Minutes of COGME 9/98 Meeting

The Council on Graduate Medical Education (COGME) met at 8:30 a.m. on April 10 in the Versailles I Meeting Room, of the Holiday Inn Select, Bethesda, MD. Dr. Carl J. Getto, COGME Chair presided. The plenary meeting concluded that day at 3:01 p.m. It reconvened the next morning, April 11 a.m. at 8:00 a.m. in the same room and adjourned at 10:53 a.m. that day.

Members Present:
Carl J. Getto, M.D., Chair
F. Marian Bishop, Ph.D., M.S.P.H., Vice-chair
William Ching, Member
Allen Irwin Hyman, M.D., FCCM, Member
Robert l. Johnson, M.D., Member
Ann Kempeski, Member
Laurinda l. Calongne, LCSW, BACS, Member
Jerry Alan Royer, M.D., M.B.A., Member
Donald C. Thomas III, M.D., Member
Stephanie H. Pincus, M.D., M.B.A., Designee of the Department of Veterans Affairs
Tzvi M. Hefter, Designee of the Centers for Medicare and Medicaid Services
Susan Schooley, M.D., Member
Regina M. Benjamin, M.D., M.B.A, Member
Douglas L. Wood, D.O., Ph.D., Member
Lucy Montalvo-Hicks, M.D., M.P.H., Member

Members absent:
Humphrey Taylor, Member
Arthur J. Lawrence, Ph.D., Designee of the Assistant Secretary for Health

Also present:
Sam Shekar, M.D., M.P.H., Assistant Surgeon General & Associate Administrator for Health Professions

Staff:
Stanford M. Bastacky, D.M.D., M.H.S.A., Acting Executive Secretary
Jerilyn K. Glass, M.D., Ph.D., Acting Deputy Executive Secretary
Richard Diamond, M.D., M.P.A.
Jerald Katzoff
Helen Lotsikas
Herbert Traxler, Ph.D.
Eva Stone

Welcome and Announcements:
Dr. Getto opened the meeting. After an introduction of and a brief update of their current activities by Council Members, Dr. Getto introduced Dr. Sam Shekar. Dr. Shekar acknowledged the panel participants and congratulated Dr. Marian Bishop as the new COGME vice-chair and Dr. Regina Benjamin on her nomination as president of the Medical Association of the State of Alabama. She is the first African-American women to be nominated as the president of a state medical society. Dr. Shekar explained how the BHPr had positioned itself to carry out its mission in the health system in providing resources to train an adequate and competent health work force. He concluded by relating the COGME's analyses of physician workforce to the appropriateness of skills in which physicians need to be trained, especially in the area of public health emergencies.

Dr. Getto recognized Dr. Joe Ivy-Boufford, former COGME Member and Vice-Chair, for her long and dedicated leadership to COGME.

Views of the Adequacy of the Physician Workforce:
Richard Cooper, M.D., Director, Health Policy Institute, Medical College of Wisconsin, described the methodology used in his analysis and the important instrumental variables, particularly the long-term population and income growth variables, that influence the demand for medical services. He proposed four conclusions based upon his analysis: 1) the U.S. appears to be in the early stages of a deepening shortage of physicians; 2) we need to expand residency training opportunities to meet the increasing need for non-primary care specialties; 3) we need to foster the development of nurse practitioners and other non-physician clinician in primary care; 4) we need to increase medical education capacity within the U.S. to meet future workforce needs adequately.

Fitzhugh Mullan, M.D., Contributing Editor, Health Affairs, noted the stability of the parameters of U.S. allopathic medical school graduates, the increasing number of osteopathic graduates, and the 4-5,000 international medical school graduates entering graduate medical education. Citing the 2 to 1 ratio of applicants for allopathic medical school admission, Dr. Mullan argued that we need to expand the number of students trained in U.S. undergraduate medical schools to fill the need for graduate medical education positions. Dr. Mullan opposed increasing the number of graduate medical education positions funded with public monies; however, investment in the expansion of undergraduate medical education might be used to achieve certain defined public goals, i.e., achieving diversity, and an increased National Health Service Corps.

Kevin Grumbach, M.D., Director, Center for California Health Workforce Studies, University of California, San Francisco, stated his disagreement with the thesis advance by Dr. Cooper that the supply of physicians is the result of economic determinism. Rather, Dr. Grumbach argues, the supply of physicians is the result of active public intervention. We should use public planning to achieve an overall workforce composition that is best suited to an efficient, equitable, and health promoting health care system.

Jonathan Weiner, Dr. P.H., Professor and Deputy Director, Johns Hopkins Health Services Research and Development Center, emphasized the importance of looking at the assumptions behind any rationale for providing medical professionals. We need to do more research; but we will have to make decisions in the use of resources with respect to cost and effectiveness. We should also be more directive in using subsidies to make it feasible for a young clinician to practice in underserved areas rather than increasing the output of medical schools or using IMGs.

Michael E. Whitcomb, M.D., Senior Vice President for Medical Education, Association of American Medical Colleges (AAMC), stated that the AAMC has no position on either the adequacy or specialty composition of the physician workforce. Head counting is not sufficient; the variations in medical practice must be understood to arrive at an informed judgement of physician adequacy. He challenged COGME to do serious analytical research regarding the issues that have been presented, provide the information to the public, and then let the public decide on the allocation of public funds.

Minutes of the December 5 -6, 2001 COGME meeting were approved at the beginning of the afternoon session.

Physician Preparedness to Meet Emerging Public Health Needs:
Judith Cooksey, M.D., M.P.H., Director, Illinois Regional Health Workforce Center, University of Illinois at Chicago, discussed the response function of various Federal, State, and Local agencies to emergencies resulting from terror attacks, natural disasters, epidemics, etc. She spoke of the difficulty of coordinating responses among the different agencies, but noted the importance of the U.S. Department of Health and Human Services in taking the lead in coordinating responses through its Office of Emergency Preparedness. She covered many aspects of the various Federal, State, and Local efforts to prepare for disasters, particularly mentioning the Federal funded Metropolitan Medical Response System to improve coordination in the major metropolitan areas.

Jonathan L. Temte, M.D., Ph.D., Associate Professor, Department of Family Medicine, University of Wisconsin discussed the interrelation of clinical medicine and public health. He considered that the system worked quite well as it responded to the Anthrax attack - cases were diagnosed and properly treated. Although interest in bioterrorism has increased, other emerging public health threats have emerged, such as TB, and the probability of pandemic influenza, with which we are not well prepared to manage. Our medical students need to be trained to prevent common health problems rather than reacting after they develop. Citing the need to train more effectively clinicians to respond to emerging public health events, Dr. Temte made several suggestions about how to accomplish such training.

Jeffery Dunlap, M.S.P.H., Acting Director, Division of State, Community and Public Health, Bureau of Health Professions, HRSA, described the mission of the Division to bridge public health and primary care and to integrate the academia, practice and community. Mr. Dunlap discussed the use of interdisciplinary efforts to accomplish the Division's mission.

Rika Maeshird, M.D., M.P.H. (Substituting for Maureen Lichtveld, M.D., M.P.H.) Office of Workforce Policy and Planning, Centers for Disease Control and Prevention, stated that bioterrorism was the "hot topic" in public health education and in medical education. The topic has increased the importance of public health and medicine being coordinated. She spoke of key training strategies that are a common requisites for both the public health and medical communities and of the AAMC/CDC cooperative agreement to develop regional public health medicine education centers.

There was no response to a request for public comments.

At 3:01, the Council divided into its three workgroups: Diversity, GME Financing, and Workforce.

THURSDAY, APRIL 11

The plenary session was reconvened at 8:00 a.m. Dr. Getto announced the IOM sponsored two day symposium in June on health professions education. Workgroup reports followed.

Dr. Schooley presented the Workforce workgroup report. Dr. Schooley stated that the procurement has been advertized to analyze the 110/50:50 recommendation from two perspectives, a supply-demand and a supply-needs analysis to address the policy recommendations inherent in bringing the need and demand numbers closer together. Dr. Schooley also noted that certain issues would not be addressed in this procurement activity, notably the issues of geographic maldistribution and an adequacy assessment within medical specialties.

Dr. Royer presented the GME Financing Workgroup report. Dr. Royer discussed the proposed analytical project titled "Analysis of Non-Federal Financing of Graduate Medical Education in the U.S. and Selected Other Nations." He reported that the Workgroup made a substantive change to exclude consideration of other countries and focus on all sources of funding in the U.S. other than Medicare. The Workgroup reviewed a list of 26 priority items developed at the preceding December 2001 meeting. A plan was proposed to meet with the American Association of HealthPlans and the Association of Community Health Plans to discuss the all payer system.

Dr. Thomas presented the Diversity Workgroup report. Dr. Thomas reported that unpublished data provided to the Workgroup suggest that attempts to raise the number of applicants to medical schools are unsuccessful. Underrepresented minorities are not being properly prepared. There is a need to understand how to increase the number of applicants that can successfully matriculate into medical schools. One immediate activity that could be pursed is to reassess the recommendations in COGME's 12^th Report and to make a report card on progress made toward meeting those recommendations. A study is needed of best practices, practices that are successful in producing a larger number of matriculates versus applicants.

Physician Workforce Modeling, Potential Applications, and Upcoming Research:
Marilyn Biviano, Ph.D., Acting Director, National Center for Health Workforce Analysis, Bureau of Health Professions, HRSA, described and explained the Bureau's demand model for physicians, formally known as the Integrated Requirements Model, how it operated, and how it could be applied to answer research questions dealing with physician supply and demand projections.

Discussion of 2002 Summary Report:
COGME Members discussed the structure and mission of the Council and suggested a few specific wording and grammatical changes in text which were approved. The Council approved that the Report go forward to publication.

Discussion of Future Activities:
Council members discussed a diverse range of possible topics and speakers for the next meeting's agenda. The topics of competencies in graduate medical education and the financial situation of teaching hospitals emerged as particularly critical issues. Chairman Getto stated that decisions to formalize the agenda for the September meeting would be made within the next couple of weeks.

Public Comments
Perry Pugno, American Academy of Family Physicians, offered to provide two manuscripts he had prepared as resources to COGME. One manuscript dealt with the impact of the "hassle factor" on physician productivity and the other concerning the institutional benefits accruing from GME programs. Sunny Yoder, Association of American Medical Colleges, made two comments: one about determining the ultimate practice location of IMGs that settle permanently in the US and the second concerned the development of an early warning system for emerging issues and problems, both in the healthcare workforce and particularly in the physician workforce.