Graduate Medical Education National Advisory Research Articles

A Tale of Two Cities: Evolution of Academic Physiatry in Boston and Baltimore: Part 1: The Boston Marathon

A Tale of Two Cities: Evolution of Academic Physiatry in Boston and Baltimore: Part 1: The Boston Marathon

The GMENAC report and the PA profession.

The 1980 report of the Graduate Medical Education National Advisory Committee (GMENAC) predicted a surplus of physicians by 1990 and 2000. The report appeared to have a depressing effect on the growth of the PA profession in the early 1980s; in the 9 years following its release, no new PA programs were started and a number of existing programs closed. The GMENAC forecast proved to be inaccurate and the PA profession saw significant program growth in the 1990s and beyond. A lesson of GMENAC is that accurately predicting health workforce supply and demand is difficult.

Rethinking cancer clinical trials for the future.

Future OncologyVol. 10, No. 9 OpinionRethinking cancer clinical trials for the futureMatthew D GalskyMatthew D GalskySearch for more papers by this authorPublished Online:22 Aug 2014https://doi.org/10.2217/fon.14.95AboutSectionsView ArticleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinkedInReddit View articleKeywords: accrualcancerclinical trialstelemedicine References1 Murthy VH, Krumholz HM, Gross CP. Participation in cancer clinical trials: race-, sex-, and age-based disparities. JAMA 291(22), 2720–2726 (2004).Crossref, Medline, CAS, Google Scholar2 Stensland KD, McBride R, Wisnivesky JP et al. Premature termination of genitourinary cancer clinical trials. J. Clin. Oncol. 32(Suppl. 4), Abstract 288 (2014).Crossref, Google Scholar3 Kasenda B, von Elm E, You J et al. Prevalence, characteristics, and publication of discontinued randomized trials. JAMA 311(10), 1045–1051 (2014).Crossref, Medline, CAS, Google Scholar4 English R, Lebovitz Y, Griffin R. Transforming Clinical Research in the United States: Challenges and Opportunities: Workshop Summary. The National Academies Press, Washington DC, USA (2010).Google Scholar5 Meropol NJ, Buzaglo JS, Millard J et al. Barriers to clinical trial participation as perceived by oncologists and patients. J. Natl Compr. Canc. Netw. 5(8), 655–664 (2007).Crossref, Medline, Google Scholar6 Kaplan CP, Nápoles AM, Dohan D et al. Clinical trial discussion, referral, and recruitment: physician, patient, and system factors. Cancer Causes Control 24(5), 979–988 (2013).Crossref, Medline, Google Scholar7 Jacoby I. Geographic distribution of physician manpower: the GMENAC (Graduate Medical Education National Advisory Committee) legacy. J. Rural Heal. 7(Suppl. 4), 427–436 (1991).Medline, CAS, Google Scholar8 Ricketts TC. Geographic Methods for Health Services Research: a Focus on the Rural–Urban Continuum. University Press of America, Lanham, MD, USA (1994).Google Scholar9 Galsky MD, Latif A, Stensland KD et al. Distribution and geographic accessibility of prostate cancer clinical trials in the United States. J. Clin. Oncol. 32(Suppl. 4), Abstract 59 (2014).Crossref, Google Scholar10 Breslow MJ. Remote ICU care programs: current status. J. Crit. Care. 22(1), 66–76 (2007).Crossref, Medline, Google Scholar11 PatientsLikeMe. www.patientslikeme.com Google Scholar12 Young LB, Chan PS, Lu X, Nallamothu BK, Sasson C, Cram PM. Impact of telemedicine intensive care unit coverage on patient outcomes: a systematic review and meta-analysis. Arch. Intern. Med. 171(6), 498–506 (2011).Crossref, Medline, Google Scholar13 Breslow MJ, Rosenfeld BA, Doerfler M et al. Effect of a multiple-site intensive care unit telemedicine progr Am. on clinical and economic outcomes: an alternative paradigm for intensivist staffing. Crit. Care Med. 32(1), 31–38 (2004).Crossref, Medline, Google Scholar14 Christensen CM. The Innovator’s Dilemma: When New Technologies Cause Great Firms to Fail. Harper Business, NY, USA (2000).Google Scholar15 Wicks P, Vaughan TE, Massagli MP, Heywood J. Accelerated clinical discovery using self-reported patient data collected online and a patient-matching algorithm. Nat. Biotechnol. 29(5), 411–414 (2011).Crossref, Medline, CAS, Google ScholarFiguresReferencesRelatedDetails Vol. 10, No. 9 eToC Sign up Follow us on social media for the latest updates Metrics Downloaded 79 times History Published online 22 August 2014 Published in print July 2014 Information© Future Medicine LtdKeywordsaccrualcancerclinical trialstelemedicine Financial & competing interests disclosureMD Galsky is supported by a Prostate Cancer Foundation Young Investigator Award. MD Galsky has served as a consultant for Astellas, Dendreon, Jannsen, GlaxoSmithKline and BioMotiv. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.No writing assistance was utilized in the production of this manuscript.PDF download

Physician Workforce Planning in an Era of Health Care Reform

Workforce planning in an era of health care reform is a challenge as both delivery systems and patient demographics change. Current workforce projections are based on a future health care system that is either an identified "ideal" or a modified version of the existing system. The desire to plan for such an "ideal system," however, may threaten access to necessary services if it does not come to fruition or is based on theoretical rather than empirical data.Historically, workforce planning that concentrated only on an "ideal system" has been centered on incorrect assumptions. Two examples of such failures presented in the 1980s when the Graduate Medical Education National Advisory Committee recommended a decrease in the physician workforce on the basis of predetermined "necessary and appropriate" services and in the 1990s, when planners expected managed care and health maintenance organizations to completely overhaul the existing health care system. Neither accounted for human behavior, demographic changes, and actual demand for health care services, leaving the nation ill-prepared to care for an aging population with chronic disease.In this article, the authors argue that workforce planning should begin with the current system and make adjustments based on empirical data that accurately reflect current trends. Actual health care use patterns will become evident as systemic changes are realized-or not-over time. No single approach will solve the looming physician shortage, but the danger of planning only for an ideal system is being unprepared for the actual needs of the population.

County-Level Estimates of Need for Mental Health Professionals in the United States

County-Level Estimates of Need for Mental Health Professionals in the United States

Pediatric workforce: A look at general pediatrics data from the American Board of Pediatrics

data using questionnaires administered in association with its various examinations and through a tracking system that provides an annual update of residents and fellows in training. These data provide critical information regarding trainees and practitioners in pediatrics and the overall workforce landscape. The Journal of Pediatrics will publish a regular series of these workforce reports; the first appears below. This introductory paper highlights the current workforce for general pediatrics and provides a brief overview of pediatric subspecialties. Future papers will feature workforce data on each of the 13 subspecialties for which the ABP administers examinations, according to the order in which the first examinations were administered: Cardiology (1961), Hematology-Oncology (1974), Nephrology (1974), Neonatal-Perinatal Medicine (1975), Endocrinology (1978), Pulmonology (1986), Critical Care Medicine (1987), Gastroenterology (1990), Emergency Medicine (1992), Rheumatology (1992), Adolescent Medicine (1994), Infectious Diseases (1994), and Developmental-Behavioral Pediatrics (2002). We welcome your comments. —William F. Balistreri, MD, Editor-in-Chief, The Journal of Pediatrics, James A. Stockman, III, MD, President, the American Board of Pediatrics, Linda A. Althouse, PhD, Director of Psychometrics, American Board of Pediatrics SPECIAL ARTICLE

Trends in general surgery workforce data

Background During the past 25 years, there has been much debate about general surgical workforce supply and demand. In the late 1970s and early 1980s, concern was raised by the Study on Surgical Services for the United States and the Graduate Medical Education National Advisory Council that there would be a gross oversupply of total physicians and surgeons by the years 1990 and 2000. Data sources In a 1990 report sponsored by the Council on Graduate Medical Education, reevaluation of the workforce data showed no surplus at that time and instead predicted a deficit of surgeons by 2010. Studies by other investigators in the mid-1990s supported these conclusions. Furthermore, a new workforce model published in 2002 predicted a significant overall deficit of physicians by 2020. The discrepancies in the projected and the actual data have been explained by a variety of factors including an aging population with increased surgical needs, an increasing number of outpatient surgical procedures, subspecialization within the field of general surgery, and decreasing interest in the field by United States medical students. Conclusions Although it is difficult to compare data among studies, and there are many confounding factors in the data, review of the workforce data does support a future deficit of surgeons, a prediction that warrants further investigation.

The United States Cardiovascular Care Deficit

A life so short, a craft so long to learn — Hippocrates, Aphorisms As we move into the new millennium, the deficit of able and willing cardiovascular physician providers widens. In 1980, the Graduate Medical Education National Advisory Committee (GMENAC) predicted an “oversupply of 145 000 physicians in the US by the year 2000.”1 Subsequently, in the early 1990’s, physician workforce analysts used physician staffing patterns at closed panel Health Maintenance Organizations (HMO’s) to predict the number of physicians required per 100,000 population. Based on the HMO model, the predicted physician surplus would exceed 150,000 by the year 2000.2 National major medical organizations responded to these predictions by reducing the number of physician training positions available, particularly in subspecialities such as cardiology, where 12% of fellowship training positions were eliminated between 1995 to 2001.3–5 However, cardiovascular diseases are more prevalent with age, and the US population is growing older. In a recent census, the most rapidly growing decade on a relative basis was that in excess of 80 years old. As older people need more cardiovascular care, who will provide it? Through enhancements in technology and care processes, the mortality due to cardiovascular disease has progressively declined over the past 20 years. This success has allowed the survival of many individuals with chronic cardiovascular disease who require extended care. Remarkably, as the overall burden from cardiovascular disease increases, the supply of qualified individuals to provide care has diminished and threatens to limit access to health care unless remedies are found.6–9 A number of factors contributing to this “cardiovascular care deficit” are eloquently defined and analyzed by Drs W. Bruce Fye, Robert Bonow, and Sidney Smith,10,11 in this issue of Circulation . Their consensus opinion is that the US cardiovascular care deficit will continue to widen …

Cardiology's workforce shortage: implications for patient care and research.

The common wisdom at the end of the 20th century was that the United States was training too many specialists, including cardiologists.1 By 2001, however, there was increasing evidence that the supply of cardiologists was not meeting the growing demand. That year, as president-elect of the American College of Cardiology (ACC), I appointed a task force to evaluate cardiology workforce. The task force undertook a 2-year process of literature review, hypothesis generation, research design, data acquisition, and analysis. This intense effort included a Bethesda Conference at which consensus was achieved on a report that will be published in the Journal of the American College of Cardiology . Based on various types of information and data, the ACC task force concluded that the United States is facing a shortage of cardiologists. This will reduce access to specialty care of proven benefit and will undermine our nation’s vital cardiovascular research effort. The Bethesda Conference report includes 8 working group documents that recommend several short- and intermediate-term strategies to help narrow the growing demand-supply gap for cardiologists (see Table 1). Some recommendations can be implemented at a local practice or institution level. Others will require a series of complex and coordinated actions at a national level. Hopefully, the report will catalyze actions by academic medical centers, regulatory organizations, federal policymakers, professional societies, and others that influence the output of cardiovascular specialists. View this table: TABLE 1. Working Groups of the ACC Task Force on Workforce Several things continue to drive demand for cardiologists. Elsewhere, I have argued that various scientific, social, and demographic “demand catalysts” outweigh factors that might decrease demand for cardiologists during the next decade2 (see Table 2). Although the relative influence of each demand factor will change over time, one thing is certain: the cardiovascular disease burden in the United States …

Manpower crisis in paediatrics: We saw it coming

Manpower crisis in paediatrics: We saw it coming

Analysis of health service areas: another piece of the psychiatric workforce puzzle.

Planning for development of a national or regional psychiatrist workforce that is the appropriate size must consider numerous issues. They include the dynamics of workforce distribution, effects of managed care, reduction in potential residency slots, participation of international medical graduates, apathy toward the field of psychiatry, service area variations, and increased interest in allied mental health professions, along with the burgeoning global burden of psychiatric illness. This paper examines the application of two benchmark standards for the number of psychiatrists needed per 100,000 population--the standard developed by the Graduate Medical Education National Advisory Committee and the Average Requirement Benchmark--to the supply of psychiatrists in Georgia in 1996 by county and by health service regions, which are geographical units based on health care utilization patterns of Medicare and Medicaid recipients. Areas with a surplus or deficit of psychiatrists are identified. The findings provide contextual evidence of a surplus of psychiatric physicians in the most populous areas of the state, given a substantial presence of health maintenance organizations. The state's less populated rural areas may potentially benefit from a redistribution of the psychiatrist workforce. The authors recommend continued refinement of models to estimate psychiatric workforce needs and suggest development of a comprehensive model that uses needs-based, demand-based, and benchmarking approaches.

Availability of anesthesia personnel in rural Washington and Montana.

Availability of anesthesia personnel in rural Washington and Montana.

Psychiatrist and nonphysician mental health provider staffing levels in health maintenance organizations.

This study attempts to determine the ratio of full-time-equivalent psychiatrists to members and that of nonphysician mental health professionals to psychiatrists in staff and group model health maintenance organizations (HMOs), and to compare the psychiatrist-to-member ratio with previous estimates of the required psychiatrist-to-population ratios in fee-for-service and managed care environments. The Group Health Association of America (now the American Association of Health Plans) collected data on mental health staffing, enrollments, and other characteristics for 30 staff and group model HMOs. The authors evaluated the number of full-time-equivalent psychiatrists and nonphysician mental health professionals per 100,000 HMO members, and the ratio of full-time-equivalent nonphysician mental health professionals to psychiatrists. The overall mean number of full-time-equivalent psychiatrists and nonphysician mental health professionals per 100,000 members in the responding HMOs was 6.8 and 22.9, respectively. The overall mean ratio of nonphysician professionals to psychiatrists was 4.5. The overall number of psychiatrists per 100,000 members is less than half the requirement estimated by the Graduate Medical Education National Advisory Committee in 1980, which assumed a fee-for-service environment, but it is about 40% to 80% greater than that estimated by other studies under the assumption of a managed care environment. Although a practice environment dominated by managed care may not require as high a psychiatrist-to-population ratio as a predominantly fee-for-service environment, it may well support a greater number of psychiatrists than previous studies have suggested.

Estimating Physician Workforce Requirements

Richard Cooper's article in this issue of JAMA titled Perspectives on the Physician Workforce to the Year ignites controversy. 1 Cooper, extrapolating from physician staffing patterns in group- or staff-model health maintenance organizations (HMOs), forecasts the physician surplus to be trivial in the year 2000 and nonexistent by the year 2020 (his Figure 1). He proclaims that the contradiction of his forecast with the reports of the Graduate Medical Education National Advisory Committee (GMENAC) in 1981, 2 Weiner in 1994 and 1995, 3,4 the Council on Graduate Medical Education in 1994, 5 and the Bureau of Health Professions of the US Department of Health and Human Services in 1995 6 is attributable to the use of insupportable assumptions in the other studies. Cooper believes that newer data now available for US population projections, HMO staffing patterns, and physician work effort justify the assumptions he has adopted. See also p

Pediatric Workforce Statement

Developing accurate forecasts for physician workforce needs is an extraordinarily difficult task. In 1980 the Graduate Medical Education National Advisory Committee (GMENAC) completed a comprehensive workforce study. Based on estimates of growth of the number of pediatricians, GMENAC predicted a potential excess of 4950 pediatricians by 1990.1 The American Academy of Pediatrics (AAP) studied the report and issued a response in 1981 that questioned many elements in the model.2 However, the Academy was concerned that an excess number of pediatricians would be produced by the 1990s, and a statement published in 1985 and revised in 1987 recommended government and academic policies ensuring the production of pediatricians of the highest quality, but in fewer numbers.3 Subsequent to the 1987 statement, consistent evidence has pointed to shortages of pediatricians rather than the projected surplus in all regions of the country. A 1990 survey of residency program directors provided the strongest empirical evidence to date that the supply of new pediatricians is not meeting the demand.4 In 1990, the Council on Graduate Medical Education (COGME) contracted with the consulting firm of Abt Associates, Inc to reexamine the adequacy of physician workforce supply. The resulting report, commonly referred to as the Abt report, contends there would be an even greater oversupply of peditricians than projected in the 1980 GMENAC report.5 The AAP concerns with this report's methodology and conclusions were strongly voiced to the COGME and in the literature.6,7 Subsequent to the Abt Report, the COGME published a report which emphasizes a growing shortage of practicing generalists (ie, general pediatricians, general internists, and family physicians) and calls for an increase in the percentage of residents who complete a 3-year training program in the generalist specialties.8

Doctors, dollars, and determination: making physician work-force policy.

Because managed care is likely to feature prominently in a reformed health care system, policymakers need to examine the impact managed care will have on medical practice, physician supply, and access to primary care providers. Goals for work-force reform should focus on five areas: (1) training physicians in the generalist disciplines of family practice, general internal medicine, and general pediatrics; (2) shaping the physician work force to reflect the nation's ethnic diversity; (3) distributing physicians in a geographically equitable way; (4) maintaining the current physician-to-population ratio rather than letting it continue to grow; and (5) establishing supply needs for nurse practitioners, primary care physician assistants, and certified nurse midwives.

How accurate was GMENAC?--A retrospective review of supply projections for diagnostic radiologists.

In 1982, the Graduate Medical Education National Advisory Committee (GMENAC), a prominent national panel, predicted there would be 25,650 full-time equivalent (FTE) diagnostic radiologists, a 34% oversupply, by 1990. The radiologists involved in GMENAC, however, using models developed by the American College of Radiology, projected 19,800 FTE diagnostic radiologists in 1990, which was similar to the GMENAC estimate of need. The disagreement arose principally from different assumptions about residents entering the specialty. Recent data show there actually were approximately 21,900 FTE diagnostic radiologists in 1990. The radiologists' projection was 10% below this figure; the GMENAC projection was 17% above it. GMENAC erred principally in assuming diagnostic radiology residencies would not replace general radiology residencies, but rather be an addition to them. The radiologists erred principally in their assumption about the effects of the financial problems of hospitals on the number of residency positions. Accurate long-term projection of physician supply in individual specialties may well not be feasible.

Geographic Distribution of Physician Manpower: the GMENAC Legacy*

ABSTRACT: The Graduate Medical Education National Advisory Committee (GMENAC) projected the need for and supply of physicians and other providers, recommended time and access standards for health care services, and developed guidelines for the geographic distribution of physicians. Since this study, analysts have given scant attention to national problems of physician geographic distribution. The issue deserves additional scrutiny in light of the current continuing problems of underservice in rural areas. The emergence of geographic information systems offers a unique opportunity to acquire data on provider distribution and provide a framework for developing and testing redistribution policy.

Geographic Distribution of Physician Manpower: the GMENAC Legacy

The Graduate Medical Education National Advisory Committee (GMENAC) projected the need for and supply of physicians and other providers, recommended time and access standards for health care services, and developed guidelines for the geographic distribution of physicians. Since this study, analysts have given scant attention to national problems of physician geographic distribution. The issue deserves additional scrutiny in light of the current continuing problems of underservice in rural areas. The emergence of geographic information systems offers a unique opportunity to acquire data on provider distribution and provide a framework for developing and testing redistribution policy.

Physician Shortage in Occupational and Environmental Medicine

To determine future training needs for physicians in occupational and environmental medicine based on goals established by the Institute of Medicine (IOM) for clinical practice in the field. A critical review of previously published estimates of the need and supply of physicians with clinical training in occupational and environmental medicine with the application of currently available data to produce revised estimates. Need estimates reviewed from the National Institute for Occupational Safety and Health, the Graduate Medical Education National Advisory Committee (GMENAC), and the Bureau of Health Professions. Supply figures reviewed from GMENAC, the American Medical Association, the American College of Occupational Medicine, and the American Board of Preventive Medicine. Revised need figures are based on the estimated number of occupational and environmental physicians needed to provide adequate nationwide coverage as full-time academic faculty, community-based specialists, and public health physicians in state and local agencies. Revised supply estimates are based on review of available data. Need is estimated at 4600 to 6700 physicians (board-certified or eligible or with special competence in occupational and environmental medicine). Supply is estimated at 1200 to 1500. This review identified a deficit of 3100 to 5500 physicians in this newly evolving specialty. In order to address this shortfall in the next decade, graduate specialty training would need to be increased to about 3 to 5 times the current maximum capacity.