MEDICINE PANEL REPORT1

INTRODUCTION

In order to assist the IOM study committee in determining how physician requirements in internal medicine should be calculated, this panel was constituted during the early months of 1990. It consisted of eight physicians specializing in internal medicine and its subspecialties. The chairman of the panel was also a member of the study committee; the panel membership roster is attached.

The analyses arising from the medicine panel's deliberations, along with its recommendations and conclusions, are summarized in this report. A more detailed description of the process of analysis that was followed by each of the study's six specialty and two clinical program panels is found in the “Overview” to this section of Volume II. The “Overview” concludes with three exhibits (Exhibits 13) that demonstrate, by numerical example, how the expert judgment procedures developed by the study committee can be used to estimate physician requirements. Because these exhibits pertain specifically to medicine, they will be referenced in the course of this panel report; but since they immediately precede this report, they will not be repeated below.

1  

The initial draft of this report was prepared by Nancy Kader, Staff Officer to the Medicine Panel during the conduct of the study. This final report was prepared by the editors of this Volume.



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Physician Staffing for the VA: VOLUME II MEDICINE PANEL REPORT1 INTRODUCTION In order to assist the IOM study committee in determining how physician requirements in internal medicine should be calculated, this panel was constituted during the early months of 1990. It consisted of eight physicians specializing in internal medicine and its subspecialties. The chairman of the panel was also a member of the study committee; the panel membership roster is attached. The analyses arising from the medicine panel's deliberations, along with its recommendations and conclusions, are summarized in this report. A more detailed description of the process of analysis that was followed by each of the study's six specialty and two clinical program panels is found in the “Overview” to this section of Volume II. The “Overview” concludes with three exhibits (Exhibits 1–3) that demonstrate, by numerical example, how the expert judgment procedures developed by the study committee can be used to estimate physician requirements. Because these exhibits pertain specifically to medicine, they will be referenced in the course of this panel report; but since they immediately precede this report, they will not be repeated below. 1   The initial draft of this report was prepared by Nancy Kader, Staff Officer to the Medicine Panel during the conduct of the study. This final report was prepared by the editors of this Volume.

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Physician Staffing for the VA: VOLUME II EXPERT JUDGMENT APPROACHES TO DETERMINING PHYSICIAN REQUIREMENTS IN MEDICINE The Detailed Staffing Exercise (DSE) Approach Initial Efforts The first meeting of the medicine panel was conducted in the spring of 1990. The primary purpose was to examine whether the expert judgment panel process, as the study committee first envisioned it, was viable for medicine and its subspecialties. This process included the development of staffing instruments that would allow the panel to review information about workload, about various nonphysician personnel that might be available to deliver care, and then, given this conditional information, to make judgments about the physician FTEE appropriate to meet that workload. The feasibility of this process was tested in the first panel meeting. A staffing instrument developed for this initial meeting elicited a great deal of discussion regarding the shared assumptions necessary for an expert group to render reasonable judgments about physician staffing. After this first meeting, the panel concluded that study staff should proceed further with the expert judgment process. Several initial conclusions were drawn from the first meeting and guided the development of subsequent staffing instruments: Residents have a two-way effect on staff physician time in the PCA; the instruction of residents absorbs staff physician time, but residents frequently carry out tasks that otherwise would have to be performed by their instructors. The net impact of residents on staff physician productivity is not a matter to be settled in the abstract, but rather to be inferred from the empirically based and expert judgment models. Insufficient support staff and nurses will tend to reduce the efficiency of the physician and may harm the quality of care. But the empirically based and expert judgment models should be structured to account for the impact of nonphysician personnel on physician requirements. Physicians generally work 50 or more hours weekly, but 40 would be used in calculating internist FTEE in order to be consistent across panels. Research is an important factor in physician requirements, but determining the appropriate amount of FTEE for this purpose is difficult in the absence of information on indicators of research productivity such as grant funding and publication records.

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Physician Staffing for the VA: VOLUME II Vacation, leave, and sick time are not currently considered in physician requirements, and should be another “multiplier” applied to the direct care requirements. Night and weekend coverage is generally provided by “Officers of the Day,” who are not purchased specifically by medicine service, or by resident coverage. Therefore no extra FTEE were allocated specifically for these off-hours. Consulting and attending and without-compensation physicians can enhance the quality of patient care and resident education and may, in some cases affect requirements for VA staff physicians. During the first meeting, the panelists were also introduced to a number of alternative specifications of the empirically based physician staffing model, including the data components collected by VA Central Office. At the conclusion of the first round of the eight specialty and clinical program panel meetings, the study committee, the data and methodology panel, and the VA liaison committee convened in May 1990 for a major strategy session, later termed Joint Meeting I. The key concepts and modeling assumptions underlying both the empirically based and expert judgment approaches were reviewed and summarized. Study staff emerged from Joint Meeting I with recommendations on how to proceed with the panel process. These were implemented on a panel-specific basis. DSE: Overall Rationale As the next step in the development of an expert judgment staffing methodology that might complement empirically based approaches, the medicine panel convened for a second meeting in the summer of 1990. As in the first panel meeting, three VAMCs (denoted here and in the committee report as VAMCs I, II, and III) were selected to provide a range in number of beds, staffing levels, services/programs, and affiliation status. The staffing instrument—later termed the Detailed Staffing Exercise (DSE) —used in the first panel meeting was revised in preparation for this meeting. The revised instrument provided a more detailed description of each VAMC, including the types of patients, number of admissions, length of stay, and the DRG mix of patients in each PCA. A distinct DSE was produced for each VAMC. The three facilities were presented in context and in sufficient

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Physician Staffing for the VA: VOLUME II detail, it was hoped, that the panel could consider physician staffing decisions just as they arise in the “real world.” Instructions and Assumptions To illustrate the instrument and the assessment process, an example of a completed DSE is found in Figure 1 of the “Overview” to this section of Volume II. This figure presents one medicine panel member's estimates of physician FTEE requirements—and the assumptions used to render these estimates—for VAMC II. As indicated in Exhibit 1, each DSE has an A and B section. Section A elicits the amount of time, in hours, required to provide quality care for individual patient care areas (PCAs) of the hospital. For each PCA, information is provided on the volume and DRG mix of workload, number of residents by postgraduate year, number of nonphysician practitioners (e.g., nurse practitioners, physician assistants), and general information about the levels of nursing and support staff. Section B focuses on physician activities not addressed in Section A, including night and weekend coverage, and non-patient-care-related activities off the PCA, such as research, classroom instruction, administrative functions, and leaves of absence. The Panel Responds Prior to the second meeting, panelists were mailed DSEs for VAMCs I and II; these were completed independently and returned prior to the meeting. The staff compiled these results on a spreadsheet showing the high, low, mean, and median responses. At the second panel meeting, these DSEs were discussed thoroughly to determine whether panelists were using the same assumptions and to allow members to discuss the underlying reasoning behind their calculations. Following this, the panel was asked to reassess physician requirements in medicine at VAMCs I and II, again working independently. Then, the actual level of internist staffing at each VAMC, as reported in the facility's CDR, was displayed for comparison. Subsequently, a third DSE, pertaining to VAMC III (another actual facility), was distributed; and the panel worked as a group to estimate staffing requirements. Following the assessment, the actual CDR numbers for VAMC III were displayed for comparison. The panel was asked

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Physician Staffing for the VA: VOLUME II to reflect on whether certain “rules of thumb” were being used (perhaps implicitly) to help quantify staffing requirements. The Staffing Algorithm Development Instrument (SADI) Approach SADI: Overall Rationale Following the second round of panel meetings, the study committee initiated a set of “postmeeting” activities to assist the specialty and clinical program panels in arriving at consensus positions regarding the most appropriate methodology for VA physician staffing. These recommendations would be regarded as advisory to the committee. A central feature of these activities was the introduction of the Staffing Algorithm Development Instrument (SADI). The overall purpose of the SADI was to help test, build upon, and ultimately strengthen the rules of thumb for staffing that emerged from the second meetings of all eight panels. It represents an alternative, more compact means to derive physician requirements, by specialty or program, for any given VAMC. Instructions and Assumptions Like the DSE, the SADI has two sections, A and B, which focus on patient care and non-patient care activities, respectively. In Section A, the respondent is asked to estimate the amount of physician time required to complete a number of patient care functions and tasks under varying assumptions about the availability of residents and nonphysician practitioners. In Section B, the respondent must determine the amount of physician time that should be allocated to research, classroom instruction, continuing education, administration, and leaves of absence. To derive physician requirements for a given VAMC, the estimated physician hours for patient care and non-patient care activities are summed, then converted to FTEE under the assumption that 40 work hours per week translate into one FTEE. (Obviously, if this 40-hour-per-week equivalency assumption is replaced by one reflecting the average workweek of VA staff physicians, the SADI-derived FTEE estimates would change accordingly; this is true also for the DSE estimates.)

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Physician Staffing for the VA: VOLUME II Presented in Exhibit 2 of this section's “Overview” is the medicine SADI, complete with the panel's median estimates for physician task times. A detailed, self-contained illustration of how this SADI can be applied to determine the number of internists required at VAMC I is found in Exhibit 3 of the “Overview” to this Volume. A careful study of this example reveals the type of facility-specific data needed to implement the SADI. Although the information requirements of the DSE are greater, both of these expert judgment approaches require data (e.g., on frequency of consults across PCAs) not presently collected in the VA system. EMPIRICALLY BASED APPROACHES TO DETERMINING PHYSICIAN STAFFING IN MEDICINE In its two meetings and a subsequent conference call, the panel evaluated alternative specifications of the empirically based physician staffing models (EBPSM) that pertained expressly to internal medicine. As noted in chapter 4 of the study committee's report, there are two variants of the EBPSM: the production function (PF) model and inverse production function (IPF) model. Production Functions Among the 14 VAMC patient care areas defined for analysis in this study, two were of particular concern to the panel: inpatient medicine and ambulatory medicine. While the derivation of total physician FTEE in medicine at a VAMC via the PF model requires an analysis of internist FTEE in all PCAs, this panel (like the others) restricted its focus to the PCAs where the internist is the “dominant” physician specialty. The final versions of the inpatient and ambulatory medicine PF models, as developed in conjunction with the study's data and methodology panel, are presented in Table 2.A. Inverse Production Function In the early fall of 1990 (following its two meetings), the panel was asked to evaluate an IPF model estimated for physicians in the medicine service.

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Physician Staffing for the VA: VOLUME II Unlike the PF, these estimated models were facility-specific rather than PCA-specific. The final version of the medicine IPF is shown in Table 2.B. EBPSM Assessment For deriving internist FTEE for patient care, resident education, administration, and leaves of absence, the panel favors the PF over the IPF (and all other approaches). The estimated PF model for the inpatient medicine PCA is particularly impressive, exhibiting a strong goodness of fit (=0.88) and a clinically plausible pattern of statistically significant coefficients. Although the goodness of fit of the ambulatory medicine PCA equation is less impressive ( =0.65), the variables that merit entry on statistical grounds are clinically reasonable. The estimated IPF model is plausible—the panel would expect internist FTEE for patient care and resident education to be a positive function of inpatient, ambulatory, and long-term care workload—but there is a significant amount of unexplained variation in the dependent variable (=0.60). Moreover, the panel feels the PF model is conceptually superior to the IPF because it is specific to the patient care area, not just to the facility. Under the PF approach, total internist FTEE for patient care and resident education at the VAMC can be derived as the sum of FTEE computed for each PCA. This allows for a more detailed consideration of how the structure and mission of the facility influence physician requirements. The panel is well aware that inaccuracies in the VA's cost distribution report, particularly related to the allocation of physician FTEE across activities, have the potential to compromise the validity of the empirically based approaches. It urges the study committee to recommend that the VA work to improve the accuracy of these data. But the panel also notes that whatever problems do exist with these data are not sufficient at present to preclude the estimation of sound, plausible physician staffing models. As indicated in Table 2, the workload variables used in both the PF and IPF models take the form of “weighted work units,” consistent with the VA's current approach for generating an output measure that incorporates case mix. Over time, new and more sophisticated workload measures may be proposed. If this occurs, the empirically based models could (and should) be reestimated, with little technical difficulty.

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Physician Staffing for the VA: VOLUME II PHYSICIAN STAFFING RESULTS FROM APPLICATION OF EMPIRICALLY BASED AND EXPERT JUDGMENT APPROACHES In Table 1 are alternative estimates of physician requirements in internal medicine at VAMCs I, II, and III in FY 1989, as derived from: the VA's cost distribution report (CDR), the PF and IPF variants of the EBPSM, the DSE (from the second panel meeting), the SADI (in both its “pure” and “modified” application formats), and a mail survey of panel members conducted just prior to Joint Meeting II (held September 7–9, 1990). From this “small sample” analysis, several inferences can be drawn. Staffing levels derived from the PF model are generally in accord with the panel's overall views about appropriate FTEE levels (as reflected in the survey medians), though estimates from the other approaches may be as close (or closer) to the panel's recommended levels in some cases. For the three facilities examined, there was a tendency for the DSE estimates to be lower and the SADI estimates to be higher than those derived using the other approaches. In each case, the IPF estimate was less than the PF estimate. These later two conclusions apply both to total FTEE and to FTEE for patient care and resident education only. It is clearly of interest to see whether these trends would be sustained in a comparative application of these approaches to a much larger sample of VAMCs. EXTERNAL NORMS Data on physician staffing in medicine were collected from external (to the VA) health care organizations in order to examine the implications of productivity performance norms that may exist in the public and private sectors for appropriate physician staffing in the VA. Initially, the study staff also obtained some “internal” VA guidelines on physician staffing in internal medicine. The earliest documentation in the VA, circa 1965, was very simple. At that time, it was considered appropriate to have 1.0 internist per 15 short-term medical beds, 1.0 internist per 25 long-term medical beds, and 1.0 internist as chief of service. If the hospital had over 100 medical beds, an additional internist to serve as assistant chief was recommended. In 1988, the VA published “Staffing Guidelines from Planning Guidelines for Medicine,” which had a more refined approach. Long-term medical beds

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Physician Staffing for the VA: VOLUME II were not used in the calculations since they were considered to be in a separate service. The bed ratio for a basic medicine service was now 1.0 internist per 10 medical beds; also to be assumed was 1.0 FTEE for each chief and an assistant chief. Intensive care required 0.1 FTEE per bed, and additional staffing was added for subspecialty services “requiring prolonged and time-consuming procedures.” Regarding norms external to the VA, the Department of Defense (DoD) provided perhaps the most useful specific criteria since it utilizes full-time physician equivalents much like the VA; however, the patient population is generally younger and includes a significant number of women and children. DoD defines physician performance levels by the number of outpatient and inpatient visits (the standard varies from 240 to 335 visits per month depending on the availability of teaching staff) and the number of inpatient days of care provided (the standard is 95 days per month). A different criterion applies if workload is sufficiently low relative to the number of residents, as it is assumed that residents need supervision regardless of workload. The Indian Health Service (IHS) has some very simple staffing criteria: Inpatient staffing is dependent on average daily census (1.0 FTEE per 12 patients). Outpatient staffing is based on a formula of 1.0 FTEE per 5000 annual visits. One interesting application was based on a 1987 core survey conducted by the American Medical Association (AMA), “1987 AMA Socioeconomic Monitoring System Core Survey.” The resulting sample contains only active, nonfederal, patient care physicians. By focusing on the number of hospital visits, office visits, times in rounds, and discharges reported in the survey, it was possible to draw some crude comparisons to the VA. The New York City Health and Hospitals Corporation (NYH&HC) provided information on physician FTEE per annual admission and per average daily census (ADC). One university (Univ) medical center in Chicago attempted to refine, for the panel's use, the number of full-time paid faculty that was believed to be an appropriate working figure for FTEE comparison. Also available was the annual number of discharges from the hospital 's medicine service. This allowed computation of an FTEE-workload relationship that was similar, in concept, to that derivable from VA data. Finally, physician staffing and workload data were available from a large nationwide HMO. However, the patient population at this HMO was substantially younger and included more females than the VA population, with considerably different disease patterns.

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Physician Staffing for the VA: VOLUME II To summarize, Table 3 illustrates the computational approach, via dimensional analysis, used to derive the staffing standards. The logic behind these calculations is presented and illustrated in the “Overview” to this section of Volume II (see “External Norms”). In Table 4, these norms—both from the VA and those external to the VA—are used to derive physician requirements in medicine for the three VAMCs studied by the panel in its second meeting. Making valid comparisons between current VA staffing and external norms was difficult due to differences in workload measures, definitions of physician FTEE, and the patient populations being compared. Several private institutions were willing to share their staffing patterns, but inferring physician FTEE levels was very difficult. University hospitals, in particular, could readily list the number of faculty associated with the medicine service; but that number typically included many physicians who had patient admission “privileges” at that institution, regardless of whether they were retired, seldom used their admission privileges, or only gave an occasional lecture. A chief of service at a prominent university in the midwest stated that he had never attempted to plan the size of his physician staff in relation to existing workload in any way, since it was more important to him to “create programs” that would encourage new workload or that would “give a good name to the university.” Clearly, there are multiple determinants of physician staffing levels in the private sector and this seriously complicates the development of valid external norms. CONCLUSIONS For determining VA physician requirements in internal medicine, the panel endorses a variant of the study committee's Reconciliation Strategy that puts primary weight on “data driven” approaches to calculating FTEE. Regarding the FTEE components of the Reconciliation Strategy, the panel recommends the following: Patient Care, Resident Education, and Administration Internist FTEE for patient care should be derived from the PF version of the EBPSM. The panel feels that the PF model is conceptually superior to the IPF because it is specific to the PCA, not just to the facility. Therefore, it allows total physician requirements for patient care to be derived as the sum of

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Physician Staffing for the VA: VOLUME II FTEE required on all PCAs. For VAMCs I, II, and III, the PF model yielded FTEE levels in better accord with the panel's own judgment about appropriate staffing than did the IPF model. Since the PF focuses entirely on patient care, additional facility-specific data would be required to capture (1) FTEE devoted to resident education and miscellaneous activities and (2) other FTEE not in the CDR and, hence, not in the PF. Included in the latter are FTEE representing contract physicians and C&A and WOC physicians. The panel believes that expert judgment approaches for determining physician requirements are also valid, but, compared with statistically based approaches, they are relatively expensive and cumbersome to operate. Because the panel concludes that the PF model represents a satisfactory approach for determining internal medicine requirements —given current VA staffing arrangements—it sees no need to utilize either the SADI or the DSE as primary tools for calculating FTEE for medicine. The panel recognizes that other specialties may find it useful to apply some form of modifier (perhaps multiplier) to the EBPSM in order to derive FTEE estimates that would properly account for historical patterns of understaffing or changes in the technology of treatment. At a given facility, this may also be required for internal medicine. The proposed Reconciliation Strategy provides a useful framework for deploying such multipliers. Research The panel had difficulty ascertaining the proper allocation for research. Many facilities are research hospitals whereas others perform no significant investigations. The issue becomes even more complicated since the goal of increased research may exist at a hospital before a full research staff can be recruited. The amount of FTEE assigned to research in the CDR over several years may serve as an initial approximation. However, the panel believes that independent support of these estimates is necessary. For example, each facility should provide a list of the staff physicians who have grant support from the National Institutes of Health or other major funding agencies (e.g., American Heart Association) or a merit award from the VA. In a given VA medicine service, if 10 FTEE are listed for research in the CDR, but only three investigators have independent grant support, then the amount of FTEE assumed for research in the execution of the Reconciliation Strategy should not be 10 but a much smaller number. (It is presumed that serious investigators will have grant support.) Other data such as dollar funding levels or published papers

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Physician Staffing for the VA: VOLUME II Other Points In implementing any staffing model, the VA should establish an appeals mechanism that allows a VAMC to question what it believes, on objective grounds, to be an unreasonable staffing recommendation. There may be evidence that the facility's reported data are in error or are no longer relevant. Factors relevant to physician requirements at the facility may have been omitted entirely from the model (since no true model will include all factors that bear on staffing at every VA). One natural step in the appeals process would be to apply either the DSE or a rather detailed version of the SADI to the VAMC in question. This result could be compared with the facility's current staffing and the level derived from the PF. With this information available, VA decision makers at the facility and Central Office would have a firmer basis on which to reach a final judgment. In this regard, the panel urges the VA to continue efforts to improve the accuracy of the FTEE data in the Cost Distribution Report. Final Remarks For determining VA physician requirements in internal medicine, the medicine panel endorses a variant of the Reconciliation Strategy that relies upon the PF for deriving FTEE for patient care, resident education, and administration. In general, the panel favors data-driven approaches to determining physician requirements in medicine.

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Physician Staffing for the VA: VOLUME II TABLE 1 Estimates of Physician Requirements in Medicine at Three VAMCs A. Total FTEE1 VAMC CDR PF IPF DSE SADI SADI-Modified2 Survey3 VAMC I 31.4 31.9 27.1 23.8 39.8 24.8 32.0 VAMC II 45.7 49.9 43.9 50.0 54.0 39.8 58.0 VAMC III 14.5 15.9 13.1 11.9 23.8 16.8 13.44 B. Direct Care Plus Resident Education FTEE Only1 VAMC CDR PF IPF DSE SADI SADI-Modified2 Survey3 VAMC I 15.4 15.8 11.1 13.0 14.6 14.6 N.A. VAMC II 32.1 36.9 30.2 29.0 23.0 23.0 N.A. VAMC III 12.0 13.3 10.6 9.9 13.9 13.9 N.A. 1All estimates are intended to exclude physician FTEE from the medicine service allocated to the emergency room and admitting & screening areas of ambulatory care; these FTEE fall under the purview of the ambulatory care panel. Also excluded from the estimates at VAMC III are internists assigned to the emergency room and admitting & screening at two satellite ambulatory care facilities. 2Derived by replacing the SADI-based estimates for non-patient-care activities with estimates based on the DSE; all FTEE for patient care and resident training in the PCAs continue to be derived from the SADI. 3Panel median response to the question, posed by mail survey in September 1990, of what is the overall preferred physician FTEE level at each VAMC. To provide a context for the response, each panel member was presented a summary of the physician FTEE level at the facility emerging, alternatively, from the CDR, from both empirically based approaches (as applicable), and from both expert judgment approaches. 4The panel's original median (26.0) was premised, in part, on CDR and PF estimates for VAMC III that did incorporate the ambulatory care functions referenced in footnote 1. When the FTEE for these functions is removed from consideration (in line with the remainder of the table), a “corrected” median estimate of 13.4 FTEE emerges.

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Physician Staffing for the VA: VOLUME II TABLE 2 Estimated Production Functions and Inverse Production Functions for Medicine A. Production Functions Inpatient Medicine Patient Care Area with =0.882 and N=159 where   W= the natural logarithm of total WWUs, plus 1, produced in the inpatient medicine PCA during the fiscal year; MED_MD= VA staff physician FTEE from the medicine service allocated to direct care in the inpatient medicine PCA; (MED_MD)2= variable testing for a nonlinear relationship between VA staff internist FTEE and workload production— specifically, that there are diminishing marginal returns to increases in internist FTEE; SUR_MD= VA staff physician FTEE from surgery allocated to direct care in the inpatient PCA; PSY_MD= VA staff physician FTEE from psychiatry allocated to direct care in this PCA;

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Physician Staffing for the VA: VOLUME II NEU_MD= VA staff physician FTEE from neurology allocated to direct care in this PCA (where the denominator is defined specifically to include all direct care FTEE recorded for internists, surgeons, psychiatrists, neurologists, and rehabilitation medicine physicians); SUPPORT/MD= support staff FTEE per physician FTEE in this PCA; RESIDENTS= second- and third-year medicine resident FTEE allocated to this PCA (interns were omitted after statistical testing); FELLOWS= FTEE of medicine residents PGY 4 and above allocated to this PCA; SOCW= social worker FTEE allocated to this PCA; HGROUP6= categorical variable assuming a value of 1 if the facility is in RAM Group 6 (psychiatric hospital); (MED_MD×FELLOWS)= interaction term for the joint influence of VA staff internists and medicine fellows on the rate of workload production in this PCA; and N= number of inpatient medicine PCAs (equivalent to the number of VA medicine services) in the sample. Ambulatory Medicine Patient Care Area with =0.647 and N=168

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Physician Staffing for the VA: VOLUME II where W =the natural logarithm of total CAPWWUs, plus 1, produced in the ambulatory medicine PCA during the fiscal year. RMS_MD =VA staff physician FTEE from the rehabilitation medicine service allocated to direct patient care in the ambulatory medicine PCA; OTHER_MD =total FTEE allocated to ambulatory medicine PCA by VA staff physicians not in medicine, surgery, psychiatry, neurology, and rehabilitation medicine. HGROUP(3+5) =categorical variable assuming a value of 1 if the facility is in RAM Group 3 (midsize affiliated) or 5 (metro affiliated). B. Inverse Production Function Medicine with =0.595 and N=164

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Physician Staffing for the VA: VOLUME II where MED_MD' =the natural logarithm of the sum of all VA internist FTEE devoted to direct care (i.e., the sum of all MED_MD variables) across all PCAs, plus total internist FTEE allocated to resident training across all PCAs, plus 1; MEDWWU =total medicine WWUs produced during the fiscal year in the inpatient PCAs of medicine, surgery, psychiatry, neurology, and rehabilitation medicine (divided by 10,000); MEDCAPWWU =total CAPWWUs produced during the fiscal year in the ambulatory PCAs of medicine and other physician services (divided by 10,000); MEDRUGWWU =total RUGWWUs produced during the fiscal year in the long-term-care PCAs of nursing home and intermediate care (divided by 10,000); FELLOWS =total FTEE of medicine residents PGY4 and above at the VAMC; HGROUP2 =categorical variable assuming a value of 1 if the facility is in RAM Group 2 (small, general unaffiliated VAMC); and HGROUP4 =categorical variable assuming a value of 1 if the facility is in RAM Group 4 (midsize general unaffiliated VAMC).

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Physician Staffing for the VA: VOLUME II TABLE 3 External Norms—Medicine Source, Result, and Derivation, if any: VA 2 MD+1 MD/15 short-term beds+1 MD/25 long-term beds Indian Health Service 1 MD+1 MD/12 ADC 1 MD/5,000 visits American Medical Association Core Survey Dis1= 4.8 dis/week×47.9 week/year ×(40 hour/week/60.1 hour/week) ×(54 hour/week/60.1 hour/week) eff factor ×[54 hour/week/(14.4+1.6)     hour/week hosp]= 464 dis/MD/year Dis2= 1 dis/3.3 hour×2,080 hour/year ×(54 hour/week/60.1 hour/week) eff factor     ×0.85 availability factor= 481 dis/MD/year ADC= 21.1 pt day/week×47.9 week/year ×1 ADC/365 pt day ×(54 hour/week/60.1 hour/week) eff factor ×[54 hour/week/(14.4+1.6)     hour/week hosp]= 8.4 ADC/MD/year Amb= 2.5 visit/hour×40 hour/week ×47.9 week/year×54/60.1     eff factor= 4,300 visits/MD/year

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Physician Staffing for the VA: VOLUME II NYH&HC ADC= ADC/attendings= 7.0 ADC/MD/year Amb= visits/attendings= 4,270 visits/MD/year Group Health Inc. of St. Paul 90 visits/MD/week×45 week/year= 4,050 visits/MD/year Large Health Maintenance Organization Dis= 1/3 med ratio×291 pt days/1,000 members ×5,436 k mem/365 day/year/0.1 inpt factor ×40 hour/week/47 hour/week/     2,412 MD= 5.1 ADC/MD Amb= 1,571 visit/k mem×5,436 k mem /2,412 MD/0.9 OP factor     ×(40 hour/week/47 hour/week)= 3,350 visit/MD/year Department of Defense Standards for the workload per MD per year are specified separately by DoD for each of a large number of specialists, e.g., internists, neurologists, general surgeons, orthopedic surgeons, neurosurgeons, etc. Further, different standards are specified for teaching versus nonteaching hospitals. Thus the overall workload per MD for a given hospital is a function of the type of hospital as well as the mix of patients seen there. For example, for an ADC in medicine of 100 with 5,000 outpatient visits per month at a teaching facility the inpatient physician requirement would be 100 ADC/10.3 ADC/MD=9.7 MD and the outpatient physician requirement would be 5,000 visit/484 visit/MD=10.3 MD

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Physician Staffing for the VA: VOLUME II TABLE 4 Application of the Staffing Norms to Three VAMCs Each of the available physician staffing norms discussed in the text was applied, in turn, to the three VAMCs studied in the second panel meeting in order to derive the number of physicians required in internal medicine (as implied by each norm). This table provides the inferred medicine staffing level for each.   VAMC I VAMC II VAMC III VA 1965 8.0 18.0 10.0 VA 1988 25.6 37.6 15.0 DoD 41.0 53.0 27.9 IHS 19.0 40.9 29.7 AMA 22.4 50.9 35.3 NYH&HC 24.2 56.0 37.6 Univ 28.0 27.3 16.2 HMO 31.8 74.2 49.2

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Physician Staffing for the VA: VOLUME II INSTITUTE OF MEDICINE Committee to Develop Methods Useful to the Department of Veterans Affairs in Estimating Its Physician Requirements MEDICINE PANEL DANIEL W.FOSTER (Chair),*† Professor and Chairman, Department of Internal Medicine, University of Texas Southwestern Medical Center at Dallas GALEN L.BARBOUR, Associate Chief Medical Director for Quality Management, Department of Veterans Affairs, Washington, D.C. JOHN G.DEMAKIS, Director, Health Services Research, and Associate Chief of Staff, Hines VA Medical Center, Chicago, Illinois WILLIAM F.DENNY, Chief, Medical Service, Tuscon VA Medical Center, Tuscon, Arizona PHILIP J.FIALKOW, Professor and Dean, School of Medicine, University of Washington, Seattle GERALD S.LEVEY, Professor and Chairman, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania EDWARD RUSCHE, Chief, Medical Service, Ft. Howard VA Medical Center, Ft. Howard, Maryland MARVIN H.SLEISENGER, Professor of Medicine and Director, Cancer Research Institute, University of California at San Francisco Staff: Nancy Kader, Staff Officer *Member of the Institute of Medicine. †Member of the study committee.

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