Policy measures taken up Sept. 11 by the Reference Committee on Education here spanned a wide range of topics -- from CME and maintenance of certification, or MOC, to graduate medical education, or GME, workforce issues and defining the specialty's future.
Members who attended the hearing took full advantage of their chance to have their say about each issue. But in the end, of course, it was the Congress of Delegates' say that mattered. Here's some of what they decided.
California alternate delegate Jeffrey Luther, M.D., of Long Beach, was first to the microphone, introducing a resolution that asked the AAFP to include chapter CME program offerings on the Academy website even before they've been accredited. Listing these items with a "CME approval pending" notation appended to them would allow members to plan further ahead when evaluating available CME options. "We found this to be a fairly low-cost option to improve members' access to CME," said Luther.
Minnesota delegate Keith Stelter, M.D., of Mankato, who also is chair of the Commission on Continuing Professional Development Chair's Subcommittee on Clinical Content and Accreditation, noted that the AAFP has a dual role as both a CME provider and a CME accreditor. He also commented on the stringent process of gaining accreditation through the Academy. "We do it differently than other accreditors," Stelter explained. "It's activity by activity and even lecture by lecture. We go through it with a fine-tooth comb.
"We do want people to know that when they click on a CME link on the AAFP website, they're getting the highest level of scientific rigor, debate and discussion through that CME."
"One downside (to adopting the measure would be) that even though only 3 percent (of CME programs) don't get approved, when do you put that notification on there?" asked Ohio delegate Gary LeRoy, M.D., of Dayton, who also is a member of the Commission on Education. Also, others asked, if such a process were put in place for chapters, wouldn't other CME providers soon start clamoring for the same treatment? How would that be dealt with? Would providing this service for chapters but not others raise any legal issues?
- The 2011 Congress of Delegates adopted, with amendments, a resolution that asked the AAFP to include chapter CME program offerings on the Academy website even before they have been accredited.
- Delegates also adopted a measure calling for the Academy to urge the American Board of Family Medicine to investigate alternatives to the proctored exam component of maintenance of certification.
- A measure that asked the Academy to seek substantiation of findings from a 2010 report on the future of nursing that was developed by the Institute of Medicine and funded by the Robert Wood Johnson Foundation also received delegates' approval.
Delegates found the answers to these questions, however, adopting the resolution after adding a clause saying that if the original request could not be accommodated within the current CME listing system, the AAFP would need to set up a members-only section that could provide this service to chapters.
In her testimony on a resolution calling for the Academy to urge the American Board of Family Medicine, or ABFM, to investigate alternatives to the proctored exam component of maintenance of certification, or MOC, Arkansas alternate delegate Julea Garner, M.D., of Hardy, observed, "In this day and age, the written exam that's the proctored part of this process is getting a bit archaic.
"Testing only retained knowledge in this day and era is really not (representative of) practicing and even administrative physicians."
Connecticut delegate Craig Czarsty, M.D., of Oakville, who is immediate past president of the ABFM, reminded those at the hearing that the proctored exam is only one of four parts of the MOC process. Some of the member boards of the American Board of Medical Specialties, or ABMS, already are struggling to implement MOC, he said, so they would be loath to give up the proctored exam. "I'm afraid this is a dead issue, as far as the ABMS is concerned," Czarsty concluded.
A number of members pointed out that if the true purpose of the educational process is to ensure that physicians know how to solve clinical problems, perhaps a more open testing process whereby learners could use available information technology to seek answers to a specific clinical question would be more representative of what physicians do every day in practice. Similar ideas are currently under consideration, Czarsty assured participants.
Given the preponderance of testimony in favor of the measure and the possibility that some palatable alternatives to the written exam eventually might be identified, reference committee members recommended adoption of the resolution, and the Congress agreed.
Testifying in support of a resolution calling for the AAFP to organize a fourth Keystone conference to bring together all members of the family of family medicine to discuss the specialty's future, Ohio's LeRoy pointed out, "It has been a decade since Keystone III, and a lot of things have changed since then," including concerns about payment issues and implementation of the Patient Protection and Affordable Care Act.
Georgia delegate John Bucholtz, D.O., of Columbus, who spoke on behalf of his delegation, which introduced the measure, observed, "The more we do, the more we figure out we need to do. The landscape has changed, and we feel we need to seriously look at this."
Those attending the reference committee hearing realized that the cost of such an event likely would be problematic, and many of those testifying called for the measure to be referred to the AAFP Board for its consideration. In its report, the reference committee recommended that course, and delegates referred the resolution.
Brent Smith, M.D., of Brandon, Miss., resident member of the Commission on Membership and Member Services, acknowledged that much of what was included in a resolution titled "Making Graduate Medical Education (GME) Financing and Reform a Priority for AAFP" was already being addressed by the Academy. "But I don't want to see this get stuck on a reaffirmation calendar," he testified, urging reference committee members to consider adding more specific, measurable elements to the measure.
"We lose (residency) positions every year, and if it doesn't change, we're going to be in workforce crisis very soon," said Smith, who also was elected resident member of the AAFP Board by the National Congress of Family Medicine Residents in July.
Kansas delegate Michael Munger, M.D., of Overland Park, agreed. "Without serious reconsideration of how GME is awarded, we are going to be in some serious trouble," he testified.
"Students are afraid," affirmed Florida alternate delegate Amber Isley, M.D., of Orange Park, in her testimony. "They're afraid of applying to residencies that may not exist" in the future.
Before adopting the substitute resolution offered by the reference committee, which drew on recommendations from the 20th report of the Council on Graduate Medical Education, the Congress of Delegates fine-tuned it further by adding language to clarify that GME funding, not quality, is the key issue to be addressed. Delegates also directed the AAFP to report back to the 2012 Congress on its progress.
Another resolution delegates adopted prompted testimony from (then) AAFP President Roland Goertz, M.D., M.B.A., of Waco, Texas.
The measure asked the Academy to seek substantiation of findings from a 2010 report developed by the Institute of Medicine and funded by the Robert Wood Johnson Foundation, or RWJF, that called for, among other things, expansion of independent practice for nurse practitioners, or NPs, and other advanced-practice nurses. The report claimed that such an expansion would permit NPs to move into practices in medically underserved areas, thus alleviating primary care workforce shortages in those areas.
Specifically, the resolution calls for the AAFP to ask RWJF to
- "evaluate the role of advanced-practice registered nurses in the physician-led patient-centered medical home model;
- evaluate the geographic distribution of advanced-practice registered nurses and primary care physicians (MD/DO) to see if, in fact, advanced-practice registered nurses help alleviate primary care shortages in underserved areas; and
- report on best practices for patient-centered care between physicians, advanced-practice registered nurses and the entire care team in markets which allow independent practice and those which do not."
"In some political arenas, the NPs have outstepped us on this topic, and we need to regain that ground," Goertz testified. The information sought by the resolution would be valuable, he noted, and could help foster common ground between the nursing and medical communities.
Furthermore, if the Congress of Delegates were to adopt such a directive, that would strengthen the rationale for seeking this information. However, Goertz warned, such an inquiry may not reveal the results FPs would hope to see.
"We already had this battle in our legislature," said Smith. "If a report is bad for us, let it be bad for us. We're doing this on behalf of our patients and what's best for our patients.
"Bring it on."