Advisory Committee on Training in Primary Care Medicine and Dentistry

Minutes of Meeting, September 28-29, 2006

Advisory Committee Members Present
Joseph A. Leming, MD, Chair
Sanford J. Fenton, DDS, MDS, Vice Chair
Perri Morgan, PA-C, MS, Vice Chair
David P. Asprey, PhD, PA-C, Member
Diego Chaves-Gnecco, MD, MPH, Member
Tina L. Cheng, MD, MPH, Member
William A. Curry, MD, Member
Alan K. David, MD, Member
Katherine A. Flores, MD, Member
Charles H. Griffith III, MD, MSPH, Member
Bonnie Head, MD, Member
Man Wai Ng, DDS, MPH, Member
Lauren L. Patton, DDS, Member
Joseph L. Price, PhD, Member
Raymond Tseng, DDS, PhD, Member
Surendra K. Varma, MD, Member

Others Present
Tanya Pagan Raggio, MD, MPH, Senior Advisor, Bureau of Health Professions
Daniel G. Mareck, MD, Acting Deputy Director, Division of Medicine and Dentistry
Jerilyn K. Glass, MD, PhD, Acting Executive Secretary, Advisory Committee

Thursday, September 28, 2006

The Advisory Committee on Training in Primary Care Medicine and Dentistry (Advisory Committee) convened its meeting at 8:30 a.m. at the Hilton Washington DC North/Gaithersburg Hotel, 620 Perry Parkway, Gaithersburg, Maryland 20877.  Joseph A. Leming, MD, Chair, opened the meeting by introducing Tanya Raggio, MD, MPH, Senior Advisor, who brought greetings from A. Michelle Snyder, Associate Administrator for the Bureau of Health Professions, who was unable to attend.  She affirmed the Bureau’s support for the Advisory Committee and listed managerial reassignments that have taken place in the Bureau.  She stated that the Bureau’s mission is to ensure an adequate, competent, and diverse healthcare workforce that serves underserved and other high-risk groups.  Key to this goal is high quality education programs for health professionals who then have the right skills to produce the right outcomes in the right places.  Dr. Raggio reviewed the results from a query of Title VII, section 747 grantees about how they are serving vulnerable and other high-risk groups.  Of over 300 grantees, 177 responded.  She presented a pie chart of the grantee programs addressing specific underserved groups.  Of interest were data that grantees were serving a number of high risk groups not specifically listed in the Title VII, section 747 legislation, such as individuals with developmental disorders, intellectual disability, and mental illness.

Dr. Leming introduced Daniel G. Mareck, MD, new Acting Deputy Director for the Division of Medicine and Dentistry, who previously worked in the Division of the National Health Service Corps.  Previously, Dr. Mareck was a faculty member for the Rural Physician Associate Program at the University of Minnesota Medical School, which provides mentoring experiences for third year medical students interested in rural, underserved primary care careers.  Dr. Mareck acknowledged the staff of the Division of Medicine and Dentistry, especially Dr. Howard Davis who is retiring after 29 years of Federal Government service.

Individual members of the Advisory Committee gave brief reviews of the commissioned papers for the sixth report.  Joseph L. Price, PhD reviewed the paper by Dr. Leiyu Shi who draws together distinctive characteristics of a vulnerability model and describes risk factor convergence.  Dr. Shi proposes a solutions-focused framework which includes training for primary care professionals.  He emphasizes teamwork, integrated care, cultural competence, and community involvement.

Surendra K. Varma, MD reviewed the paper by Dr. Paul Wise.  The author describes a changing epidemiology of childhood illness, with chronic illness having ever increasing relevance to pediatric practice, the use of health services, and consequently, the training of pediatricians.

Katherine A. Flores, MD reviewed the paper by Dr. Rubens Pamies who describes health disparities and vulnerabilities secondary to race and ethnicity.  Dr. Pamies calls for curricula to teach skills needed by health professionals to navigate cross-cultural interaction, urges efforts to increase minority students in the healthcare education pipeline, and stresses support for culturally competent care by National guidelines/standards and funding sources.      

Perri Morgan, PA-C, MS reviewed the paper by Dr. John Frey who presents a resource-based model composed of financial, human, and social capital.  Providing case studies, he discusses resilience and how extra capital in some areas can overcome vulnerability.  The author suggests a multi-disciplinary teaching approach that is integrated throughout preclinical education.  He favors the teaching of population characteristics, having training sites with relevant population health data readily available, and including vulnerability aspects in the medical record.    

Lauren L. Patton, DDS reviewed the paper by Dr. Burton Edelstein whose model of dental care vulnerability highlights the intersection of social and health gradients, which ultimately relate to treatment difficulty and access to care.  He states that only by addressing the competency, social normative, and attitudinal constraints that currently limit the number of dental providers willing to treat special needs patients, will these individuals gain routine access to quality interdisciplinary primary dental care.  He urges a common medical-dental curriculum, efforts to stimulate service learning, expansion of Title VII authorization for pre-doctoral dental curriculum development and faculty development, grants for advanced medical/dental residencies/fellowships, and expansion of dental accreditation requirements to include competency in the care of vulnerable populations.         

Sanford J. Fenton, DDS, MDS clarified that in dentistry there is no mandated general practice residency and he, too, favors some sort of mandated fifth year, not an extra year of dental school, but a year of residency.  He hopes that in the future there will be a mechanism for transitioning pediatric dental patients into adult practice and that “vulnerability,” as a Federally designated term, expands to include individuals with special healthcare needs. 

Ms. Morgan reviewed the work the Sixth Report Writing Group did on report recommendations since the last meeting a year ago.  After discussion, the Advisory Committee drafted five recommendations on: 1) funding and policy; 2) funding to support the teaching of vulnerable populations at all levels of medical, dental, and physician assistant curricula; 3) workforce diversity, 4) accreditation standards, licensing exams, maintenance of certification; and 5) assessment and epidemiology of vulnerable populations.  

The Advisory Committee decided to draft a letter to the Secretary and to the chairs of the two Congressional committees that receive the annual reports.  The letter outlines the current funding situation of Title VII, section 747grant programs, describes the difficulty the Committee is experiencing in having an impact, and urges a new model that may be more appropriate than the current one for advising about primary care training.  The draft letter was prepared by Alan K. David, MD, William A. Curry, MD, and David P. Asprey, PhD, PA-C.   

The Advisory Committee held its annual elections.  Dr. Leming was re-elected Chair and both Dr. Fenton and Ms. Morgan were re-elected Vice Chairs.

After lunch, the Advisory Committee divided into two workgroups to further refine the language of the five report recommendations.  One group worked on recommendation two and the other group on recommendations one, three, four, and five.  Dr. Leming suggested that measurable outcomes be incorporated into the recommendations as much as possible. 

Ms. Morgan reported that her group split the second recommendation into several parts which were discussed and modified by the full Committee. 

Recommendation Two

1. Priority must be given to programs that develop and implement curricula to assess and care for vulnerable patients and populations.
2. Programs must develop faculty capable of teaching best-practices for care of vulnerable patients and populations.
3. Priority must be given to support innovative models of physician, pediatric and general dental and physician assistant faculty development to enhance the quality and capacity for the effective/efficient delivery of primary health care for vulnerable populations.

The group proposed adding language at the end of the recommendation saying that grantees should propose measurable outcomes for their programs.        

Tina L. Cheng, MD, MPH reported the work done on the other recommendations which were discussed and edited by the full Committee. 

Recommendation One

To prepare future primary healthcare providers with the training to meet the emerging challenges to the health of the public, the Title VII, section 747 grant program requires re-authorization and an appropriation at a minimum level of $198 million.

Recommendation Three

In order to address health disparities as outlined in Healthy People 2010, the recruitment, education, and training of a larger and more diverse primary care workforce of physicians, pediatric and general dentists and physician assistants is necessary to address the Nation’s critical healthcare needs, specifically those of vulnerable individuals and populations.

Recommendation Four

Encourage the educational accreditation, licensure and certification organizations for physicians, general and pediatric dentists and physician assistants to mandate policies and procedures that ensure that the healthcare workforce is prepared to provide competent care to vulnerable individuals and populations.

Recommendation Five

1. Review and expand the definition of underserved and high-risk populations to include all aspects of vulnerability.  Title VII, section 747 proposals that address primary care education and training to serve vulnerable populations should be prioritized.
2. Encourage programs to provide their trainees with the means to know the basic demographics about their patient populations and to understand the implications for the care of those patients.

There was no public comment.  The meeting adjourned at 4:59 p.m.  

Friday, September 29, 2006

The Advisory Committee meeting was reconvened at 8:05 am.  The Committee developed the following definition: “Vulnerability is the susceptibility to poor medical, mental and oral health.”  While the majority concurred with the definition, several favored inclusion of the phrase “disproportionately high” in the definition, a concept that still can be developed in the supporting text. 

The Advisory Committee decided to place the commissioned papers in the appendix of the report.  There was discussion about summarizing the grantee data in a table, in a paragraph, or in a pie chart and making reference to it in the text of the report.  One suggestion was to highlight the fact that every region in the country had institutions training professionals to serve vulnerable populations.  Another suggestion was to point out the number of programs that report a focus on more than one vulnerable or high risk group.  A small group will work further on the issue.

The Advisory Committee discussed in a generic sense the use of clinical photographs and vignettes in the body of the report.  The members questioned the typical process of printing thousands of copies of the report.  Several members suggested simply putting the report up on the Advisory Committee’s website.

The Advisory Committee broke into three workgroups with each reporting back to the full Committee.  Ms. Morgan reported her group’s expansion of text on the definition of “vulnerability.”  Raymond J. Tseng, DDS, PhD presented the outline for the report developed by his group. 

Dr. Asprey reported that his group drafted a description of the grantee query for the report.  It proposed two key pieces of data to report:  the average number of vulnerable populations addressed per program and the percentage of programs addressing two or more vulnerable populations.  There was discussion about presenting the data in table form or in the text or both.  The group pointed out that the two least addressed areas were health literacy and the neuro-developmental disorders, meriting attention in the future.  The programs demonstrate current success in addressing the needs of vulnerable populations, with the potential of addressing an emerging awareness of additional vulnerable groups.

A plan was made to have a conference call of the Executive Committee and chairs of the three workgroups to plan a process for getting the sixth report written.

There was no public comment.  The meeting was adjourned at 12:01 pm.

During lunch, groups were set up by discipline to review the anecdotes submitted by grantees, for possible inclusion in the report.  Each group was asked to turn into staff its three top choices.