Graduate Medical Education National Advisory Research Articles

Overview of The GMENAC Report

On the national scene, most of the recent discussions about physician manpower and the issue of “surplus” have focused on the activities of the Graduate Medical Education National Advisory Committee (GMENAC). The final GMENAC Report contains many recommendations that have elicited considerable criticism and concern within the medical sector. Historically, the desire for an advisory body such as GMENAC was recognized by Congress and the Administration in the mid-70s during the debates on health manpower legislation. The creation of this Committee, which was opposed by “organized medicine” of the private sector, was viewed as an alternative to legislation at that time. Now, however, there is concern among the medical community that instead of allowing the private sector to take the leadership, some of GMENAC's recommendations will be used as the basis for legislative or regulatory policy changes affecting the education, supply, and practice of physicians. Seven major areas of concern are discussed. With a new administration, it is uncertain how GMENAC's recommendations will be viewed and used.

Overview of The GMENAC Report

On the national scene, most of the recent discussions about physician manpower and the issue of “surplus” have focused on the activities of the Graduate Medical Education National Advisory Committee (GMENAC). The final GMENAC Report contains many recommendations that have elicited considerable criticism and concern within the medical sector. Historically, the desire for an advisory body such as GMENAC was recognized by Congress and the Administration in the mid-70s during the debates on health manpower legislation. The creation of this Committee, which was opposed by “organized medicine” of the private sector, was viewed as an alternative to legislation at that time. Now, however, there is concern among the medical community that instead of allowing the private sector to take the leadership, some of GMENAC's recommendations will be used as the basis for legislative or regulatory policy changes affecting the education, supply, and practice of physicians. Seven major areas of concern are discussed. With a new administration, it is uncertain how GMENAC's recommendations will be viewed and used.

Projecting Physician Requirements for Child Health Care—1990

In 1976 the Secretary of the Department of Health, Education and Welfare appointed the Graduate Medical Education National Advisory Committee (GMENAC) with the charge to advise the Secretary on five national health planning objectives, including estimates of the numbers of physicians required to meet the health care needs of the nation, recommendations regarding the most appropriate specialty distribution of these physicians, and development of strategies to achieve the recommendations formulated by the committee. GMENAC evaluated projected supply and requirements for all major specialties, including child health care, for 1990, and recommended strategies to bring supply and requirement into reasonable balance. Despite the range of error of the methodology used, these data represent the most detailed scientific study to date on this subject. Pediatrics, the portion of child health care accruing to the pediatrician in 1990 was projected to be in "near balance" for supply/requirement ratio. Inasmuch as GMENAC recommended that larger surpluses be created deliberately in the three primary care fields, it is unlikely that the numbers of pediatric residency training programs will be decreased. As several hundred pediatric residency positions are unfilled each year, a concomitant decrease in residency offerings in oversupplied fields would be required to accomplish the recommended subspecialty distribution.

Changing patterns of graduate medical education.

Postgraduate medical education underwent substantial change during the 1970s: medical-school classes grew, the internship year was eliminated, and the numbers of M.D.s entering primary-care specialties increased. The purpose of this study is to develop a planning model of graduate medical education that can project the impact of these and other changes on the numbers and specialty mix of physicians completing training. The model is applied to an analysis of trends in graduate medical education and to the probable consequences of policy recommendations made by the Graduate Medical Education National Advisory Committee (GMENAC). The results show that the trend toward increasing percentages of M.D.s entering primary-care specialties from 1970 to 1976 changes to no increase from 1976 to 1980. Thus, the GMENAC policy recommendation to increase primary care further is not likely to occur spontaneously in the near future.

Pediatric Manpower

The "Critique of the Final Report of the Graduate Medical Education National Advisory Committee by the Committee on Pediatric Manpower" (Pediatrics 67:585, 1981) and the special article by Dr Budetti, "The Impending Pediatric ‘Surplus’: Causes, Implications, and Alternatives" both fail, in my opinion, to address the principal dilemma that faces pediatricians and particularly pediatric educators. I refer to the paradox that while there is a projected surplus of 7,500 pediatricians by the year 1990, there are projected shortages in the five pediatric subspecialties of pediatric cardiology, endocrinology, hematology-oncology, nephrology, and neonatology.

Manpower Requirements in Ophthalmology

Ophthalmology manpower requirements estimates presented to the Graduate Medical Education National Advisory Committee (GMENAC) are explained and compared to previous estimates published by the American Academy of Ophthalmology. Both studies used similar methods but reached different conclusions; the reasons for this are explored and shown to be due principally to (1) differences in projected hours per week spent in patient care by ophthalmologists, and (2) differences in the medical workload traceable to differences in estimated visit time and needs for care in the area of systemic ophthalmology. The manpower implications of the principal contributors to the ophthalmology workload are examined, and differences between the two studies regarding these conditions are documented. Areas for further research are suggested.

GMENAC: its manpower forecasting framework.

The Graduate Medical Education National Advisory Committee (GMENAC) was an advisory group to the Secretary, US Department of Health and Human Services. Its charter ended September 30, 1980. It submitted 107 recommendations to achieve a better balance between future physician requirements and future physician supply, by specialty and geography. Among its contributions were the development of a manpower forecasting framework and series of models which are described here, together with the results of these models. These models may have significant utility in future human resource planning at both national and local levels.

Critique of the Final Report of the Graduate Medical Education National Advisory Committee

I. INTRODUCTION: THE GMENAC REPORT In 1976, the federal government took two major steps that were to have a major impact on public attitudes and policies toward the health professions. (1) Congress passed the Health Professions Educational Assistance Act of 1976, formally declaring an end to the notion that there was an overall shortage of physicians in the United States, and emphasizing geographic and primary care shortages instead. (2) Earlier, in April of the same year, the Department of Health, Education and Welfare (DHEW), now the Department of Health and Human Services (DHHS), established the Graduate Medical Education National Advisory Committee (GMENAC) to advise the Secretary of DHEW on a set of issues related to the health professions. The formal charge to GMENAC included five specific questions: (a) What number of physicians is required to meet the health care needs of the nation? (b) What is the most appropriate specialty distribution of these physicians? (c) How can a more favorable geographic distribution of physicians be achieved? (d) What are the appropriate ways to finance the graduate medical education of physicians? (e) What strategies can achieve the recommendations formulated by the Committee? After 4½ years of meetings, analysis, and developing and applying a complex methodology, GMENAC has now completed its work. Its recently published conclusions and recommendations are the subject of this policy statement. II. GMENAC's APPROACH GMENAC chose a ten-year span for its analysis, producing separate estimates for supply of and requirements for health professionals in 1990. Decisions on whether there would be a "shortage" or a "surplus" in a given field were based on a comparison of estimated supply with estimated requirements; the Panel's recommendations were, in turn, based on those decisions.

Future of Transfer Programs

To the Editor.— The Graduate Medical Education National Advisory Committee has recommended that entering medical school classes be decreased by 10% and that transfer programs from foreign medical schools be abolished. Implementation of this recommendation would mean that 10% of the students who are currently qualified for entry into US medical schools suddenly become not good enough. Admissions committees, while dedicated and sincere, recognize that they are also fallible. Many students rejected, then later accepted as transfers from foreign medical schools, perform as well as or better than their peers who were accepted initially into a US medical school. More rigorous admissions criteria tend to penalize the person who makes a late decision on a career in medicine or is a late maturer whose grade-point average is lower. Thus, many highly motivated and competent persons must seek an education abroad if they are to enter medicine. While the transfer programs

Manpower Studies for the United States: Part II Demand for Eye Care A Public Opinion Poll Based upon a Gallup Poll Survey

This is the second in the series of Ophthalmology Manpower Studies. Part I presented estimates of disease prevalence and incidence, the average amount of time required to care for such conditions, and based on that information, the total hours of ophthalmological services required to care for all the projected need in the population. Using different estimates of the average number of hours worked per year per ophthalmologist (based on a 35, 40 and 48 hours/week in patient care), estimates of the total number of ophthalmologists required were calculated. This method is basically similar to the method later adopted by the Graduate Medical Education National Advisory Committee (GMENAC) to arrive at estimates of hours of ophthalmological services required for 1990. However, instead of using all the need present in the population, the GMENAC panel chose to use an "adjustedneeds based" model as a compromise between total need and actual utilization, the former being an overestimation and the latter being an underestimation since it is in part a function of the barriers to medical care.Since some of these barriers to medical care include informational factors, as well as availability and accessability, this study was undertaken to assess the utilization of these services and the adequacy of present ophthalmological manpower in the opinion of the consumer. Also, since the consumer's choice or behavior depends on being informed about the differences between optometrists and ophthalmologists, such knowledge was assessed and the responses further evaluated after explanatory statements were made to the responders.

Too Many Physicians: Sound Alarm!

In late September 1980, the Graduate Medical Education National Advisory Committee (GMENAC), after four years of study, turned in a report to the US Department of Health and Human Services and announced that there will soon be too many physicians. The 21-member committee, appointed to advise, followed the trend so often shown by federally appointed groups and concerned itself with management, thus demonstrating that federal advisory committees haven't changed much during the present decade. 1,2 As reported in American Medical News (Sept 19, 1980), one committee member, Bruce E. Spivey, MD, emphasized the turn of the tide when he said: We started... with the understanding that we were going to try to describe [emphasis added].... Now, for some reason, we feel compelled to make specific recommendations. Another member, Mr Carl Barrera, assistant general counsel for Metropolitan Life Insurance Co, sounded like the well-known economist, Milton Friedman, when the assistant general counsel

Public policy and patient care: Implications for internal medicine

I ssues concerning manpower for the future in internal medicine are critical for several reasons. First, they reflect a generic type of activity that has already become important and will become more so; that activity is the formulation of policy in health matters by people and agencies outside of medicine, chiefly in the federal government. In relation to internal medicine manpower a de facto partnership has been established between the public and private sectors in the form of the National Study of Internal Medicine Manpower (NASIMM), generated by the Association of Professors of Medicine and funded by the Federated Council for Internal Medicine, on the one hand, and the Graduate Medical Education National Advisory Committee of the Department of Health and Human Services (GMENAC) on the other. The activities of GMENAC [a public sector enterprise) are based in part on data being assembled by the NASIMM study (a private sector effort) and in part on the herculean labors of its own membership and advisory bodies, all from the private sector. This kind of cooperative effort in health policy development is something we have to promote, to become expert in and to be willing to contribute to if governmental efforts in health are to be enlightened and if public policy is to be tempered with the professional insights it requires. We must learn to look at federal and state policy initiatives without polarizing the debate between “our” system and “theirs”; we are going to have to see the governmental system, at least as it relates to policy development, as “ours” to a considerably greater degree than in the past, and to get into it in a broader manner, earlier in the development of issues, and with a mix of data-based positions and concerns for the individual sick, for the medical educational and training systems and for the research enterprise; all these positions will have to be argued clearly, rationally and in an articulate manner. A second general point about these issues is that, like a number of others, they cannot be left unattended by us; they will not go away, and they will not remain unchanged: something will certainly be done in relation to them. We in medicine should make ourselves as knowledgeable as possible and should try to contribute responsibly to their resolution, both by government and by our own internal governance apparatus. If we do not, the policy decisions will be made anyway, without us, without crucial insights from the profession itself. The issues in public policy as they bear on internal medicine may be approached through a set of relatively straightforward questions. The first of these, and the most compelling, is What are the needs of the patients? These can be assembled fairly readily: patients need access to the system and they need care, and they need both of these at a fiscally rational level. All three needs are intertwined, and all must be addressed. The access issue has been approached through increasing the number of physicians, by efforts to broaden the types of physicians available and by reducing financial barriers to care. This has been seasoned with the appropriate view that the most coherent access to the care system is through a personal physician who not only provides that function in a general sense but who is also himself a source of broad care which is characterized also by continuity over time and by a personal relationship with the patient. Views of the adequacy of the access system vary widely; there are clearly geographic areas in which physician density is low, but some studies, notably that of Aiken and her group [l], suggest that the bulk of the population do have reasonable access to care or will shortly. In any case, the

Internal Medicine

<i>How many internists are necessary for optimal health care in the United States, and how do these needs relate to the total medical manpower issues confronting the nation? What are the factors responsible for the current interest in general internal medicine in academic centers and in internal medicine societies? A perceptive analysis of recent developments and future trends is presented by Mark Siegler, MD, and Alvin Tarlov, MD. These coauthors are uniquely qualified to present an authoritative update on internal medicine today. Siegler, a member of the faculty of the University of Chicago Department of Medicine, was coeditor of a special issue of the</i>Archives of Internal Medicine<i>devoted to the subject of "The Role, Training and Responsibilities of the General Internist" (</i>Arch Intern Med<i>137:1271-1334, 1977). He and his colleagues have</i>published many reports in recent years on such subjects as "Development of an Academic Section of General Internal Medicine, " "The University Medical School Reaching to the Community Physician," and "A Right to Health Care: Ambiguity, Professional Responsibility and Patient Liberty." His interests in clinical ethics and in medical education have resulted in the formulation of creative approaches to the physician-patient relationship. Siegler contends that the patient should have a primary principal physician. This clinician should assume ultimate responsibility for the complex system of health care involved in diagnosis and therapy. In a sense this physician is an advocate of the patient in dealing with the hospital, the consultants, and the clinical laboratory. Tarlov is chairman of the Department of Medicine of the University of Chicago. He is chairman of the Federated Council for Internal Medicine and president-elect of the Association of Professors of Medicine. His skills and authority in the realm of manpower needs in internal medicine are widely respected. These interests encompass health manpower planning for all disciplines in medicine, and this leadership role has recently been recognized by the secretary of Health, Education, and Welfare (DHEW). Secretary Califano named Tarlov as chairman of the Graduate Medical Education National Advisory Committee of DHEW. Responsibilities of this committee are to assess the number of physicians needed in the United States and to make recommendations on the distribution of professionals among the various medical specialties, how they should be deployed geographically, how graduate medical education should be financed, and what the role of the federal government should be in influencing all of these factors. Tarlov heads another national project to evaluate aspects of this problem; he is the chairman of the Association of Professors of Medicine Task Force on Manpower Needs in Internal Medicine.—A.S.