GME e-Letter, July 2008

Dear colleague,
 
The National Center for Studying Health System Change has just released "Falling Behind: Americans' Access to Medical Care Deteriorates, 2003-2007."

Here are some direct quotes from the report:

• "Uninsured people continue to have much higher levels of unmet medical need and delayed care compared with insured people, and access for the uninsured decreased between 2003
  and 2007 . . ." 
  
• "Insured people also faced large increases in unmet need between 2003 and 2007. In fact, insured people experienced a greater percentage increase in unmet medical needs compared with uninsured people -- a 62 percent increase for the insured vs. a 33 percent increase for the uninsured. As a result, ironically, the access gap between insured and uninsured people narrowed slightly. In 2003, uninsured people were 3.4 times as likely to report going without care as insured people and 2.8 times as likely in 2007."
  
• "Insured people are facing growing cost pressures, including higher out-of-pocket spending for care, more difficulties finding providers who will accept their insurance and renewed limits on what their insurance will cover."
  
• "Although rising costs continue to be the dominant obstacle to access to needed care, people face growing barriers related to health care system capacity and provider accessibility. This is consistent with a perception of growing medical workforce shortages, especially among primary care practitioners, which will be difficult for policy makers to address in the short term."

It's impossible to edit a message so clearly stated. I urge my colleagues to read the entire report.

(Note: The report was referenced in a June 30 New York Times editorial, "Maybe I'll Get Better on My Own."

As always, we welcome your comments on these or other issues at gme@ama-assn.org

Paul H. Rockey, MD, MPH, Director
AMA Division of Graduate Medical Education 

1. AMA adopts new policies at annual meeting

2. Reader feedback: How to fix primary care
 
In the June issue of the GME e-Letter, we noted the growing media chorus about the many challenges facing primary care, and asked, "Are primary care physicians an endangered species?"

We received some interesting responses to this question: 

• Primary care reimbursements should be doubled. 
  
• Physician extenders can help primary care physicians handle their workload and keep their sanity.
  
• Primary care physicians can't do it all, and should rely on hospitalists for inpatient duties and ER docs to cover the ER -- and stay away from obstetrics-gynecology.

Read all responses.

In related news, an article in the May issue of Academic Medicine argues that the three primary care specialties (family medicine, internal medicine, and pediatrics) should come together to form a single discipline.

Also, recent data that some nurse anesthetists earn more than family practitioners led to a lively discussion in the Wall Street Journal's Health Blog (June 18).

3. Geriatric care, faculty development discussed at AMA meeting

Facing a future with more senior citizens and fewer physicians, ensuring that tomorrow's doctors are well-versed in geriatric care is a major challenge facing US medical schools.

This issue, along with innovations in faculty development, was on the agenda at an educational session (PDF, 135KB; see p. 2) sponsored by the AMA Section on Medical Schools during the recent AMA annual meeting.

Ensuring adequate care for the elderly will require changes in education and practice across the medical education continuum (AMNews, June 9).

4. New around here? Update your FREIDA Online program data

Attention newly accredited programs, and new program directors: 

Make sure your program information is up-to-date on FREIDA Online by completing the program survey on GME Track.

Programs that complete and approve the survey by July 11 will have their information on FREIDA Online updated in August. If you need login information for GME Track, please call (800) 866-6793 and select option 1. 

5. AMA, 27 medical schools seek to transform medical education

A wide-ranging AMA project is bringing together researchers from 27 medical schools to explore ways to improve physician training and patient outcomes.

The two current projects of the AMA's Innovative Strategies for Transforming the Education of Physicians (ISTEP) are:

• Managing the influence of pharmaceutical marketing on physician prescribing practices 
  
• Developing educational materials for medical students and residents to promote prevention of substance abuse as well as diagnosis and treatment of patients with substance abuse

To read more, see the March/April issue of AMA Voice for academic physicians (PDF, 1.46MB).

6. Adolescent medicine faces supply, recruitment challenges

Since adolescent medicine became a board-certified subspecialty in 1991, the number of fellows entering the field has not increased and fewer fellowship programs exist now than did prior to board certification. 

A new report from Incenter Strategies, the National Alliance to Advance Adolescent Health, examines these and other challenges facing the field.

7. New resource available on ECFMG Acculturation Web site

A new resource, "The Interdisciplinary Health Care Team," has been added to the Acculturation Program from the Educational Commission for Foreign Medical Graduates (ECFMG).

This program helps introduce newly arriving international medical graduates (IMGs) to the interdisciplinary health care team as it currently exists and functions in US medicine. 

It includes an overview of the concept of the health care team and its evolution as well as descriptions of more than two dozen medical, nursing, and related staff members of the team, explaining their function, role, and training and how they contribute to care of patients.

Although targeted to IMGs, these resources may also be of value to US-trained physicians and other members of the health care team.

8. Medical education in the news: Bias is natural -- deal with it

"Bias is not a crime, is not necessarily intentional, and is not a sign of lack of integrity; rather, it is a natural human phenomenon," write Cain and Detsky in the June 25 JAMA  (extract). "[E]veryone is likely capable of rationalizing beliefs and denying influences that bias them. The most important action physicians can take as a profession is to recognize this."

The number of medical school slots is growing more rapidly than the number of GME positions, meaning that the US will still face a physician shortfall in the future (AMNews, June 23/30).

This GME "bottleneck" is the result of the cap on residency positions that was part of the Balanced Budget Act of 1997 (JAMA [extract], June 25).

In south Florida, at least, GME has expanded, with a new 50-slot internal medicine program opening. Program director Charles Posternack, MD, compared the program to a baseball team’s farm league: "You can bring in free agents or build your own farm system to supply physicians for Palm Beach County forever," he said (South Florida Sun-Sentinel, July 1).

Texas A&M's Health Science Center is working to develop a regional campus in Round Rock, to provide clinical training for third- and fourth-year medical students (Austin American-Statesman, June 18).

Similarly, plans for two regional medical school sites in Kentucky are aimed at increasing the number of physicians in the state's medically underserved rural areas (University of Kentucky News, June 17).

The University of Chicago Pritzker School of Medicine, on the other hand, is reducing its entering class size from 104 to 88 per year as it implements a new curriculum with increased student-faculty interaction and fewer large lecture classes.

Despite widespread appeals, including advocacy by the AMA, medical school graduates beginning with the class of 2009 will no longer qualify for a federal loan deferment plan (AMNews, June 16).

As medical student debt continues to rise, primary care becomes less attractive to tomorrow's physicians (Detroit News, June 18).

The Michigan State Medical Society drafted a resolution on medical student debt that was approved by the AMA House of Delegates at its June meeting.

A survey of 101 internal medicine residents found that only one in five felt competent in prescribing weight-loss programs to patients with obesity (Medical Education Online) (PDF, 668KB).

IMGs in Michigan are back in the driver's seat, after a fix to a law targeted at illegal immigrants that also prevented legal residents on student or work visas, including physicians, from getting a driver's license(AMNews, June 23/30).

9. Virtual Mentor: Sex and gender in medicine
 
Women, whether patients or physicians, face sex and gender stereotypes (eg, women patients exaggerate pain symptoms; surgery is a man's field).
 
While such biases can be overcome only by considering each woman as a unique individual, some gender inequities also demand changes in the social and cultural role expectations of women collectively.
 
This July issue of Virtual Mentor examines the effects of these stereotypes on men and women in medicine.

10. Program requirements' revisions approved at ACGME meeting

At its June meeting, the ACGME approved major revisions to the following program requirements, effective July 1, 2009:  

• Neurological surgery
• Plastic surgery 
• Radiation oncology
• Six subspecialties of pediatrics:
     Pediatric endocrinology
     Pediatric nephrology
     Pediatric pulmonology
     Pediatric gastroenterology
     Pediatric infectious diseases
     Developmental-behavioral pediatrics

Minor revisions, effective August 10, 2008, were approved in: 

• Surgery
• Pediatric surgery

11. Predicting physician workforce a complex business

Physician retirement patterns, sex and generational differences in work patterns, and education cost and debt (on the supply side), and insurance coverage and reimbursement reform, new technologies, and nonphysician clinician production (on the demand side) are some of the variables that go into calculating the complex physician workforce equation.

"Given the time required to train competent physicians and the growing reliance on other nations to provide physicians, it would seem in the national interest to err on the side of expanding US medical schools. The alternative is to risk the devastating effects of a physician shortage. . . ."

"Confronting the Complexity of the Physician Workforce Equation" (extract)
Darrell G. Kirch, MD; David J. Vernon, BA
JAMA, June 11

12. Pediatric asthma featured in AMA Therapeutic Insights newsletter
 
"Gaining Control of Asthma in Children" is the subject of the latest AMA Therapeutic Insights newsletter.
 
This free online quarterly newsletter spotlights one medical condition per issue and features state and national prescribing data along with evidence-based guidelines for treatment. Previous newsletters covered such conditions as dyslipidemia, depression and osteoporosis.
 
Note: Continuing Medical Education credit (PRA category 1) is offered for each newsletter.

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About us ...

The GME e-Letter is produced by the Medical Education Group of the American Medical Association (AMA), publishers of the Graduate Medical Education Directory ("Green Book") and other medical education products.

Our monthly e-mail communication covers information of interest to the graduate medical education community. Readers include program directors and staff at ACGME-accredited and board-approved residency and fellowship programs, designated institution officials (DIOs), hospital administrators, professional associations, medical school deans, and governmental organizations.

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What's happening in the world of GME? If you have any ideas for future e-letters, please contact us. Also, let us know what you think about this newsletter--and feel free to forward it to your colleagues.

Direct suggestions, comments, compliments, gripes, to

Fred Donini-Lenhoff
Medical Education Products
American Medical Association
515 N State St, Chicago, IL 60654
(312) 464-4635
(312) 464-5830 fax
gme@ama-assn.org

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