Primary Care Physicians Financing Their Graduate Medical Education in Ambulatory Settings (1989) / Chapter Skim
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Appendix A: Workshop Program and Proceedings
Appendix A: Workshop Program and Proceedings
Pages 65-142
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From page 65... ...
APPENDIX A PROGRAM AND PROCEEDINGS OF A WORKSHOP Held By The Committee to Study Strategies for Supporting Graduate Medical Education for Primary Care Physicians In Ambulatory Settings Institute of Medicine April 17 and is, 1989 65
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Federman, M.D., Chairman, Committee to Study Strategies for Supporting Graduate Medical Education in Primary Care 9:00 am CHARACTERISTICS OF PRIMARY CARE GRADUATE MEDICAL EDUCATION IN THE AMBULATORY SETTING Evan Charney, M.D., Professor & Chairman, Department of - Pediatrics, University of Massachusetts Medical School Jack M ColwitI, M.D., Professor & Chairman, Department of Family & Community Medicine, University of Missouri-Columbia Jordan Cohen, M.D., President APDIM, Dean, School of Medicine, SUNY at Stony Brook Fred Tinning, Ph.D., President, Kirksville College of Osteopathic Medicine & Chairman, Board of Governors, Association of Colleges of Osteopathic Medicine Moderator: Richard E
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A Alpert, M.D., Professor & Chairman, Department of Pediatrics, Boston University School of Medicine, Chief of Pediatrics, Boston City Hospital Steven ~ Wartman, M.D., Ph.D., Director of the Division of General Internal Medicine, Brown University Moderator: Henry W
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Ross Anthony, Ph.D., Associate Administrator for Program Development, Health Care Financing Administration Arthur M Fournier, M.D., Associate Dean for Community Health Affairs, University of Miami Medical School 12:00 pm ADJOURN 68
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By bringing together experts from primary care education and practice, health care institutions, federal agencies, insurance and health care financing and others, the workshop was to be both a useful event for the participants and provide the basis for the committee's deliberations. The workshop was held in Washington, D.C., April, 1988.
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From page 70... ...
The Setting of Residency Training The hospital setting in which pediatric residency is based presents certain problems for primary care education: On hospital inpatient services, children have illnesses more complex and more severe than in the past. Attending physicians are increasingly specialized, and children are often segregated by disease category to more efficiently pronde that care (separate intensive care units for neonates and older children with full-time attending supervision, inpatient units divided by subspecialties, emergency departments staffed by specialists rather than generalists)
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From page 71... ...
Medical Education as an Apprenticeship Model Graduate medical education is based on an apprenticeship model, as opposed to the classroom/seminar approach typical of law and engineering schools, for example. The core philosophy of this education is to expose trainees to appropriate patients, in appropriate settings, taught by role-model faculty.
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From page 72... ...
The point here is that primary care practice within the hospital may not resemble community-based primary care practice either in setting' patient mix, or facula. The Residency Review Committee The Special Requirements for pediatric residency programs have been modified (revised in 1985 and 1990)
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Although some of these skills can be learned in short block rotations in office practice, there is considerable value to learning how skilled primary care physicians manage problems over time, and that is best achieved by a longitudinal, several year experience (particularly for the primary care practice)
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In summary, pediatrics retains its strong commitment to primary care: the majority of pediatricians are engaged in that activity. Changes in the Residency Review Committee Guidelines for pediatrics should enhance primary care education, but may tend to concentrate residency training in larger tertiary care centers where such educational experiences must compete with the service demands of complex patient care.
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From page 75... ...
Alpert d. Residency training in general pediatrics: The role of federal funding.
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From page 76... ...
is not increasing significantly because of the high retirement rate of aging general practitioners. The Council on Graduate Medical Education, COGME, indicates that we continue to have a shortage of family physicians and probably of other primary physicians.
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~c o ~ c to ~ ~ { r' ~ c ~, ~.~ to ~ -A o ~ - ~ 't~ ~ ~-A .
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Characteristics of problems seen in the primary care ambulatory setting differ in major ways from those seen in the inpatient setting. Problems tend to be common, early, subtle, and to fall within the domain of many clinical disciplines.
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Ad Ad Lo x Lo Ad Lo ~of an .' Lo He ~ c An 1 ~ c x to to r' ~ ce o In AL Lo o 81 x to to _ rid a
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From page 82... ...
Overhead costs for the family practice center exceed those of private practice, but probably are comparable to the costs of teaching clinics in other specialties. The well-known added "teaching" costs consist of the increased administrative, medical records, and patient care staffing costs common to all educational ambulatory settings.
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~ co us a)
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C3 u} 153 ~ ~ co · ED a' J an Lo a)
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For the hospital, reductions in family medicine and other primary care residency support would be financially preferable to reductions in residencies which function in high revenue-generating areas of the hospital. Family practice programs have been blessed with state and federal training support to a greater degree than primary care programs in internal medicine and pediatrics.
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From page 87... ...
This fall is especially distressing in as much as Babbott's study of the 1987 cohort of U.S. medical school graduates demonstrated that 46% of those entering family medicine had planned to enter family medicine when they took the MOAT test.4 Utilizing the above trends in family practice, Babbott's data, and data from the AAMC Graduation Questionnaires for general internal medicine and pediatrics from 1982 and 1988, I project that interest on the part of senior medical students in the three primary care specialties will drop from 36% of graduating students in 1982 to only 17.1% of students graduating in 1992.
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From page 88... ...
Percent 1982 1988 Change Family Practice 15.6 11.2 - 28 General Eternal Medicine 14.3 8.1 - 43 General Pediat;rice 6.2 5.3 - 15 Total Primal Care 36.0 24.6 - 32 Source: Association of American Medico Colleges. Medical Student Graduation Questionnaire.
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Table 4 Specialty Choice - Medical School Matriculants 1978 1983 1987 Family Medicine 37% 24% 16% Source: Association of American Medical Colleges. Medical College Admimions Test Questionnaires.
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Table 6 Projection Specialty Preference 1992 1982 1988 1992 Family Practice 15.5 11.2 B.2 General Internal Medicine 4.3 8.1 5.1 General Pediatrics 6.2 5.3 4.8 Percent Pruna~y Care 36.0 24.6 17.1 90
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"Financing Graduate Medical Education in Family Medicine", Academic Medicine, 1989, (March)
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We have recognized for some time that these goals will be increasingly difficult to attain if we continue to depend on the inpatient setting as the primary educational venue. As we all know, wrenching changes have occurred in hospitals over the past decade or two and these changes have rendered hospitals incapable of providing an adequate classroom for primary care education.
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Most ambulatory settings also do not currently contain adequate conference room space for the teaching missing.
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The reasons for this declining interest in internal medicine (a decline paralleled by the experience of Family Medicine and Pediatrics) are multiple and still largely speculative.
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Broadly focused b) Highly focused on the whole on immediate patient problem Resemblance to primary care practice Use of Community Resources Opportunities to learn health promotion!
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Thus, despite universal acknowledgement that more ambulatory training is an educational imperative for the 1990's, the inadequacy of current mechanisms supporting graduate medical education in internal medicine to accommodate this change threatens to prevent it from occurring. We need help.
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, and the other one at Michigan State UniversityCollege of Osteopathic Medicine (MSU-COM) -- I would like to give you some background regarding the osteopathic profession and KCOM.
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In an effort to increase the numbers of primary care providers to their former levels, schools of osteopathic medicine are returning to and/or strengthening their traditional ambulatory-based intern and residency education programs. MSU-COM's ambulatory-based pediatric residency program and primary care specialty residency training programs and KCOM's growth from the rotating senior clerkship and rotating internship to the family medicine residency and internal medicine residency programs being conducted in extended care facilities, rural clinics, the Gutensohn Osteopathic Health and Wellness Clinic, and smaller, rural hospitals3 are examples of this trend.
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From page 99... ...
3. Combine undergraduate exposure to primary care with the first two years of graduate medical education in the same discipline under the control of the medical schools with a hospital(s)
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Primary care resident programs based on ambulator clinical education experience have been developed in general practice/family medicine and general internal medicine. A three-year grant was awarded to the College by the U
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6. Increase the number of residency-trained osteopathic general practice/family medicine physicians who may choose to practice in small towns and rural areas, including underserved rural areas.
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Prepare residents to practice competently well into the next century; 3. Pronde a continuum of education from the undergraduate to the graduate level and an opportunity for continuing osteopathic medical education; 4.
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(8) Michael Glasser, Ph.D., and Judith Grevdal, M.D., "Graduates Assessments of Undergraduate Training in Ambulatory Primary Care Education," Journal of Medical Education, Vol.
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Wager, D.O., B Charles Leonard, Ed.D., et al., Predoctoral Training in Family Medicine, Kirksville College of Osteopathic Medicine KirksnIle, Missouri, November 1987.
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~ ~ ~ ^ via The question of the quality of patient care and the quality of training in ambulatory residencies was also addressed. At issue is whether the patient population of continuity clinics, particularly in urban areas, is sufficiently representative of the general population to provide an adequate training experience; whether practitioners and faculty, who have not been specially prepared to teach in ambulatory settings, can provide an adequate quality of teaching; and whether lowincome patients who attend continuity clinics are well served by being cared for by residents.
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Introduction The financing of graduate medical education is complex and evolved pragmatically with the historic development of teaching hospitals and patient care financing. For almost all of this century, medical and graduate medical education clinical instruction has been concentrated in the hospital setting.
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Federal direct support for schools and undergraduate medical education began in 1963. This support was relatively brief.
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State university hospitals provide approximately 15 percent of all of the graduate medical education positions. Primacy Care Residencies and Ambulatory Care Training Historically, support of graduate medical education has come from hospital financing.
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There are no national data on financing of graduate medical education in ambulatory care settings. Family medicine residencies are structured differently than other residencies.
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Who Should Support GME? The question of who benefits and who should pay for graduate medical education has been a subject of debate for many years.
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- Fees or salary support from patients/third-parties for the provision of services. - Salary support or fee sharing from faculty Moving to increased fee support for primary care training in the outpatient setting raises the following problems, and probably is not feasible unless the financing of practice plans on a departmental basis is changed to institution wide plans.
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The issue is not the amount of revenues but the distribution of the revenues in support of graduate medical education priorities.
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The question that has attracted the most attention in the literature is the following: is it more costly to provide medical care in ambulatory settings in which residents are both being trained and are providing services than it is to provide such care by fully trained physicians? If costs are higher, the "net costs" of training will be positive; if lower, then the net costs of training will be lower.
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Patients Per flour Cost Per Visit J o S o Faculty lo) Input Per Resident Vis t)
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In before and after studies, analysts examine the effect of introducing residents and medical students into practice settings by estimating the level of costs and output at both points of time. In comparative cost studies, analysts compare the costs of care across settings which have different levels of involvement in graduate medical education.
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The introduction of medical students into the ambulatory practice setting leads to an increase in patient care costs while second and third year residents lead to a decrease in patient care costs.
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was the discussant for the presentations by Ruth Hanft and Judith Lave. Discussion noted that available evidence indicates that there are both net and gross costs to residency training in primary care ambulatory settings.
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There are a number of areas for which the information base is inadequate for policy-making, or in which further study would help primary care residency programs establish effective ambulatory training sites. Questions to be answered include: Where is outpatient training conducted today?
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These experiences provide the principle basis for my current views about graduate education in primary care. In the last three months I invited the leadership of Colorado's family medicine residencies to share with me their views of graduate medical education, I unsystematically discussed current affairs with various faculty members at the American Academy of Family Physician's 1989 Residency Advisory Program Workshop in Kansas City, and then I identified four "lessons" to present here today.
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From page 120... ...
Our texts advise prompt operative intervention. Yet, primary care clinicians notice that miscarriage as they see it has great psychological morbidity, infrequent hemodynamic and infectious morbidity, and is subject to discriminating non-operative management.6 The first lesson from those who aspire to teach doctors to do primacy care is that the clinical phenomena of primary care are important, they differ from hospital phenomena, and they have intrinsic importance in and of themselves.
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From page 121... ...
One hospital CEO responded, "Since we depend very heavily upon the participation of the private practitioners in the education of the residents, it would be self-defeating to pursue ambulatory care growth beyond that which is necessary for the purpose of the program." Yet we know in Colorado that throughout the 1980's it consistently has cost us $70,000 to $80,000 per year, per resident to provide family medicine training as we now understand it.7 About one-third of this amount was spent on resident stipends, one-third on the cost of the primary care practice site, and one-third on 121
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Despite efficient management outpatient revenu essential to the economic viability of family medicine residencies. Having breakfast last month with a group of family medicine residency directors from both coasts, ~ asked what advice they would offer a program director concerning their sponsoring hospital and in the next 30 seconds the comments ricocheted from -- "Never trust a hospital administrator", to "Never believe the numbers they give you", to "Never forget you are making money for them".
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In short, the primary care environment is an unusually complex environment, and effective information management is not peripheral but central to effective patient care, teaching, and relevant research. The fourth lesson is that the costs of information management are a legitimate part of the cost of primary care education.
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Report of the Citizens Commission on Graduate Medical Education. Chicago.
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Professor and Chairman Department of Pediatrics Boston University School of Medicine Director of Pediatrics, Boston City Hospital The pediatric residency at Boston City Hospital and Boston University School of Medicine stresses primary care pediatrics. The program emphasizes continuity in training experience, has developed a psychosocial curriculum, includes the practice of preventive pediatrics and provides pediatric residents with the opportunity to care for inner city children at risk.
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From page 126... ...
Just as there is not enough time to educate for all of the specialties, so there is not enough time to have experience in all of these settings, particularly if one is locked into an arbitrary definition of a primary care site. Recruiting minorities has been an important part of our program, and we are having difficulty despite a special program which the Boston City Hospital House Officers Association, with funds from the Department of Health and Hospitals, has implemented, offering a subsidized elective program for senior medical students.
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From page 127... ...
Without an emphasis on general pediatrics, ~ believe that training at the municipal hospital would be in conflict with its service mission. But the issues identified in educating for general pediatrics are not confined to the public hospital, but have application to a broad range of pediatric training programs, including tertiary care hospitals devoted exclusively to the care of children as well as to any academic, public, general, or community hospital where children receive care and residents are educated.
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It was essential that ambulatory medicine not be treated as an "add on" to inpatient care. During ambulatory block, residents spent about half their time in continuity of care, a quarter in ambulatory specialties (e.g.
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From page 129... ...
We finally concluded that they would best serve in the role of "continuity-gap providers", caring for residents' patients on their team when the residents were not available. We also needed to train physician faculty, as clinic preceptors, and to develop an ambulatory care core curriculum.
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From page 130... ...
~ won't go into the details, except to point out that resolution of the service/education conflict is central to the future of primary care residencies. A major point of the paper is that merely shifting more training to the outpatient setting does not resolve the service/education conflict but may merely shift it to the outpatient setting from the inpatient setting.
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From page 131... ...
of graduate medical education. Does it make sense to consider combining training for family medicine, general pediatrics and general internal medicine in some imaginative way that reduces the cost of training, pools faculty strengths and resources, and reduces destructive competition so as to produce a better "product"?
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From page 132... ...
Discussion Discussion of the presentation by program directors noted that if program directors are to be able to negotiate with hospital administrators and establish beneficial arrangements, the financial relationship between teaching hospitals and the primary care residency programs needs to be properly understood. Some discussants pointed out that hospitals derive greater revenues from patients admitted by subspecialists than from the smaller volume of admissions by primacy care physicians.
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The state has no history of support for graduate medical education. Who in the hospital and the medical school will support and who will oppose your attempts to fund the program?
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One possible source of financial support for the program that is sometimes controlled by the department chairman is the faculty practice plan. It should, however, be noted that there exist many of ways of organizing faculty practice plans.
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Graduate medical education takes second place. Thus, the chairman's argument that the new track would strengthen faculty in ways that mesh with the missions of the medical school would carry weight.
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From page 136... ...
Thus the more important question for the hospital president is whether the size of the residency programs relates to the population being served, and whether the residency programs together form a coherent and uniformly strong whole. These are the overarching considerations within which the question of financing a residency is considered.
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From page 137... ...
The current mechanisms of GME financing favor inpatient and procedural care, making the support of primary care programs difficult, since they are more oriented towards outpatient evaluation and management. The majority of graduate medical education funding comes from patient care reimbursement through Medicare Part A direct and indirect payments, and other third party payers.
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From page 138... ...
o Include residents' primary/ambulatory care time in the calculation of resident FTEs for Medicare direct and indirect medical education payment, add incentive for primary care training in direct payment, and recalibrate payment per resident to maintain budget neutrality. 0 Increase state support through Medicaid participation in payment for GME and through grants for primary care education.
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From page 139... ...
I, The option of paying for services on the basis of a resource based relative value scale (RBRVS) was generally thought to have potential for both facilitating the financing of primary care residency programs, and for making the primary care specialties more attractive to physicians by decreasing the income differential between primary care and other specialties.
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From page 140... ...
While this proposal incorporated incentives to expand primary care programs, it did not directly tackle the question of funding residencies in ambulatory settings However, the additional revenues obtained by primary care programs should help make available resources to succors ambulatory training.
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, , Federal Grant Programs Grants to sunnort family medicine. general internal medicine, and pediatrics training programs have played a major role in generating new primary care residency programs.
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From page 142... ...
This strategy poses dangers to hospitals that provide large amounts of uncompensated care and may lack a sufficient base of charge paying patients on whom to pass the cost. Furthermore, some states use a tax on hospitals to garner revenues with which to pay for uncompensated care, making this mechanism less accessible for use by policy makers attempting to enhance GME revenues.
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