Minutes
of Meeting, September 11-12, 2002
The Council on Graduate
Medical Education (COGME) met at 8:30 a.m. on September 11 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 2:28 p.m. It reconvened the next morning, September 12
a.m. at 8:30 a.m. in the same room and adjourned at 9:45 a.m. that
day.
Members Present:
Carl J. Getto, M.D., Chair
F. Marian Bishop, Ph.D., M.S.P.H., Vice-chair
Regina M. Benjamin, M.D., M.B.A., Member
Laurinda L. Calongne, LCSW-BACS, Member
William Ching, Member
Allen Irwin Hyman, M.D., FCCM, Member
Robert L. Johnson, M.D., Member
Lucy Montalvo, M.D., M.P.H., Member
Jerry Alan Royer, M.D., M.B.A., Member
Susan Schooley, M.D., Member
Humphrey Taylor, Member
Douglas L. Wood, D.O., Ph.D., Member
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
Members absent:
Donald C. Thomas III, M.D., Member
Staff:
Stanford M. Bastacky, D.M.D., M.H.S.A., Acting Executive Secretary
Jerald Katzoff, Acting Deputy Executive Secretary
Howard Davis, Ph.D.
Eva Stone
Welcome and
Announcements:
Dr. Getto
welcomed participants to the meeting and read a statement from HHS
Secretary Tommy Thompson commemorating the anniversary of September
11, and a moment of silence was observed. Approval of the minutes
was deferred to the second day of the meeting to allow members to
review them. Dr. Getto recognized Dr. Marian Bishop for receiving
the John G. Walsh Award for dedicated and effective leadership in
furthering the development of family practice from the American Academy
of Family Physicians. He also recognized Dr. Regina Benjamin for becoming
the first African-American female President of a State (Alabama) in
the U.S. Council members made opening comments in turn.
Competencies
in Graduate Medical Education:
Marvin R. Dunn,
M. D., Director of Residency Review Committee Activities, Accreditation
Council for Graduate Medical Education (ACGME), explained the introduction
of six competency requirements that are being considered by the ACGME
to further competency-based education of medical students. The six
competencies are: patient care, medical knowledge, practice-based
learning and improvements, interpersonal and communication skills,
professionalism, and systems-based practice. He described the efforts,
difficulties, and collaboration among the various medical educational
organizations involved in the development of the competencies and
the measurements of outcomes. Rather than evaluating the curriculum,
goals and objectives as is currently done, the Residency Review Committees
would evaluate programs upon how well students achieve learning objectives.
Perry A. Pugno,
M.D., M.P.H., C.P.E., Director, Division of Medical Education,
American Academy of Family Physicians, spoke on the connection between
competency, accreditation, and certification. He described the process
used by the Academy to maintain quality of the
physician practice
through problem-based learning assessment. A survey of prior graduates
highlighted deficiencies in physician preparation in practice-based
learning and improvement and in systems-based practice competencies.
Dr. Pugno described efforts to improve descriptors for these two problem
areas. The development of reliable measurements of physician performance
is difficult, and faculty who are conversant with competency-based
education and can teach these specific competencies are in short supply.
Donald E.
Melnick, M.D., President, National Board of Medical Examiners,
explained the operational procedures used in the administration of
the Clinical Skills Assessment (CSA) examination. The CSA is composed
of a test of clinical skills and a test of communication skills performed
on standardized patients. These tests are valid measures of the clinical
skills for which they are targeted and a passing score must be achieved
on each test. Implementation is currently planned for mid-2004, affecting
the U.S. class of 2005. Dr. Melnick stated that ten to twenty percent
of examinees who would pass the cognitive examinations are expected
to fail the CSA. The deficiency of clinical training in U.S. medical
schools was noted, especially since 1964 when the NBME dropped clinical
skills exams.
Financial Situation
of Teaching Hospitals:
Dr. Schooley,
Chair, Department of Family Practice, Henry Ford Health System (HFHS),
Detroit, described the impact of a constellation of adverse events
on the continuing capability of HFHS to delivery quality care because
they are eroding both the health care delivery capability and the
teaching and research infrastructure of the institution. These events
include the increasing shift of health care costs from the purchasers
to the health care providers and patients, reduced Medicare rates,
disenrollment from managed Medicare, shift of demographics in the
community leaving a larger proportion of sicker patients, a deteriorating
economic environment, adverse legislated reimbursement changes, huge
increases in uncompensated care, and other adverse factors. The impact
of these events have resulted in substantial losses to HFHS, $13 million
in 1999, $88 million in 2001, and forecasted double-digit loss in
2002.
Robert M.
Dickler, Senior Vice President, Association of American Medical
Colleges, noted that Medicare provides the lowest margin for teaching
hospitals while the dependency on Medicare has increased. This increased
dependency makes these hospitals vulnerable to changes in Medicare
reimbursement policy. Of the 200 members of the Council of Teaching
Hospitals (COTH), many had reversed the decline in revenue but 1/3rd
of the membership lost money in the year 2001 compared with 13 percent
in 1997, the year in which the BBA was enacted. Some of these losses
are attributable to the 7 percent of expenditures for uncompensated
care. The legislated reduction in Medicare reimbursement to physicians
will adversely affect hospital income. "Boutique" hospitals
have diverted higher profit-margin procedures from teaching hospitals.
Further reduction in expenditures will be difficult to make. Dr. Dickler
commented on other developing pressures that will adversely affect
bottom line of hospitals.
John Crosby,
Executive Director, American Osteopathic Association, noted that the
same adverse developments experienced by allopathic teaching hospitals
are having a devastating result on osteopathic hospitals, which are
mostly small, either rural or urban, and cater to the underserved
population. Reimbursement to osteopathic hospitals is based upon 1984
as a base year, which at that time included a large number of volunteer
faculty, and is no longer adequate when such faculty no longer exist.
The current shortfall of such faculty, which combined with the nursing
shortage and limits on resident work hours, will necessitate the use
of non-physician health care providers. These and other factors are
imposing greater costs upon teaching hospitals.
Development
of a Framework for Revised COGME Physician Workforce Goals:
Edward Salsberg
reported the progress on a contract to review workforce goals.
After reviewing the history of the COGME 110/50:50 recommendation,
he detailed the caveats to compiling meaningful numbers on physicians
to use in analytical work. Mr. Salsberg noted that demand for specialists
exceeds that for generalists in many markets and that training responds
quickly to demand changes. Mr. Salsberg described the two scenarios
to be developed for the contract project, one demand driven, the other
need driven, but he cautioned about estimating physician needs without
considering the manifested demand. He stated the goals of the study
are to assess the overall supply, demand, and need in 2020.
The plenary session
was adjourned at 2:28 p.m. to convene into three workgroups: Diversity,
GME Financing, and Workforce.
Betty Duke,
Ph.D., HRSA Administrator, visited briefly with COGME members
during the afternoon. Dr. Duke stated that she was pleased to report
that all of her top administrative staff was finally in place.
THURSDAY, SEPTEMBER
12
The plenary session
was reconvened at 8:30 a.m.
Dr. Getto
introduced Sherrie Hans. M.D., a representative of the Assistant Secretary
of Health, Eve Slater, M.D. Dr. Hans conveyed the support of Dr. Slater
for COGME.
June Summit
With Institute of Medicine (IOM)
Dr. Getto
reported on the IOM Summit, a major meeting of 300 leaders in health
professions education in the U.S. He reported that an agenda was produced
to implement interdisciplinary education of health professionals in
various areas. There followed discussion of the summit by those who
had attended.
Reports by
Workgroup Chairs
Dr. Johnson
reported for the Diversity Workgroup, which reviewed the 1998 12th
Report of COGME report covering minorities in health care. The group
agreed that the content of the 1998 report remained current because
of a lack of progress in workforce diversity, but found deficiencies
in the recommendations of the report that impaired their implementation.
The group recommended: the development of an RFP to review the effectiveness
of methods to enhance diversity throughout the continuum of education
(i.e., primary and secondary education, undergraduate education, medical
schools and professional organizations); the examination of the results
from the 1998 report in order to review the feasibility of unaccomplished
recommendations; and the development of methodologies to accomplish
feasible recommendations.
Dr. Schooley
gave the report of the Workforce Workgroup, which heard further detail
from Mr. Ed Salsberg on his report during the first day’s meeting.
Mr. Salsberg presented some of the constructs to be articulated. The
group discussed the merits of both current supply and demand and the
needs-based modeling. The major issue will be to develop policy to
move the demand model towards the needs-based model. The group found
that, on a policy level, needs should be assessed over the long-term
according to individual specialties and subspecialties, and the different
branches of primary care.
Will Ching
presented the report of the Finance Workgroup. Members briefly discussed
to contract to study non-Federal financing of graduate medical education.
Agenda items were looked at, which included a review of the recommendations
from the 15th report of COGME. Workgroup members agreed
that RFPs might be developed to study the development of a method
to assess costs arising from implementation of the clinical competencies
and how those costs should be distributed and to study the costs and
their allocation arising from the limitation on resident duty hours.
The Workgroup also considered compiling a contingency plan in case
the current litigation on the National Resident Match Program is successful
that would allow COGME to advise the Federal government on ways GME
financing could be used address the impacts of potential cost shifts.
Future Work
Following discussion,
the Council agreed to have a presentation on the role which graduate
medical education should play in efforts surrounding the strengthening
of the public health workforce and combating bioterrorism.
Public Comment
Sunny Yoder, Holly
Mulvey, and Dr. Sherrie Hans made brief comments.
Approval of
Minutes
The minutes of
the April, 2002 COGME meeting were unanimously approved, and the meeting
was adjourned at 9:45 a.m.
