REFERENCE COMMITTEE F

Health Professions and Facilities Item No. Resolution(s)/Report(s) Page No.. 0-: ADDRESSING THE SHORTAGE OF GENERAL SURGEONS IN CALIFORNIA. 0-: MEDICAL SCHOOL LOAN FOR UNDOCUMENTED MEDICAL STUDENTS AND LOAN FORGIVENESS ELIGIBILITY 0-: IMPROVED ACCESS TO MEDICAL STUDENT LOANS. 0-: PHYSICIAN RE-ENTRY INTO THE WORKFORCE. 0-: MAINTENANCE OF CERTIFICATION. 0-: ALTERNATIVE DEFINITIONS OF BOARD CERTIFICATION. 0-: TEACHING ABOUT PREVENTION OF DISEASES IN MEDICAL SCHOOLS. 0-: EXPOSURE TO SPECIALTIES IN MEDICAL SCHOOLS. 0-: ENCOURAGING BIOMEDICAL CAREERS FOR UNDERRPRESENTED MINORITIES AND DISADVANTAGED STUDENTS. 0-: IMPLICIT BIAS TRAINING FOR MEDICAL STUDENTS 0. -: PATIENT MOBILITY PERFORMANCE IMPROVEMENT PROGRAM. -: EQUALIZING MATERNITY AND PATERNITY LEAVE FOR RESIDENTS. -: CONTINUITY OF CARE IN HOSPITAL. -: SUPERVISION OF RETAIL HEALTH CLINIC PERSONNEL 0. -: ORAL TRANSMISSION OF SCHEDULE II HOSPICE ORDERS. -: QUALITY STANDARDS FOR THE PRACTICE OF MEDICINE. -: PHYSICIAN STANDARD OF CARE. -: EARLY NOTIFICATION OF NON-PHYSICIAN SUPERVISION. F--: POLICY SUNSET REVIEW

REPORT OF CALIFORNIA MEDICAL ASSOCIATION HOUSE OF DELEGATES October -, 0 Report of Reference Committee F Health Professions and Facilities Presented by Angie Chen, MD, Chair NOTE: This report and the recommendations of the Reference Committee do not represent the official actions or policy of the California Medical Association. These recommendations are presented for consideration by the CMA House of Delegates, which then promulgates the policies of the CMA. 0 0 0 Members of the CMA House of Delegates: The reports and resolutions referred to Reference Committee F have been considered by our Committee, which met at :00 p.m. via Uber Conference and Telephone Conference in California on October, 0. Members of the Committee present include: Angie Chen, MD, Chair; Kyle Edmonds, MD; Marcia Gollober, MD; Po-Yin Samuel Huang, MD; Eleanor Martinez, MD; Vincent Mason, MD; and Rahul Parikh, MD.. Resolution 0-: ADDRESSING THE SHORTAGE OF GENERAL SURGEONS IN CALIFORNIA Authors: Anirudh Saraswathula, Katherine Salcedo-Concepcion, Anna Yap, Pooja Desai RESOLVED: That CMA recognize the shortage of general surgeons; and be it further RESOLVED: That CMA, in order to increase the number of new general surgeons and to ease the strong pressures for further specialization, support: () the continued creation and funding of general surgery programs and fellowships and () increased scholarship and loan-forgiveness programs for graduates choosing to open general surgery practices, especially in areas of shortage. APPROVAL OF RESOLUTION #0- AS AMENDED AND THE RESOLVED PORTION IS AMENDED TO READ: RESOLVED: That CMA recognize the shortage of general surgeons; and be it further RESOLVED: That CMA reaffirm its support for addressing the shortage and geographic maldistribution of all physicians in California and supporting advocacy for increased residencies and loan repayment programs for all physicians.

Page REPORT OF 0 0 0 0 A. The majority of testimony recognized the shortage of general surgeons in California as a physician supply issue. B. The Reference Committee s amended language recognizes existing policy recognizing the shortage and geographic maldistribution of all physicians in California and supporting advocacy for increased residencies and loan repayment programs for all physicians. C. Advocacy for additional residency programs and financial support for a particular medical specialty could divide the CMA membership and set a precedent of prioritizing the needs of some medical specialties over others.. Resolution 0-: MEDICAL SCHOOL LOAN FOR UNDOCUMENTED MEDICAL STUDENTS AND LOAN FORGIVENESS ELIGIBILITY Authors: Medical Student Section (MSS), Margaret Juarez, MD, Efrain Talamantes, MD, MBA, Allen Rodriguez RESOLVED: That our CMA ask the state of California to create and fund a loan program for undocumented medical students enrolled in any accredited California medical school that is equitable and comparable to loans offered through the Federal Government; and be it further RESOLVED: That CMA support the inclusion of a public service loan forgiveness option in the aforementioned loan program. Resolution 0-: IMPROVED ACCESS TO MEDICAL STUDENT LOANS Authors: Allen Rodriguez, LeeAnn Li, Lobsang Marcia, MD, Nipun Bhandari, MD, Michelle Lin, MD, Jerry P. Abraham, MD, MPH RESOLVED: That CMA ask the State of California to create and fund a loan program for medical students enrolled in any accredited California medical school who are unable to secure federal loans that is comparable to loans offered through the Federal Government; and be it further RESOLVED: That CMA support the inclusion of a loan forgiveness option in the aforementioned loan program for public service in underserved areas of California. RESOLUTION (FOR RESOLUTIONS #0- AND #0-) AND RESOLVED: That CMA support allowing undocumented medical students to apply for state-funded scholarships and loans; and be it further RESOLVED: That CMA support that undocumented licensed physicians be eligible to apply for loan forgiveness and repayment programs

Page REPORT OF 0 0 0 0 such as the Steven M. Thompson Loan Repayment Program; and be it further RESOLVED: That this matter be referred for national action. A. The substitute resolution is consistent with CMA s support for equal access to financial aid resources for all medical students. B. Advocating for the establishment of a targeted loan fund is potentially very resource intensive and would likely benefit only a small number of medical students. C. The Reference Committee discussed that changes to eligibility requirements for existing state loan programs may be more feasible and effective than advocating for the establishment of a new loan program. D. The substitute resolution includes a referral for national action because the original resolution requests the establishment of loan programs comparable to those administered by the federal government and the AMA does not have policy on loan programs for undocumented medical students.. Resolution 0-: PHYSICIAN RE-ENTRY INTO THE WORKFORCE Author: David Bazzo, MD RESOLVED: That CMA work with the Medical Board of California and the Osteopathic Medical Board of California to develop provisional licensing for physicians wishing to retrain prior to re-entry (as defined by the American Medical Association) into medical practice. RESOLUTION (FOR RESOLUTION #0-) AND RESOLVED: That CMA study and develop principles and recommendations on the issue of physician reentry into clinical practice; and be it further RESOLVED: That CMA work with the Medical Board of California and the Osteopathic Medical Board of California to develop and implement a physician reentry policy. A. The majority of testimony received was in favor of CMA addressing the issue of physician reentry. B. Physician reentry is a complex issue that requires further study to determine the conditions under which a physician should be subject to closer monitoring.

Page REPORT OF 0 0 0 0 C. The Reference Committee s discussed the need for CMA to study and develop policy on the issue of physician prior to providing recommendations to the Medical Board and taking a position on provisional licensing.. Resolution 0-: MAINTENANCE OF CERTIFICATION Authors: J. Steven Poceta, MD, Will Tseng, MD, MPH RESOLVED: That CMA acknowledge that current ABMS maintenance of certification requirements are onerous, costly, and time-intensive, and be it further RESOLVED: That CMA work with AMA and other parties to study alternative methods for physician life-long learning after initial board certification. APPROVAL OF RESOLUTION #0- AS AMENDED AND THE RESOLVED PORTION IS AMENDED TO READ: RESOLVED: That CMA work with AMA and other parties to continue studying alternative methods for physician life-long learning after initial board certification. A. The majority of testimony received expressed frustration with the current maintenance of certification process and support for alternative methods of board certification. B. Maintenance of certification requirements for each specialty are established by individual specialty boards and declaring that all maintenance of certification requirements are onerous, costly and time-intensive would be a point-in-time assessment and argumentative. C. The Reference Committee s amended resolution recognizes that the AMA is already working with the American Board of Medical Specialties to take steps toward improving maintenance of certification programs, including removing the requirement for testing at renewal.. Resolution 0-: ALTERNATIVE DEFINITIONS OF BOARD CERTIFICATION Authors: J. Steven Poceta, MD, Will Tseng, MD, MPH RESOLVED: That CMA work with the Medical Board of California to re-assess California Business and Professions Code section (h)()(a)&(b) and to consider allowing physicians initially certified by an ABMS member board to use pathways other than ABMS member board s MOC programs to fulfill requirements for life-long learning and to advertise that they are board certified.

Page REPORT OF 0 0 0 0 DISAPPROVAL OF RESOLUTION #0- AND ASKS FOR A "NO" VOTE ON IT. A. Amending Business & Professions Code (h)() to direct the Medical Board to allow the use of the term board certified without being certified by a recognized board is likely to cause confusion among patients. B. The Medical Board of California has no authority over maintenance for certification standards over any board it may recognize. C. The Reference Committee discussed that the American Board of Medical Specialties and some specialty boards are already implementing changes to their maintenance of certification requirements. There may be more value in supporting the continued improvement of the existing board certification system than advocating the use of alternative pathways.. Resolution 0-: TEACHING ABOUT PREVENTION OF DISEASES IN MEDICAL SCHOOLS Author: Ronald P. Hattis, MD RESOLVED: That CMA recommend that the teaching about specific diseases or disease groups in medical schools include information on the epidemiology and the primary and secondary prevention of those diseases, including the roles of nutrition and lifestyle as relevant; and be it further RESOLVED: That CMA transmit this recommendation to the deans of California s medical schools, the Liaison Committee on Medical Education (LCME), the Association of American Medical Colleges, and the American Osteopathic Association; and be it further RESOLVED: That this matter be referred for national action. RESOLUTION (FOR RESOLUTION #0-) AND RESOLVED: That CMA recommend that the teaching about specific diseases or disease groups in medical schools include information on the epidemiology and the primary and secondary prevention of those diseases, including the roles of nutrition and lifestyle as relevant. A. The resolution is consistent with CMA policy supporting proactive wellness and prevention programs.

Page REPORT OF 0 0 0 0 B. The substitute resolution provides flexibility for CMA to effectively advocate for this goal as appropriate which may include, but is not limited to, sending letters to medical school deans. C. The substitute resolution deletes the direction to refer the resolution for national action because the AMA has existing policy addressing this issue.. Resolution 0-: EXPOSURE TO SPECIALTIES IN MEDICAL SCHOOLS Author: Ronald P. Hattis, MD RESOLVED: That CMA recommend that medical schools provide at least brief clinical exposure to as many as practical of the major medical specialties recognized by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association; that they facilitate access by medical students to online resource information about all recognized medical specialties and subspecialties; and that they provide and encourage access to at least one elective rotation, extramural (offcampus) if needed, for a specialty not available in the regular curriculum but in which a student is interested; and be it further RESOLVED: That CMA transmit this recommendation to the deans of California s medical schools, the Liaison Committee on Medical Education (LCME), the Association of American Medical Colleges, the American Osteopathic Association, and the American Board of Medical Specialties; and be it further RESOLVED: That this matter be referred for national action. RESOLUTION (FOR RESOLUTION #0-) AND RESOLVED: That CMA support that medical schools provide medical students with access to information about all recognized medical specialties, through a range of mechanisms including, but not limited to clinical rotations, online resources, physician mentors, and exchange programs with other medical school programs. A. The substitute resolution provides support for medical students to receive broad exposure to medical specialties and provides medical schools with flexibility to achieve this goal. B. The substitute resolution provides flexibility for CMA to effectively advocate for this goal as appropriate which may include, but is not limited to, sending letters to medical school deans.

Page REPORT OF 0 0 0 0 C. The majority of testimony was in favor of increasing medical student exposure to more medical specialties.. Resolution 0-: ENCOURAGING BIOMEDICAL CAREERS FOR UNDERRPRESENTED MINORITIES AND DISADVANTAGED STUDENTS Authors: Stacy Songco, Allen Rodriguez, Anna Yap RESOLVED: That CMA support county medical societies and medical student organizations with pipeline programs, targeting underrepresented minority and disadvantaged students at any level of academic education, to help increase ethnic minority physicians in medically underserved areas; and be it further RESOLVED: That CMA work with medical and allied health professional societies, the Department of Public Health, and other appropriate organizations to develop biomedical career exposure and intervention programs such as work-based internship opportunities in health careers. APPROVAL OF RESOLUTION #0- AND ASKS FOR A "YES" VOTE ON IT. A. The resolution is consistent with existing CMA policy promoting scientific careers to students. B. Pipeline programs have been demonstrated to be successful in encouraging students to pursue health careers and to return to their home communities to practice. C. All testimony received was in support of this resolution.. Resolution 0-: IMPLICIT BIAS TRAINING FOR MEDICAL STUDENTS Authors: Keyon R. Mitchell, Rabia Aslam, Nazeela Sabir, Asadullah Awan RESOLVED: That CMA acknowledge that implicit biases exist, and that they have adverse effects on patient care; and be it further RESOLVED: That CMA encourage all California medical schools introduce their students to the concept of implicit bias; and be it further RESOLVED: That CMA encourage all California medical schools to support the provision of debiased training opportunities for medical students; and be it further RESOLVED: That CMA supports studies to demonstrate the positive impacts of deconstructing implicit bias for medical students and patient care.

Page REPORT OF 0 0 0 0 RESOLUTION (FOR RESOLUTION #0-) AND RESOLVED: That CMA acknowledge that implicit biases exist, and that they may impact patient care; and be it further RESOLVED: That CMA support further studies on the impact of implicit biases on patient care and strategies for educating medical students, residents and physicians on deconstructing these biases; and be it further RESOLVED: That CMA support the inclusion of implicit bias training in medical school curriculums and continuing medical education programs. A. The Reference Committee s substitute resolution recognizes the impact of implicit biases in health care and the need for further study. B. The substitute resolution broadens the support for implicit bias education beyond medical schools to include continuing medical education for practicing physicians. C. The majority of testimony received was in support of this resolution. 0. Resolution -: PATIENT MOBILITY PERFORMANCE IMPROVEMENT PROGRAM Author: Michael Liu, MD, MBA, FACP RESOLVED: That CMA strongly advocate for study, testing and development of a standardized evidence-based mobility and ambulation program pilots for adult patients that can be eventually spread and adoptable by almost any hospital; and be it further RESOLVED: That CMA advocate that almost all hospitals that care for adult patients measure and improve patient mobility activities by 0; and be it further RESOLVED: That CMA should seek support of other health care advocacy groups to support this program; and be it further RESOLVED: That the requirements of this program include the following: assessment of the patient s prior level of function, current level of function, determination of appropriate mobility activities, measurement of frequency of prescribed activities, proper training and equipment allocation for safety, and data measurement of program goals including percentage of prescribed activities that patients participated in, percentage of patients who functionally declined and injuries to staff or patients; and be it further RESOLVED: That this matter be referred for national action.

Page REPORT OF 0 0 0 0 RESOLUTION (FOR RESOLUTION #-) AND RESOLVED: That CMA work with the California Hospital Association and other stakeholders to encourage the adoption of hospital mobility and ambulation programs in California hospitals; and be it further RESOLVED: That this matter be referred for national action. A. There is significant evidence supporting the use of patient mobility programs in hospitals for adult patients. B. The substitute resolution recognizes differences in hospital patient populations and resources and provides flexibility for hospitals to adopt patient mobility programs that appropriate to their resources and patient population. C. The referral for national action is appropriate, because AMA does not have existing policy on the issue of patient mobility programs in hospitals.. Resolution -: EQUALIZING MATERNITY AND PATERNITY LEAVE FOR RESIDENTS Authors: Pooja Desai, Nuriel Moghavem, Mark Ard, Trevor Cline RESOLVED: That CMA recommend that residency departments develop equal paid and unpaid maternity and paternity leave policies for residents. APPROVAL OF RESOLUTION #- AND ASKS FOR A "YES" VOTE ON IT. A. This resolution does not require residency programs to increase the amount of leave granted under parental leave policies, but does encourage that the policies developed should be equal. B. This resolution is consistent with CMA policy in support of clear family leave policies. C. The majority of testimony received was in support of the resolution.. Resolution -: CONTINUITY OF CARE IN HOSPITAL Authors: Vimal Nanavati, MD, FACC, FSCAI, Sumanta Chaudhuri Saini, MD RESOLVED: That for every patient admitted, there should be one attending hospitalist in charge of the patient without change with the exception of night or weekend call; and be it further

Page 0 REPORT OF 0 0 0 0 RESOLVED: That a hospitalist should remain with the patient until discharge or at least for one full week without interruption or change. RESOLUTION (FOR RESOLUTION #-) AND RESOLVED: That CMA support the development of hospital policies and procedures that support continuity of patient care. A. Not every hospital uses hospitalists, so it is not feasible to establish a policy that requires every patient to be assigned a hospitalist to oversee their care. B. The substitute resolution supports the development of policies that support improved continuity of care without requiring implementation of a specific strategy that may not be feasible for all hospitals. C. The majority of testimony received opposed mandating a prescriptive continuity of care program.. Resolution -: SUPERVISION OF RETAIL HEALTH CLINIC PERSONNEL Author: Michael Borok, MD RESOLVED: That CMA support legislation requiring that any physician that employs or supervises nurse practitioners working in retail health clinics must spend at least 0% of their professional time in active medical practice directly treating patients. DISAPPROVAL OF RESOLUTION #- AND ASKS FOR A "NO" VOTE ON IT. A. Nurse practitioners are already required to practice under physician supervision and consistent with standardized protocols, regardless of the setting in which they are practicing. B. Current law does not impose restrictions on the practice of physicians who are supervising nurse practitioners in any setting. Supporting a requirement that nurse practitioners may only be supervised by physicians who spend 0% of their time in active practice directly treating patients may result in less supervision of nurse practitioners or decreased access to care for patients. C. There is no evidence that physicians who spend 0% of their time in direct patient care provide better supervision of nurse practitioners than physicians who are engaged in other activities as part of their professional practice.

Page REPORT OF 0 0 0 0 D. The majority of testimony received was in opposition to this resolution.. Resolution -: ORAL TRANSMISSION OF SCHEDULE II HOSPICE ORDERS Author: Russ D. Granich, MD RESOLVED: That CMA support changes to federal law to allow oral transmission of Schedule II medication orders for hospice patients; and be it further RESOLVED: That this matter be referred for national action. RESOLUTION (FOR RESOLUTION #-) AND RESOLVED: That CMA support amending federal law to allow for pharmacies to fill an oral prescription for a Schedule II (C-II) controlled substance for a hospice patient. A. Support for the amendment of federal law consistent with state law on this issue is consistent with CMA s support for AB 0 (Thomson, 000) which allowed for fax, oral and e-mail prescription of Schedule II controlled substances for hospice patients. B. The referral for national action proposed in the resolution is unnecessary because the AMA has already adopted policy in support of federal legislation to allow oral or computer-generated electronic prescription for a Schedule II (C-II) controlled substance for a hospice patient. C. The majority of testimony received was in support of this resolution.. Resolution -: QUALITY STANDARDS FOR THE PRACTICE OF MEDICINE Author: Jeffrey Young, MD RESOLVED: That any practitioner who engages in the practice of medicine (as defined by the Medical Board of California) be held to the same standard of a physician; and be it further RESOLVED: That CMA encourage the California Department of Consumer Affairs to make the necessary regulatory changes to enforce these standards; and be it further RESOLVED: That CMA adds to its mission statement that CMA is dedicated to the maintenance of the delivery of the highest quality of care to patients; and be it further RESOLVED: That this matter be referred for national action.

Page REPORT OF 0 0 0 DISAPPROVAL OF RESOLUTION #- AND ASKS FOR A "NO" VOTE ON IT. A. There is no single standard of care for all medical services and procedures. Standards of care are specific to practitioners in the same profession with the same education and training at a specified point in time. B. Establishing a single standard of care could have implications for how primary care physicians are evaluated compared to specialists for patient care. C. There is already existing CMA policy that medical procedures may be performed by non-physicians only when the individual practitioners have the requisite training and experience and there is appropriate physician supervision.. Resolution -: PHYSICIAN STANDARD OF CARE Author: Robert Bitonte, MD RESOLVED: That the public be informed through public education that physicians, and physicians only, are required to provide a standard of care consistent with the standard of care of other physicians. RESOLUTION (FOR RESOLUTION #-) AND RESOLVED: CMA supports that a physician s standard of care is the level of skill, knowledge, and care in diagnosis and treatment that other reasonably careful physicians with similar levels of skill and knowledge would use in the same or similar circumstances. A. Standard of care is a complex legal issue for which it would be very difficult and expensive to execute an effective public education campaign. B. The Reference Committee s substitute resolution states a position on standard of care which is consistent with the legal definition of standard of care. C. The testimony received expressed concerns regarding the cost associated with implementing a public education campaign.

Page REPORT OF 0 0 0 0. Resolution -: EARLY NOTIFICATION OF NON-PHYSICIAN SUPERVISION Author: Robert Bitonte, MD RESOLVED: That patients should be notified at the time of appointment scheduling, that they will, or will not, be treated by a physician or a physiciansupervised practitioner; and be it further RESOLVED: That in non-appointment circumstances or venues, a conspicuous sign will be posted in the waiting area if the patient will, or will not, be seen by a physician or a physician-supervised practitioner. RESOLUTION (FOR RESOLUTION #-) AND RESOLVED: That CMA supports that patients should be notified when an appointment is scheduled and at the time of the visit, if they will be treated by a physician or an allied health professional. A. The Reference Committee s substitute resolution recognizes the patient s right to know the license of the health provider who will be providing care. B. The substitute resolution is consistent with current law that requires health care providers to wear nametags specifying their name and license and provides another mechanism for ensuring that patients are informed about who will be providing their care. C. Requiring the use of waiting room signs to notify patients about who will be providing care may be cumbersome and difficult to implement. The substitute resolution provides flexibility regarding how the patient should be notified regarding who will be providing care.. Report F--: POLICY SUNSET REVIEW THAT POLICIES 0-0 Resolved, 0a-0 Resolved, 0a-0 Resolved, 0-0 Resolved, 0-0 Resolved, 0-0 Resolved, 0-0 Resolved, 0a-0 Resolveds, &, 0a-0, &, -0 Resolved, -0 Resolved, a-0 Resolveds,, &, -0 Resolveds, &, - 0 Resolveds, &, -0 Resolved, 0-0 Resolved, -0 Resolved, -0 Resolved BE

Page REPORT OF 0 RENEWED AND THAT POLICIES 0a-0 Resolved, 0-0 Resolved, 0-0 Resolved, a-0 Resolveds, &, -0 Resolved, -0 Resolved, -0 Resolveds &, F--0 BE ALLOWED TO SUNSET. This concludes the report of Reference Committee F. I would like to thank the CMA members who testified; our Committee members, Kyle Edmonds, MD; Marcia Gollober, MD; Po-Yin Samuel Huang, MD; Eleanor Martinez, MD; Vincent Mason, MD; Rahul Parikh, MD; and our CMA staff, Yvonne Choong and Jennifer Williams. Angie Chen, MD, Chair