Advisory Committee on Training in Primary Care Medicine and Dentistry

Minutes of Meeting, MAY 19-20, 2005

Approved on August 17, 2005

Advisory Committee Members Present

Eugene C. Rich, MD, Chair
David P. Asprey, PhD, PA-C, Vice Chair
Man Wai Ng, DDS, MPH, Vice Chair
Tina L. Cheng, MD, MPH, Member
Michael W. Donohoo, DDS, Member
Sanford J. Fenton, DDS, MDS, Member
Michelle Hauser, PA-C, Member
Bonnie Head, MD, Member
Warren A. Heffron, MD, Member
Matilde M. Irigoyen, MD, Member
Rubens P. Pamies, MD, Member
Joseph L. Price, PhD, Member
Raymond J. Tseng, Member
Craig D. Whiting, DO, FACFP, Member

Others Present

Kerry Paige Nesseler, RN, MS, Associate Administrator for Health Professions
Tanya Pagan Raggio, MD, MPH, FAAP, Director of Division of Medicine and Dentistry and Executive Secretary of the Advisory Committee
Jerilyn K. Glass, MD, PHD, Deputy Executive Secretary of the Advisory Committee
O’Neal Walker, PhD, Chief, Dental, Psychology, and Special Projects Branch, Division of Medicine and Dentistry

Thursday, May 19, 2005

The Advisory Committee on Training in Primary Care Medicine and Dentistry (Advisory Committee) convened at 8:30 a.m. in the Congressional Ballroom Salon I of the Bethesda Marriott, 5151 Pooks Hill Road, Bethesda, Maryland 20841.  Eugene C. Rich, MD, Chair, opened the meeting and introduced Kerry Paige Nesseler, RN, MS, Associate Administrator for Health Professions. 

Captain Nesseler thanked the Advisory Committee for its work and said that the fifth report on outcomes has a lot of synergy with the performance measures of the Bureau of Health Professions.  She described the all-grantee meeting on June 1-3, 2005 as an opportunity for the Bureau to get feedback from grantees on three levels of performance measures: core, program specific, and National outcomes.  Next steps are to develop data collection forms, automate and update the CPMS/UPR system, pilot the measures with nine grantees, provide technical assistance, get Office of Management and Budget approval to implement the measures, and evaluate the system.  Referring to the Advisory Committee’s fifth report, Captain Nesseler commented on its statement of purpose for the Title VII, section 747 program, educational pipeline drawing, and review of the literature.  She stressed the importance of prioritizing program objectives, stating objectives that are clear to the public, and using words consistently across objectives, logic models, and outcomes.  She welcomed input from the Advisory Committee on how its fifth report recommendations fit in with the Bureau’s performance measures.

Tanya Pagan Raggio, MD, MPH, Director of the Division of Medicine and Dentistry, provided an update on grants.  She said that the review of the almost 250 grants submitted has been completed and approval/disapproval letters will be sent out in the next several weeks.  She reviewed funding amounts for both new grants and continuation grants.  She pointed out that the Council on Graduate Medical Education (COGME) has released two reports, one on physician workforce policy guidelines and the other on minorities in medicine.  Dr. Raggio brought the newest set of logic models for Title VII, section 747 programs.     

Man Wai Ng, DDS, MPH, Chair of the Fifth Report Writing Group, gave a group report on work accomplished during conference calls and at a meeting on April 11 and during conference calls.  A subgroup led by David P. Asprey, PhD, PA-C developed recommendations and objectives for the report, and Charles H. Griffith, III, MD, MSPH, added references to the report.  The early work on near-term and long-term outcomes by Gregory Strayhorn, MD, PhD, former Chair of the Advisory Committee, was acknowledged as providing the foundation for the report.. 

Dr. Ng summarized changes made to the report draft including revision to the wording in the logic model boxes and consistent use of “education and training” throughout the document.  The Writing Group decided to keep the actual measurements specific and the outcomes general.  The group members reworked the recommendations.  The recommendation placed last referred to the need for additional financial resources to implement effective evaluation of Title VII, section 747; no dollar amount was specified.  They decided to separate the first objective into two, one about quality and the other about capacity of training and education.  They felt that the executive summary should emphasize educational outcomes and include the pipeline drawing.  The abstract should be organized around a statement of the problem, a statement of the purpose for the report, and a discussion of changing legislation and shifting priorities.  Dr. Ng pointed out that the report still needed detailed definitions and descriptions for the measures in the appendix and a  cohesive flow to the argument. 

The Advisory Committee decided that the purpose statement for Title VII, section 747 should appear immediately before the recommendations in the abstract.  Dr. Asprey emphasized that the focus of the program is preparing individuals to serve underserved populations rather than placing them.  The word “should” will be used throughout the recommendations.  In the last recommendation, the phrase “additional resources” rather than “appropriate level of funding” will be used, and the request will be for funding to evaluate the program rather than funding for the program itself, as has been done in previous reports.  Tina L. Cheng, MD, MPH, suggested that the first sentence in the abstract incorporate the concept of “acute” in addition to “chronic” care, and Sanford J. Fenton, DDS, MDS, suggested the use of “conditions” instead of “illnesses.”

The Advisory Committee agreed that health disparities and vulnerable populations need to be included in the abstract.   

The Advisory Committee reviewed the logic model in the body of the report and offered ways to simplify and clarify it.  Rubens J. Pamies, MD, recommended that a textual description of how to read and interpret a logic model be included in the report.  Dr. Rich said that the report could describe the logic model in two ways in the appendix, each tracking the flow of the logic model  with respect to 1) the role of the Advisory Committee, and 2) the role funding level plays on outcomes.  The arrows will be kept in the logic model.    

The Advisory Committee convened two breakout sessions.  Dr. Asprey led the group developing explanatory paragraphs for each of the recommendations.  Dr. Ng led the group that was asked to discuss material appropriate for the appendix and to examine the Bureau’s performance measures.  In plenary session, Dr. Ng reported that group members made changes to the material in the appendix.  They felt that the table on near and longer-term outcomes on page 25 of the draft should be eliminated because of its similarity to the table on page 29.  Each near-term and longer-term outcome in the logic model should reference its corresponding objective.  A narrative should precede the logic model to explain it.  They examined the Bureau’s core performance measures and selected those appropriate for use with Title VII, section 747 programs.  They found some measures to be too specific, which would make accountability unreasonably difficult.  They proposed that the text in Section 3.2.2. show the specific alignment between the report’s measures and the Bureau’s core measures.  Dr. Raggio had provided the group a list of Healthy People 2010 measures and explained how the Bureau, for each of its performance measures, has included a corresponding Healthy People 2010 objective. 

Dr. Rich reviewed the timeline of the fifth report.  Mr. Moore will work with the Writing Group and staff to prepare a draft report that will be reviewed by the entire membership before it goes out for public comment by the end of June.  Public comments should be received by the beginning of August and will be considered by the Writing Group via conference call.  The revised document will be sent out to the entire membership for review prior to the September meeting.  Dr. Pamies asked that all comments from the public go to the entire membership, not just the Writing Group.  Advisory Committee members will review the Division’s constituent mailing list of professional organizations and suggest additions.

The Advisory Committee suggested wording changes to the supporting paragraphs under the recommendations, as reviewed by Dr. Asprey.  It was decided that copies of the recommendations and paragraphs will be given to members to review prior to the meeting tomorrow.  The members will also review a list of possible topics for the sixth report that had been generated previously.   

During the public comment period, Perry Pugno, MD, from the American Academy of Family Physicians said that Advisory Committee recommendations, especially those that refer to the statute and relate to the purpose of the original legislation, are very helpful.  He said it is best if  the recommendation can stand alone because statements are cut-and-pasted to fit particular legislative issues.   

Friday, May 20, 2005

The Advisory Committee resumed work on the recommendations of the fifth report.  Joseph L. Price, PhD, pointed out that while evaluation language is used throughout the document, terms are used inconsistently.  The Advisory Committee decided that the contract writing team and members of the Advisory Committee with evaluation expertise will be important in the final review of the document.  Dr. Ng asked if the logic model should be included in the Executive Summary, a decision left to the Writing Group. 

Turning to the topic for the sixth report, the Advisory Committee made additions and combinations to the list of 11 possible topics.  After several rounds of voting, the Advisory Committee decided on “The Role of Title VII, Section 747 in Preparing Primary Care Practitioners to Care for Underserved and Other High-Risk Groups and Vulnerable Populations,” with a vote of 12-to-1.  The at-risk groups discussed were the elderly, individuals with HIV/AIDS, substance abusers, individuals with special health care needs, the homeless, victims of domestic violence, individuals with neurodevelopmental or intellectual disabilities, and/or the mentally ill.  The Advisory Committee sees the report as setting forth a conceptual framework for understanding vulnerability relevant to patients and patient populations and a framework for programs to educate/train professionals to serve vulnerable populations at risk for health care disparities.  The members felt that Title VII, section 747 has a role in casting a larger vision.

The Advisory Committee discussed the importance of community partnerships, interdisciplinary approaches, partnerships between primary care providers and specialists, and engagement of the private practice world to help solve very pressing problems.  Dr. Pamies made the point that primary care professionals need to work on ways to engage the community in partnerships to address the issues of vulnerable populations and health disparities.  He added that  the report needs to outline a specific direction if it is to be given consideration.  Dr. Cheng said that a framework would have to define vulnerability, a task that requires an understanding of the patient and the community, using a population health orientation.  Dr. Ng said that partnerships between primary care providers and specialists are critical because many of the patients who are high-risk also have very complex medical and dental needs.                 

Dr Fenton and Dr. Cheng volunteered to be members of the writing group for the sixth report and to assist the Executive Committee in planning the next meeting around this new topic.

Dr. Raggio reviewed several issues about travel reimbursement.  In response to a request made earlier in the meeting, she provided data on grant applications and grant awards in FY 2004 and for applications in FY 2005.

Mr. Moore summarized the changes he will make to the fifth report based on this meeting.  Dr. Ng requested that the recommendations be sent out for review to the group who worked on them immediately after the meeting.  Similarly, she requested that the description of measures in the appendix be sent out to appropriate members.  Dr. Rich requested that the abstract with recommendations and paragraphs be sent to the full membership for review. 

Dr. Rich asked that at the time the fifth report is sent out to the public, a copy be sent to Dr. Strayhorn, previous chair, thanking him for his work on the report and inviting further comment.  The Advisory Committee voted to have the draft sent to all previous members asking for input.

During the public comment period, Michael Dyer, JD, from the American Association of Colleges of Osteopathic Medicine commended the Committee for its reports which have been extremely valuable to the work of professional associations. 

The meeting adjourned at 11:34 a.m.