STRENGTHENING OUR VOICE IN PUBLIC POLICY ON MEDICAL EDUCATION

Abstract

Medical education is in the eye of public policy makers more than ever before. Many forces contribute to the interest of policy makers in medical education, including public awareness of how policies can affect access to and quality of clinical care. Governmental legislatures are getting more involved in medical education policy, with less acceptance of the profession's autonomy. Professional societies are not positioned to respond optimally to governmental involvement in medical education policy due to limited resources, poor coordination, and competing concerns. To urge leaders in medicine to strengthen their voice in public policy on medical education, I review educational issues that have recently received attention in the policy arena, and what professional societies have focused on. I highlight strengths and weaknesses of how professional societies have addressed public policy on medical education, and suggest opportunities for strengthening the voice of the medical community.

INTRODUCTION

Medical education increasingly is targeted by public policy makers for a variety of reasons. First, education is viewed as a public good because of its role in improving the health of communities by preparing the workforce the country needs (1). Medical education policy can affect access to and quality of clinical care, and ideally should be aligned with the nation's health priorities (2). The interest of policy makers in medical education is stimulated by concerns of health care payers, providers, and other stakeholders in the health care system. Stakeholders have expressed concern about the unrelenting rise in the cost of medical education, a sizable portion of which has been borne by tax payers through governmental funding of graduate medical education and student loan repayment programs (3). With decreasing acceptance of the autonomy of the health professions (4), legislatures have shown increasing interest in addressing problems in current systems of training for the health professions (5). Such attention is expanding beyond the national government level to the state or local level (6).

Unfortunately, the medical community is not optimally positioned to respond effectively to increasing interest of policy makers in medical education. Professional societies in medicine have an important role in supporting physicians in the policy arena (7), but they have many competing concerns. Thus, they often have limited resources for addressing policy issues in medical education. Although concerns about medical education cut across disciplines, professional societies have not been well coordinated in efforts to improve medical education. In a challenging political environment, the lack of coordination makes it more difficult for the medical profession to shape the direction of education policy.

The aim of this article is to urge leaders of the medical community to strengthen their voice in policy making on medical education. I focus on four questions: 1) Which medical education issues have received attention in the public policy arena? 2) What medical education issues have professional societies focused on? 3) What are strengths and weaknesses of the current approach to public policy on medical education? 4) How can we strengthen the voice of academic medicine on medical education policy?

WHAT MEDICAL EDUCATION ISSUES HAVE RECEIVED ATTENTION IN THE PUBLIC POLICY ARENA?

Policy makers have been giving attention to problems across the spectrum of medical education, including undergraduate and graduate medical education. Because of persistent concerns about the shortage of physicians in many different disciplines, policy makers have explored ways to change undergraduate and graduate medical education to recruit more trainees into specialties experiencing the greatest shortages (8-9). Policy makers have shown interest in addressing issues affecting medical students, including efforts to protect student loan forgiveness and allow student documentation in electronic health records (10-11). Policy makers also have shown increasing interest in issues related to graduate medical education, stimulated by the large amount of Medicare and Medicaid funding devoted to graduate medical education (3,12). Other issues garnering attention include the Common Program Requirements of the Accreditation Council for Graduate Medical Education which set standards for the training of resident and fellow physicians (13), restrictions in duty hours for residents (14-15), and changes in immigration policy that threaten the status of residency programs with residents from other countries (16). Although federal policies designed to promote privatization of the Veterans Affairs health care system were not intended to affect training programs, such policies could affect undergraduate and graduate medical education programs that have relied on strong academic affiliations with the Veterans Affairs system.

With regard to continuing education of physicians, policy makers are getting involved in a number of issues. In response to concerns of many physicians about maintenance of certification programs, policy makers at the state level have been asked to consider new policies for regulating the approach to maintenance of certification (17). At the federal level, policy makers have been asked to consider new ways to support the training of physician-investigators (18).

Medical education also has an important role to play in addressing health topics of national priority. For example, education is an important part of governmental strategies to address the epidemics of opioid use and obesity in this country (19-21). Similarly, medical education is an important part of local and federal policies intended to address other health problems such as promoting vaccine use and preventing gun violence.

WHAT MEDICAL EDUCATION ISSUES HAVE PROFESSIONAL SOCIETIES FOCUSED ON?

As part of its mission, the Association of American Medical Colleges (AAMC) seeks to transform health care through innovative medical education. The AAMC has been very active in addressing important issues in medical education. It has shown a sustained commitment to preventing doctor shortages and preserving doctor training by establishing the Graduate Medical Education Advocacy Coalition, by creating the Health Professions and Nursing Education Coalition to support Title VII and VIII programs, and by launching Project Medical Education to inform policy makers about “the process of medical education, the benefits it provides, its complex funding mechanisms, and the essential role of government in providing financial support” (22). The AAMC has supported training programs by advocating for policies to protect immigrants, and to prevent overregulation of training. The AAMC also has advocated for federal support of research training through its Research Means Hope campaign and its Ad Hoc Group for Medical Research. To support all of its advocacy efforts, the AAMC created a digital grassroots initiative (www.aamcaction.org).

The American Medical Association (AMA) is the largest association of physicians in the US, and has influenced a broad range of educational policies through its Council on Medical Education. In recent years, the AMA has focused on creating physicians equipped to flourish in the future, giving attention to several education-related policy areas. One area is to reduce gender bias, promote equal pay and transparency of compensation, and establish educational programs on structural bias. Another area calls for medical students, residents, and physicians to get training in lifestyle medicine and social determinants of health. A third area is to promote diversity in the medical workforce. The AMA has pursued the latter by advocating to clear the backlog for converting H1-B visas to permanent residents, by helping students and residents get training on implicit bias, diversity, and inclusion, by publicizing strategies for educating residents about disparities in their fields, and by calling for more research on educating physicians how to eliminate disparities. In addition, the AMA works with the AAMC as joint sponsors of the Liaison Committee on Medical Education, the accrediting body for medical schools recognized by the US Department of Education.

The American College of Physicians (ACP) is a national organization of internists whose mission encompasses being a leader in education for internal medicine and its subspecialties. The ACP has given attention to several education-related policy areas. The ACP currently is very engaged in advocating for changes in maintenance of certification processes. As declared in a 2016 position statement created in collaboration with the Alliance for Academic Internal Medicine (AAIM), the ACP continues to advocate for making graduate medical education funding more effective, with an emphasis on ensuring an adequate supply of physicians, using appropriate training sites, spreading the cost across the health care system, evaluating the true cost, being transparent, and promoting innovation in training (23). For many years, the ACP has sought to strengthen the primary care workforce by advocating for support of the federal Primary Care and Training Enhancement Program and the National Health Service Corps. In 2016, the ACP made a resolution to advocate for meaningful use of electronic health records by medical students (24). Subsequently, the Centers for Medicare and Medicaid Services changed their clinical documentation requirements to allow teaching physicians to verify medical student documentation in a patient's electronic health record.

The American College of Surgeons (ACS) aspires to set high standards for surgical education, and has been active in addressing education- related policy issues. The ACS has focused attention on changing graduate medical education to strengthen the workforce. In its 2017 position statement, the ACS called for more data collection and research to improve graduate medical education, while also advocating to maintain funding for current programs and add money to modernize graduate medical education (25). The position statement also proposed combining graduate medical education and indirect medical education funding, and regionalizing the governance of programs. On other policy fronts, the ACS has advocated for better opioid-related education of patients and providers, and for better education in palliative care. The ACS also has consistently advocated for policies that support surgical training as defined by a recognized specialty board and delivered by an appropriately accredited organization.

AAIM is dedicated to enhancing the professional growth of academic internal medicine faculty, administrators, and physicians-in-training, and thus has strong interests in policies affecting training in internal medicine. AAIM has advocated for changes in accreditation requirements for medical schools and residency programs, and for sustained federal funding of graduate medical education. It worked with the ACP to advocate for the change in Centers for Medicare and Medicaid Services policy allowing student use of electronic health records. It joined other internal medicine organizations in advocating for changes in maintenance of certification processes. It also has been a long-time supporter of funding to preserve the pipeline of physician-scientists.

My own professional society, the Society of General Internal Medicine (SGIM), has focused most of its education-related advocacy efforts on primary care training, diversity of the health professions, and interdisciplinary education. In a position paper published in 2014, SGIM called for reform of graduate medical education funding (26). Over the years, SGIM has consistently advocated for preservation of the Health Resources and Services Administration's Title VII funding for the Primary Care Training and Enhancement Program, Centers of Excellence, and Health Careers Opportunity Program. SGIM also has advocated for federal support of career development awards from the Agency for Healthcare Research and Quality.

The above-mentioned professional societies range in size and mission scope, but together illustrate similarities and differences in interests across organizations. Of course, many other professional societies get involved in education-related policy. However, no resource exists for cataloging all of the education-related interests of professional societies.

WHAT ARE STRENGTHS AND WEAKNESSES OF OUR CURRENT APPROACH TO PUBLIC POLICY ON MEDICAL EDUCATION?

The most important strength of the current approach to public policy on medical education is the existence of strong experienced health policy teams at the AAMC, AMA, and major specialty societies such as the ACP and ACS. Although most subspecialty societies do not have enough resources to support a large health policy team on staff, many have very active health policy committees that get members engaged. Some subspecialty societies also engage lobbyists to support their advocacy work. Across all organizations, a wide variety of methods are used to address policy issues in medical education. The methods include web-based resources, position papers, legislative alerts, letter-writing campaigns, coalitions, organized visits to Capitol Hill, testimony before legislators or regulators, and placement of representatives on policy-making groups. All together, the resources committed to public policy are quite substantial. However, only a fraction of those resources are devoted to medical education when organizations focus most of their attention on clinical practice issues.

Unfortunately, our approach to public policy on medical education has several major weaknesses. Professional societies generally operate independently in much of their policy work even when they have common interests. For example, the organizations mentioned above generated three different position papers on graduate medical education reform, only one of which explicitly involved more than one organization. All professional societies face many competing policy issues, especially in the clinical practice domain where many changes are occurring. For many societies, even those with substantial resources, relatively little attention is given to educational policy. Every professional society must set limits on its advocacy agenda in order to be effective. Many national professional societies choose to focus on federal policy and do not have the bandwidth to expand their policy work to the state or local level. For societies that do not have the resources to support a sizeable policy team, the lack of training in health policy and advocacy becomes another limiting factor.

HOW CAN WE STRENGTHEN THE VOICE OF ACADEMIC MEDICINE ON MEDICAL EDUCATION POLICY?

To strengthen our voice, we need to promote more consistent communication between the policy arms of professional societies. Because professional societies differ in the roles of members and staff in public policy efforts, efforts should be made to define the best communication channels between organizations. By establishing clearer communication channels, organizations should be better able to collaborate in setting, revising, and acting on education-related priorities. Such communication would also help to identify opportunities for sharing resources.

Although academic physicians often have considerable influence as leaders within their professional societies, they also have opportunities to be more active in influencing policy through their own academic institutions. Because academic medical centers have a major stake in local and federal policy, they generally have staff with expertise in government affairs. Faculty should become familiar with the government affairs staff and associated resources available locally. Those connections may become increasingly important as education-related policy issues arise more frequently at the local or state level — where some national professional societies may lack the infrastructure to be effective. Faculty may also be able to provide valuable advice and mentoring to medical students and other trainees who seek to get involved in advocacy efforts (27). Trainees certainly have an important stake in educational policy.

Of course, advocacy efforts can consume a lot of effort. Professional societies will continue to make difficult decisions about the resources they can afford to devote to influencing public policy in medical education. Individual educators will need to decide how much time they can devote to the issues most important to them, keeping in mind there is no guarantee that education-related issues will get much attention if educators do not speak up with a stronger voice. If professional societies can improve communication and collaboration on policy issues in education, educators will have a way to strengthen their voice. They may not agree on all issues due to differences in priorities and differences in where members lie on the political spectrum, but more effective communication will enable groups to work out differences and come together on shared concerns.

Professional societies can strengthen their voice on public policy in medical education by focusing on four aspects of their role: inform, motivate, enable, and coordinate. Society leaders should keep members informed about education issues in their field. They should motivate members to get involved in advocating for better policies in medical education, and enable members to be more effective advocates. Lastly, they should coordinate the efforts of their members with other organizations. The resulting collective voice will be much stronger than the individual voices that otherwise may get lost amidst many competing concerns in a rapidly changing health care system.

DISCUSSION

Thibault, Boston: Thank you Eric. That's an absolutely timely talk. And the relevance of medical education to health care delivery reform needs to be emphasized in every forum that we have a chance to do so. The only other point I would make — to what is a superb list and a charge — is that this effort, in addition to our educational efforts, needs to be more interprofessional. We should make this effort to influence policy more interprofessional and find, where possible, common grounds with leaders of other professional organizations — like nursing and pharmacy — that will increase our strength as we go in our advocacy positions. I'd love your view on that.

Bass, Baltimore: Well, thank you. I was hoping that I would hear from you and your successor at the Macy Foundation, because obviously the Foundation has an important role in this sort of agenda that we all share. I certainly agree that we really need to be looking for ways to bring the whole profession together, because I really do think we have a lot in common, particularly in the medical education realm. We need to do this in the clinical practice realm as well, but it will be even more challenging there. And it's easy to lose sight of the education topics and miss all the other stuff that's going on.

Selker, Boston: That was a great talk Eric, thank you. You've suggested bringing in the public affairs people from our institutions. Your institution has great experience in that. Yet I find when you bring those individuals in (I actually try to run under our institution's radar candidly, because there are a lot of conflicts, if you think about CME and things like that) there are some things that would have to be resolved. So, if you're going to do that, have you had experience in trying to bring together the stakeholders on your campus so they actually allow the public affairs person to speak?

Bass, Baltimore: Yes, thanks for asking that. What I have found is that despite the fact that oftentimes there are these conflicting interests, the folks in our government affairs office really know the scene so well. I think they actually appreciate hearing from the faculty, and what I hear more often is that they wish more faculty would share with them their concerns. They really have gone out of their way, whenever I've asked, to help to bring more attention to the issue and bring it to the connections that they have at both the federal and the state level. So, I think we need to do a bit more of that.

Selker, Boston: You all have a very sophisticated government affairs office.

Bass, Baltimore: Lastly, I just have to thank my wife for being here and for supporting all of my work and the extra responsibilities I took on with my new position that's added stress to our lives. I want to thank my nominators Mark Anderson and Sherita Golden. Thank you.