COGME Focuses on Access Problems in New Report to HHS, Congress

The United States should establish a national medical school or system of schools that would waive tuition in exchange for graduates' subsequent service in underserved areas. That's one of five recommendations advanced by the Council on Graduate Medical Education, or COGME, in its 18th report to HHS and Congress on physician workforce issues.

HHS released the report, "New Paradigms for Physician Training for Improving Access to Health Care," this month. The report, which does not define the length of service graduates would be asked to provide, focuses on improving access in rural areas and for the urban uninsured.

A 19th report by COGME, "Enhancing Flexibility in Graduate Medical Education," was released at the same time. It offers recommendations on the content, structure and setting of GME training, as well as on funding mechanisms and regulations pertaining to those mechanisms.

The consensus reports "build on each other and are as meaningful as anything that COGME has put out in its recent history," says COGME's chair, Russell Robertson, M.D., professor and chair of the family medicine department at Northwestern University Feinberg School of Medicine in Chicago. "They deserve the attention of everybody involved in delivering health care. We hope family physicians will read the reports and recognize that we have an opportunity to advocate not for ourselves, but for our patients, many of whom are suffering because they can't find the physicians they need in the areas where they live."

A national medical school "is a bold concept for addressing the health care access problems many Americans face," Robertson says of COGME's 18th report. "This idea cuts to the core of what needs to be done, so we felt we should recommend it."

The American Medical Student Association, or AMSA, had earlier proposed the concept of a national medical school during the presidency of Leana Wen, M.D., M.A. Wen now is a COGME member -- and a current Rhodes Scholar, Robertson notes.

As envisioned in the COGME report, the national medical school system would be unique in its emphasis on service, public health issues, epidemiology, and emergency preparedness and response. The system would "intentionally target cultural competency and rural and urban medical issues as part of its integrated curriculum," the report says. "Moreover, the admissions process would select people based on the necessary attitudes, knowledge, skills and experiences to excel in this model."

In a previous report, COGME had projected that the nation would be short about 96,000 physicians by the year 2020 and had recommended that medical school sizes be enlarged by 15 percent. The Association of American Medical Colleges subsequently recommended a 30 percent increase in the number of U.S. medical students.

Yet according to the 18th COGME report, existing medical schools are projected to expand by less than 15 percent, so new schools are needed to alleviate the impending physician shortage. Several new schools have opened, and others are in the pipeline, Robertson says.

But COGME members working on the 18th report were concerned that expecting market forces alone to solve access problems just wouldn't work, says Robertson. The COGME report notes that "traditional medical education in the United States has been unsuccessful in reversing geographic physician maldistribution and barriers to health care access. Additional problems include a growing lack of primary care physicians and a limited degree of cultural diversity in medicine."

Robertson says it's true that most U.S. medical schools tend to perpetuate a system of admitting people from well-to-do urban and suburban communities. "Students from rural and urban underserved communities often face an uphill battle for medical school admission," he says. "For example, research from the Academy's Robert Graham Center showed us that the number of medical school applicants from rural communities has been relatively steady, but the number actually gaining admission has been on decline."

The 18th COGME report also calls for

In its 19th report, "Enhancing Flexibility in Graduate Medical Education," COGME recommends increasing funded GME positions by a minimum of 15 percent to accommodate medical school expansion. The support should be directed to innovative training models that address community needs and reflect emerging models of health care delivery. Program directors should have to demonstrate that they would educate their graduates to proficiency in all six Residency Review Committee core competencies, as well as in the five core areas reviewed in the Institute of Medicine's 2003 report, Health Professions Education: A Bridge to Quality.

The 19th COGME report notes that potential examples of innovative educational programs may come from sources such as family medicine's residency demonstration initiative, P4: Preparing the Personal Physician for Practice.

The report also makes these recommendations:

Like its 18th report, COGME's 19th report calls for reinvigoration of Title VII funding for GME.

COGME was authorized by Congress in 1986 to provide an ongoing assessment of physician workforce trends, training issues and financing policies and to recommend appropriate federal and private-sector efforts aimed at addressing problems or deficiencies identified.