Medical Education in the United States 1976-1977 Coordinated and
Compiled by Sylvia
The 77th Annual Report on Medical Educa¬ tion, prepared by the staff of the AMA Group on Medical Education, is based on information provided by individual medical schools, hospi¬ tals, government agencies, the Association of American Medical Colleges, and the American Public Health Association.
Following the format of recent years, Section I, "Recent Events of Special Interest to Medical Education," contains summaries of significant activities relating to medical education and brief comments regarding each. Section II provides information on undergrad¬ uate medical education, including accredita¬ tion, medical schools in the planning stages, curriculum, faculty, students, and medical
I. Etzel
school finances. Information and statistics on graduate medical education programs is pre¬ sented in Section III, and the annual reports on continuing medical education and allied medical education appear in sections IV and V. Section VI contains a description of programs in medical education sponsored by government agencies, and a report on grad¬ uate education in public health may be found in Section VII. Statistical data on medical schools in the United States and Canada are presented in Appendixes I and II. Appendix III lists ac¬ credited sponsors of continuing medical edu¬ cation.
Section I
Recent Events of Special Interest to Medical Education C. H. William Ruhe, MD Senior Vice-President for Scientific Activities This section includes information about special studies, reports, legislation, and other events and activities that currently have an influence on, or relation to, medical education, and that might be expected to influence the future course of events in medical education. Most of the items listed are extensions of reports given in earlier years and are still in development or in transition. Some of these items are also considered in other sections of the EDUCATION NUMBER.
Coordinating
Council
on
Medical Education
The Coordinating Council on Medical Education (CCME) has been described in several previous issues of the EDUCA-
TION NUMBER.
late in
Since its establishment
1972, it has been involved in studying and developing reports on a number of important issues affecting medical education. Major reports were prepared and were published previous-
ly in JAMA on the subjects of "The Primary Care Physician" and "The Role of the Foreign Medical Graduate," both of these being under the general subject heading "Physician Manpower and Distribution." A third report on the subject "The Geographic and Specialty Distribution of Physicians" was under preparation
for more than two years, and it had been anticipated that the report would be completed and published by the end of 1976. However, several drafts of the
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report were regarded as unsatisfactory by one of the parent organizations, and
the report was remanded to committee for study and revision. It now seems unlikely that a report on this subject will be published by CCME without the assembly and analysis of a substantial amount of additional data. During the year, the CCME and the parent organizations reached agree¬ ment on several statements related to the subject "Financing Graduate Medi¬ cal Education." A report of the
Committee
on
Continuing Competence
of Physicians was also under prepara¬ tion and should be ready for presenta¬ tion to the parent organizations by the end of 1977. The CCME will complete its fifth
operation at the end of 1977. Since the chairmanship of the organi¬ zation rotates among the parents, each of the parent organizations will have occupied the chair by the end of 1977. The chairmen for the five years were as follows: 1973, Dr William Anlyan, Association of American Medical Col¬ year of
leges (AAMC); 1974, Dr Tom Nesbitt, American Medical Association; 1975, Dr Jack Myers, American Board of Medical Specialties (ABMS); 1976, Dr Rollins Hanlon, Council of Medical Specialty Societies (CMSS); 1977, Dr Robert Cathcart, American Hospital Association (AHA). The chairmanship
will revert to the AAMC for the begin¬ ning of the second cycle in 1978. The CCME is still new and its final role and definition of purpose have yet to be determined. Established to coor¬ dinate the activities of the various liaison committees that serve as ac¬ crediting bodies and to initiate review and recommend policy decisions relat¬ ing to medical education to the five parent organizations, the CCME has been envisioned in various ways by various people. Many have seen it as a simple coordinating organization with no absolute authority of its own. Others have viewed it as eventually becoming an independent, free-stand¬ ing commission with authority to regu¬ late all levels of medical education. The situation has been complicated by the fact that various governmental and private groups have attempted to persuade the CCME to assume regula¬ tory functions. In some instances, these efforts to persuade have approached the form of threats that some federal agency would be authorized to regulate the numbers, types, and locations of residency positions if the CCME refused to accept the responsibility. This has caused some dissension within the ranks of the CCME members. Some would like to see CCME become a regulatory agency. Others do not favor such a role for CCME, but would prefer to have CCME in that role rather than a federal agency. Still others believe that a regulatory role would completely distort CCME's pur¬ pose and function and that, if there must be regulation, it should be carried out by some other agency. Most of the last group believe that regulation of residency training is not appropriate and that regulation may be resisted if the profession will remain united against it. In addition to this concern for the CCME role in the future, there is considerable interest on the part of some organizations in establishing an independent staff for CCME. When the
CCME and the Liaison Committee Graduate Medical Education (LCGME) were established, and the Liaison Committee on Continuing Medical Education (LCCME) was pro¬ posed, it was agreed that staff services for all of these bodies would be provided by the AMA for the time being. The term "for the time being" was not defined. The AMA had offered to provide the staff services to insure that the new organizations would become established properly and to assure continuity in the accreditation of graduate and continuing medical education, since AMA staff had al¬ ready been engaged in staffing these operations for many years. In so doing, AMA agreed to continue to supply a major portion of the financing of the accreditation activities. Those favoring independent staffing do so for a variety of reasons: some allege that the public credibility of the CCME and its related liaison commit¬ tees suffers because the AMA provides staff services; some believe that AMA has too much influence over the bodies because of their staffing services; some believe that the AMA staff afford preferential interest to AMA concerns in their staffing operation; some believe that an independent staff could give more time to the activities, and therefore would provide better services; some believe that the AMA staff is incompetent and that an independent staff would do a better job. Discussions have been ongoing in both the CCME and the LCGME, and to a lesser extent in the LCCME, about the future role of the CCME and the liaison committees, their proper rela¬ tionship to each other, the pattern of staffing that will be most effective for the future, and the mechanisms by which financial support will be pro¬ vided for the staff and for the opera¬ tional activities. on
Liaison Committee on Graduate Medical Education
The LCGME began its formal oper¬ ations as the official accrediting body for residency training in January 1975. During its three operational years, it has gradually developed a closer and more effective relationship with the 22 residency review committees that for¬ merly served as separate accrediting bodies. As noted in last year's report, some friction had developed between LCGME and the review committees because of questions concerning the level of LCGME authority and alleged overlapping function. More recently, questions were raised concerning the development of policy proposals and
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in the absence of direct communication between the LCGME and the parents of the resi¬ dency review committees. While all of these matters have not been resolved, relations between the LCGME and the review committees appear to be improving, largely be¬ cause the chairmen of the residency review committees have been attending LCGME meetings on a regular basis. The LCGME has also agreed that resi¬ dency review committee chairmen may be present when the programs of their own committees are reviewed by the LCGME. The LCGME has spent considerable time in attempting to resolve the prob¬ lems attendant on the first graduate year of medical education. Although the first graduate year, formerly called the internship, has not been reviewed for accreditation as a separate year of graduate medical education since 1975, there continues to be agitation for the existence of a free-standing year that would provide broad, general, and clin¬ ical education for all medical grad¬ uates. The concern is most evident among those in the so-called nonbedded specialties and in the relatively narrow specialties and subspecialties where the residency programs them¬ selves do not provide broad, general training. Because of the major move¬ ment toward primary care specialties, and the desire to provide complete training for family physicians, general internists, general pediatricians, and general obstetrician-gynecologists, it has been difficult for these primary care specialties to offer the year of broad training for the graduates who intend to go into more limited specialty fields. The problem is further compli¬ cated by the rising costs of graduate medical education, the high costs of medical care, and the desire of hospi¬ tals to restrict their costs. As noted in the section under the Coordinating Council on Medical Edu¬ cation, there have been proposals that an independent staff be provided for the LCGME. There are those who favor this for the LCGME alone, while others would prefer a large indepen¬ dent staff that would provide staff services for CCME, LCGME, LCCME, and the Liaison Committee on Medical Education, thus removing all of these bodies from direct staff support by any of the parent organizations. The mat¬ ter is complicated by the substantial costs that are involved. The LCGME has a committee on future staffing as does the CCME, and they are attempt¬ ing to work out proposals that will be acceptable to all parent organizations.
positions by LCGME
Liaison Committee
on
Continuing Medical Education Early in 1977, the bylaws of the were accepted by the five parent organizations of the CCME and by the two additional organizations that are represented on the LCCME. LCCME
The LCCME then became the ac¬ crediting body for organizations and institutions offering educational pro¬ grams for the continuing education of the physician as of July 1,1977. The LCCME plans to continue most of the procedures that had been followed by the AMA Council on Medical Education in its conduct of the accreditation process for continuing medical education since 1966. Changes in the process may be anticipated for the future, as would have been the case had the Council on Medical Education continued its function, but it is not foreseen that there will be any abrupt or revolutionary changes under the LCCME sponsorship. At least for the present, the LCCME will continue to receive recommendations from survey and review bodies established by the state medical associations for institu¬ tions and organizations that offer continuing medical education designed essentially for intrastate consumption. A new review committee for continu¬ ing medical education has been es¬ tablished to make recommendations concerning those institutions and orga¬ nizations that offer programs designed for national consumption. To provide continuity with previous procedures, this committee will include six mem¬ bers of the Advisory Committee on Continuing Medical Education to the Council on Medical Education of the AMA, which had been serving as the review body under the AMA's accredi¬ tation system. In addition, each of the other sponsoring organizations of LCCME will have one representative on the new review committee. Through its subcommittees on goals and priorities and on procedures, the LCCME is continuing to explore the future scope of its activities and how these will be conducted. Liaison Committee on Medical Education
The Liaison Committee on Medical Education (LCME), which is the offi¬ cial accrediting body for institutions offering programs leading to the MD degree, has been in existence since
1942. Composed of six representatives of the AMA Council on Medical Educa¬ tion, two public representatives, and one federal representative, LCME has for many years carried out its accredi-
tation responsibilities and has been widely recognized both in federal and in state legislation as the official ac¬ crediting body for undergraduate med¬ ical education. During 1976, that role was chal¬ lenged by the Federal Trade Commis¬ sion (FTC). The LCME, like all other official accrediting bodies, has been recognized by the United States Office of Education (USOE) and must submit its procedures for review periodically to maintain that recognition. Shortly before LCME representatives were to appear before the Commissioner of Education's Advisory Committee on Accreditation and Institutional Eligi¬ bility, the FTC addressed a letter to the USOE staff contending that LCME should not be recognized because it included representatives of the AMA that, as the major professional organi¬ zation for practicing physicians, might have a conflict of interest in ac¬ crediting medical schools. The letter stated that it might be considered that AMA would have an interest in limiting the supply of physi¬ cians and that this constituted a poten¬ tial conflict of interest. Although extensive review of LCME procedures and extensive search of AMA files has been carried out during the year before the submission of this letter, the letter stated that there was no allegation that there had in fact been improper conduct on the part of the LCME. The letter contended, however, that it was not necessary to establish improper conduct but simply to point out that there was potential for such conduct. The USOE hearing was postponed to permit LCME and AMA to respond to the FTC letter. Attorneys for all three organizations appeared before the USOE Advisory Committee and, after extensive discussion and consideration, the Advisory Committee recommended continuation of LCME recognition for a period of two years. The FTC then protested the recommendations in a letter directly to the Commissioner of Education but, after some delay, the commissioner supported the recom¬ mendation of the USOE Advisory Committee and did not accede to the FTC request. The granting of contin¬ ued recognition for a period of two years was accompanied however by the citation of several deficiencies in the compliance of the LCME with the USOE criteria for recognition, most of them depending on or relating to the autonomy of the LCME. LCME will be
required to submit a progress report showing that efforts are being made to
correct
Since
a
the identified normal period of
deficiencies.
recognition is
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four years, and this is the first time that LCME has received anything less than a full period of recognition, it must be considered that LCME's future recognition is in some jeopardy as the result of these developments.
Meanwhile, LCME's relationship to CCME is still under review, as is also its composition. The other parent orga¬ nizations of CCME that are not repre¬ sented on LCME have requested that the LCME membership be broadened to include them. So far, LCME has refused to comply. The pattern of future staffing is also under considera¬ tion. For many years, staffing respon¬ sibility has alternated between AMA and AAMC in alternate years. One of the matters being considered is wheth¬ er LCME should be a part of the total CCME-Liaison Committee family of organizations for which an indepen¬ dent staff should be established. Committee on Allied Health Education and Accreditation This section of previous education numbers has reported on the efforts of the AMA to develop a modified pattern of accreditation of allied health occupa¬ tions that would be broadly acceptable in both professional and educational circles. Following the Study of the Accreditation of Selected Health Edu¬ cational Program, the AMA approved and proposed to the parent organiza¬ tions with which it collaborates in the accreditation of allied health educa¬ tional programs that there be estab¬ lished a Joint Council on the Accredita¬ tion of Allied Health Education (JCAAHE). However, the assembled representatives of the collaborating organizations voted by a margin of more than two to one against the proposal, and JCAAHE was therefore abandoned as nonviable. The AMA then attempted to develop a body within its own structure that would meet the criteria for recognition by the USOE and would at the same time answer objections that had been voiced concerning the accreditation procedures. After many meetings and discussions, the AMA House of Dele¬ gates finally adopted a report from the Council on Medical Education recom¬ mending that there be established a Committee on Allied Health Education and Accreditation (CAHEA) as an outgrowth of the council's existing Advisory Committee on Allied Health Education. The Advisory Committee was expanded to include representation from the public and from the Council on Medical Education itself. The coun¬ cil delegated to CAHEA the authority to make final decisions on the accredi-
tation of individual programs, and the House of Delegates gave to the Council on Medical Education the authority to give final approval to essentials for all allied health educational programs. The CAHEA became operational early in 1977 and has held two formal meetings to carry out its accreditation responsibilities. The new committee appears to meet
objections previously
cited by the USOE and also meets with the approval of most of the collabo¬
rating organizations.
Some of the allied health organiza¬ tions are, however, still searching for a pattern that will enable them to be independent of the AMA. Several consortia of various allied health groups have been proposed and ex¬ ploratory discussions are continuing. Meanwhile, the American Physical Therapy Association (APTA) was fi¬ nally recognized by the USOE as an independent accrediting agency after two years of seeking such status. The Committee on Allied Health Education and Accreditation of the AMA was also recognized for such purpose for a period of six months, so that at the time of this writing, there were two
accrediting organizations recognized by the USOE in the field of physical therapy education. The success of APTA in breaking away from AMA, after 40 years of collaboration in the accreditation of physical therapy edu¬ cational programs, was expected to encourage other allied health organiza¬ tions to seek independent status as
accrediting agencies.
Graduate Medical Education National Advisory Committee
spring of 1976, Dr David Matthews, Secretary of Health, Educa¬ tion and Welfare, announced the appointment of a Graduate Medical Education National Advisory Commit¬ tee (GMENAC). In appointing the committee, Secretary Matthews stated that In the
the Secretary and, by delegation, the As¬ sistant Secretary for Health, are charged under Title VII of the Public Health Service Act with responsibility for taking national leadership in the development of programs addressed to graduate medical education and in the research, development and anal¬ ysis of programs that impact on the health manpower needs of this nation. The purpose of this Committee is to analyze the distribu¬ tion among specialties of physicians and medical students and to evaluate alternative approaches to insure appropriate balance. The Committee will also encourage bodies controlling the number, types, and geo¬ graphic location of graduate training posi¬ tions to provide leadership in achieving the recommended balance.
The committee was appointed at a time when the House of Representa¬ tives and Senate were both considering new health manpower legislation as extensions of the 1971 Health Man¬ power Act. Both the House and the Senate bills contained variations on a proposal calling for a study concerning the distribution of physicians by spe¬ cialty, with the implication that resi¬ dency training would be controlled in the future to provide optimal percent¬ ages of physicians within each special¬ ty. Presumably, GMENAC would have removed the necessity for much legis¬ lative proposals, which were eventually removed from the Health Manpower Act before it was finally passed and signed into law. The functions assigned to GMENAC were
to
advise, consult with and make recommenda¬ tions to the Secretary on overall strategies on the present and future supply and re¬ quirements of physicians by specialty and geographic location; transition of physician requirements into a range of types and numbers of graduate training opportunities needed to approach a more even distribution of physicians' services, taking into account national health planning goals, guidelines, standards, and, as appropriate, the health system plans developed by health system agencies; factors which affect physician career choice; the impact of various activi¬ ties which influence specialty distribution and the availability of training opportuni¬ ties, including systems of reimbursement of services and financing of graduate medical education; and the relationship of graduate medical education to the provision of services in training institutions, including alternatives for the provisions of these services. It
was
stated that
the Committee shall advise on data require¬ ments and systems needed to conduct the activities of the Committee; propose nation¬ al goals for the distribution of physicians in graduate training; and recommend federal policies, strategies, and plan to achieve the established goals in concert with the private sector and nonfederal agencies.
The GMENAC consists of 21
bers, three of whom
mem¬
officio members from the Public Health Service, Department of Defense, and Veterans Administrations, and the remaining 18 of whom are representa¬ tives of health care providers, payers, and interested national and local orga¬ nizations. The committee was ap¬ pointed for a period of two years and was expected to submit an annual are
ex
report.
Although appointed in the spring of
1976, GMENAC did
not
hold its first
meeting until June 27 to 28, 1977. The first meeting was occupied largely with
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review of the committee's charges and the presentation of background infor¬ mation on graduate medical education, including a review of activities of other organizations in the field. A sub¬ stantial amount of time was devoted to review of the report from the US General Accounting Office (GAO) con¬ cerning graduate medical education and responses to that report that had been presented by various organiza¬ tions. The GMENAC appointed two task forces from its own membership: one to review and make recommendations on the GAO draft report, and the other to determine and define the nature of problems facing the committee regard¬ ing the distribution and geographic location of physicians, and to develop a set of assumptions and issues for the committee's deliberations. A second meeting was to be held before the end of 1977.
Emergency Medicine An application for recognition as a primary specialty board has been
submitted to the Liaison Committee for Specialty Boards (LCSB) by the American Board of Emergency Medi¬ cine, whose cosponsors are the Amer¬ ican College of Emergency Physicians, the University Association of Emer¬ gency Medical Services, and the AMA Section on Emergency Medicine. At the time of the preparation of this report, the application had been reviewed and recommended for ap¬ proval by the LCSB through its two parent organizations, the AMA Council on Medical Education and the ABMS. The application was then approved by the AMA Council on Medical Educa¬ tion, while the ABMS had appointed a committee to consider ways in which appropriate recognition might be af¬ forded in the field of emergency medi¬
cine.
Emergency medicine has been a rapidly growing field of practice during the past ten years. Most physicians devoting full time to the field have been second-career physicians; ie, they have been hired by hospitals as emer¬ gency physicians after having had previous careers as general surgeons, obstetricians, orthopedic surgeons, general practitioners, or other types of physicians. More recently, -however, residency training programs in emer¬ gency medicine have been developed and there are now approximately 30 such programs in existence, with medi¬ cal graduates enrolled in residency training. Through the efforts of the American College of Emergency Physicians and
the
University Association of Emer¬ Services, a body of knowledge and set of skills have been gency Medical
identified to form the basis of a threetraining program for those wish¬ ing to enter the field as a primary medical career. The development of an appropriate core curriculum has been complicated by the fact that emergency physicians in many settings are called on to deliver ordinary ambulatory care in addition to dealing with life-threat¬ ening emergency situations. In the typical community hospital, it has been estimated that as much as 80% of the conditions encountered by the emer¬ gency physician are ordinary ambula¬ tory care problems such as might be encountered by the family physician. In many larger municipal hospitals, however, the incidence of life-threat¬ ening problems may be much higher. The application from the American Board of Emergency Medicine has aroused considerable controversy, since there are many who feel that those who deliver emergency medicine should be certified by one of the existing specialty boards rather than by a new board. Other possibilities are that certificates of special competence might be issued by existing boards for those who take extra training in dealing with life-threatening emergen¬ cy conditions. The last previous primary specialty board to be recognized by LCSB-AMAABMS was the American Board of Family Practice in 1969. Conjoint boards in Allergy and Immunology and Nuclear Medicine were recognized in 1973. Problems in Training and Appropriate Mix of Physician Specialists year
Report of the US General Accounting Oftice
Early in 1977, the GAO released to a
selected audience of organizations and individuals a draft of a proposed report on the subject "Problems in Training and Appropriate Mix of Physician Specialists." The report was initiated by the GAO staff because of Congres¬ sional concern about "the number of physicians practicing in the various medical specialties—and whether a proper mix of specialists is available in the US to provide appropriate and quality medical care to persons needing it." The study was carried out during the previous year through review of activi¬ ties at the Department of Health, Education and Welfare, the Veterans Administration, and the Department of Defense, as well as at a number of medical schools and teaching hospitals. Opinions and views were requested from several medical organizations and directors of graduate medical educa¬ tion programs. The draft report con¬ cludes that a system does not presently exist, in either the private or public sector, to coordinate and regulate the size and specialty mix of residency training programs with the physician manpower needs of the nation. The draft report recommends that "The Secretary of HEW should discuss with the Coordinating Council on Med¬ ical Education (CCME) the possibility of entering into a contract to develop and implement a system for seeing that the number and type of physician specialists and subspecialists being trained is consistent with the approxi¬ mate number needed." Under the contract, the CCME would have the
responsibility to develop optimal physi¬ cian-to-population ratios, compare these ratios with those currently in practice and in training, and adjust through the accreditation system the
numbers and types of physicians in residency training programs to that
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consistent with national needs. The report recommends that if the CCME does not choose to accept this responsi¬ bility, the Secretary of HEW should do so.
In
addition, the report recommends that it estimate, from the CCME or HEW studies, the total number of first-year residency posi¬ tions needed, and consider whether to
Congress
additional medical schools should be
established, the capacity of existing schools increased, or any shortage of first-year trainees should be filled by foreign medical graduates or US citi¬ zens studying abroad.
In responding to the draft report, the CCME pointed out many deficiencies and simplistic assumptions, and em¬ phasized that accreditation should not be used to control either numbers or kinds of specialty training programs. The CCME agreed to accept responsi¬ bility for collecting the necessary infor¬ mation, analyzing and correlating the data, and making recommendations for the education and training of physi¬ cians, since these were already ongoing CCME activities and were consistent with its responsibilities. The CCME stated, however, that it "should at¬ tempt to achieve the desired goal of matching the ongoing production of physicians to the changing needs in the country for medical care without the difficulties and implications involved in regulation, either by the government or by any organization in the private sector." Many of the other organizations consulted by the GAO also responded to the request for review and comment on the draft report. At the time of this publication, the final version of the report had not yet been approved, and the report had not yet been trans¬ mitted from GAO to the Congress.
Compiled by Sylvia
The 77th Annual Report on Medical Educa¬ tion, prepared by the staff of the AMA Group on Medical Education, is based on information provided by individual medical schools, hospi¬ tals, government agencies, the Association of American Medical Colleges, and the American Public Health Association.
Following the format of recent years, Section I, "Recent Events of Special Interest to Medical Education," contains summaries of significant activities relating to medical education and brief comments regarding each. Section II provides information on undergrad¬ uate medical education, including accredita¬ tion, medical schools in the planning stages, curriculum, faculty, students, and medical
I. Etzel
school finances. Information and statistics on graduate medical education programs is pre¬ sented in Section III, and the annual reports on continuing medical education and allied medical education appear in sections IV and V. Section VI contains a description of programs in medical education sponsored by government agencies, and a report on grad¬ uate education in public health may be found in Section VII. Statistical data on medical schools in the United States and Canada are presented in Appendixes I and II. Appendix III lists ac¬ credited sponsors of continuing medical edu¬ cation.
Section I
Recent Events of Special Interest to Medical Education C. H. William Ruhe, MD Senior Vice-President for Scientific Activities This section includes information about special studies, reports, legislation, and other events and activities that currently have an influence on, or relation to, medical education, and that might be expected to influence the future course of events in medical education. Most of the items listed are extensions of reports given in earlier years and are still in development or in transition. Some of these items are also considered in other sections of the EDUCATION NUMBER.
Coordinating
Council
on
Medical Education
The Coordinating Council on Medical Education (CCME) has been described in several previous issues of the EDUCA-
TION NUMBER.
late in
Since its establishment
1972, it has been involved in studying and developing reports on a number of important issues affecting medical education. Major reports were prepared and were published previous-
ly in JAMA on the subjects of "The Primary Care Physician" and "The Role of the Foreign Medical Graduate," both of these being under the general subject heading "Physician Manpower and Distribution." A third report on the subject "The Geographic and Specialty Distribution of Physicians" was under preparation
for more than two years, and it had been anticipated that the report would be completed and published by the end of 1976. However, several drafts of the
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report were regarded as unsatisfactory by one of the parent organizations, and
the report was remanded to committee for study and revision. It now seems unlikely that a report on this subject will be published by CCME without the assembly and analysis of a substantial amount of additional data. During the year, the CCME and the parent organizations reached agree¬ ment on several statements related to the subject "Financing Graduate Medi¬ cal Education." A report of the
Committee
on
Continuing Competence
of Physicians was also under prepara¬ tion and should be ready for presenta¬ tion to the parent organizations by the end of 1977. The CCME will complete its fifth
operation at the end of 1977. Since the chairmanship of the organi¬ zation rotates among the parents, each of the parent organizations will have occupied the chair by the end of 1977. The chairmen for the five years were as follows: 1973, Dr William Anlyan, Association of American Medical Col¬ year of
leges (AAMC); 1974, Dr Tom Nesbitt, American Medical Association; 1975, Dr Jack Myers, American Board of Medical Specialties (ABMS); 1976, Dr Rollins Hanlon, Council of Medical Specialty Societies (CMSS); 1977, Dr Robert Cathcart, American Hospital Association (AHA). The chairmanship
will revert to the AAMC for the begin¬ ning of the second cycle in 1978. The CCME is still new and its final role and definition of purpose have yet to be determined. Established to coor¬ dinate the activities of the various liaison committees that serve as ac¬ crediting bodies and to initiate review and recommend policy decisions relat¬ ing to medical education to the five parent organizations, the CCME has been envisioned in various ways by various people. Many have seen it as a simple coordinating organization with no absolute authority of its own. Others have viewed it as eventually becoming an independent, free-stand¬ ing commission with authority to regu¬ late all levels of medical education. The situation has been complicated by the fact that various governmental and private groups have attempted to persuade the CCME to assume regula¬ tory functions. In some instances, these efforts to persuade have approached the form of threats that some federal agency would be authorized to regulate the numbers, types, and locations of residency positions if the CCME refused to accept the responsibility. This has caused some dissension within the ranks of the CCME members. Some would like to see CCME become a regulatory agency. Others do not favor such a role for CCME, but would prefer to have CCME in that role rather than a federal agency. Still others believe that a regulatory role would completely distort CCME's pur¬ pose and function and that, if there must be regulation, it should be carried out by some other agency. Most of the last group believe that regulation of residency training is not appropriate and that regulation may be resisted if the profession will remain united against it. In addition to this concern for the CCME role in the future, there is considerable interest on the part of some organizations in establishing an independent staff for CCME. When the
CCME and the Liaison Committee Graduate Medical Education (LCGME) were established, and the Liaison Committee on Continuing Medical Education (LCCME) was pro¬ posed, it was agreed that staff services for all of these bodies would be provided by the AMA for the time being. The term "for the time being" was not defined. The AMA had offered to provide the staff services to insure that the new organizations would become established properly and to assure continuity in the accreditation of graduate and continuing medical education, since AMA staff had al¬ ready been engaged in staffing these operations for many years. In so doing, AMA agreed to continue to supply a major portion of the financing of the accreditation activities. Those favoring independent staffing do so for a variety of reasons: some allege that the public credibility of the CCME and its related liaison commit¬ tees suffers because the AMA provides staff services; some believe that AMA has too much influence over the bodies because of their staffing services; some believe that the AMA staff afford preferential interest to AMA concerns in their staffing operation; some believe that an independent staff could give more time to the activities, and therefore would provide better services; some believe that the AMA staff is incompetent and that an independent staff would do a better job. Discussions have been ongoing in both the CCME and the LCGME, and to a lesser extent in the LCCME, about the future role of the CCME and the liaison committees, their proper rela¬ tionship to each other, the pattern of staffing that will be most effective for the future, and the mechanisms by which financial support will be pro¬ vided for the staff and for the opera¬ tional activities. on
Liaison Committee on Graduate Medical Education
The LCGME began its formal oper¬ ations as the official accrediting body for residency training in January 1975. During its three operational years, it has gradually developed a closer and more effective relationship with the 22 residency review committees that for¬ merly served as separate accrediting bodies. As noted in last year's report, some friction had developed between LCGME and the review committees because of questions concerning the level of LCGME authority and alleged overlapping function. More recently, questions were raised concerning the development of policy proposals and
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in the absence of direct communication between the LCGME and the parents of the resi¬ dency review committees. While all of these matters have not been resolved, relations between the LCGME and the review committees appear to be improving, largely be¬ cause the chairmen of the residency review committees have been attending LCGME meetings on a regular basis. The LCGME has also agreed that resi¬ dency review committee chairmen may be present when the programs of their own committees are reviewed by the LCGME. The LCGME has spent considerable time in attempting to resolve the prob¬ lems attendant on the first graduate year of medical education. Although the first graduate year, formerly called the internship, has not been reviewed for accreditation as a separate year of graduate medical education since 1975, there continues to be agitation for the existence of a free-standing year that would provide broad, general, and clin¬ ical education for all medical grad¬ uates. The concern is most evident among those in the so-called nonbedded specialties and in the relatively narrow specialties and subspecialties where the residency programs them¬ selves do not provide broad, general training. Because of the major move¬ ment toward primary care specialties, and the desire to provide complete training for family physicians, general internists, general pediatricians, and general obstetrician-gynecologists, it has been difficult for these primary care specialties to offer the year of broad training for the graduates who intend to go into more limited specialty fields. The problem is further compli¬ cated by the rising costs of graduate medical education, the high costs of medical care, and the desire of hospi¬ tals to restrict their costs. As noted in the section under the Coordinating Council on Medical Edu¬ cation, there have been proposals that an independent staff be provided for the LCGME. There are those who favor this for the LCGME alone, while others would prefer a large indepen¬ dent staff that would provide staff services for CCME, LCGME, LCCME, and the Liaison Committee on Medical Education, thus removing all of these bodies from direct staff support by any of the parent organizations. The mat¬ ter is complicated by the substantial costs that are involved. The LCGME has a committee on future staffing as does the CCME, and they are attempt¬ ing to work out proposals that will be acceptable to all parent organizations.
positions by LCGME
Liaison Committee
on
Continuing Medical Education Early in 1977, the bylaws of the were accepted by the five parent organizations of the CCME and by the two additional organizations that are represented on the LCCME. LCCME
The LCCME then became the ac¬ crediting body for organizations and institutions offering educational pro¬ grams for the continuing education of the physician as of July 1,1977. The LCCME plans to continue most of the procedures that had been followed by the AMA Council on Medical Education in its conduct of the accreditation process for continuing medical education since 1966. Changes in the process may be anticipated for the future, as would have been the case had the Council on Medical Education continued its function, but it is not foreseen that there will be any abrupt or revolutionary changes under the LCCME sponsorship. At least for the present, the LCCME will continue to receive recommendations from survey and review bodies established by the state medical associations for institu¬ tions and organizations that offer continuing medical education designed essentially for intrastate consumption. A new review committee for continu¬ ing medical education has been es¬ tablished to make recommendations concerning those institutions and orga¬ nizations that offer programs designed for national consumption. To provide continuity with previous procedures, this committee will include six mem¬ bers of the Advisory Committee on Continuing Medical Education to the Council on Medical Education of the AMA, which had been serving as the review body under the AMA's accredi¬ tation system. In addition, each of the other sponsoring organizations of LCCME will have one representative on the new review committee. Through its subcommittees on goals and priorities and on procedures, the LCCME is continuing to explore the future scope of its activities and how these will be conducted. Liaison Committee on Medical Education
The Liaison Committee on Medical Education (LCME), which is the offi¬ cial accrediting body for institutions offering programs leading to the MD degree, has been in existence since
1942. Composed of six representatives of the AMA Council on Medical Educa¬ tion, two public representatives, and one federal representative, LCME has for many years carried out its accredi-
tation responsibilities and has been widely recognized both in federal and in state legislation as the official ac¬ crediting body for undergraduate med¬ ical education. During 1976, that role was chal¬ lenged by the Federal Trade Commis¬ sion (FTC). The LCME, like all other official accrediting bodies, has been recognized by the United States Office of Education (USOE) and must submit its procedures for review periodically to maintain that recognition. Shortly before LCME representatives were to appear before the Commissioner of Education's Advisory Committee on Accreditation and Institutional Eligi¬ bility, the FTC addressed a letter to the USOE staff contending that LCME should not be recognized because it included representatives of the AMA that, as the major professional organi¬ zation for practicing physicians, might have a conflict of interest in ac¬ crediting medical schools. The letter stated that it might be considered that AMA would have an interest in limiting the supply of physi¬ cians and that this constituted a poten¬ tial conflict of interest. Although extensive review of LCME procedures and extensive search of AMA files has been carried out during the year before the submission of this letter, the letter stated that there was no allegation that there had in fact been improper conduct on the part of the LCME. The letter contended, however, that it was not necessary to establish improper conduct but simply to point out that there was potential for such conduct. The USOE hearing was postponed to permit LCME and AMA to respond to the FTC letter. Attorneys for all three organizations appeared before the USOE Advisory Committee and, after extensive discussion and consideration, the Advisory Committee recommended continuation of LCME recognition for a period of two years. The FTC then protested the recommendations in a letter directly to the Commissioner of Education but, after some delay, the commissioner supported the recom¬ mendation of the USOE Advisory Committee and did not accede to the FTC request. The granting of contin¬ ued recognition for a period of two years was accompanied however by the citation of several deficiencies in the compliance of the LCME with the USOE criteria for recognition, most of them depending on or relating to the autonomy of the LCME. LCME will be
required to submit a progress report showing that efforts are being made to
correct
Since
a
the identified normal period of
deficiencies.
recognition is
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four years, and this is the first time that LCME has received anything less than a full period of recognition, it must be considered that LCME's future recognition is in some jeopardy as the result of these developments.
Meanwhile, LCME's relationship to CCME is still under review, as is also its composition. The other parent orga¬ nizations of CCME that are not repre¬ sented on LCME have requested that the LCME membership be broadened to include them. So far, LCME has refused to comply. The pattern of future staffing is also under considera¬ tion. For many years, staffing respon¬ sibility has alternated between AMA and AAMC in alternate years. One of the matters being considered is wheth¬ er LCME should be a part of the total CCME-Liaison Committee family of organizations for which an indepen¬ dent staff should be established. Committee on Allied Health Education and Accreditation This section of previous education numbers has reported on the efforts of the AMA to develop a modified pattern of accreditation of allied health occupa¬ tions that would be broadly acceptable in both professional and educational circles. Following the Study of the Accreditation of Selected Health Edu¬ cational Program, the AMA approved and proposed to the parent organiza¬ tions with which it collaborates in the accreditation of allied health educa¬ tional programs that there be estab¬ lished a Joint Council on the Accredita¬ tion of Allied Health Education (JCAAHE). However, the assembled representatives of the collaborating organizations voted by a margin of more than two to one against the proposal, and JCAAHE was therefore abandoned as nonviable. The AMA then attempted to develop a body within its own structure that would meet the criteria for recognition by the USOE and would at the same time answer objections that had been voiced concerning the accreditation procedures. After many meetings and discussions, the AMA House of Dele¬ gates finally adopted a report from the Council on Medical Education recom¬ mending that there be established a Committee on Allied Health Education and Accreditation (CAHEA) as an outgrowth of the council's existing Advisory Committee on Allied Health Education. The Advisory Committee was expanded to include representation from the public and from the Council on Medical Education itself. The coun¬ cil delegated to CAHEA the authority to make final decisions on the accredi-
tation of individual programs, and the House of Delegates gave to the Council on Medical Education the authority to give final approval to essentials for all allied health educational programs. The CAHEA became operational early in 1977 and has held two formal meetings to carry out its accreditation responsibilities. The new committee appears to meet
objections previously
cited by the USOE and also meets with the approval of most of the collabo¬
rating organizations.
Some of the allied health organiza¬ tions are, however, still searching for a pattern that will enable them to be independent of the AMA. Several consortia of various allied health groups have been proposed and ex¬ ploratory discussions are continuing. Meanwhile, the American Physical Therapy Association (APTA) was fi¬ nally recognized by the USOE as an independent accrediting agency after two years of seeking such status. The Committee on Allied Health Education and Accreditation of the AMA was also recognized for such purpose for a period of six months, so that at the time of this writing, there were two
accrediting organizations recognized by the USOE in the field of physical therapy education. The success of APTA in breaking away from AMA, after 40 years of collaboration in the accreditation of physical therapy edu¬ cational programs, was expected to encourage other allied health organiza¬ tions to seek independent status as
accrediting agencies.
Graduate Medical Education National Advisory Committee
spring of 1976, Dr David Matthews, Secretary of Health, Educa¬ tion and Welfare, announced the appointment of a Graduate Medical Education National Advisory Commit¬ tee (GMENAC). In appointing the committee, Secretary Matthews stated that In the
the Secretary and, by delegation, the As¬ sistant Secretary for Health, are charged under Title VII of the Public Health Service Act with responsibility for taking national leadership in the development of programs addressed to graduate medical education and in the research, development and anal¬ ysis of programs that impact on the health manpower needs of this nation. The purpose of this Committee is to analyze the distribu¬ tion among specialties of physicians and medical students and to evaluate alternative approaches to insure appropriate balance. The Committee will also encourage bodies controlling the number, types, and geo¬ graphic location of graduate training posi¬ tions to provide leadership in achieving the recommended balance.
The committee was appointed at a time when the House of Representa¬ tives and Senate were both considering new health manpower legislation as extensions of the 1971 Health Man¬ power Act. Both the House and the Senate bills contained variations on a proposal calling for a study concerning the distribution of physicians by spe¬ cialty, with the implication that resi¬ dency training would be controlled in the future to provide optimal percent¬ ages of physicians within each special¬ ty. Presumably, GMENAC would have removed the necessity for much legis¬ lative proposals, which were eventually removed from the Health Manpower Act before it was finally passed and signed into law. The functions assigned to GMENAC were
to
advise, consult with and make recommenda¬ tions to the Secretary on overall strategies on the present and future supply and re¬ quirements of physicians by specialty and geographic location; transition of physician requirements into a range of types and numbers of graduate training opportunities needed to approach a more even distribution of physicians' services, taking into account national health planning goals, guidelines, standards, and, as appropriate, the health system plans developed by health system agencies; factors which affect physician career choice; the impact of various activi¬ ties which influence specialty distribution and the availability of training opportuni¬ ties, including systems of reimbursement of services and financing of graduate medical education; and the relationship of graduate medical education to the provision of services in training institutions, including alternatives for the provisions of these services. It
was
stated that
the Committee shall advise on data require¬ ments and systems needed to conduct the activities of the Committee; propose nation¬ al goals for the distribution of physicians in graduate training; and recommend federal policies, strategies, and plan to achieve the established goals in concert with the private sector and nonfederal agencies.
The GMENAC consists of 21
bers, three of whom
mem¬
officio members from the Public Health Service, Department of Defense, and Veterans Administrations, and the remaining 18 of whom are representa¬ tives of health care providers, payers, and interested national and local orga¬ nizations. The committee was ap¬ pointed for a period of two years and was expected to submit an annual are
ex
report.
Although appointed in the spring of
1976, GMENAC did
not
hold its first
meeting until June 27 to 28, 1977. The first meeting was occupied largely with
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review of the committee's charges and the presentation of background infor¬ mation on graduate medical education, including a review of activities of other organizations in the field. A sub¬ stantial amount of time was devoted to review of the report from the US General Accounting Office (GAO) con¬ cerning graduate medical education and responses to that report that had been presented by various organiza¬ tions. The GMENAC appointed two task forces from its own membership: one to review and make recommendations on the GAO draft report, and the other to determine and define the nature of problems facing the committee regard¬ ing the distribution and geographic location of physicians, and to develop a set of assumptions and issues for the committee's deliberations. A second meeting was to be held before the end of 1977.
Emergency Medicine An application for recognition as a primary specialty board has been
submitted to the Liaison Committee for Specialty Boards (LCSB) by the American Board of Emergency Medi¬ cine, whose cosponsors are the Amer¬ ican College of Emergency Physicians, the University Association of Emer¬ gency Medical Services, and the AMA Section on Emergency Medicine. At the time of the preparation of this report, the application had been reviewed and recommended for ap¬ proval by the LCSB through its two parent organizations, the AMA Council on Medical Education and the ABMS. The application was then approved by the AMA Council on Medical Educa¬ tion, while the ABMS had appointed a committee to consider ways in which appropriate recognition might be af¬ forded in the field of emergency medi¬
cine.
Emergency medicine has been a rapidly growing field of practice during the past ten years. Most physicians devoting full time to the field have been second-career physicians; ie, they have been hired by hospitals as emer¬ gency physicians after having had previous careers as general surgeons, obstetricians, orthopedic surgeons, general practitioners, or other types of physicians. More recently, -however, residency training programs in emer¬ gency medicine have been developed and there are now approximately 30 such programs in existence, with medi¬ cal graduates enrolled in residency training. Through the efforts of the American College of Emergency Physicians and
the
University Association of Emer¬ Services, a body of knowledge and set of skills have been gency Medical
identified to form the basis of a threetraining program for those wish¬ ing to enter the field as a primary medical career. The development of an appropriate core curriculum has been complicated by the fact that emergency physicians in many settings are called on to deliver ordinary ambulatory care in addition to dealing with life-threat¬ ening emergency situations. In the typical community hospital, it has been estimated that as much as 80% of the conditions encountered by the emer¬ gency physician are ordinary ambula¬ tory care problems such as might be encountered by the family physician. In many larger municipal hospitals, however, the incidence of life-threat¬ ening problems may be much higher. The application from the American Board of Emergency Medicine has aroused considerable controversy, since there are many who feel that those who deliver emergency medicine should be certified by one of the existing specialty boards rather than by a new board. Other possibilities are that certificates of special competence might be issued by existing boards for those who take extra training in dealing with life-threatening emergen¬ cy conditions. The last previous primary specialty board to be recognized by LCSB-AMAABMS was the American Board of Family Practice in 1969. Conjoint boards in Allergy and Immunology and Nuclear Medicine were recognized in 1973. Problems in Training and Appropriate Mix of Physician Specialists year
Report of the US General Accounting Oftice
Early in 1977, the GAO released to a
selected audience of organizations and individuals a draft of a proposed report on the subject "Problems in Training and Appropriate Mix of Physician Specialists." The report was initiated by the GAO staff because of Congres¬ sional concern about "the number of physicians practicing in the various medical specialties—and whether a proper mix of specialists is available in the US to provide appropriate and quality medical care to persons needing it." The study was carried out during the previous year through review of activi¬ ties at the Department of Health, Education and Welfare, the Veterans Administration, and the Department of Defense, as well as at a number of medical schools and teaching hospitals. Opinions and views were requested from several medical organizations and directors of graduate medical educa¬ tion programs. The draft report con¬ cludes that a system does not presently exist, in either the private or public sector, to coordinate and regulate the size and specialty mix of residency training programs with the physician manpower needs of the nation. The draft report recommends that "The Secretary of HEW should discuss with the Coordinating Council on Med¬ ical Education (CCME) the possibility of entering into a contract to develop and implement a system for seeing that the number and type of physician specialists and subspecialists being trained is consistent with the approxi¬ mate number needed." Under the contract, the CCME would have the
responsibility to develop optimal physi¬ cian-to-population ratios, compare these ratios with those currently in practice and in training, and adjust through the accreditation system the
numbers and types of physicians in residency training programs to that
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consistent with national needs. The report recommends that if the CCME does not choose to accept this responsi¬ bility, the Secretary of HEW should do so.
In
addition, the report recommends that it estimate, from the CCME or HEW studies, the total number of first-year residency posi¬ tions needed, and consider whether to
Congress
additional medical schools should be
established, the capacity of existing schools increased, or any shortage of first-year trainees should be filled by foreign medical graduates or US citi¬ zens studying abroad.
In responding to the draft report, the CCME pointed out many deficiencies and simplistic assumptions, and em¬ phasized that accreditation should not be used to control either numbers or kinds of specialty training programs. The CCME agreed to accept responsi¬ bility for collecting the necessary infor¬ mation, analyzing and correlating the data, and making recommendations for the education and training of physi¬ cians, since these were already ongoing CCME activities and were consistent with its responsibilities. The CCME stated, however, that it "should at¬ tempt to achieve the desired goal of matching the ongoing production of physicians to the changing needs in the country for medical care without the difficulties and implications involved in regulation, either by the government or by any organization in the private sector." Many of the other organizations consulted by the GAO also responded to the request for review and comment on the draft report. At the time of this publication, the final version of the report had not yet been approved, and the report had not yet been trans¬ mitted from GAO to the Congress.
