack Colwill, M.D., which contained two
assertions: (1) the type of health care delivery system would affect the
physician supplydemand; and a (2) a taut physician supply would restrain
costs. Dr. Colwill further stipulated that COGME should still note its
concern about the decline in the supply of primary care physicians.
COGME members discussed the basis and implications of assumptions and the
rationale of the proposed recommendations. During Council deliberations,
members expressed several concerns. Some of these concerns dealt with
the tenuous nationsnature of the assumptions, the fact that the problem of
physician maldistribution was not addressed, and the ineffectiveness of
directing GME policy without addressing overall reimbursement issues.
Dr. Getto recognized Dr. Marilyn Biviano, Director of the National Center
for Health Workforce Analysis (NCHWA) in the Bureau of Health
Professions. Dr. Biviano explained that the NCHWA was currently preparing
a physician manpower workforce report using their own as well as Mr.
Salsberg's the Bureau's workforce models., but with differing assumptions
about the future compared with Mr. Salsberg's analysis. She stated that
since the report had not yet been cleared by HRSA, she could not share the
report findings with Council members at this time. However, the NCHWA
study will not indicate any long-term shortage physician shortage.
After considerable discussion, Dr. Getto achieved Council consensus by
asking the contractor to incorporate several revisions into the report.
Revisions included the need for re-writing one or more recommendations,
deleting the recommendation calling for modest increases in the number of
non-physician providers, and including a statement concerning the
desirability of COGME's continued tracking of physician access in
underserved areas
The Council gave preliminary approval to the findings and revised
recommendations of the draft report, subject to approval of the final
editing at a later date.
The meeting was adjourned at 4:52 p.m.