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Minutes of Meeting, September 6-7, 2006

The Council of Graduate Medical Education (COGME) convened in the Montgomery Room in the Hilton Washington, DC North/Gaithersburg at 8:30 am on September 6^th, 2006.

Members Present

Russell G. Robertson, M.D., Acting Chair
Denise Cora-Bramble, M.D., M.B.A, Member
Joseph Hobbs, M.D., Member
Mark A. Kelly, M.D., Member
Rebecca M. Minter, M.D., Member
Thomas J. Nasca, M.D., M.A.C.P., Member
Angela D. Nossett, M.S., Member
Robert L. Phillips, Jr., M.D., M.S.P.H., Member
Kendall Reed, D.O.,F.A.C.O.S., F.A.C.S., Member
Earl J. Reisdorff, M.D., Member
Vicki L. Seltzer, M.D., Member
Jason C. Shu, M.D., Member
William L. Thomas, M.D., F.A.C.P., Member
Leana S. Wen, M.S., B.S., Member
Barbara J, Chang, M.D., M.A., Designee of the Department of Veterans Affairs
Tzvi M. Hefter, Designee of the Administrator, Centers for Medicare and Medicaid Services

Members Absent

Designee of the Acting Assistant Secretary of Health

Staff

Henry Lopez, Acting Director, Division of Medicine and Dentistry
Jerald M. Katzoff, Executive Secretary
Howard Davis, Ph.D.
Eva Stone
Hyoun-Kyoung Higgerson, Ph.D.

Welcome

Dr. Robertson, Acting Chair, welcomed both the returning and new COGME members.  He introduced the new members: Dr. Denise Cora-Bramble, Dr. Joseph Hobbs; Dr. Mark A. Kelly; Dr. Thomas J. Nasca; Robert L. Phillips, Jr.; Dr. Kendall Reed; Dr. Vicki L. Seltzer; Dr. Jason C. Shu; Dr. William L. Thomas; Lena S. Wen.

Opening Remarks

Mr. Steven Pelovitz, BHPr Deputy Associate Administrator, representing A. Michelle Snyder, Associate Administrator, BHPr, conveyed her welcome COGME members and noted the importance of the Councils work and recommendations.  Mr. Pelovitz described current objectives and plans for both HRSA and BHPr and noted recent changes in senior management at the Bureau

Meeting Overview

Henry Lopez, Acting Director, Division of Medicine and Dentistry (DMD), welcomed COGME members on behalf of the Division.  He noted the importance of the Council’s work and recommendations.  He reviewed recent staff changes in DMD and also recognized COGME staff members, commending them for their efforts in bringing the meeting to fruition.

Executive Secretary’s Report

Mr. Katzoff, after welcoming the COGME members, noted the layout of the agenda book, explained the report writing process, and emphasized the importance of member participation in writing the reports.

Election of New Chair

COGME membership, by acclamation, elected Dr. Russell G. Robertson as Chair and Dr. Robert L. Phillips, Jr. as Vice-chair.

Orientation of New Members

Mr. Katzoff oriented the ten new members to the purpose of COGME, its legislative mandate, its recent history of being continued through appropriation language, and the mandated entities to which Reports are sent.  He also presented the process which will be used to develop the reports on the two current topical areas selected by COGME.

• Presentations: National Service for Physicians
• Presenters:
  • Doug Campos-Outcalt, M.D., M.P.A.
    “Mandatory Social Service for Physicians: A Discussion of Issues”
  • Robert Graham, M.D.
    “Mandatory Service for Physicians: Issues and Approaches”
  • Robert Graham, M.D., presented  for Roger A. Rosenblatt, M.D.
    “Is Mandatory National Service for Physicians Desirable and Feasible?”

The papers elicited a discussion of a range of cogent issues.  Included among these issues was the belief that national service would not address physician geographical or specialty maldistribution.  Many areas are currently experiencing shortage of physician specialists, an issue that would not be addressed by mandatory service.  The consensus was that mandatory service was neither desirable nor feasible.  However, there was an overriding theme; those who practice medicine have a social obligation to provide medical care to all persons, regardless of their social-income status.

• Presentations: GME Flexibility
• Presenters:  
  • Robert Dickler
    “GME Flexibility: Challenges and Opportunities”
  • Gar Elison
    “Discussion Paper on the State of Utah’s Experience with Graduate Medical Education Funding Flexibility”
  • Larry A. Green, M.D.
    “Graduate Medical Education in the United States: Time to Move On”

These papers elicited discussion of a number of compelling issues and concerns, some of which are illustrated by the following themes: The influence of external factors, such as the Residency Review Committees (RRC), which may encumber changes; accountability for monies allocated for GME; appropriate use of Indirect Medical Education (IME) funds; achieving a balance between program and institutional accreditation; making the graduate medical educational training component correspond to alternate health care delivery systems; the fragile commitment that many residency programs have toward medical education, relying instead upon using residents for service delivery.

Breakout of Council Members into Two Writing Groups

The chair and members were identified to participate in two groups.  Each group was charged with preparing a draft outline and recommendations for each report.  The chair of each writing group was to identify member(s) responsible for drafting a narrative for each section contained in the outlines.

Report to Council on Draft Recommendations, Proposed Outline, and List of Members to Draft Each Section of the Two Reports

The chair of each writing group reported to the plenary meeting success in produced a draft outline, recommendations, and identifying members responsible for developing the appropriate narratives for each topical subject.

National Physician Service Writing Group

The writing group entitled its report as: New Paradigms for Physician Service in Improving Access to Healthcare

The following members composed the writing group dealing with the national service physicians: Earl Reisdorff (Chair), Angela Nossett, Lena Wen, and William Thomas.

Tentative recommendations are as follows:

1. Mandatory service should not be a categorical requirement for medical school graduates.
   
   
2. Establishment of a National Medical School (UHUHS look-alike).  Training would be free to all students, but there would be service requirement after residency training (Estimate 3-5 years of service at Federally-designated area).
   
   Review the AMSA White Paper on this topic (amsa.org/usphmc).  Faculty should be “teaching focused”, and not dependant on research grants and/or clinical practice.  Sensitivity to the balance between a primary care focus and the specialty care needs of a patient population must be considered.
   
   
3. Increasing NHSC / State-based needs programs – scholarship and loan repayment.  It is understood that NHSC slots are being adequately filled.  Department of Defense positions are currently incompletely filled.  Selected States have loan repayment programs for going to underserved areas.  These should be expanded.  Given the increasing indebtedness of medical students, loan repayment programs should have an increasing appeal.   
   
   
4. Create incentives for medical school programs to recruit and prepare for “under-served” practices.  Certainly sharing knowledge is the first step; nonetheless, this has not been sufficient in and of itself. 
   
   
5. Encourage expansion of Title VII funding.

Graduate Medical Education Flexibility Writing Group

The writing group entitled its report as: Flexibility in GME

The following members composed the writing group dealing with GME flexibility: Dr. Barbara Chang (Chair), Dr. Rebecca Minter, Dr. Mark Kelly, Dr. Vicki Seltzer, Dr. Kendall Reed, Dr. Robert Phillips, Jr., Dr. Joseph Hobbs, , Dr. Denice Cora-Bramble,

Dr. Thomas Nasca, and Ms. Renate Rockwell representing Tzvi Hefter of CMS.

Tentative recommendations are as follows:

1. Aligning GME with future healthcare needs
1. Development of new models of GME training
2. Increase funded GME slots by 15% but these funds should only be directed towards innovative training models which address community needs and which reflect future models of healthcare delivery
3. Proposed models for implementation – UMEC, two tier approach described above, others

2. Accountability for public health should be the driving force for GME
1. Develop mechanisms by which local/regional groups can determine workforce needs, assign accountability, assign funding, and develop innovative models of training which meet the needs of the community and trainee.
2. Continued funding is dependent upon meeting pre-determined performance goals for the training model

3. Broaden the definition of “training venue” (beyond traditional training sites)
1. Decentralization
2. Create flexibility within system which allows for exploration of new training venues while maintaining quality training for residents

4. Remove regulatory barriers to executing flexible GME training programs
1. Use Tsvi Hefner’s response to issues raised in the 15^th report to address several of the limitations that currently exists within the CMS rules for expanding application of Medicare GME funds for other sites of care.
2. Invite CMS to use its Demonstration authority to fund innovative GME demonstration projects with the goal of preparing the next generation of physicians to achieve the quality outcomes they have identified for clinical demonstrations
3. Revitalized or altered Title VII to support development of innovative GME demonstration projects

Public Comment

Ms. Holly Mulvey of the American Academy of Pediatrics stated that the Academy, prompted by the COGME presentation in its September 2005 meeting regarding reentry of physicians into the workforce, was implementing an initiative to bring together many organizations and societies to further study the issue with the goal of facilitating physician reentry into the workforce.

Dr. Steven Shannon, President of the Association of American Colleges of Osteopathic Medicine, expressed his wish on behalf of his Association to  have an opportunity to review and make comments on COGME report drafts prior to publication.