2013 Congress of Delegates

Workforce Pipeline, Education Issues Up for Debate by AAFP Delegates

October 01, 2013 03:13 pm Matt Brown San Diego –

The 2013 Congress of Delegates went to bat for the future of family medicine Sept. 24, adopting one resolution intended to help bolster the primary care workforce by shoring up the physician pipeline and calling for further study of another. A third measure seeking to survey family medicine residents about their medical school experience also was adopted.

Kansas alternate delegate Michael Kennedy, M.D., dean for rural health education at the University of Kansas, tells reference committee members that only about 5 percent of internal medicine residents and 11 percent of pediatrics residents that graduate from his program actually end up practicing primary care.

Although it seems clear that the number of primary care physicians medical schools indicate they're producing does not line up with the actual number who end up in primary care practice, it can be difficult to discern why. One resolution discussed during the Sept. 23 hearing of the AAFP Reference Committee on Education sought to address that problem by tying graduate medical education (GME) reimbursement and medical school accreditation to a minimum percentage of graduates selecting primary care.

Minnesota delegate Lynne Marie Lillie, M.D., of Woodbury, testified in favor of the resolution.

"As the funding for graduate medical education is going to become a very significant issue for America going forward with the (Patient Protection and) Affordable Care Act, simply increasing funding for primary care internal medicine residencies that only put 5 percent of their residents into primary care won't meet the big picture goal that we're trying to obtain," she said.

Story highlights
  • The Congress of Delegates considered a trio of workforce pipeline resolutions debated before the Reference Committee on Education, adopting two of them and referring the third.
  • Delegates also adopted a substitute resolution supporting increased training about intrauterine devices, as well as a resolution recognizing the merits of the Comprehensive Advanced Life Support course.
  • Delegates voted down a measure intended to give physicians the choice to opt out of providing demographic information currently required to take the American Board of Family Medicine board exam.

Although he agreed with the spirit of the resolution, said Missouri delegate Lawrence Rues, M.D., of Kansas City, he acknowledged he was uncomfortable with accreditation being part of the package.

The AAFP can't force the accreditation issue, which is the purview of the Liaison Committee on Medical Education, he said. "I would, however, say (to schools), 'Good, do your own thing, but you're not going to get as much money.'

"The public needs primary care … and as ([then] AAFP President) Jeff Cain said, we need to prioritize GME funding to the needs of the public, because that's going to move things."

The resolution eventually was referred to the AAFP Board of Directors to work out details and coordinate with the AAFP's current advocacy efforts in regard to GME funding.

The reference committee also heard extensive testimony in support of a resolution asking the AAFP to request that

  • the Association of American Medical Colleges (AAMC) define primary care residencies as those that offer a family medicine, primary care internal medicine, primary care pediatrics, or combined internal medicine/pediatrics focus when reporting statistics;
  • all U.S. medical schools annually report the number and percentage of graduating students selecting primary care residencies as defined in the resolution; and
  • all U.S. medical schools report the number and percentage of alumni practicing primary care five years after graduation.

New Hampshire delegate Paula Leonard-Schwartz, M.D., of Manchester, expressed her dismay regarding what she called a misrepresentation of the numbers of medical school graduates going into primary care. "The statistics are used to overrepresent the numbers of physicians that actually stay in primary care," she said.

"Medical schools should be able to track their alumni and report who has stayed in the primary care field. Shining a light on medical schools by asking them to provide this information is one way to get them to be more truthful in their reporting."

Kansas alternate delegate Michael Kennedy, M.D., of Kansas City, who also serves as the associate dean for rural health education at the University of Kansas, also spoke in support of the resolution.

"When you compare how successful we are at getting people into family medicine and then we have to compare those (figures) to other schools that predominantly put people in internal medicine and pediatric residencies, the numbers are skewed," he said. "Regarding our (internal medicine residents), about 5 percent stay in general medicine (11 percent for pediatric residents) and the rest go into (sub)specialty (fields), so I strongly support this and standardizing this definition."

In addition, delegates approved a resolution directing the AAFP to survey new family medicine residents, looking for details on the feedback they received -- positive and negative -- regarding their choice to become family physicians. The resolution also asked the Academy to "work with medical schools to encourage educational environments more supportive of students' choice of family medicine." In its recommendation to adopt the measure, the reference committee acknowledged that objective data about "the hidden curriculum" that discourages students from entering family medicine are lacking.

California alternate delegate Jeffrey Luther, M.D., testifies that intrauterine devices are a safe, effective and low-cost means of contraception.

More Training in IUD Use, Advanced Life Support

Delegates also adopted substitute resolutions supporting increased education about intrauterine devices (IUDs) and recognition of the Comprehensive Advanced Life Support course (CALS), but voted down a measure that sought to give physicians the choice to opt out of providing demographic information currently required to take the American Board of Family Medicine (ABFM) exam.

Noting the overlap in resolutions submitted by California and Texas that support increased IUD use and instruction, the reference committee combined both into a substitute resolution that asked the Academy to support the use of IUDs and other long-acting reversible contraception as first-line contraceptive options and encourage that these tools be promoted as an option for most women. The AAFP is also to encourage U.S. family medicine residency programs to offer core curriculum evidence-based indications and hands-on insertion and removal training for these products, as well as "continuing professional development opportunities regarding intrauterine device eligibility, insertion and removal."

"IUDs are a safe, effective and low-cost means of contraception," California alternate delegate Jeffrey Luther, M.D., of Long Beach, told the reference committee. "According to this Academy, they are considered a core skill of the well-trained family physician. That being said, surveys indicate that as few as 39 percent of practicing family physicians provide IUD services to their patients compared to 89 percent of obstetricians and gynecologists."

Luther pointed out that those percentages may be attributable to family physicians holding on to misconceptions regarding the contraindications and risks associated with IUDs.

"They may be using somewhat dated criteria for determining which patients would or would not benefit from the use of an IUD," said Luther. "One way or another, I think improved training in this area for both our practicing physicians and our residents in training would go a long way to redressing this issue."

The debate on the CALS course centered on a single aspect of the original resolution's language, with the reference committee offering a substitute measure that the AAFP "recognize" rather than "endorse" the tool as "an appropriate advanced life support course for the purpose of improving rural emergency medical care." On the floor of the Congress, delegates then added a clause directing that the CALS curriculum be referred for review by both the Special Interest Group in Emergency Medicine (SIG-EM) and the Working Group on Rural Health to assess its appropriateness to serve as an alternative to Advanced Trauma Life Support (ATLS) for state trauma designation.

"Our purpose in (adding the SIG-EM portion of the resolution) is to make sure that this is going to be a place where people can get training that is a more comprehensive alternative than ATLS in rural settings," said Minnesota delegate Carol Featherstone, M.D., of New Hope.

Special constituency delegate Jennifer Bacani McKenney, M.D., says the benefits gleaned from data gathered in a demographic survey attached to the American Board of Family Medicine exam outweigh the privacy risks.

Demographic Data Over Privacy Concerns

With regard to the resolution targeting the demographic survey attached to the ABFM board exam, Michigan delegate Robert Reneker Jr., M.D., of Wyoming, said that although he is aware the data are important to the ABFM -- and board certification is keenly important to family physicians -- physician privacy should weigh out.

"Try getting credentialed by an insurance company without board certification," said Reneker. "Try getting … admitting privileges to a hospital; it just does not happen. You have to give how much you make and all sorts of other (information) about your practice in order to take the board exam. Well, I'm sorry; they don't have a right to that."

Special constituency delegate Jennifer Bacani McKenney, M.D., of Fredonia, Kan., disagreed, siding with the reference committee's position that the benefits gleaned from the data gathered outweigh the privacy risks.

"We feel that the demographic information collected from the questions asked during the board exam is beneficial in making sure that this exam is not biased towards any population of family physicians that may be taking it," she said.

"We talk a lot about health care disparities and how we can find a solution to this issue, but the trouble is that we often do not have the information to be able to find those solutions. In this case, we are able to collect data that can help us to make sure there is no bias to the family physicians trying to become certified."

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