Before we start our closing plenary, I wanted to publicly thank both Helen Burson and Sue Sidori for their extraordinary leadership, and perhaps as your last parting gift, we'd love to hear some words of wisdom from you, Sue, as you depart the presidency. Thanks, Patricia, and I—oh, okay, I will do that—and I would also say thank you to Helen as well. You know, when you get to lead an organization of your peers, it's really an honor. It just truly is, and I think you all know that this organization is special. That's why we're here, and I think that the key for us is to keep that alive and keep that going, so it's really essential that I think we all think about what CMSS means to us. I talked to the CEOs the other day and said the same thing. We all want our board members and our members to go back and spread and tell other people about how great this organization is, how great this meeting is, and this is our job to do that. So I really want to make sure that everybody in this room takes that assignment to heart and really puts that time and effort back into this organization. We're very serious about the mission of this organization, that we know that making each of our organizations stronger is the best way that we can make our collective voice as medical societies stronger. I think there's no greater time than now to make that really happen, so I want us all to really kind of take that to heart. Thank you. It's been a great pleasure. and privileged to move into this role with you at CMSS. And we have a really fantastic closing plenary session. It's also importantly the opening session for GLEAM. And so as we think about what are the thorny topics that address all of our needs and how can we help from the CMSS perspective, I think there's no topic that's perhaps more near and dear to many of our hearts in this conversation about physician workforce. What do we do about it? What are the challenges? What are the issues? What are the data? How do we address it as a collective? And what does it mean for the future of our profession and our ability to care for our patients? So this closing plenary session is titled Physician Workforce Challenges, Strategies, and Future Opportunities for Specialties. And so what we're going to do just to frame the conversation is we're going to have a couple, I'm gonna actually have all of you come forward, those of you who are on the panel come forward while I'm describing. So we're going to have a couple of talks that will be about 10 minutes in length from Dr. Chaudhry, who I'll introduce more formally, and Dr. Chen talking about some of the challenges that are facing us. And then we'll have some responses from many of our specialty societies telling us about some of the ways that they're addressing these issues and addressing these concerns. And they'll be sharing their perspective from pathology, from nephrology, from the AAMC, from anesthesia. So as they're coming up, I would encourage you to hold your questions. We're going to hear from each of the speakers here on the panel, and then we'll have a time for Q&A. And then at the end, we'll have the society reactor panel, where we'll have some of the CEOs of our medical specialty societies come up and give their reactions as the CEOs of their organization. So I know it's going to be a robust time. I look forward to an engaging opportunity with all of you. So our first speaker is Dr. Chaudhry, who is the leader of the Federation of State Medical Boards. So as you know, and he'll describe this in his conversations, he has the opportunity to have really a holistic view countrywide of the things that we need to think about as it relates to the physician workforce shortage. So Dr. Chaudhry, please. Thank you very much, Dr. Turner. Good afternoon, everyone. Good to be back at CMSS. I don't come every year, but often I have over the last 15 years. So a lot is going on in physician workforce, and some of it is on the horizon. So I don't know how much of this you know, but I'm going to start this off, and we have a wonderful lineup of speakers. So first of all, about the FSMB, you may or may not know, I've already been mistaken for ABMS. The FSMB is the Federation of State Medical Boards. These are the ones who license, remember the license? And they also regulate the practice of medicine for physicians, PAs, and sometimes other healthcare practitioners, depending on the state. The principal mission of every state board is to protect the health and welfare and safety of the general population. We don't always talk about it, but also it's to guard the profession, to make sure that only those who are qualified to practice medicine are actually given the legal right to practice medicine. So one of the things we do is we have a lot of data. We have data on every licensed physician in the United States. We know where they went to medical school. We know where they did their training. We know what they're specially certified in. We have a lot of data on, it used to be all in a file room, but it's all electronic now. Every two years we do a census. And so this is from our last census two years ago. 1,062,460 licensed MDs and DOs in the United States and the District of Columbia. We're doing the current census now, so I'll have data next year for end of December 31st of this year. Now that number is 25% larger than 2010, but I think you all know there's a shortage, right? There's a shortage of physicians, there's a shortage of nurses, pharmacists, every healthcare worker. But how do you know that there's a shortage, right? There's 340 million people in the country. One million, how do you know one million is enough or not? So there are a number of ways in which this is tracked. One way from the World Health Organization is to look at the number of physicians per 100,000. We do this in public health and epidemiology. And as it happens, those states in red have in absolute numbers, forgetting about which specialty, just absolute numbers, fewer physicians than they need. Now, of course, I'm from New York. I used to be a health commissioner on Long Island. I can tell you there are large pockets of upstate New York that have a lack of primary care, they don't have OBGYN physicians, they don't have oncologists, but that's also true on Eastern Long Island. You can't get an appointment right away with a specialist if you can find a specialist in every field. So not only is there an absolute number shortage, but there's a maldistribution across many specialties, if not all of them. So one of the ways you address a shortage is you increase the production, right? So this is actually three-year-old data, but today we have 154 medical schools, MD schools, and 41 DO schools. Four of the MD schools are historically black colleges and universities. Still not enough for what the nation needs. Last week, I don't know how many of you went to the WMC meeting in Atlanta. The latest data from WMC is that there's at least 80,000 fewer physicians predicted by 2050, which sounds like a far away, but it's actually not as far as you might think. So one way you address this is by increasing the number of US graduates. Of course, we know there aren't enough, you know, graduate medical education spots are not keeping track with the number of US grads and IMGs seeking those positions, but those have been incrementally increasing, but not perhaps at the speed we would like. Now, what about telehealth? Telehealth has been remarkable. Prior to the pandemic, it was less than 1% utilization, and you all know this, we all lived through this. At one point, there was more telehealth visits than in-person care across every specialty, pretty much. Now, those levels have dropped off quite a bit. Mental health is still up there. Primary care, infectious diseases, but they're not at less than 1%, but they're not at 50 to 60% either. So telemedicine may be helpful to rural areas and perhaps to help part of this access to care issue, but not completely. Another way is you enable more licensed physicians and PAs and others to practice across state lines to more jurisdictions. How many of you, by a show of hands, are familiar with the Interstate Medical Licensure Compact? Okay, most of you, but not all. This is an idea that came forward back in 2015. This is the article we wrote about it in New England Journal. This was an idea of where if we can get the state boards, which are very disparate, even though they have similar constitutions, they're rather different. If we can get them to agree on some common denominators of what they want for licensed physicians, maybe we can facilitate the mobility of physicians so they can practice either in person or by telehealth across more jurisdictions. So this led to, under the FSMB stewardship, this sort of criteria list. We managed to get the state boards. We basically locked them in a room in Dallas and said, let's figure this out. That's a simplification. Took a little bit longer than that. But these are the nine eligibility requirements that if you as a physician meet all of these nine criteria, participating states in the Interstate Compact are willing to give you a license to practice medicine instantly, I repeat, instantly, that's it. And it's part of the law. And a lot of it is straightforward. Graduation from medical school, you must have passed the U.S. Assembly or the Comlex within three attempts for each of the steps and levels. Completion of GME is unusual because normally for licensure, that's not required. But for this, the state said, look, if we're gonna hand out licenses, we want tough criteria. We want higher criteria than for anything else. It's almost like a TSA pre-check. It also, look at the fourth bullet, hold specialty certification. Now, you know, that's not a requirement, an absolute requirement for licensure anywhere in the United States, despite people thinking that it is. But for the Interstate Compact, eligibility, it is. Because again, the states were saying, look, if we're gonna be handing out multiple licenses at one time, we wanna make sure it's the best qualified physicians. Now, what if you don't meet these nine criteria? You're more than welcome to get as many licenses as you like, but you're gonna have to do it in the other line, one state at a time maybe, and it could take you a while. So how many states have signed off on this since this was initiated back in 2013 and 14? 40 states. Wow, all the states in dark blue have passed laws to adopt the Interstate Compact. So if you live in one of those states, you can get a license in all the other states pretty much easily. You still have to pay fees, there's a processing fee, there's always a fee. But remember, that licensing fee doesn't just enable you to be licensed, it also looks out for you. Because if there's a complaint, you wanna make sure there are investigators and attorneys and make sure you have due process. But other states like New York and North Carolina have introduced legislation, they haven't passed it into law yet. California's a little bit further behind. It's really voluntary, they don't have to do this, but I'm impressed that 40 states have done this, and then some states are in the process of adapting it. So that's one way that you can address access to care, but it's still not enough. And by the way, in April of this year, just so you know the numbers we're talking about, the Interstate Medical Licensure Compact Commission announced that 100,000 licenses had been issued through this pathway. So this is really working, and the license is just like any other license. You can practice medicine in person or by telehealth, and I think this is a success story that you don't always hear about, but it does help in addressing access to care. This is a slide from the AAMC data. There's gotta be someone here from AAMC, I'm sure. Raise your hands. Okay, that's right, on this panel. There was a lot of data shown. Every year they have this update on physician workforce. This is the slide that blew me away, so I had to take a picture of it. Physicians, it says, continue to work fewer hours. Back in 1968, that was about just below 60 hours a week. This is across all specialties. Look where we are roughly today, close to today. It's closer to 50 hours. So it's not just the absolute number of physicians. Physicians are working fewer hours. Your individual results may vary in your state, but that's a change. And so, you know, and I have data about how many physicians are licensed. I couldn't tell you how many of them are actively practicing. I couldn't tell you if they're practicing full-time or half-time, and I couldn't tell you if they're practicing in the field in which they train. So there are still some gaps in data that we don't have across the country. So this brings me to yet another approach to addressing access to care and workforce. Many of you may be familiar with this. This is the traditional IMG licensure pathway. I'm not gonna go through everything, but on the left-hand side, you gotta obviously have a medical degree or equivalent. You have to be certified by the ECFMG. You have to have passed U.S. Emily Steps 1 and 2. And if you're not a legal resident or a U.S. citizen, you have to get a visa. Remember, a lot of international graduates are actually U.S. citizens who go to the Caribbean or elsewhere in Europe or in the Middle East to get their medical degree. But then that arrow in the middle is critical because for decades, the state licensing boards, and I think you all know this, have required, even if you're trained overseas, you have to be trained in the United States. Even if you trained in cardiology at a respectable institution, if you're coming into the United States, unless you're an eminent physician in that domain and you've written papers and maybe gotten awards, there may be exceptions, and many states have that, but it's not an easy bar. But you still have to apply for residency, and many do, thousands. And then once you get into residency, you take U.S. Emily Step 3, and then at the end of completion of your training or someplace along that pathway, usually two to three years of GME training is required for licensure, and then they become a fully licensed physician who's an IMG. So states began to wonder, legislators more than the state licensing boards, could we do something here? Could we speed this up? Because we need doctors. We need, across all professions, but we need doctors. So they began to wonder about that arrow in the middle. And so eight states last year, beginning with Tennessee, anybody here from Tennessee? Okay. Beginning with Tennessee, the legislators, without telling the state licensing boards, or I'm assuming any of your organizations, or the AMA or the AOA, decided to introduce legislation that they would no longer require international graduates to do residency training in the United States to become licensed. It happened so fast that there was very little testimony, if at all, and suddenly became law in not just Tennessee, but other states said, oh, I didn't know we could do that. Let's do that too. Now, suddenly the state boards are left with the details to figure out. And each state, and it's the states in dark blue, by the way, in case you're wondering which states did that. So Tennessee was the first, but there are eight others. But there are several other states in light blue that are just ready to do this as well, but they're a little bit more cautious. The states in yellow are the states that have long had special pathways. For example, California has such a need for Spanish-speaking physicians. They have a special agreement with Mexico that if you're an international graduate from Mexico, you can get a license to practice medicine in California for a number of years. So there's always been certain pathways that certain states like Washington, New York, and California have, but this is a big change. And so the state boards came to the FSMB and said, can you help? We don't know how to do this. What kind of rules do we put in? What kind of guardrails to protect the public? We understand why this is happening, but we wanna make sure we do this right. And so what we did was, normally we would create a work group or a committee. This is complicated. So we brought in our colleagues from ACGME, because they're the experts on graduate medical education. We brought in our colleagues from INTELF, which is the parent organization for ECFMG, and then we brought in all of our friends from CMSS, AMA, AOA. It's an alphabet soup of acronyms, not all of them, but many of them, and they're pictured here, to create an advisory commission on alternate licensing models. And very quickly we learned that words matter, and so we were told that the word alternate is a pejorative. So now it's known as the Advisory Commission on Additional Licensing Models, because we don't wanna create a different pathway and a different type of a doctor. A doctor is a doctor, and a licensed doctor should be perceived as a licensed doctor. So we've been meeting for the last year. We've had four meetings of this commission to try to help give some guidance to the state licensing boards. Very quickly we figured out, we don't have all the answers. We're not as smart as we are. So we had a symposium in June of this year in D.C. We invited 100 people, additional organizations, so you may recognize folks from ACCME, the Accreditation Council for CME, Donna Lamb from National Resident Matching Program, and others, as well as international graduates who would be impacted by this, and members of the public who are ultimately served by whatever we do. And so we heard lots of testimony, lots of ideas, lots of discussions, and this is my last slide. These are the draft initial recommendations for state medical boards about these additional IMG licensure pathways. They're out for comments. If you have an idea about this, or a constructive idea, or you think this whole thing is wrong, you can go to FSMB's website, fsmb.org, or to the websites of ACGME or Intel, and there's a link where you can read the recommendations and give us your feedback. The deadline for feedback is December the 6th. We hope to finalize this in January. I'm not gonna go through each of the recommendations, but they include things like making sure that the state boards have, the states have resources to do this, making sure that the individuals are indeed graduates of a medical school from overseas. I'll give you an example of why that's important. Some of the states said, again, these are legislators trying to be helpful. They said it's important that the physician be a graduate of a medical school that's accredited by the World Health Organization. Well, that's lovely, but the WHO doesn't accredit medical schools. Another state, I won't say which one, made a list of requirements and put a semicolon after each one, but forgot to add the word and. And so this became law, and the lawyers said this could be interpreted as or. They're like, oh no. And so they went back and passed a second law just simply to add the word and, because it makes a difference if you have a list versus just one. So it's a learning experience. I'm not gonna go through each one, but we think these make sense. Please go to the website, take a look at it. Now remember, final comment. How is this relevant and important to you other than being academically interesting? This is only about licensure. So what happens to the OB-GYN who trained overseas, would like to practice OB-GYN, I'm just picking on OB-GYN, goes through this pathway, which by the way requires a provisional licensure period where you're employed by a hospital or health system, and you're supervised for a period of years before you're eligible for a full license, but you're still getting a license. A license is not specialty specific in the US. So who's gonna recognize you as an obstetrician and gynecologist? Will the specialty board do it? Will the hospital do it? Would the payers do it? Lots of questions here, because this is only about licensure. We don't get involved in specialty certification. It just so happens ABMS, the American Board of Medical Specialties, has created a task force to look at this issue. There's an interesting pilot with the American Board of Internal Medicine looking at super qualified internists from overseas who may possibly be eligible and allowed to sit for the ABIM certification exam, so that maybe they'd be able to call themselves legally internists, but this is still a big issue. Final issue, who's gonna pay for all this? How's this gonna work? How many people are we expecting to go through this? Those are questions that we don't have the answers for, but we'll go through this one day at a time, one month at a time, and so stay tuned. Thank you. Thank you, Dr. Chaudhry. That was fantastic. Our next speaker is Dr. Candice Chen, who's the Acting Associate Administrator for the Bureau of Health Workforce for HRSA. Dr. Chen. Thank you. I think that you're gonna hear some recurring themes in what I have to talk about, and I think I have the opportunity to do a little bit of overarching workforce framing. I am a pediatrician by background, so I've walked the path, and it is very nice to be here with all of you. Thank you, Mark, from the AAP. I have no disclosures, and first off, I just wanna start with what is HRSA? If you've never heard of HRSA, the Health Resources and Services Administration, we are an agency of the Department of Health and Human Services. The way I describe HRSA's mission is, HRSA's mission is to make sure that there's high quality health care for all communities. But that necessarily means that we focus on the rural and underserved communities. And so there are programs like community health centers, the Ryan White HIV AIDS programs, maternal child health, and the Bureau of Health Workforce. And the Bureau of Health Workforce, what I'd like to say is that there is no health care without the people who deliver it, and that is workforce. And what we do in the Bureau of Health Workforce is work to make sure that there is the workforce to ensure that high quality access for all communities. What are the challenges that we face? I think you've already heard some of these issues. There is that issue of overall supply, the number. But it is also the number of different specialties and different health professions. Beyond number, there's an issue of distribution. And so specialty and profession, you could say that's a distribution issue, but there is the geographic distribution issue as well. There is the distribution across the United States in different states. There is the issue of rural and underserved. And I think as Dr. Chowdhury was also highlighting, there is an issue of global distribution. And what's our role in the global workforce and what we do affects the workforce of other countries, particularly we need to be thinking about low and middle income countries. So distribution. When you think about supply, when you think about distribution, we always have to be thinking about health equity. Both of those go into health equity. And whether or not there are people in health care clinicians, providers in different communities who are going to be there to provide the services of need and provide the services of need to the populations of greatest need. So unfortunately, we definitely have places where there might be a provider that does not take Medicaid, that we have individuals who remain uninsured who have no access to health care. So these are ongoing, ongoing issues. And when I talk about health equity, I also like to talk about equity for the workforce. And the fact that when health care makes up almost 20% of our GDP, it is one of the largest employers in the United States. And in the physician workforce, this is a high paid, stable workforce opportunity, economic opportunity for individuals coming along. And related to equity, I think that there is an issue of well-being. And we have to be thinking about well-being. I think you can't come out of COVID without worrying about burnout and the environment in which people are practicing in. So how do we then, what strategies are we using? And I kind of look at this almost, and I'm not going to read them all to you, but I kind of look at this as almost like along the career pathway. And I'm actually going to start at the end of the pathway, which is practice. And I know that many, many, many of your organizations are engaged in policy and in payment. And I do want to, I'm not going to talk about it too much more, but I do want to recognize the role of payment. It is what we pay for. It is how much we pay. It is how we pay will ultimately affect our workforce. And it's not just about how much money people walk home with at the end of the day, the average income and the disparities across the different specialties inside of health care, inside of the physician workforce. It is also when different specialties experience different payment, it also affects the way that they are able to practice. It affects the resources they have, the staffing that they have around them, and it affects the practice of medicine. So linking it back to the issue of well-being, recruitment, retention, and some of the challenges that we're facing across some of our physician workforce professions, specialties. But beyond that, we focus on programs that counteract the financial disincentive. We focus on graduate medical education programs and before that, for the physician workforce, medical school. And before that, there is the issue of who do we recruit into the health professions. Again, a little bit of an economic opportunity issue, but also we know, and I like to say this, it's not rocket science. There's plenty of evidence, but it is not rocket science that if we have problems in rural community, that if you recruit somebody into medical school from a rural community, they are much more likely to go back and serve the communities that they are connected with, the communities that they came from. We also know that if you're from a disadvantaged background, we also know that if you're from an underrepresented in medicine background, you are more likely to pick high need specialties. You are more likely to practice in underserved communities. But I also have to just say, I think that it matters in terms of language, in terms of culture, in terms of trust, all issues that we are going to be grappling with. So really quickly now, what does HRSA do? HRSA works across those various areas, except for maybe in the payment area. We're probably best known for something called the National Health Service Corps. It's our scholarship and loan repayment. Largely, our biggest tranche of funding goes out to loan repayment in exchange for service in underserved communities, focused on primary care, physicians, advanced practice nurses, also on the dental workforce, also on the mental behavioral health workforce. We have another bucket that is out to graduate medical education, but a large bucket goes out to our training grant programs. Grants to training programs to oftentimes to enhance the training that they're doing. Because it's not just about, can we get them into the communities? It's, how do we train them and prepare them to be able to provide care in those communities? And then the last thing is, and I was supposed to talk about data, and I will talk about data, we do workforce analysis at the national level. So just really quickly, some of our programs. It's a long list. I'm not going to read them all to you. Our scholarship and loan repayment programs are probably best known for the National Health Service Corps program. But we have a great sister program, the Nurse Corps, and a couple of others, including a pediatric specialty loan repayment program. It is one of the few, few programs that we have that can support a subspecialty workforce. It's a little bit unusual for HRSA, which has a tendency to focus on primary care, rural and underserved communities, but a really important program. Graduate medical education. We have to talk about the fact that graduate medical education is where the federal government makes the biggest investment in the workforce, in any health workforce. And it's not out of HRSA. It's out of CMS. Medicare and Medicaid. Medicare puts out about $18 billion a year to teaching hospitals to support residency programs. Medicaid, between the federal and state match, puts out about $4 to $5 billion. At HRSA, we have about $450 million to put out towards graduate medical education, but two incredibly, incredibly important programs. I'm not going to talk too much about them, but our teaching health center GME program flips the model, sends the money to primary care organizations. 75% are community health centers. And while the requirements, you probably all know, for training are going to be the same, by sending the money to a community-based organization, a primary care setting rather than to the hospital, flips the priorities of those programs. Not to disparage our hospital-based primary care residency programs, but the teaching health centers are getting incredible outcomes in terms of people staying in primary care, people going into rural and underserved communities. Children's hospital GME, I do want to just talk about for a second. Pediatric workforce is like a case study in everything that is hard about the health workforce, very dependent on the Medicaid. So payment is quite, quite an issue for the pediatric workforce. And then it's, in some ways, lucky in that the population that children's hospitals and pediatricians take care of tends to be relatively healthy. That's not 100%, of course, but tends to be relatively healthy, which then creates this real challenge of distribution across large areas sometimes of the population that needs to be taken care of and the concentration of the workforce oftentimes in our, for example, freestanding children's hospitals. And the reason that I point this out is we're thinking about workforces is because oftentimes that's literally what we're trying to do. We're trying to understand, where is the population? What is the, not just demand, but what is the need? And then how does our workforce match or fail to match that? And a very interesting thing, I think, that Dr. Chowdhury was showing us at the very end about states moving forward to not require GME for licensing for international medical graduates, and we had been using GME as basically a quality, a minimum quality standard, shows us that as the sense of need, to a certain degree, our failure to meet that need rises, the policymakers will go around us and start to push innovations. And I'm very thankful that Dr. Chowdhury and so many organizations are engaged in figuring out, how do we do this well? How do we do this right? But I think it's a really important lesson for us to think about. This is just really quickly our training grant programs. This is just a small smattering of the training grant programs that we have. But what it's here to remind me of is the fact that it is not just one specialty. It is not just one profession. We do grants across the professions, including in behavioral health workforce. We are supporting the training of peer support workers. And the reason I highlight this is because we cannot do analysis. We cannot do advocacy in silos. Ultimately, if any part of our teams are suffering, we will all suffer. And COVID really reminded us this, I think, for the direct care workforce. As hospitals were trying to discharge people, and they couldn't because the direct care workforce was not there in nursing homes to be able to accept those people. And it just causes backup right into the hospital. And so the last, last thing I was supposed to talk about was workforce analysis. We have the National Center for Health Workforce Analysis. We do analysis across 100 different occupations. This is just really quickly some of the workforce data. But what I wanted to show you was this is just one example. It's the infectious disease physicians. Blue line is supply going out to 2036. The orangish line is demand. And you can see that we are projecting a shortage of infectious disease physicians. But part of the reason I show this one to you is because when I showed it to the HIV AIDS Bureau Advisory Committee, a wonderful infectious disease physician immediately responded with everything that she thought was wrong with the projections, which is totally OK. And what I just wanted, you know, CMSS has more than 50 societies represented, right? And when you do work, we can start to take that to make our projections better. So when you dig in a little bit deeper, when you dig in to understand who is the workforce who is out there, how much are they working? Was anybody else struck by the fact that 50 hours a week for any other profession would be like much more hours than we would expect anybody to be working? And how is it changing over time? How do those hours of work then translate into service? And what does that then mean for supply, demand, need, right? And the more that you do, the more that we can start to make our national projections better. And so it is a bit of a plea. And as well as a bit of a plea to, as much as possible, share your data across your organizations. Because again, that issue of siloing and the need to understand the workforce as a whole, as a team, right? And to understand how the different models actually come in to influencing, again, how do we meet the demand and the need that is out there? So thank you. Thank you so much, Dr. Chen. Very informative. Our next speaker is Dr. David Gross, who's a policy director for the College of American Pathologists. So I'm going to introduce them all as he's coming forward. Following him, you'll hear from Mr. Curtis Pivart, who's a director of data science for the American Society of Nephrology. You can come on up. Ms. Ashley Bentley, the manager of student initiatives at the AAFP Family Practice, and Ms. Mary Halicki, who's a director of careers in medicine for the AAMC. Thank you. Sure. Of course. I should give a correction. I'm director comma policy, but there are people who do policy who are much higher than me. But thank you for being here. And all the speakers, so many of the speakers I've seen, this is my first meeting, are physicians. I am an economist. As you all know, an economist is someone who's good with numbers but lacks the personality of an accountant, but I'll try to keep you awake in the next seven minutes. The issue I'm talking about today is obviously pathologist supply. Pathologist supply has been an issue at the College of American Pathologists. Around 2011, a study that I was only tangentially involved in because I was just starting, projected a retirement cliff, what they called it, around 2015, basically because, well, after doing a lot of study, it was all because that we used to train 800, 900 pathologists a year, would enter residency in the 70s and 80s. That dropped down. Now it's about 600 a year. Pathologists can't practice forever. And we haven't found one who, well, there's one who I think is, but other than that, no. And demand keeps going up. Spoiler alert, it hasn't been decreasing, but while we were expecting that, a paper came out in 2019 saying that pathologist supply in the U.S. dropped 17% from 2007 to 2017, or it was 14%, a lot, and they compared it to Canadian supply where it was going up. And we had a WTF moment because that wasn't consistent with any of our research or any of our numbers, and this study used the AAMC data, which I will say, you know, we talk about it being the gold standard in our publications, and also AAMC, and it didn't make sense. But we had access that year to the same AMA database that AAMC has, and we said, oh, they are not counting a big group of pathologists. And we published something on that. And we worked with the AAMC Workforce Research Group, who are outstanding people, and we agreed on a change of methodology, and that's what they're using now. So what's, oh, I've got one here. So this is what we call the legacy methodology that AAMC had, there we go, showing a decrease in pathologists from 15,700 in 2004 to 12,400 in 2020, 21% decrease in supply over time. I said people are being left out. What did I mean? Well, I'm going to skip that slide for a bit, and hopefully I can go back. Let's talk about why there was an undercount. So AAMC uses the AMA, what was the AMA master file, which is now called the AMA Physician Professional Data Files. AMA, to my understanding, uses this for marketing, not for counting, but AAMC discovered this is a great database. This is a while ago they discovered this. It's probably the best one for counting specialty. This data file has two fields, which they call primary specialty and secondary specialty. In studying how this gets done, and AAMC folks agreed with us, it's not primary and it's not secondary, it's just field one and field two. So that's the way we use it. And the fields are populated in two ways. The seems to be the most prevalent way is when a physician enters a residency program or gets board certified, the data goes to AMA, click, there's a change in there. And each one of these rows represents an individual physician. This is obvious. This is real data taken from there, but realize there's like 20,000 or more people who have pathology somewhere and a million doctors. So I couldn't put that all on this chart. So this is just an example. So somebody might have been, I don't know what it is for when you just get out of medical school, but then you might enter pathology residency, click, you get a new one up there, and then maybe you didn't finish residency, but you go into a fellowship program, go back to finish residency, it changes to whatever that subspecialty was. You just went right to fellowship after that, it changes, and so on. I'm going to focus on this box here where, well, I'll talk about why in a second. By the way, the second way is physicians could go in and update this manually. Can I ask who's a physician? Just raise your hands. Do you know how to update this manually? Yeah. That's what we found with our experts, which included some of the leaders of the College of American Pathologists. Anyway, so AMA, this master file, has 15 different categories. General pathology, anatomic pathology, AP, clinical pathology, CP, something called chemical pathology, and then 11 different subspecialties, cytopathology, hematopathology, neurologic pathology, renal pathology, facial and maxiofacial and something pathology. There's actually, we have two groups that represent those physicians, not in our council, different organizations. But for reasons we don't understand, because the people are no longer here or at AAMC, when they developed this in 2004, they just looked at anatomic and clinical pathology and this chemical pathology and general pathology. We'd be looking at AAMC data and says, well, every pathologist is either clinical pathologist or anatomic or both. So didn't think anything of it and didn't take a close look at the numbers, which I suspect many specialties don't. But when we looked at these data, this is what we found is, because a former president who was part of our workforce workgroup had the data and figured it out. AAMC counted what was green, pathology, anatomic pathology. But these people would be left out. It's just because, I don't know why, but I'm guessing they didn't think to look. I'm looking for pathologists, so I'm going to go for those categories. For reasons for our methodology, we had a pathologist panel to say, who should we count? They decided we would count people within this box who are unambiguously not in another specialty. They have pathology in both box or it's unspecified or it's some general category. But if they're in the lower category, we're not going to count them, just because they may be something else. They may be oncologists. And we do know that there are some people who practice pathology who we haven't counted, but we've decided to use this measure. The discrepancy is just a few hundred. So the other thing is, well, let me go back here. We'll go, oops, go back, back, back, back, back, back, back, uh-oh. I'm going to have some issues. Okay. When we include these people, there wasn't that much of a discrepancy in 2004. It was about 10%, right? But then it got up, it went up to 24%. Why is that? Because there was, I won't go into it unless people want a known question and answer, but for some reason, a good one, around 2005, 2006, almost everybody in pathology residency went on to get one or two fellowships, and therefore get subspecialty certification, and therefore had the database classification change where they were not being counted. And so you've got a period of people leaving the profession, retiring or otherwise expiring, and people, and not counting these other people. And by 2004, it was a 39% undercount, so zip through there. And here you can see the numbers of residency that growth, or the oranger people with subspecialty training, and you can see how those numbers increased over time. So through 2003, and the numbers just came out about a week ago, pathology supply is still increasing two to 300 a year, shocking me and some others, but it is increasing. On the other hand, we do surveys of the job market for pathologists, and between our data and some other things, the number of job openings may be twice as much or more than the number of people entering residency each year. I don't have numbers on how many come out and how many of those who come out practice pathology in the United States, but we don't have enough pathologists to fill these openings, and we haven't for a few years. And the future doesn't look good. These are age bands from 2004 to 2020. Just focus on the right there, and look at the bands of the 60, 69-year-olds, 50 to 59-year-olds, even 40 to 49-year-olds. Those are wide bands. In 10 years, they're gonna move into different categories or leave practice. But there's not very many in the 40, under 40, and that's because we still are having about 620 positions each year. That's been stable for maybe 15 years or so. So right now, we still have an increased supply. It's not like what was put in that paper, which had implications for us because people would use those data, and groups that wanted to get into pathologists' scope of practice would say, look what's happening to pathology. Their supply is going through the floor. We should go and get paid for what they do. It's not there, but there's something to be aware of. This is the paper that we published in Health Affairs Scholar, it was the second issue. You can see all the people who worked on that, including the great Michael Dill and Zakia Nouri from AAMC. The implications for you, why do you care about pathology? There's so few of them. Well, first of all, know that AAMC has changed the way that count and report pathologists apply, and as I said, it increases. Note that this claim contradicts those other things, but AAMC was wanting to work with us, and the message that I wanna give, and also that's in the paper, is that they will work with you, and our recommendation is that societies, or somehow in the profession, they should look at their data, say, do these make sense? Should we find out what assumptions were made in our specialty supply? Because specialty supply numbers, HRSA will use them to make decisions. People who want your scope will use them. You wanna know where you stand. You wanna be able to follow that over time, and see if it makes sense, and we had something unique going on in pathology that led to that increase in subspecialization, but again, they'd be very happy to contact you, for you to talk to them. If you wanna know how, you can email me at dgross at CAP.org, and that's all. Thank you. Well, thanks very much. There's a lot of co-linearity in the talk so far, and you're going to get more co-linearity. So thank you very much for the opportunity to briefly discuss using data to inform medical society initiatives. This is my sole disclosure. I just want to take a moment to acknowledge the Council of the Three Fires, who are the traditional owners of the land and waters where we're meeting today. So in 2009, nephrology rejoined the match. And in the first several years, the number of candidates were keeping pace with the growth in fellowship positions. And while training programs continue to expand, between 2013 and 2015, the number of match nephrology fellows declined 31%. Now, the match is an artifact, of course. But ASN wanted to understand what was causing this shift away from nephrology, and first we needed to take a step back and understand where we were with our current workforce, where we were going with our incoming workforce, and we needed to identify the factors that were deterring residents from choosing the subspecialty. Now, just to level set here, I just wanted to define the nephrology workforce. The team that's providing care for the 37 million Americans with kidney diseases cuts across multiple disciplines. But for this presentation, I'm just going to be focusing on clinicians. And there's approximately 12,000 adult nephrologists, not PDs, that's about 800, but 12,000 adult nephrologists practicing in the United States today, the majority of whom, 53%, are international medical graduates, which is the highest proportion of any specialty in the United States. The majority also are men, 69%, and there's an increasing percentage of men approaching retirement age and reducing hours, which several people have already mentioned before. And it's a common concern across multiple specialties. However, we can't know how representative this workforce is of the patient population that it's surveying and also the U.S. population as a whole. And that's because the AMA PPD, which was also just referenced, does not capture race and ethnicity data. And that's especially concerning for nephrology because African American and black individuals, Hispanic individuals, and Native Americans all have higher risk for developing kidney disease and to progress into kidney failure. We also want to know where nephrologists were practicing and if they were in the right place. And to approximate this geographic adequacy, we created a very blunt heuristic, which is using the ratio of nephrologists per 100 Medicare beneficiaries per county in the United States and comparing it to, for example, the prevalence of chronic kidney disease per 100 Medicare beneficiaries per county in the U.S. And when you blend these and merge these datasets together, the areas of imbalance become very apparent. So, all those violet and dark purple areas indicate a very low ratio or no nephrologists per this underlying Medicare beneficiary population and a very high prevalence of chronic kidney disease. Now, of course, this is a blunt heuristic and it's only applicable to the Medicare population, so you can't generalize it to the U.S. population as a whole. We also want to know if the number of nephrologists were going to be keeping pace with the increasing number of Americans burdened by kidney diseases. As Dr. Chowdhury noted, you know, the FSMB census showed that there was a higher percentage of growth of physicians than the U.S. population, so we wanted to see how nephrologists compared to, for example, the prevalence of kidney failure. And you can see here that the growth in the number of nephrologists is barely keeping pace with the growth of prevalence of kidney failure, which is an undercount because it does not reflect Medicare Advantage beneficiaries. And it's very important to note here that, you know, kidney failure and dialysis are only one aspect of nephrology practice, which spans inpatient and outpatient care settings and a wide range of pathophysiologies. Just a note on the WMC's new workforce model, incorporating APPs. Research showed that APPs could reduce the number of hours nephrologists spend in providing patient care by between 16 and 20 percent, but of course you have to factor in state limitations on scope of practice. Next, the incoming workforce. So who's entering nephrology? The majority of nephrology fellows, 65 percent, are IMGs, similar to our current workforce, and the majority are also male, 61 percent. But we do know that we're underrepresented in terms of the black and African American fellows and Hispanic fellows. So ASN wanted to better understand our fellows and the challenges that they were facing. So we started an annual nephrology fellow survey, which captures leading job market indicators, shifts in practice patterns, and identifies gaps in training. And to Ms. Jones' comment yesterday, the top gap in training were our home dialysis modalities. We wanted to also understand whether fellows would recommend the specialty or not to medical students and residents, which was only 72 percent when we started the survey, and identify the factors that fellows were looking for when they chose employment, overwhelmingly lifestyle factors in the top three. Next, why not nephrology? First reason, perceptions of low compensation. But our internal assessments, and more importantly, the MBER dataset shows that nephrology is clearly in the middle of the pack in terms of compensation for medical subspecialties. Next up, perceptions of poor work-life balance. And this is a little bit harder to assess, although Dr. Landry's example of barricading herself in her bedroom to keep her toddlers out would definitely be zero on the visual analog scale. And of course, WorkRVUs are nowhere near a direct analog to work-life balance. But again, our internal assessments saw that the WorkRVUs being reported were much lower than the targets being reported in the literature. Finally, a lack of interest. Now interest outpaced compensation by nearly two to one in terms of reasons why not to choose nephrology. And we know that exposure is critical to instilling interest in nephrology, which is why ASM began multiple initiatives across different touch points in the medical educational continuum to increase exposure to nephrology. And based on what we found from the fellow survey, that these later touch points may be more meaningful since more fellows come to nephrology in PGY2 and PGY3 years. So of course, there are a lot of unanswers remaining, including what's going to happen with this year's match. I think there's an opportunity for like-minded associations to work together to get access to more timely and complete data to help medical society shape the future of medicine together. I just want to take a moment to acknowledge my collaborators, Dr. Sozio at Hopkins and Dr. Boyle at Temple. Thanks very much. All right. I think the word used was co-linearity. There's going to be less co-linearity. It's going to be co-linear less in this presentation. So we are so excited to be here and excited to be part of this panel. I represent the American Academy of Family Physicians. My name's Ashley. I've worked there for 13 years and had the opportunity to work with medical students and on this really exciting challenge of building our workforce that entire time. And when we were invited to this panel, we looked at our esteemed colleagues that would be here with us. And we decided we could lean away a little bit from talking to you about workforce data and statistics, because you've heard a lot of that. And we're representing family medicine. So I probably don't need to make a case for you that we need more family physicians in this nation. And we thought we'd talk to you more about what we actually do to try to encourage workforce growth and hopefully spur some ideas and potentially some collaboration. So I want to share with you first the logic model that we use at the American Academy of Family Physicians, really trying to focus in on what are the drivers of medical students choosing family medicine. And I think what's really important here and to leverage the thoughts of our opening speakers this morning, when you get down to a micro level of your workforce, what we're really talking about is human beings making one of the most important decisions they'll ever make in their entire life. So each of those workforce data points is a person on a multi-year, multi-decade journey to a career and then obviously through a career. So this is not something small that we're trying to impact. And that's why it's an issue that is worthy of this discussion today. So when we look at what is impacting students choosing family medicine careers, the first thing we acknowledge is it's their own life experiences, the things, the family they came from, their personal characteristics, their community. Did they have a physician growing up? All of those things that shape their human experience. Next we think about what they experience in the academic journey specifically. And this isn't just medical school. We do a lot of work in the medical school space, but we really acknowledge that the opportunities to influence somebody's career trajectory, if you only intervene in those four years of medical school, you're going to have some limited results. So the academic journey starting as early as possible. Financial factors. And here we look at that student's own financial background, their maybe debt aversion, the landscape of student debt, and then also payment issues. Students looking at career opportunities and seeing what could my payment look like in those careers, as well as then what's my personal financial situation. The practice of medicine is a huge driver of students deciding on the profession. So what family, in our case, what family physicians are experiencing in practice, their stories, their challenges, all of those things impact students' choices. And then the future outlook for medicine, for family medicine, and generational changes, things that might affect what today's students are interested in, what inspires them, and what they hope for out of a career. Now when we look at all of these things together, it's a whole lot. And we can't influence every single thing, but we can do something in each one of these spaces. We can't change each of these alone by ourselves. This is a big systems challenge. It requires system solutions. And we actually need to move in all of these spaces. But we focus in on what we can do as a medical specialty society. We're already doing a lot of work around payment, a lot of work around practice. So our work to engage students and build the workforce is really focused on those life experiences, academic journey, and then understanding their aspirations and meeting them where they are. So I'm going to share a few things that we do within our organization. And then I'm going to talk about a couple partnerships that we have and actually let one of my colleagues from one of our partner organizations elaborate on some of the work that we've done together that could maybe inspire some of the work that you could do. So we offer free membership for medical students. We don't have a pre-med membership. That's pretty exciting. We have free membership for medical students. We also support our family medicine interest groups. So those of you who maybe already work with interest groups in your specialty, we continue to do that. That's actually even post-pandemic still. We've seen a decrease in engagement of those groups, but it's still the number one way that students come to membership through us. It's still vitally important and seems to be regaining some traction in the medical school setting. We also have a national conference every year for medical students and residents. It's called Future, the Conference for the Future of Family Medicine. And we get more than 5,000 people to come to that event, more than 500 residency programs. They're doing some recruiting and students there exploring careers in family medicine and making those connections. And of course, we do that important policy and advocacy work. We've already heard a lot about some of the policy work that takes place. We do workforce analyses. We look at trends in practice. We look at trends in the incoming workforce. We analyze all of those things and try to help impact policies, laws. We work a lot with our state chapters across the country. So many of the policies that shape our workforce challenge happen at the state level. So we really make sure to work closely with them as well as at the federal level. We also support students to be successful in the match in family medicine. We have pretty robust resources for students going through the match. And then we also produce an analysis on family medicine's performance in the match so that we are able to inform and advise any important groups that might be interested in our take on those things. And then we started a new program this year called Family Medicine Champions that provides anyone who's in a position to be a champion for healthcare careers, a champion for family medicine in particular, with some resources and tools to be able to do that. And we're just learning a lot from starting that program. But we can't do it alone. And in particular, in some of these spaces, you know, we're not the experts. We're a medical specialty organization. Even within the space of supporting medical students, we really have a lot more for third and fourth year students than we do for even first and second year students. So we've really leaned into some partnerships at different points along the journey to help us reach not only the students, but reach the people who are part of the systems and structures and environments that our students experience. And what we've found is that some of those influencers, you know, you reach one influencer, and they are reaching the students, and the ripple effects there are more than you could ever do on your own. In the pre-health space, one partnership we're really excited about is with hosts of future health professionals. They're recognized by the U.S. Department of Education, a career and technical student organization focused on health professions workforce. The AAMC is actually also involved with that organization. They're representing all of medicine. But the AAMC is really focused on medical school recruitment and admissions and supporting those advisors to help students get into medical school. We're able to be there and talk to students about careers in medicine. We're the only specialty organization there right now, and I'm not actually sure why I'm telling you all about this, because we're enjoying that market exclusivity. But I actually think, you know, the more we work together to inspire students toward health professions and really physician careers, we could accomplish so much more together. The tide would rise all of our boats. So that's been a partnership we're really excited about. We built a family medicine program in their structure, and then that program has been growing each year since we've built it. Then in the premed space, the college space, and moving into the medical school space, we lean into some efforts especially to recruit recruits the wrong word, to support and engage students from underrepresented backgrounds for all of the reasons we've already heard about today. And we have some really exciting partnerships with the Latino Medical Student Association, the Student National Medical Association, and then some of our members have even created an association of black family medicine physicians that also focuses on supporting students in a journey toward a career in family medicine. So we have some partnerships with them, some liaison relationships that allow us to do a variety of things throughout the year. And that's another space where we also end up working with the AAMC's workforce transformation team to engage underrepresented groups and really transform our workforce. Then as it moves into residency, we're doing a lot of support around the match that might not be our most innovative work, that actually may be the work that you all are already doing already. So I wanted to tell you more about what we're doing at even earlier points in the pathway. And a couple things that we are doing specifically with the AAMC, because I'm about to turn the mic over to Mary Halicky, who is one of the great partners I get to work with over there. These are a couple new things we've tried. The AAMC has a virtual specialty forum, they get thousands of students to come with a specific purpose of exploring specialties. And we get to put up a little shingle in a virtual booth, and they bring some students to us for a really focused time to engage. And they're specifically there for specialty exploration. That has been engaging for us. We've gotten to connect with hundreds of students through that platform. And then we just this year tried a new webinar series called Vibe Check. And we focused on is family medicine right for me, brought six family physicians together to talk about their career journey, how they chose family medicine and what they do today. And we actually had 1,400 medical students register for that webinar. So a lot of excitement around that partnership with the careers in medicine program and bringing students in to hear stories of family physicians. So I'll close with just a few thoughts and then pass the mic over. But I just wanted to share a few of the lessons we've learned from this work. One is that this is a systems challenge. It requires system solutions. If we do nothing, the system is built for the results that we're getting today. There's no quick fix. There's no silver bullet. We can't only fix payment. We can't only fix administrative burden. There's not one thing that we can do. We really need to be doing a lot of things. And we need to be thinking about what we, as specialty organizations, can have the most impact over. There are students who need extra support. There are students that the pathways right now are not reaching. So we need to think about where do we put some extra effort to really get the workforce that we need and reach some of those students that are not being reached by today's pathways. We should own our part of the solution. And I could also put here, we should own our part of the mess. We each contribute also to some of the challenges that we see. And by looking at where are we part of the challenges and where could we be part of the solutions, we can really think of some of the work we could especially do together as a house of medicine. I'll give one quick example. When I go to medical student conferences, sometimes I'll hear from my specialty organization colleagues. And they'll say things to me like, oh, of course you're there, family medicine. Yeah, of course you're here recruiting students. And they'll have put into place maybe a workforce initiative really just focused on the very end of medical school or maybe just focused on academic achievement for medical students so they can meet some rigorous residency application requirements in their specialty. But if we all worked together, and even earlier in the pathway, we could actually increase diversity of medical education and we could bring in more students into the pathway so we're not all so focused on a limited number of students that make it to medical school. And lastly, stories are very powerful. Stories are powerful for students, as evidenced by a webinar that was very successful just by bringing six docs together to tell stories. And stories are also powerful for our members, our members that we get involved in this work, that we have do some of our events, that we have talking to students across the country. They really tell us that they get some well-being benefit from that. It reconnects them with their purpose and their joy in medicine. And so it's also been a member engagement initiative for us. So I would like Mary to come up and tell you a little bit more about what the AAMC could potentially do with your organization. Thank you. Great. Thanks, Ashley. And again, I'm Mary Halicky. I'm the director of the careers in medicine program at the AAMC. I really appreciate Ashley's partnership in the AAFP. And also, Helen, thanks for the three minutes. And I follow directions. I wrote my notes down, so I won't go over. So make sure I stick with it here. Really thinking about this from my lens, but I'm also representing AAMC as a whole, really thinking about AAMC as a key partner for the future physician workforce, so trying to work at every phase. We'll see a lot of synergies of what I'm talking about here, what you've already heard. And the tactics and strategies I'm going to talk about really quickly, again, are not exhaustive, or we'd be here all night, which I won't do to you, especially with the weather. But want to make sure, again, to highlight some of the larger initiatives that we're working on. What we think about with workforce opportunities is like a funnel, really, right? You start with a large, inclusive pool early in the process. And we use tools and data to help make decisions along the way. So the first strategy there is increasing exposure to medicine generally. And AAMC has done a lot of work, and Ashley alluded to some of this earlier, through various partnerships with our pathway programs consortia, really thinking about an emphasis and focusing on increasing the pool of those who are underrepresented in medicine, also doing a lot in the K through 12 space, which is fairly new for the AAMC. Once a student decides to pursue medicine and then matriculates to medical school, there's a number of strategies and steps there. And really, where my job comes in in careers in medicine is the exposure to medical specialty options. As I mentioned, I lead the careers in medicine program at AAMC. And our goal is really to help students make informed decisions on specialty choice and also in residency selection. A big part of what we do is thinking about equity, thinking about exposure, and thinking about alignment of a student's particular interests, skills, and values in a medical career. The other thing we try to do quite often is dispelling narratives that there is a specialty soulmate. We think that students can be successful and find value and find meaning in a lot of different specialties. The other thing we try to socialize is that 73% of students change their mind from when they enter medical school to when they actually go to residency and what specialty they choose. And that's OK. And we want to encourage, again, and socialize that change. One of the big events also that we do in our portfolio, and Ashley spoke to this just a minute ago, is the virtual specialty forum. We reach thousands of students. And Ashley shared the booth from AAFP. We actually work with a number of you for that. We expand every year. It's a great way virtually to engage with students in their first and second year primarily to meet and talk and engage with those who are actually practicing in the specialty. And we're looking to expand if anyone is interested in participating in that. And also, Ashley talked about some of the co-branded webinars. So I won't go into additional detail there. But I did want to highlight the benefit of the AAMC network. As you probably know from all of the mentions, again, I don't work in data. I'm happy that they provide it. But we have a vast network of medical school staff and students who use our network to promote events, various specialty events, and help specialty societies increase their reach as well. The next strategy there is connecting medical students with residency programs that have shared values, and then also those who will thrive in that transition to residency. First through VSLO, which is the platform that assists with the weight rotation applications and placement, and then most notably with the Residency Explorer tool. And that takes source data from programs, the ACGME and GMA track survey, to help students research and find residency programs that hopefully align with those values and interests. And then the final strategy is enhancing the student, excuse me, the resident selection process as a whole. And by this point, the pool of students is finite, right? So just like the previous tactic, we're hopeful that the Residency Explorer is a helpful tool for students and programs to find each other, focusing on that alignment from the program perspective. And then the AAMC ARIS Application Service and our new Thalamus Partnership that collects key data and information from students that contributes to a program's mission and patient care goals. The other thing we're working on I wanted to mention is again, we're working very hard to reduce the burden on the high number of residency applications to allow residency programs to better conduct holistic review, and using ARIS application data more easily and effectively. In thinking about equity, we do provide fee assistance for those who are pursuing medicine and also those who are applying through residency. So as you can imagine, while these systems and initiatives and partnerships, we also, as I mentioned, and I didn't have to mention, a lot of people are talking about our access to our data, we have a plethora of data. And a lot of that is customized for our specialty partners. So again, if you have interest in what we have, please reach out, we'd be happy to put you in touch. And lastly, we've got several overarching initiatives within the transition to residency and specialty workforce pathways, which I don't have time to go into detail, but I do want to quickly mention. The first is with OPTA. We've worked collaboratively with that group to provide webinars to share information and spark conversation within the GME community specifically. And some of those topics have include recruitment processes, resident unionization, AIs, the other hot button issue. And then WMC is also assembling a national collaborative, and this is really intended to keep the conversation going from a lot of that transition to residency work that happened with the UGRC recommendations. So I'll just close with, you know, our goal as an organization is really to focus on what is relevant, what is important, what is equitable, and then also what is accurate in each stage and really engage in new ideas and collaborations along the way. That can be through CFAS, which is the Council of Faculty and Academic Societies, the program I lead with Careers in Medicine, any of our service programs with ERIS and Residency Explorer. But please reach out if you have any questions or concerns about past engagements or future opportunities. We would love any opportunity to partner with you all. And thanks again, Helen, for the opportunity today. Thank you. Thank you to all of our panelists. Those were all great presentations. I particularly liked the last speaker's comment about making sure that our medical students identify what resonates with them and that all options are available and open to them. So we have a few minutes for questions. So the floor is open. I will ask one question while you're perhaps gathering your thoughts and coming to the microphones. So for you, Dr. Chaudhry, sort of going back to your thoughts about the international pathway, I think we would all agree that for all specialties, there are shortages and there are maldistributions. And, you know, a surgeon is not interchangeable with a nephrologist, is not interchangeable with a pathologist. And so as we think about smoothing the pathway, how do we make sure that we're bringing in the right specialties that we need? And you've highlighted that that's a bit of a challenge because you license, you're not responsible for specialty assortment. Can you comment on that and how we should think about that? Yeah, that's a great question. Our recommendation in our list of guidance for state licensing boards is if they're gonna do this, maybe start off with a pilot, start off small and slow, see how this plans out. Maybe start with primary care first before you jump into the specialties, because we do have some concerns about what happens with the general surgeon, let's say, who comes through this pathway and for whatever reason, just doesn't seem to progress the way he or she should. What do you do with that individual? He's now licensed, but, you know, he's not licensed or recognized to be able to practice surgery. Does he do primary care as a default? Can he do primary care? Primary care is not a default. You know, it's a specialty of its own. I'm proud to be an ACP member. But so that's a concern. The other concern we have is we don't want these individuals to be exploited. There's a concern about that because they're coming in not as residents, and they're not coming in as full attending physicians, either, so they're somewhere in between. And so there's a concern about what happens if they don't progress? Does the hospital take advantage of them in some ways? And says, well, all right, they may not be licensed, they may not be recognized for surgeons, but we'll have them first assist. But how does that work? So lots of questions, but your point is well taken. Great, thank you. Another question perhaps for you, Dr. Chen. Can you comment on the loan repayment programs and how what we can do with CMSS to support perhaps better funding, more funding, more expansion? I mean, that's something that obviously we know medical student debt can be crippling. If we want to incentivize physicians to go to particularly underserved areas, you know, that's one way to do it. Can you comment, is there any way that we as CMSS can help you in that argument? I would just say yes, yes, please. I mean, one of the things to consider is the National Health Service Corps is what we would consider on a funding cliff. Effectively, on December 30th, the program runs out of money. And it is, I'm just gonna say, it is gonna be a tough environment over the course of the next, well, I'll just put a little question mark on the timeframe. But the more that workforce programs and workforce policies get onto your organization's priorities, I think that, I think it's important. I think it is really important. So even if the value of me being here today is that all of you walk out going, hey, that National Health Service Corps program, what, you know, the value, the potential value of it, and if you can talk about it, that would be really important. Perfect, thank you, yes. Jerry Penso with American Medical Group Association. One thing I haven't heard any of you mention is AI. And the potential for AI to perhaps change productivity of physicians or change how patients are empowered and how care is delivered. Wonder how you're beginning to incorporate your thinking on AI. Please. So I'll start. So I've been to a lot of meetings where AI is being talked about, including this meeting. I always learn something new. I think there's real hope for AI in the area of ambient documentation, hopefully getting rid of that laptop between the doctor and the patient. And there's some studies that show that that could save as much as seven minutes per encounter. But the caveat is, I was at a meeting in D.C. of CEOs of health systems, and this data came out, and the CEO literally said, isn't that great, seven minutes, more productivity. They could see more patients. I'm like, oh, I don't think that was the goal. So yes, AI can be a powerful tool in workforce, but let's be mindful of the workforce. Great, thank you, yes. Hi, Davrine Chick, American College of Physicians. I am curious, we've heard about the need for international medical graduates to continue to serve our workforce needs. And just to be clear, I think it's worth saying that IMGs disproportionately serve our most needy patients in this country, and that's just something we need to acknowledge and thank and deal with ethically. But also, we heard that we are spending an enormous amount of our financial resources as a federal government supporting GME. We have a lot of federally funded, GME-trained physicians who are coming through the current pipeline as an international physician who can't stay in the U.S., who would like to because of visa issues. Dr. Chaudhary, do you have a sense of what the volume of need could be met using our current immigration and visa status issues versus need? So, great question, Dr. Chick. It's an issue that we're talking with our colleagues at Intel and ECFMG. They're sort of the experts on working with the State Department. I think in light of the recent elections, anything is possible, so we're not entirely certain how that will play out. But I think there is a role in that because that's also part of the solution for the U.S. workforce that hasn't been considered. The other issue, of course, on the other side is the ethics of this. Is the goal to get the best physicians of the world to come to America? You've heard of brain drain, and so there's some concerns about that as well. And the World Health Organization in early next year will be coming up with some guidance about the ethics of physician mobility around the world. So lots of issues. I think immigration is just a big issue in and of itself, and we'll have to see how it plays out. Great, thank you. We'll take these last two questions, and then we'll have our panelists step down and bring our reactors up. But our panelists, I assure you, will be happy to have conversations with you after the session ends. Yes, please. Bill Fox, Chair, American College of Physicians, and thank you so much for this fantastic session. This might be a question directed towards Mary Halicky. Recently, AAMC came out with a report that suggested that we may not be or shouldn't be worried about a primary care workforce issue, because even though there was a deficit in physicians, there was a surplus of mid-level providers, advanced practice providers. And I was wondering if you could provide a little context on that report. And my questions are, do you see advanced practice providers as interchangeable with physicians? And do you see the workforce going into primary care as opposed to specialty care? In our society, for instance, we obviously value the work of our advanced practice providers, but we see them working in the context of a physician-led team, and that could have significant implications for our workforce. And obviously, the reason we feel that way is there is a significant disparity of training between those two disciplines. Thank you. Yeah, I appreciate the question. And fortunately or unfortunately for you, that is not my area of expertise. So what I will certainly do, I knew the question was going to come up. I've seen the report. And similar to what my colleague shared earlier, I know our workforce team is always willing to have conversations about those projections and calculations. And if you have questions or concerns about how that is projected or things that you've seen differently, please let us know and we can go back. You know, from my side, it's all about exposure. We are pretty much, we don't play favorites when it comes to specialty or primary care or subspecialties or if it's surgical specialties. So from my lens, it's all about exposure and finding students who will thrive in their area. But your point is well taken. And like I said, I knew this was going to come up and I'm already making note to Dr. Grover. All right, Dr. Chen. Oh, I'm sorry. I just wanted to share, yeah, one quick comment on that because it's related to primary care and family medicine. I shared we have the Robert Graham Center, which focuses on policy studies in primary care. And our Robert Graham Center team is connected with the AAMC team. And I'm asking some questions about methodology on that report as well. And we think there are some ways that some of those health professions were counted as well as the physicians were counted that resulted in the analysis shared and similarly to some of our colleagues that shared today. There's an opportunity there. My old boss used to say, one thing that's consistent about all workforce projections is they're always wrong. There's not anyone out there that's ever been right. And it's just an opportunity for our organizations to engage, ask questions, and find opportunities to improve the methodology to help those workforce reports. You really ultimately help patients and our physician workforce, which is what we want. Great. I just wanted to add, I think that that question also highlights an area of need in terms of understanding the workforce. Our advanced practice nurses, our physician associates, they are some of the fastest growing workforce. They're filling incredibly important gaps in primary care, in mental behavioral health, in maternal health, in our specialty workforce. But there is that question of what makes a physician unique? What makes an advanced practice nurse unique, a certified nurse midwife unique? And how do they fit together to ultimately maximize healthcare? If we keep patients at the center, we're looking at access, but we're also looking at quality, right? And those are questions that, in all honesty, I don't think that we've answered. And so then when you ask, what are we projecting, right? Well, we're projecting what the current models of care are, which also has primary care physicians oftentimes running panels of 2,500, right? So there's a lot of things that need to be grappled with in that. So I'll just say that I think that's an incredibly important topic, and I'm going to suggest to Helen that we put this on the docket for another conversation and another meeting, because this notion of scope of practice and who does what and what is appropriate to have done by someone who's not a physician and what's appropriate is really a thorny issue, and who should say who's qualified to do what. So rest assured this will come back and you'll hear more about it. Yes, last question. Steve Fleishman from ACOG. I have like 12 questions, so I'm trying to figure out which one. I just want to make one comment up the APP. In many cases, especially from nephrology, one of my partner's husband's a nephrologist, and the APPs create so much more work for him because they can see the patient, they can order labs, but they don't always know how to interpret them specifically, and so he spends hours every night, which is why he's miserable, because he's not only doing his own work, he's doing someone else's. He doesn't get paid for the work he's doing for the APPs. Separate issue. But I guess one comment I just want to make is we hear over and over again about crippling student debt, and it really frightens students away from certain things, and I know the numbers are astronomical, and when I hear what my new partner came out of school owing compared to what I did, but my starting salary when I came out was commensurate with what my debt was. It took me 10 years to pay it off, but we can pay it off, and I'm not suggesting we stop fighting for making medical school more affordable, but I do think we have to stop scaring people. When you say crippling, that doesn't sound so great. It's a big loan you're taking out for your education, but people can pay it back over time, and you're investing in your own education, and if we want to get mad at someone, I would say our medical schools are not doing a great job of controlling costs because I will say at our institution, and I don't want to say where it is because I'll get in trouble, but our institution kicks more money from the medical school back up to the university's coffers than the other way around. And so I'm sure we could go tuition free at our medical school based on the amount of money and revenue that comes through and that goes up to the university and the endowment coming back. And so I understand we have to work on this issue, but I think we're constantly looking to the government, and it's not always the government's purview. My final statement is we also, from a workforce perspective, are losing so many people as soon as residency is over. And GME is funded through the government. We are paying for people to work and get their training. And then when they leave, we've now invested hundreds of thousands of dollars in some of these people into our workforce and we get nothing in return. And so maybe there needs to be some at least requirement that if you're getting your graduate medical education, there's a commitment that you will practice medicine for a certain number of years since we paid for your training. I know that may not go over well, but it's fun. So thank you for those comments. I'm going to take the privilege of the podium and thank our speakers. So really you've done an extraordinary job. I'm going to have you step down and have my panelists come up. So as they're coming forward, I'd just like to introduce them. We've had an extraordinary conversation and we have some extraordinary leaders who are going to come and give us their perspective. So as they are coming forward, Mr. Mark Del Monte, who is the CEO of AAP, our pediatric colleagues, Ms. Mary Post, who's the CEO of the American Academy of Neurology, and Mr. Paul Pomerantz, who is the immediate past CEO, I believe CEO emeritus, if I'm getting that right, of the ASA, the American Society of Anesthesiologists. So I know that we're running a tad bit behind, but I think it was really important to hear the perspectives of all of our speakers and to hear some of the questions. So what I'm going to ask is for each of you to maybe give two minutes of your sort of reaction. So two minutes off the bat and then we'll go back around and hear more comments. But that way we'll also have a chance to ask you some questions and we'll have a chance for you all to kind of ping off of each other. But I'll start with you, Mark. Two minutes and then we'll go to Mary, then we'll go to Paul, and then we'll loop back around. Great. Thank you very much. Hello, everybody. I'm Mark Del Monte. Are you on? Oh, hello. I'm going to get really close. Asking a CEO to limit remarks to two minutes, it's really hard, but I'll try. The American Academy of Pediatrics, 67,000 members. We have pediatric primary care, medical subspecialty care, and surgical care. So thinking about workforce challenges across the House of Pediatrics is a heterogeneity of workforce challenges. And so I'll say a couple things about each of that. I think one thing to say, first of all, is there's a popular narrative and then some data. And sometimes our narrative doesn't match our data. And sometimes that helps us and sometimes that works against us. And I think that's true maybe for other specialties as well, and it might be true for physicians as a group. But just taking pediatrics as an example, we are producing more residents than ever before. So we are at a high watermark of the number of pediatric residency slots ever before. We had a tough match this year, but even after that, we are still at the highest high watermark of pediatric residents. But yet there's this narrative of worry about pediatrics. And so this match between where we are and where we feel is really important. And I think the fastest way for us to create a self-fulfilling prophecy is to start talking about some specialties of medicine as sort of ending or being sort of dead ends of medicine. I really appreciate the talk about pathology, where you start to create self-fulfilling prophecies in that way. And what we know about at least pediatrics is that we're producing more than ever. There's still an enormous amount of excitement. Ninety-three percent of pediatric residents who graduate residency programs would return right again and take residency over again. There's a high level of satisfaction. They get to practice medicine on the floor with children. What could be better than that? There's a tremendous amount of joy in the practice. Our headwinds are the people going into medicine and going into residency are not representative of the population that they take care of from a race and ethnicity perspective. We need to worry about that and we need to work on that. They're not always located in the places where the children are, so a distribution issue that Dr. Chen mentioned before. And we don't always have the subspecialties that we need. And so for pediatrics, primary care and subspecialty workforce challenges are very, very different. And so I think we need to think very creatively about reaching deep into the early, early, into the pipeline and inspiring people into medicine and thinking about that much, much earlier. And then the last point I'll make is if you look at people who are through training and into practice, we see a couple differences between what trainees say and what practicing physicians say. People entering training who are worried about becoming a pediatrician or a pediatric medical subspecialist or pediatric surgical specialist worry now about the feasibility of that given the debt load, given the rigors of training and all of their future. Financial feasibility, work-life balance, all that, can I make it even though this is a passion, even though I want to do this, this is consistent and concordant with my dreams about my professional life, is it feasible for me to have a family and work in the way that I want to for my life? Practicing physicians in our survey data, feasibility and actually financial drivers is actually not what is the worrisome and the thing, worrisome things and things that are creating burnout. It's the administrative burden. It's the lack of agency over their decision-making and the vicarious trauma about seeing their patients not being able to get what they need. And so that mismatch is a hard problem as well. Great. Thank you so much. Great comments. Ms. Post. Thank you. I was thinking about, as I was preparing for today, I was thinking about kind of a concentric circle. You know, workforce is kind of the center point for all of us on this issue. And as we share our stories and our examples across each of our specialties, much of the same strategies, much of the same tactics, much of the same experiences and challenges, opportunities that we have are all kind of coming together. And I think about what can we do in the CMSS community together? Actually, I think a lot about what you were saying here. When we are thinking about the brand of medicine and thinking about the brand of choosing to be a physician, how do we work together to raise up that brand? There are opportunities for longitudinal studies that we are all working together in this community to think and measure and understand what those challenges are, what's working, what's having impact and what is not. How can we raise that up together? So I kind of start with that. We as a community, we as a group, how are we working together to address some of these challenges? Neurology is no different. We in neurology have been working on workforce for many, many years. We just launched our next five-year strategic plan in March. Number one goal was to grow a more diverse neurology workforce. Second goal was to strengthen neurologic practice. Those two goals are intertwined with all of the tactics and objectives to try to really address from medical student all the way down in that pipeline, how do we widen that pipeline? How do we work with advanced practice providers and that neurology-led care team to grow that access to care? So really thinking about how we are working together. For neurology, more than one in three individuals suffer from a neurologic condition in the world. People are living longer. Advances in healthcare, beautiful healthcare, advances in healthcare are having them live longer. But they are living longer and as they live longer, they have more neurologic conditions and needs to see a neurologist. There was a recent study by the Institute of Health Metrics and Evaluation at the University of Washington. Our goal number three, by the way, our goal number three is to promote brain health. The National Institute of Health Metrics and Evaluation at the University of Washington, global spending on brain health is $1.8 trillion. One trillion of that is neurologic disease. $826 billion is mental health disorders. These are staggering numbers for us, right, and how do we make sure that we have enough supply to meet, to address these numbers? So I really would think the opportunity for us in this community to collaborate together and the proactive end to really try to address these together. Great. Thank you so much. Paul. This was just a superb panel. One of my key takeaways is that while each specialty may have a separate set of issues that we're addressing, there's more opportunity to collaborate, share resources, how we're learning and studying the issue. I'll share a little bit about anesthesiology's perspective. It's a very popular specialty. We've had for several years running a match at 100% or close to 100%, but not near enough to meet demand. And there's a lot of factors affecting that. One is there's an increasing fragmentation of anesthesiology care in the hospital, you know, not only in the OR, but the non-operating room settings, ambulatory care settings. There's changes in work style, work style expectations. And there's increasing aging of the population. These are among the factors that are affecting workforce. And then coming out of the COVID pandemic, there was a lot of demand. So what we did at ASA was we've organized a series of summits. And I think part of the features of these summits looking at workforce was to bring in the ecosystem, the larger ecosystem of the specialty to study some of the issues. Not only society leaders, but our experts, our internal and external experts, people who employed our members from ambulatory surgery centers to hospitals, surgeons as well, and trying to represent academic, private practice and the corporate side. And what we looked at and tried to understand was the factors not only affecting supply, and we're heavily focused on supply here, but also the demand side and how demand can be better managed and how evolving care models, technology, use of APPs could really affect and help us better manage the demand. A couple themes that have emerged just overall from the summits is that societies do have a big role, and I think we have a huge role working together. The first is convene, publish, educate, really educate the health system. There's a tremendous need not only to educate ourselves, but hospital execs, there's a big issue for hospital administrators getting in front of groups like the American College of Healthcare Executives and really coming with common solutions. Secondly, to advocate, and the advocacy is not only at the government level, state and federal, but at the health system level, to collaborate among ourselves, and to identify those system opportunities, such as the role of AI and the role of the APPs. And then in this, I was really inspired by the talks, the opportunities for us to work together, to learn from each other, you know, listening to the different perspectives here, but I think principally is how we look at data, use data, and can study data together to understand the underlying trends. So I'll stop there. Great. Thank you so much. I will ask a couple of short questions while, again, ideas are coming forth, and you come to the microphones. We are going to run probably five minutes over into the break, but two quick questions for each of you. So other careers may be attracting the best and the brightest because, you know, we've got smart, capable people that used to maybe go into medicine, but they hear about some of the frustrations or the market forces and this and that, and they may be making other decisions. So first of all, how far back do you go? High school, you know, junior high, med school? So if you can answer for each of your specialties, how far back do you go in terms of that conversation and recruitment and widening the funnel, as you described? And secondly, what percentage of your members are in an employed model versus a private practice model? Because, again, I think that has some impact for some specialties positive, for some specialties negative. The changing practice configuration may change the interest in your specialties. So maybe if each of you could answer those questions, and we'll see if there are others from the floor. Oh, you want to go first? Yeah, just to kind of start. On the funnel question, I think that's an area where we can collaborate and go back as early as possible. And we got involved at ASA in a project called Project Lead the Way. So that kind of rhymes, ASA and lead the way. But that starts in the, you know, secondary school setting, interesting kids in careers in science and gives us an opportunity to get in front and talk about careers in medicine. Together we could really work on that together. And then in terms of the employed model, anesthesiologists, I think for the most part, probably I would say about two-thirds. It's growing rapidly between the corporate style, the large companies, as well as those large academic systems. It's two-thirds or maybe a little more. I mentioned the workforce has been a challenge for us for many, many years. We used to have a program called the Neuroscience Is, and we had a number of efforts, K-12, where we were really trying to reach children early on in their education to be thinking about neuroscience as a career and as an opportunity for their future. We more recently sunset that effort and we're more focused. We do have a very strong and impactful student interest group in neurology program worldwide. It's a global program. We are seeing a lot of energy and success around that student interest group efforts. And then, of course, as you get to undergraduate and graduate, a lot of tactics and efforts to really grow interest, grow the brand of neurology, and really help support those choices. Medical students is one of our largest growing membership segments currently for us, and we're very excited about that medical student. They're clearly telling us that access to their neurology rotation matters in terms of their choices. So they usually make their choice somewhere in the mid to end of their third year. And about 33 percent of our programs, that rotation isn't until that fourth year. And so that's an impactful experience in terms of getting in front of them and having that experience and helping them understand the fun and the value of neurology. And then just also battling, I think, all of the other things we all battle in healthcare, but neurophobia, neurology is a very, very large field, lots of subspecialty areas, and making sure that it's not scary and that they can see the wonderful opportunity, and that's something we are continuing to work to address. We have a huge advantage in this area because we can start recruiting at infancy right out of the gate. So that's our recruitment initiative. The physicians don't give the shots, so we don't have that problem. I think this is hugely important, and I think Mary's just brought up a point that didn't get talked about much in the session, which is exposure during training to various specialties and primary care, in particular ambulatory settings. We need to really think about that, and we need to have a large conversation about what medical students are exposed to and when in training, because that really matters. And there's enormous pressures in medical training about when and how that happens, and we can have a conversation. That's probably another plenary discussion at some other point. But I think that that is really worth some additional discussion. And you asked about employed physicians. For us, that is an increasing number rapidly. We're north of 60 percent and growing very, very quickly. Great. Thank you. Todd. Todd Ibrahim, American Society of Nephrology. Looking forward to reporting AAP to the NRMP, so thank you. I've been working on a theory, and I just related to this topic, and I'm just sort of curious if you or others think there's something here, which is we sort of have three workforce-related goals that we've conflated, and depending on which of those goals we focus on, that really dictates how early we go, just as broadly. So if the goal is a diverse workforce, and if we want the physician workforce to represent the U.S. population, we would have to start as early as possible, I would think. If the goal is to produce sort of the next generation of physician scientists or Ph.D. scientists, we're going to also have to probably start relatively early. And then if the goal is our own sort of specific specialty needs, obviously that depends on when people enter, as Curtis's slide showed, in terms of, you know, the different pathways. But then that's a little later, and I'm just wondering, A, if any organizations are thinking about it like that and have sort of different programs that have these different interventions, and B, particularly for the physician scientists, since there hasn't been as much discussion about that group today, advice on, you know, what's likely to be a real challenge over the next decade in terms of getting people interested in pursuing that career path. Well, I can mention in neurology, that goal I talk about, grow a more diverse neurology workforce, includes advanced practice providers, an important part of the care team, includes neuroscience researchers, includes diversity in all ways, and trying to set metrics on how we might be able to grow them in all those ways. So I would say yes to those goals, and there are going to be different challenges to each one. Yeah, I agree with that. I think, you know, at least in pediatrics, the evidence base is very clear that outcomes change when there's concordance between the provider and the patient on race, ethnicity. And so there is a very substantial imperative here to hurry and work on this. And so on all the categories and strategies that you mentioned, and so we have made substantial investments in this at AAP in terms of our own algorithms and our own policy development, and I would just acknowledge Helen's hard work and CMSS in this space. A medicine has a lot of work to do in this area if we want to turn that curve and change those outcomes, and the workforce is part of it. It's not the only part of it, but it is a substantial part of it. The only thing I'd add, and I agree with it all, I think Curtis did a good job of framing some of the misperceptions that are out there, and, you know, I wonder for somebody who's, you know, kind of gone through their sort of deciding what career, whether they're in high school or earlier, that they're learning what they're hearing about medicine from the papers, from the media, is burnout, or things that are not necessarily positive, and together I think we have the opportunity of understanding those misperceptions and perhaps working to change them. So just a thought on that, that's. Yeah, and I'll just add from the American College of Surgeons' perspective, I mean, we go back as far as high school. We have a high school program. I do not go to the neonates, as my pediatric colleague does, but we do have a high school program at our annual clinical congress, and the thing I'd comment about with our surgeon scientist idea is that we really have given that a lot of thought recently and have put together a task force to change the timing of research during residency, so typically we're five years where research is done between PGY2 and PGY3, and then people go on to do a fellowship for two years at the end of it, so by the time you get finished training, what you did in the lab is five years in the past, so the recommendation that will be coming forth is going to be to shift the time that you do in the lab to later in training so that there's a little bit more of a direct pathway, so that's our thought around making sure that we're growing the next generation of surgeon scientists. So anyway, I think we are five minutes over, but thank you so much. I think our respondents were amazing. Our panelists were amazing. Congratulations to you all, and have a great gleam summit. Thank you so much. Thank you.

Helen Burson

Sue Sidori

physician workforce

Interstate Medical Licensure Compact

telehealth

international medical graduates

HRSA

healthcare diversity

financial incentives

workforce planning

medical careers

collaborative efforts

systemic challenges

healthcare delivery