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Minutes of Meeting, September 13-14, 2005

The Council on Graduate Medical Education (COGME) convened in the Washington Room in the Holiday Inn Select, 8120 Wisconsin Avenue, Bethesda, Maryland, at 8:30 am. on September 13-14, 2005. 

Members Present

Robert L. Johnson, M.D., Vice Chair
Rebecca M. Minter, M.D., Member
Angela Dee Nossett, M.D., Member
Earl J. Reisdorff, M.D., Member
Russell G. Robertson, M.D., Member
Jerry Alan Royer, M.D., Member
Humphrey Taylor, Member
Tzvi M. Hefter, Designee of the Administrator, Centers for Medicare and Medicaid Services
Barbara K. Chang, M.D., M.A., Representative of the Department of Veterans Affairs

Retired Members Present:

Carl J. Getto, M.D.
William Ching, M.D., Ph.D.
Lucy Montalvo, M.D., M.P.H.

Members Absent:

Howard Zucker, M.D., Designee of the Acting Assistant Secretary for Health

Staff:

Tanya Pagan Raggio, M.D., M.P.H., F.A.A.P., Executive Secretary
Jerald M. Katzoff, Deputy Executive Secretary
Howard Davis, Ph.D.
Eva Stone
Jaime Nguyen, M.D., M.P.H.

Welcome and Announcements

Dr. Raggio, acting as interim chair, welcomed COGME members.  She expressed regret that Bureau Management Staff were not able to attend because of the exigencies resulting from hurricane Katrina and noted that many HRSA personnel, especially commission corps officers, were assisting the victims of Katrina.

Dr. Raggio presided over the election of chair and vice-chair.  COGME members elected Dr. Robert L Johnson as chair and Dr. Russell G. Robertson as vice-chair. 

Dr. Raggio, as COGME Executive Secretary, gave her report.  She explained the process that would govern the production of future COGME reports.  Current resource limitations will preclude the use of contractors to develop reports.  Limited resources will be available to pay honorariums for presentations on the topic by experts and for these experts to develop papers related to the material they presented. These papers will serve as the resource material that will be used to compose the final report.  COGME members, with the help of staff, will need to assume the responsibility to develop final reports,

incorporating materials provided by the presenters and providing their own expertise.    .

Dr. Raggio recognized retiring members for their invaluable sustaining service to COGME.  Each retiring member received a plaque inscribed with a dedication and noting the length of service.

Discussion of Potential Report Topics

COGME membership broke into three discussion groups (workforce, graduate medical education, and GME financing) to consider potential report topics.  The groups reported to the plenary session as to the topics considered.  The following topics were considered by COGME membership to be among the most critical facing the nation’s physician workforce and health care system. The plenary session then prioritized these topics and selected the following as viable potential report topics. The topics were categorized as to the length of time their completion would be expected to take.  Short/brief reports, expected to take less than a year are indicated by SR, and long reports, expected to take  18 months or more, by LR.

Topics

1.  National Service: SR

• What is the possibility of developing and implementing a national service mechanism for compensating for the public subsidy provided students for their medical education? Should we include all federal health care facilities and not limit national service to working in the Public Health Service, and include entities such as the Department of Veteran’s Affairs, Indian Health Service? This would allow for more accountability, and determine where public and federal dollars are being spent for medical education.  Should this national service program be mandatory, or should there be increased funding or more positions for programs that provides repayment or scholarships? 

2.  Emergency Preparedness: SR

• What systems or policies need to be in place for emergency preparedness mobilization, especially in natural crisis and disasters?

3.  Flexibility in Training and GME: LR

• Access needs to be understood beyond distribution, especially since many reports already exist that discuss distribution.  Access should be addressed in regard to patients and their ability to receive health care.  A broader and more comprehensive approach is needed to define “access.” 
• How can the current GME system be more flexible?   (How can GME be made more flexible to accommodate the need of the public for greater access to medical care or to increase the medical care provided to underserved populations and areas? What system changes are needed in GME to allow, for example, more appropriate policy development, medical education and training, public access, and flexibility in GME payment and payment schemes? )  
• Is the current model for GME funding still appropriate and meeting the needs of the community and health care systems? What entity should receive GME funding; i.e. the health care provider, the educational institution, the hospital based training program, or the ambulatory facility?  How should GME funds be allocated among the receiving entities, and how can accountability be established for these funds?

4.  Osteopathic Medicine: SR

• The number of physicians being trained as Doctors of Osteopathy (D.O.s) continues to grow.  There also appears to be a trend where D.O.s are choosing to enter specialty fields along with allopathic physicians. Traditionally, D.O.s have been trained as primary care physicians and/or chosen fields in primary care.  The impact of D.O.s and osteopathic training on the overall physician workforce, and on specialties and subspecialties, needs to be addressed.

5.  Technology: SR

• How does technology impact medical training and the physician workforce?  How can technology be utilized to improve medical training and education, and access and health care delivery for patients?  How can telemedicine address the health disparities prevalent in health professions shortage areas (HPSAs) and other resource limited communities?   

6.     Forecasting Models: LR

• Many assumptions and data that were used in COGME’s 16^th Report, “Physician Workforce Policy Guidelines for the United States, 2000-2020”, will most likely change and require updating.  It is critical that resources continue to be devoted to updating and reviewing the recommendations presented, and both the data and the forecasting model used in the 16^th Report to ensure the most accurate analysis and predictions on the nation’s future physician workforce.   

After some deliberation, COGME members chose the first and third topic issues (National Service and Flexibility in Training and GME) on which to develop its next two reports.

Other related issues the Council addressed were:

1. There need for COGME to incorporate the impact of women on the physician workforce in its deliberations and develop a new report on this subject. (COGME’s Fifth Report, in 1995, was devoted to this topic)

2. The large amounts of uncompensated care hospitals are writing off, how much represents an actual expense to the hospitals, and how much may be shifted in some form to consumers or patients, insurance companies, and to the federal government. 

3. The fact that more training is occurring in the community because the goal of primary health care is to keep people out of the hospital.  As a result, services and training related to chronically ill patients traditionally provided in hospital settings are now transpiring more frequently in ambulatory and other community based facilities. However, almost all GME reimbursement is for hospital training.

Presentation on Physician Re-entry

The Wednesday morning session began with a presentation by Saralyn Mark, M.D., Senior Medical Advisor, U.S. Department of Health and Human Services, Office on Women’s Health.  Dr. Mark discussed the issue of reentry of physicians after an interruption of practice for reasons related to family responsibility, health, alternative career choices, and other reasons not related to disciplinary actions.  She noted that although initially considered an issue mostly relevant to women physicians, information obtained indicated substantial interest among male physicians who wished to resume active practice after a period of interruption.  A major issue for physicians wishing to resume active practice after a period of interruption is to assure that such physicians possess those competencies currently needed in their respective specialties.  A major question concerns the structure necessary to provide the training required for this assurance.

The Council concurred that this topic is important and will plan to address it more thoroughly at future meetings.

Future Meetings

Tentative plans are that COGME will reconvene in April and September, 2006. The April agenda is expected to include presenters on both topics selected for reports after which Council members will begin the effort to compose these reports.

Public Comment

Two individuals responded to a call for public comment:

Holly J. Mulvey, M.A., Director, Division of Graduate Medical Education & Pediatric Workforce, stated the concern of the American Academy of Pediatrics that suitable measures be implemented to provide an adequate and well trained pediatrician workforce composed of appropriate numbers pediatric subspecialties to meet the health needs of the country’s children and young adults.  She expressed concern, however, with COGME’s recent recommendation to expand the total physician workforce. 

Konrad C. Miskowicz-Retz, Ph.D., Director, Department of Accreditation, American Osteopathic Association, expressed concern about certain misapprehensions related to the governing structure of Osteopathic Schools of Medicine.  He also spoke to the curricula and training processes used to produce Doctors of Osteopathic medicine.

The meeting on the second day adjourned at 10:00 a.m.