ACS Views on Legislative, Regulatory, and Other Issues

Graduate Medical Education—

• Background
• Other Activity: COGME and MedPAC
• Resident Work Hours

• ACS letter to The Honorable Phil English on the Higher Education Act, 5/24/05
• Letter to The Honorable Mark McClellan, MD, PhD, 6/12/04 (Re: Comments on Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2005 Rates, Proposed Rule [CMS-1428-P]
• ACS Letter to COGME on Workforce Study, 4/30/04
• Physician Coalition Senate Letter on Higher Education Act, 4/19/04
• Physician Coalition House Letter on Higher Education Act, 4/19/04
• ACS Senate Letter on Higher Education Act, 3/30/04
• ACS House Letter on Higher Education Act, 3/30/04
• Letter to Secretary Thompson on Unused Resident Positions, 3/8/04
• Letter to David C. Leach, 8/1/02
• Letter to David C. Leach, 6/6/02

April 30, 2004

Carl J. Getto, MD
Chair
Council on Graduate Medical Education
5600 Fishers Lane, Room 9A-21
Rockville, MD 20857

Dear Dr. Getto:

The American College of Surgeons would like to comment on the proposed physician workforce policy recommendations presented by Edward Salsberg at the Council on Graduate Medical Education's (COGME's) September 2003 meeting.

As you know, the College is a voluntary educational and scientific organization devoted to the ethical and competent practice of surgery and to enhancing the quality of care provided to surgical patients. For over 90 years, we have provided educational programs for our more than 66,000 Fellows, and other surgeons in this country and throughout the world. Accordingly, the College has a longstanding interest in graduate medical education (GME) and surgical workforce issues.

Recommendation 1: End 110:50/50 policy recommendation.
The College agrees that the 110:50/50 workforce goal should be eliminated. An October 2003 report by the General Accounting Office (GAO) found that the U.S. physician population increased by 26 percent between 1991-2001—twice the rate of the total population growth. GAO also determined that the generalist/specialist mix remained about 1/3 generalists and 2/3 specialists.¹ These data clearly indicate that current demand for physician services, and specialty care in particular, far exceeds the 110:50/50 model.

In addition, the College has longstanding concerns with the 50/50 specialty mix goal. Initial recommendations about the need to produce a workforce comprised of at least 50 percent generalist physicians were based on outdated population statistics and comparisons to other countries. Furthermore, the 50/50 formula only defined those services provided by general internists, family physicians, and general pediatricians as primary care. It did not take into account the true nature of care being provided by both generalists and specialists, nor did it reflect different patterns of growth in medical and surgical specialties. Finally, the formula did not consider the rapidly growing supply of non-physician primary care practitioners.

Recommendation 2, 3 & 4: Increase number of new physicians from 24,000 per year to 27,000 per year; increase US medical school graduates by 3,000 per year (15 percent) by 2015; and gradually increase the number of training positions and begin to raise Medicare cap on GME positions.
The College acknowledges that earlier predictions of a physician surplus have not materialized. In fact, many recent workforce analyses predict a physician shortage, particularly in certain specialties and geographic regions. A recent study in the Annals of Surgery by Etzoni, et al, predicted that the aging of the U.S. population will result in a significant growth in the demand for surgical services.²

This increase in demand presents a unique challenge for surgery. Surgical residency programs are resource and quality based. To be accredited, programs must demonstrate a quality, diversity, and complexity of patients sufficient to support the learning needs of each resident in the specialty, as well as a curriculum that meets rigorous standards of educational quality. Patient and educational resources are finite, and these strict limitations have served to constrain the proliferation and expansion of surgical residency programs.³ As a result, general surgery has graduated approximately the same number of trainees each year for 20 years (that is, approximately 1,000).⁴ In order for surgical residency programs to expand in response to increased patient demand, they will clearly need additional patient and educational resources.

However, the College is concerned about proposals to increase all medical school graduates and residency positions by a set percentage or number. The College believes that quality should be the major factor in determining which education and resident training programs should be funded and how actual residency slots will be allocated. Other factors, such as geographic need and minority participation, are important and worthy of consideration, all things being equal, but our nation's finest physician education and training programs must be preserved. We suggest that the Accreditation Council for Graduate Medical Education's Residency Review Committees might be given the responsibility of evaluating existing residency programs on the basis of quality.

Recommendations 5 & 6: Track physician supply, demand and need and conduct a comprehensive reassessment within the next four years; assess supply, demand and need by specialty on a systematic basis to guide medical student and physician decision making on specialty mix rather than set a specific target for the nation.
The College strongly agrees that COGME should comprehensively reassess physician supply, demand, and need within the next four years. The American health care system is constantly evolving, and a variety of factors can interfere with the best efforts to project physician supply and demand.

In addition, largely because of new medical technologies, today's generalists and specialists are performing a growing number of services historically performed solely by each other. This overlap in performance of services is compounded by the increased use of non-physician providers to perform many of the duties that were once performed solely by physicians.

Accurate physician workforce assessments will also help medical students make more informed career choices. Although medical students consider a number of factors when selecting a specialty—including personality, interest, and role models—accurate data on job availability and patient demand will help to direct new physicians into underserved communities and needed specialties.

Recommendation 7: Promote efforts to increase physician productivity, including investing in new technologies, such as information systems.
As medicine moves through the 21st century, technology will play an increasingly important role in every physician's practice. Recent advances in the areas of laparoscopic surgery have truly improved the quality of surgical care. In addition, the development and implementation of information systems, such as electronic medical records and electronic prescribing, are expected to reduce the number of medical errors and improve patient safety.

The College supports federal efforts to promote investment in new technologies, such as the creation of uniform standards for electronic transactions. We urge caution, however, when considering mandatory programs that would place unrealistic technological and financial burdens on providers.

Recommendation 8: Expand the National Health Service Corps (NHSC) and other federal programs that address access problems created by shortages.
The NHSC and other federal health professions programs play a vital role in addressing geographic and demographic access issues. While these programs currently provide training and funding for primary care physicians, nurses, and allied health professionals, the College believes NHSC should be expanded to include general surgery.

The mission of NHSC is to improve the health of the Nation's underserved population by providing comprehensive team-based health care that unites communities in need with caring health professionals and supports communities' efforts to build better systems of care. As the Graduate Medical Education National Advisory Committee stated in its 1980 Summary Report, surgery is a basic type of health care. In fact, in many rural communities general surgeons often provide primary care, obstetrical, and emergency services in addition to surgical care. Also, general surgeons are often the sole providers of trauma care in rural areas. Expanding the NHSC to include general surgery would be an effective and cost efficient way to ensure underserved populations have access to essential surgical care.

Conclusion
The College appreciates COGME's dedication and commitment to improving our nation's graduate medial education system and ensuring a balanced physician workforce. After many years of research and dialog, we are encouraged by the draft version of the physician workforce recommendations as they address many of the College's concerns with previous workforce models. While we are hopeful the Council will consider the concerns and suggestions discussed above, we support this necessary policy change and look forward to working with COGME and the Congress on its implementation.

References

1. GAO: October 2003 Report, "Physician Workforce: Physician Supply Increased in Metropolitan Areas by Geographic Disparities Persisted."
2. Etzioni, DA, Liu, JH, Maggard, MA, Ko, CY, "The Aging Population and Its Impact on the Surgery Workforce," Annals of Surgery, Vol. 238, No. 2, 2003.
   
3. Kwakwa, "The Longitudinal Study of Surgical Residents, 1993-1994," Journal of the American College of Surgeons, November, Pg. 425-433, 1996.
   
4. Sheldon, GF, "Great Expectations: the 21st Century Health Workforce," The American Journal of Surgery, Vol. 185, Pg. 39, 2003.

Sincerely,

Thomas R. Russell, MD, FACS
Executive Director
American College of Surgeons

Revised March 7, 2005

ACS Views on Legislative, Regulatory, and Other Issues

Advocacy and Health Policy