NATIONAL ACADEMY PRESS
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for this report were chosen for their special competences and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy’s 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education.
This study was supported by the U.S. Department of Veterans Affairs under Contract No. V101(93)P-1166.
Library of Congress Catalog Card No. 91-62497
International Standard Book Number 0-309-04549-5
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COMMITTEE TO DEVELOP METHODS USEFUL TO THE DEPARTMENT OF VETERANS AFFAIRS IN ESTIMATING TIS PHYSICIAN REQUIREMENTS
DAVID R. CHALLONER (Chair),* Vice President for Health Affairs,
University of Florida, Gainesville
MARJORIE BEYERS, Associate Vice President for Nursing and Allied Health Services,
Mercy Health Services, Farmington Hills, Michigan
JO IVEY BOUFFORD, Director, King's Fund College,
King Edward's Hospital Fund For London
JOHN D. CHASE,* Dean Emeritus,
School of Medicine, University of Washington, Seattle
ROBERT M. DONATI, Executive Associate Vice President,
St. Louis University Medical Center, St. Louis, Missouri
JOHN W. ECKSTEIN,* Dean,
College of Medicine, University of Iowa, Iowa City
JACOB J. FELDMAN,* Associate Director for Analysis and Epidemiology,
National Center for Health Statistics, Hyattsville, Maryland
DANIEL W. FOSTER,* Professor and Chairman,
Department of Internal Medicine, University of Texas Southwestern Medical Center at Dallas
ERNEST W. JOHNSON, Professor of Physical Medicine and Rehabilitation and Associate Dean for External Affairs,
Ohio State University College of Medicine, Columbus
ROBERT J. JOYNT,* Vice President and Vice Provost for Health Affairs,
University of Rochester, Rochester, New York
KERRY E. KILPATRICK, Chairman,
Department of Health Policy and Administration, University of North Carolina, Chapel Hill
DAVID J. KNESPER, Director,
Division of General Hospital Services, Department of Psychiatry, University of Michigan, Ann Arbor
W. EUGENE MAYBERRY,* Chairman,
Board of Development, Mayo Foundation, Rochester, Minnesota
J WARREN PERRY,* Professor and Dean Emeritus,
School of Health Related Professions, State University of New York at Buffalo
DAVID C. SABISTON, Jr.,* Professor and Chairman,
Department of Surgery, Duke University Medical Center, Durham, North Carolina
HAROLD M. VISOTSKY, Professor and Chairman,
Department of Psychiatry and Behavioral Sciences, Northwestern University, and
Director,
Institute of Psychiatry, Northwestern Memorial Hospital, Chicago, Illinois
ALBERT P. WILLIAMS, Director,
RAND Health Sciences Program (through November 1990);
Corporate Research Manager,
Social Policy, RAND (from December 1990), Santa Monica, California
SANKEY V. WILLIAMS, Professor of Medicine and Director of Clinical Scholars Program,
University of Pennsylvania, Philadelphia
CHERYL E. WOODSON, Director,
Fellowship Program in Geriatric Medicine, Pritzker School of Medicine, University of Chicago, Chicago, Illinois
STUDY STAFF
Division of Health Care Services
JOSEPH LIPSCOMB, Study Director (from July 1989)
BOBBIE J. ALEXANDER, Staff Associate/Study Administrator
JUDITH L. TEICH, Staff Officer (until December 1990)
NANCY KADER, Staff Officer (from December 1989 until November 1990)
ASHLIN HARMAN, Senior Secretary (from December 1989 until August 1990)
H. DON TILLER, Administrative Assistant,
Division of Health Care Services
KARL D. YORDY, Director,
Division of Health Care Services
ITZHAK JACOBY, Study Director (until April 1989)
DOROTHY AMEY, Staff Officer (until October 1989)
JOHN VALENTINE, Staff Officer (until October 1989)
CAROL MCKETTY, Research Associate (until July 1989)
DELORES SUTTON, Senior Secretary (until March 1989)
LESLIE SHERMAN, Secretary (until March 1989)
Consultants
KERRY L. LEE, Associate Professor of Biostatistics,
Division of Biometry, Department of Community and Family Medicine, Duke University, Durham, North Carolina
KAREN S. PIEPER, Statistician,
Clinical Biostatistics, Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina
WARREN E. CRANE, Computer Programming Consultant,
Washington, D.C.
WM. DANIEL CULVER, Program Analyst,
Strategic Planning and Policy Office, Veterans Health Administration, Department of Veterans Affairs, Washington, D.C.
PREFACE
Unlike most Institute of Medicine (IOM) studies, which deal purely with policy choice, this project's task was to develop a method by which the Department of Veterans Affairs (VA) could determine its physician manpower requirements. The implications of this difference are significant. To construct a new state-of-the-art tool for calculating physician staffing requirements, by specialty and at the facility level, calls for an element of creativity in the development and use of quantitative analytic methods, data bases, and professional judgment. While these efforts taxed both committee and staff, they responded admirably and have broken new ground.
The VA manages this country's largest and, arguably, one of the world's most important health care systems. It is critical for the VA's future that it have a sound plan for determining the number of physicians required for its three mission-connected responsibilities of patient care, education, and research. We believe we have created a tool for determining physician requirements that will be of great utility to VA decision makers in their policy roles.
The committee's background varied from "quantniks" to bedside physicians of many specialties. It took a significant effort to marshall this expertise to produce an approach that is methodologically innovative, capable of being applied systemwide in a relatively efficient fashion, and sufficiently detailed and concrete to be relevant to the realities of the clinical environment. Here also the members of the committee enriched each others' experience and understanding. No one could have asked more of a committee and its panels.
My thanks go to Sam Thief who was supportive over a longer-than-usual IOM project and who understood the uniqueness and complexities of our task. Division director Karl Yordy personally added his considerable experience to our effort, and the committee is grateful. However, to Joe Lipscomb, the staff director, go the committee's and my own personal thanks, admiration, and even
awe. His prodigious efforts made this complex project run smoothly. More important, he was a nidus of creativity around which the committee's efforts crystallized. He was vigorously seconded by Bobbie Alexander and the rest of the staff. In all my years of involvement in IOM endeavors, I have never seen such a hard-working group.
Now we pass the baton back to the VA.
David R. Challoner, Chair
Committee to Develop Methods Useful to the Department of Verterans Affairs in Estimating Its Physician Requirements
ACKNOWLEDGMENTS
This study could not have been accomplished without the assistance of numerous individuals in VA Central Office and VA medical centers around the country.
The committee is especially indebted to the leadership and staff of the VA's Boston Development Center (Braintree, Massachusetts) for their unfailing diligence in providing the data and interpretive expertise that enabled the committee to produce the empirically based physician staffing models. Deserving of special praise are the contributions of Frank Holden, the center's director, and of Stephen Kendall and Michael Doyle.
The committee is grateful to the administrative and clinical officials at the four VA medical centers (labeled in the report as VAMCs I, II, III, and IV) whose locally generated data were crucial to the development of accurate depictions of these facilities in the expert judgment staffing exercises.
Over the course of the study, committee and panel members and staff conducted site visits at 16 different VA medical centers across the country. To the VA professionals who participated in the organization and conduct of these visits, the committee owes special thanks. The committee also expresses its appreciation to the administrative and clinical professionals in the 60 VAMCs that participated in surveys conducted by the affiliations and nonphysician practitioners panels.
The VA Liaison Committee, chaired by Elizabeth Rogers, offered the committee thoughtful commentary, and encouragement, throughout the study. This group of VA clinicians, administrators, and health services researchers improved the committee's understanding of the rapidly changing VA health care system and the role that a physician staffing methodology might play in it.
From the project's beginning to its conclusion, the committee has greatly benefited from the advice and support of its VA project officer, Gabriel Manasse. No one has had a better understanding of the subtle complexities—both administrative and clinical—that have characterized this complicated and lengthy endeavor. He, of course, does not shoulder the responsibility for what
the committee produced, but he has most certainly enhanced the quality of the product.
Finally, the committee expresses its deep appreciation to the members of the 11 panels appointed to advise this study. For their diligence and intellectual leadership, the chairs of these panels deserve special recognition: Robert M. Donati (other physician specialties); Daniel W. Foster (medicine); Ernest W. Johnson (rehabilitation medicine); Robert J. Joynt (neurology); Kerry E. Kilpatrick (data and methodology); W. Eugene Mayberry (affiliations); Harold M. Visotsky (nonphysician practitioners); Harold M. Visotsky and co-chair Robert L. Leon (psychiatry); David C. Sabiston, Jr. (surgery); Sankey V. Williams (ambulatory care); and Cheryl E. Woodson (long-term care).
For excellent editorial assistance, the committee thanks Julie Phillips, consulting editor; Leah Mazade, IOM staff editor; and Wallace K. Waterfall, director of the IOM Office of Communications.