May 20, 2013

Shane Rogers
Designated  Federal Official
Council on Graduate Medical Education
Room 9A-27, 5600 Fishers Lane
Rockville, MD 20857

Dear Mr. Rogers,

The Council of Medical Specialty Societies, with 39 member organizations representing more than 700,000 physicians in the US, is pleased to respond to your request for comments on COGME’s 21st Report: Improving Value in Graduate Medical Education. Our comments will correspond to the organization of the draft report.

Page 1:

 Preamble:

The final sentence of the Preamble notes that GME receives “significant levels” of public funding. This statement is misleading, as “significant” connotes high or substantive. Relative to the total amount of funding for health care, funding for GME is actually relatively small.  This is a point that is made later in this report (i.e. “The size of this educational investment is relatively small.”) Therefore, the current final sentence of the Preamble should be removed or revised.

Second paragraph:

This paragraph describes challenges to the physician workforce and notes that the population of the US is aging. It should also be mentioned that the physician population is aging, which will exacerbate the workforce shortage.  This point is not made until page 9.

Page 6 of 28:

First paragraph:

We recommend revising the sentence that begins “Without additional . . .” by including the words “adult medicine” so that the sentence would read: Without additional funding, the number of training positions continued to grow slowly, largely in adult medicine subspecialties. This is an important distinction, especially in light of Recommendation 2.1.

Third paragraph:

We recommend including a comment that the un-prioritized growth of the workforce can be expected to result in the unintended consequence of reducing the needed primary care base.

Page 11 of 28:

 Third paragraph:

We recommend removing the reference to “subspecialty boards”, as the American Board of Medical Specialties (ABMS) is already represented as a Member of the Accreditation Council for Graduate Medical Education (ACGME).

Page 13 of 28:

Second paragraph:

This paragraph discusses the all-payer system (in support of Recommendation 1.3). It appears that this report is defining “all-payer” as the current funders (including DOD) plus insurers. Consideration should be given to broadening the concept of “all-payers” to include pharmaceutical companies, equipment/device manufacturers, and others.

Page 14 of 28: 

  Third paragraph:

The text reads, “The location of GME training is a strong predictor of practice location. COGME recommends that these incentives be directed toward training programs in health care markets with relatively low physician supply.” Here and earlier in the document there is confusion regarding the report’s intent.  The recommendation asks programs to encourage trainees to practice in “regions with relatively lower per capita supplies of physicians.”  However, this sentence seems to call for the actual training program to be in such a region.  This could be problematic because, by definition, areas of shortage may not have the appropriate faculty and other resources to train residents/fellows in many specialties, especially for the pediatric medical and surgical sub-specialties.  We agree that the location of residency training is a strong predictor, but it is not the only predictor.  Physicians will need other effective incentives (e.g. tax credits and practice subsidies) to locate in regions with relatively lower per-capita numbers of physicians.

Page 20 of 28:

Last paragraph:

Rather than specifying “didactics”, consider using a reference to utilizing best practices from the science of learning in medical education.


 Comments on Recommendations of the Report:

Recommendation 1: “Funding for GME should increase and broaden beyond current sources to provide high quality, compassionate, and evidence-based care.”

 Recommendation 1.1: “Congress should continue funding for current GME positions, while increasing funding for additional positions.”

CMSS supports increasing funding for additional GME positions to alleviate the mismatch between the shortage of physicians in many specialties and the growth of the US population.

 Recommendation 1.2: “Congress should increase funding for new residency positions in order to graduate 3,000 more physicians per year.”

CMSS supports this recommendation.

Recommendation 1.3: “Sources of funding in addition to Medicare (global or “all payer”) should be examined.”

The definition of “all-payer” should be broadly defined to include pharmaceutical companies, device/equipment manufacturers, and others.

 Recommendation 2: “GME funding should be prioritized to accelerate physician workforce alignment with population and health delivery needs.”

 Recommendation 2.1: “Increases in GME funding should be directed toward the following high priority specialties:

  • Family medicine
  • Geriatrics
  • General internal medicine
  • General surgery
  • High priority pediatric subspecialties
  • Psychiatry”

 CMSS recommends that COGME consider adding Hospice and Palliative Care to the list of high-priority specialties:

A. A disproportionately high percentage of Medicare dollars go towards care in the final months of life. Hospice and Palliative Medicine programs have been shown to both improve quality and control costs for these patients in hospitals, homes, hospices, and nursing facilities.

B. 42% of all deaths are attended by a hospice program, while all 5000+ hospice programs need at least one physician certified in Hospice and Palliative Medicine. 80% of hospitals in the US with more than 300 beds have a palliative care consultation service, each of which needs physicians certified in Hospice and Palliative Medicine.

C. The grandfathering period for Hospice and Palliative Medicine certification has closed, leaving only 97 certified fellowship programs. (For the 2012-2013 academic year, these programs were training 206 physicians in hospice and palliative medicine.) Many require external funding because they are outside of the GME “cap” positions.

D. The Baby Boomers will need end-of-life care in the coming years, while the workforce is aging rapidly. Retirements will only increase the supply-demand mismatch in the near future.

CMSS recommends that COGME also consider adding Preventive Medicine to the list of high-priority specialties.

Our recommendation is consistent with several recent reports:

COGME 2000, “Physicians in the Public Health Workforce”, by Jerilyn K. Glass;
IOM 2007, “Training Physicians for Public Health Careers”; and 
Academic Medicine Supplement 2000, “Prevention for the 21st Century: Setting the Context through Undergraduate Medical Education.”

The preventive medicine training competencies are directly linked to both clinical and population-based medicine. As such, preventive medicine physicians are trained to treat individuals and populations with a focus on increased access to, and utilization of, clinical preventive services.

 Recommendation 2.2: “Increases in GME funding should be directed toward training programs that have a higher proportion of individuals continuing in one of the specialties noted in Recommendation 2.1 and locating within regions with relatively lower per capita supplies of physicians.”

CMSS recognizes the use of the word “continuing” in this recommendation is important. Many if not most who enter an internal medicine residency will go on to subspecialty fellowship training, ultimately not practicing primary care. Consistent with the findings of the AAMC Workforce Research Conference (2012), CMSS recommends that the outcome of residency training be assessed five years after medical school graduation to determine if those graduates are actually practicing in one of the high-priority specialties.

 In addition, tracking medical school graduates beyond residency will require that training programs have in place a system to track where their graduating residents locate. Such a system will need to differentiate between where graduates live from where they practice, and it will need to track them over an extended of time. 

Recommendation 2.3: “Increases in GME funding should prioritize training programs that have a particular emphasis on new competencies needed to meet the changing health care system.”

       CMSS supports this recommendation.

 Recommendation 3: “Funding and accreditation efforts should work toward improving training efficiency.”

 Recommendation 3.1: “Training funds should be used more efficiently by eliminating transitional post graduate year positions and excess preliminary non-categorical positions.”

CMSS offers that eliminating the transitional post-graduate year may have the unintended negative consequence of precipitating attrition from family medicine, internal medicine and general surgery programs, as many residents annually enter these high priority programs after completing a transitional year.

 Recommendation 3.2: “Accreditation and licensing organizations should permit flexibility in certain clinical training in the fourth year of medical school to be credited toward residency training.”

CMSS supports this recommendation. In addition, flexibility should be permitted in fellowship training to allow part-time work over multiple years. All of the training milestones and requirements could be met with an adjusted time frame suitable to mid-career physicians transitioning into a high-priority specialty.

Recommendation 4: “Criteria for recruiting medical students, as well as graduate medical education training requirements, should be revised to align with development of a physician workforce that meets the health care needs of the populations served.”

                CMSS supports this recommendation.

Recommendation 5: “The clinical learning environments and curricula for undergraduate and graduate medical education training requirements should be revised to prepare a physician workforce capable of providing patient-centered, safe, and effective care.”

Recommendation 5.1: “The Accreditation Council for Graduate Medical Education (ACGME) should evaluate sponsoring institutions’ clinical learning environments to ensure that the Institute of Medicine competencies of safe, timely, effective, efficient, equitable, and patient-centered care are being met.”

                CMSS supports this recommendation.

 Recommendation 5.2: ‘Congress should direct the Secretary of Health and Human Services to support the development and dissemination of innovative faculty development programs to improve graduate medical education training across all specialties, and it should appropriate sufficient funds to carry out these activities.”

CMSS recommends that the “activities” described herein should be directed to the new competencies referenced earlier, including population health, care coordination, team-based practice, and other aspects of new systems of care.

Recommendation 5.3: Training institutions should use a portion of their GME funding to develop and support faculty to teach and assess the ACGME competencies, and the ACGME should evaluate these programs as part of the institutional accreditation process.

                CMSS supports this recommendation.

 Recommendation 5.4: “Decisions regarding successful completion of each phase of medical education should be based on a rigorous assessment of competence rather than solely on time spent in training.”

                CMSS supports this recommendation.

 Recommendation 6: “The nation should invest in medical education research to improve the quality of GME and the competencies of our physician workforce.”

 Recommendation 6.1: The Institute of Medicine should develop a national agenda for ongoing medical education research that advances training toward meeting patient preferences and improving population health outcomes.

CMSS suggests the addition of Recommendation 6.2 could make 6.1 superfluous. An Institute of Medical Education within the National Institutes of Health would be well positioned to develop a national agenda for ongoing medical education research. Additionally, the concept of “meeting patient preferences” has been supplanted in the National Quality Strategy with the broader concept of “patient-centered care.”

 Recommendation 6.2: “Congress should authorize and finance an Institute of Medical Education within the National Institutes of Health to support innovative medical education research that improves both learner and patient-care outcomes.”

CMSS supports this recommendation. CMSS also supports funding of the authorized National Workforce Center to determine on an ongoing basis the physician workforce needs of the nation. This commission could be informed by the products of an Institute of Medical Education within the National Institutes of Health.

The Council of Medical Specialty Societies appreciates the opportunity to comment on COGME’s 21st Report: Improving Value in Graduate Medical Education. We applaud COGME for its good work and for the open process of soliciting and responding to comments.

Sincerely,

Dr. Kahn Signature

Norman Kahn MD
Executive Vice-president and CEO