I. BACKGROUND

Many factors influence the number and distribution of graduate medical education (GME) positions sponsored by and affiliated with UC medical school campuses. Over time, these have varied from campus to campus, region to region, and specialty to specialty. Flexible guidelines concerning the number and specialty distribution of GME positions increase the likelihood that UC campuses will maintain high quality programs that fulfill their teaching, patient care, and research missions. The ability of UC programs to address public health needs, respond to new diseases and changing technologies, and to develop programs responsive to societal needs requires institutional planning, flexibility, and access to adequate clinical and other resources. As new bodies of scientific knowledge emerge, and as new fields of practice develop, UC medical centers are expected to serve at the leading edge of clinical training and patient care. Meeting these expectations requires the capacity and flexibility to periodically adjust the size and scope of UC's more than 250 physician training programs.

For nearly a quarter of a century, the total number of state-supported GME positions within UC has been unchanged at 3,829 positions systemwide. This has been true despite profound increases in the size, diversity and aging of the California population, and dramatic growth in the number of new specialties and sub-specialties for which specific training and accreditation standards exist. For most of the past decade, the size and specialty distribution of UC residency training programs have been governed by a 1994 agreement with the State calling for 1) significant increases in the number and proportion of family medicine positions offered by UC-based and UC-affiliated programs, 2) reductions in non-primary care specialty training at four of five campuses, and 3) maintenance of a systemwide enrollment of more than 50% primary care positions. This agreement ended in summer 2002 with the submission of two final reports providing enrollment
and other data for the 2001-02 academic year.

While calls to increase the training of primary care physicians were common in California and nationally in the early 1990s, the lack of flexibility characteristic of the past decade for UC campuses resulted in a number of negative and unanticipated consequences. Among these, most campuses avoided development of programs in emerging fields such as pain management and medical genetics because growth of such programs would have required further reductions in non-primary care to meet overall campus limits for specialty training. For the same reasons, campuses lacked the flexibility to expand much needed physician-scientist and other specialty programs to address emerging areas of workforce need, such as those in adult and child psychiatry. In several instances, campuses were required to choose between closing small programs and reducing the size of multiple programs to comply with campus goals. This in turn resulted in either increased workloads for other hospital personnel or reductions in patient services. Many of UC's smaller training programs expressed concerns about the need to maintain a critical mass of residents in order to meet expected standards for teaching and to ensure adequate support and supervision for more junior residents and medical students. At the same time, budget realities for UC hospitals allowed limited options for hiring new staff, adding still greater challenges for both maintaining access to services and meeting new accreditation requirements limiting resident work hours.

II. PROGRAM AND ENROLLMENT STANDARDS

Because no growth in state support has occurred for more than two decades, and because the University may not see new funding for GME for several years, new standards and procedures are needed to facilitate planning and decision making. Although major changes in the specialty distribution of UC training positions have occurred, there has been little change in total GME systemwide enrollments over the past decade.

The University is currently engaged in a comprehensive health sciences planning process that will likely result in a request for an increase in state-supported GME enrollments. This process is on schedule for completion for all health professions programs by spring 2004, but will be expedited if UC's overall budgetary outlook improves before then. The following definitions and standards address the counting and reporting of residents enrolled in UC-based and UC-affiliated programs, and parameters for planning and decision making for various categories of state funded and non-state funded enrollments. These standards and procedures are effective November 1, 2002 for campus planning purposes and apply to all new and continuing residents as of July 1, 2003. For purposes of this document, the term resident is defined according to the national Accreditation Council on Graduate Medical Education (ACGME) to include trainees pursuing first specialty board training, as well as those pursuing subspecialty board or fellowship training (throughout this document the term resident includes trainees that are also referred to as fellows). These standards and procedures will remain in place until superceded by new standards from the Office of the Vice President-Health Affairs.

A. Definitions and Categories of UC Medical Resident Enrollments

Effective July 1, 2003, for purposes of counting, reporting, and planning for changes in residency program size, residents in UC-based and UC-affiliated programs will be categorized according to the following definitions:

Category I: Residents in UC-Based First Board Programs

Includes residents enrolled in UC campus-based, ACGME or ABMS approved first board (primary specialty) training programs for the minimum number of years required for specialty board accreditation. Campus-based programs are those based at a UC teaching facility, where the supervising physicians are UC faculty members, and where UC is the accredited entity that sponsors the program. First board programs are those that do not require completion of prior specialty board training in another program as a condition for acceptance (e.g., internal medicine, ophthalmology, and pediatrics). Residents in preliminary and transitional programs are included in this category.

Category II: Residents in UC-Based Second Board Programs

Includes residents enrolled in UC campus-based, ACGME or ABMS approved second board programs for the minimum number of years required for subspecialty board accreditation. Campus-based programs are those based at a UC teaching facility, where the supervising physicians are UC faculty members, and where UC is the accredited entity that sponsors the program. Second board programs, also referred to as "fellowships," are those that require satisfactory completion of training in a primary specialty board as a condition for acceptance (e.g., infectious disease and pediatric rheumatology). Residents in UC-based subspecialty programs leading to a Certificate of Added Qualifications (CAQ) are included in this category (e.g., geriatrics).
Category III: Residents in UC-Affiliated First Board Programs

Includes residents enrolled in UC-affiliated ACGME or ABMS approved first board (primary specialty) training programs for the minimum number of years required for specialty board accreditation. UC-affiliated residency programs are those based at non-University owned teaching facilities that are formally affiliated with UC for purposes of residency training. An approved UC affiliation agreement defining the terms and conditions of the affiliation is required. UC-affiliated programs differ from UC-based programs in that institutions other than UC are the accredited entities that sponsor the program(s) and make final determinations about program size, resident rotations, resident salaries and working conditions, and other programmatic matters. First board programs are those that do not require completion of prior specialty board training in another program as a condition for acceptance. Within this category, two groups of UC-affiliated first board programs (and residents) are recognized.

Category IIIA will be defined by each campus as a designated resident enrollment level for a limited number of long-standing, UC-affiliated first board programs that contributed to increases in campus-budgeted enrollment levels (i.e., resulted in FTE instructional support through the UC budget). Each campus will designate this number in coordination with the Office of Health Affairs and Budget Office. Unless otherwise approved by those offices, this number shall not be less than that in effect on January 1, 1980. (Note: This date was selected because no increase in the number of state-supported GME positions has occurred since then).

Category IIIB includes residents enrolled in UC-affiliated first board programs who are not included in Category IIIA. This includes two groups: (1) residents enrolled in UC-affiliated, first board programs that have established some type of approved affiliation arrangement with a UC campus since 1980, but for which no state-support is (or ever has been) provided in the University's budget (e.g., the East Bay Surgical Program affiliated with UCSF and various programs sponsored by Kaiser Permanente), and (2) residents enrolled in long-standing affiliated programs that have grown beyond the enrollment level funded in 1980 and for which no additional state support was provided.

Category IV: Residents in UC-Affiliated Second Board Programs

Includes residents enrolled in UC-affiliated ACGME or ABMS approved second board training programs for the minimum number of years required for subspecialty board accreditation. UC-affiliated residency programs are those based at non-University owned teaching facilities that are formally affiliated with UC for purposes of residency training. An approved UC affiliation agreement defining the terms and conditions of the affiliation is required. UC-affiliated programs differ from UC-based programs in that institutions other than UC are the accredited entities that sponsor the program(s) and make final determinations about program size, resident rotations, resident salaries and working conditions, and other programmatic matters. Second board programs, also referred to as "fellowships," are those that require satisfactory completion of training in a primary specialty board as a condition for acceptance. Residents in UC-affiliated subspecialty programs leading to a Certificate of Added Qualifications (CAQ) are included in this category (e.g., geriatrics).

Category V: Residents in UC-Based "Other" Clinical Training Programs

Category V includes residents in other UC-based clinical training programs of recognized study that are not approved by the ACGME or ABMS (e.g., glaucoma) and residents in programs of extended durations (e.g., chief residents in internal medicine, residents completing a research year as part of an approved program that is beyond the minimum number of years required for specialty or subspecialty accreditation, etc.). Residents in this category must have UC Post-Graduate Year (PGY) titles (i.e., this category does not include physicians with UC clinical faculty titles or other non-PGY titles).

Category VI: Residents in UC-Affiliated "Other" Clinical Training

Category VI includes residents in other UC-affiliated clinical training programs of recognized study that are not approved by the ACGME or ABMS (e.g., glaucoma) and residents in programs of extended durations (e.g., chief residents in internal medicine, residents completing a research year as part of an approved program that is beyond the minimum number of years required for specialty or subspecialty accreditation, etc).

B. Counting and Reporting UC-Based and UC-Affiliated GME Enrollments

All UC medical school campuses will continue to count all residents in UC-based and UC-affiliated first and second board training programs. By contrast to enrollment reporting practices in the 1990s, effective July 1, 2003, UC campuses will distinguish between programs and enrollments for which the University receives state support as part of its budgeted resident enrollment, and those programs (and residents) for which no state support is provided. For purposes of counting and reporting state-supported and non-state supported GME enrollments, campuses will use the above categories and definitions as follows:

Category I residents will continue to be counted and reported as part of each campus's state-supported enrollment. The total number of residents in this category will continue, as in the past, to be subject to budgeted enrollment limits for each campus.

Category II residents will be counted and reported as part of each campus's non-state supported enrollment unless otherwise approved or designated by the campus GME committee (see section entitled Planning and Oversight).

Category IIIA residents will be counted and reported as part of each campus's state-supported enrollment. As defined above, this number will be designated by each campus to reflect the state's intent in supporting such enrollments at or above the number of positions funded in 1980.

Category IIIB residents will be counted and reported as part of each campus's non-state supported budget (i.e., enrollments in UC-affiliated first board programs for which no state support is provided).

Category IV, Category V, and Category VI residents will also be counted and reported as part of each campus's non-state supported budget.

C. Instructional Support

The level of state instructional support and approved budgeted enrollment for GME changes only when the state authorizes a change. The budgeted GME enrollment and associated level of health sciences instructional (19900) support for each campus therefore will not change with the adoption and use of these guidelines. Until an increase in instructional support is approved by the state, the budgeted GME enrollment (i.e., the budgeted number of GME positions) will be the same for each campus as that which has been annually funded since 1980.

The level of institutional support (i.e., 19900 instructional support and other non-19900 instructional support) for individual training programs will continue to be determined at the campus level and is not expected to change by virtue of a program's designation in any given category.

D. Parameters for Future Growth

Effective July 1, 2003, and until an increase in state support for increased enrollments is approved, growth in each category is subject to the following:

Category I enrollments are subject to budgeted enrollment limits for each campus. Growth in this category may occur within budgeted enrollments only. For example, a campus with an actual enrollment of 550 residents and a budgeted enrollment of 600, may grow by up to 50 positions.

Category II enrollments may increase if approved by the campus GME Enrollment Committee and funded locally. Resources may include departmental discretionary income, research contracts and grants, or other sources that are approved for this purpose by the campus committee. Unless specifically designated by the campus committee as part of the state-supported enrollment, growth in this category is non-state supported and not subject to state-supported enrollment limits for each campus (see section entitled Planning and Oversight).

Category IIIA enrollments are fixed by historical definition and therefore not subject to growth. Although this number is part of the budgeted enrollment for four of UC's five medical school campuses, the actual current enrollment in many of these programs has grown over the past 20 years. With limited exceptions, this is because the affiliate is the entity that is responsible for authorizing and funding such growth.

Category IIIB enrollments are therefore subject to growth, unless otherwise specified in the approved UC affiliation agreement, if authorized and funded by the affiliate and approved by the ACGME. For example, UCLA is affiliated with two (non-state supported) family practice programs sponsored by Kaiser Permanente and located in southern California. If Kaiser chooses to increase enrollment in one of those programs and the ACGME approves expansion, enrollment growth would occur and be reported in Category IIIB for as long as the affiliation arrangement continued. Growth in this category is non-state supported and not subject to state-supported enrollment limits for each campus.

Category IV enrollments are very limited at most UC campuses (e.g., Davis, Irvine, and San Diego have no enrollments in this category in 2002-03). If, however, growth in this category were approved and funded by affiliate, an increase would occur and be reported (like Category IIIB) as part of the University's non-state supported enrollment. Future growth in this category is non-state supported and not subject to state-supported enrollment limits for each campus.

Category V and VI enrollments are relatively constant from year to year and typically involve only a limited number of positions in a very small number of programs (e.g., the number of chief resident positions for internal medicine programs does not change appreciably from year to year). Other types of changes in this category occasionally will occur (e.g., approval by the ACGME to add a required year of research to an existing gastroenterology program). Future growth in this category is non-state supported and not subject to state-supported enrollment limits.

E. Planning and Oversight

Campus GME Enrollment Committee

A campus GME Enrollment Committee consisting of at least the Dean of the School of Medicine, the Chief Executive Officer of the Medical Center, and the Associate Dean for Graduate Medical Education (or equivalent institutional official) will be established at each medical school campus. Separate from the Graduate Medical Education Committee (GMEC) that is required by the ACGME, and which already exists on each campus, the campus GME Enrollment Committee will be responsible for reviewing all categories of enrollments outlined above on at least an annual basis.

The campus GME Enrollment Committee will ensure that effective July 1, 2003, actual enrollments for state-supported positions do not exceed approved budgeted enrollment levels for the campus. Consistent with the definitions outlined above, each campus will designate all Category I residents and all Category IIIA residents as part of their state-supported enrollment. If a campus has enrollments in these two categories that do not meet the campus's budgeted enrollment limit, the campus GME Enrollment Committee may approve growth in new or existing Category I programs up to the authorized budgeted enrollment level.

If no growth in Category I enrollments is desired, and if total enrollments do not meet the budgeted enrollment limit, the campus GME Enrollment Committee may designate some or all Category II positions as budgeted under the enrollment cap. The designation of such programs as part of the state-supported enrollment shall not result in a total that exceeds the budgeted enrollment limit. For example, if a campus has an actual enrollment of Category I and IIIA trainees that totals 550, and if the campus has an authorized budgeted enrollment of 600, the campus could designate up to 50 Category II residents as part of its state-supported enrollment. In the event, however, that the campus has a total of 70 Category II trainees, no more than 50 may be designated as part of the campus's state-supported enrollment.

The campus GME Enrollment Committee will be responsible for reviewing and approving all requests for enrollment change (i.e., growth or reduction) in all Category II programs. The campus committee will also be responsible for developing proposals requesting future increases in budgeted enrollments. Campus proposals for increasing budgeted GME enrollment levels will be transmitted (like other proposed enrollment increases) to the Chancellor, who will determine whether or not to include the request in the campus's annual enrollment plan. This plan is due at the UC Office of the President in mid-August of each year. All requests to the Office of the President for growth in resident enrollments will be sent to the Systemwide GME Committee (see below) for review in conjunction with the UC Budget Office.

Systemwide GME Enrollment Committee

The Systemwide GME Enrollment Committee will consist of at least the GME Associate Dean from each campus, the UC Vice President for Health Affairs, and the UC Vice President for Clinical Services Development. The UC Director for Academic Health Sciences will serve as an ex-officio member. The Systemwide GME Enrollment Committee will: review and monitor the number and distribution of all categories of resident enrollments; review requests from the campuses for increases in the number of state-supported positions; and forward recommendations to the Budget Office for consideration and possible inclusion in the Regents' budget.

The Systemwide GME Enrollment Committee will meet at least semi-annually. On at least an annual basis, there will be a meeting of the systemwide committee with the Director of the Office of Statewide Health Planning and Development (OSHPD) to discuss UC physician training programs and workforce needs for the State. The systemwide committee will also meet on an annual basis with a group of health workforce stakeholders from state government, academia, and the private sector.

Each spring the Office of Health Affairs will provide recommendations to the deans of UC schools of medicine about those factors that are likely to result in a favorable outcome for growth in the health sciences. To the extent possible, these recommendations will be based on relevant information provided by OSHPD, members of the California Legislature, and other health workforce stakeholders. These recommendations will be intended to provide guidance in developing new campus proposals for growth that are likely to be favorably reviewed. Future increases in state support for GME instruction will be requested at the historically approved student: faculty ratio for medical residents. This ratio varies depending upon the location in which the new positions are based (i.e., the approved ratio for positions at UC and county teaching facilities is seven residents to one faculty FTE (7:1); and 10:1 for residency positions based at VA and community sites).

F. 2002-03 Assessment of California Physician Workforce Needs

To ensure that future growth in UC GME programs includes opportunities to address health workforce needs, the Office of Health Affairs has received funding from The California Endowment for a California Physician Workforce Study that will begin in September 2002 and be completed in summer 2003. The findings of this study will provide information regarding California's current physician supply and projected future demands. This and other information included in the study will be utilized to help guide UC health sciences enrollment planning and future growth in GME.

III. OTHER CONSIDERATIONS

A. UC San Diego - Enrollment Levels

The UCSD is recognized by the Office of the President and other UC medical school campuses as having a budgeted resident (GME) enrollment that is inequitable by comparison to other UC medical centers and inadequate to allow full development of clinical and academic programs at the campus. This inequity derives not from a lack of planning at UCSD, but to a freeze on health sciences enrollments imposed by the State in the 1980s. As an unintended side-effect of this freeze, which has now lasted two decades, the San Diego campus has been unable to develop new programs that would expand educational opportunities and the range of patient services that are provided. The freeze has inhibited the ability of the campus to train physicians to meet critical needs in the San Diego region, and to develop a cadre of clinicians and physician scientists to optimize faculty growth and development.

The Office of Health Affairs will use its best efforts to obtain increases in state-supported GME positions for the San Diego campus. In the event that other UC campuses demonstrate equally compelling needs for growth, and in the event that only limited growth is possible initially, no less than two-sixths of any new enrollment growth will be reserved for UCSD, with no more than one-sixth allowed for each of the other four campuses. This arrangement will remain in place until the number of state supported positions at San Diego has increased by 30%. Thereafter, growth at UCSD will occur according to the same standards as apply for other campuses.
B. UC San Francisco - Fresno Medical Education Program

The UCSF-Fresno Medical Education Program was established in the mid-1970's as part of new efforts to address health workforce needs in the region. Since 1980, UCSF's budgeted enrollment of 1000 GME positions has included 130 positions for UCSF-Fresno. In 2001-02, total enrollment in Fresno programs was 164. In view of the critical needs in the Central Valley, and because increases beyond the budgeted level are funded by regional facilities that cannot be served effectively by UCSF-based programs, enrollments in Fresno are considered within the context of Fresno's budgeted enrollment of 130. Fresno enrollments are thus not subject to the UCSF campus enrollment limit of 870. Future requests for growth in the number of state supported positions (i.e., beyond the 130 Category IIIA positions) must be submitted to the campus GME Enrollment Committee for review, approval, and (if approved) inclusion in the campus budget submitted by the Chancellor to the Office of the President (see section entitled Campus GME Enrollment Committee). Because state support for UCSF-Fresno programs flows through the UCSF campus budget, and because UCSF is ultimately accountable to The Regents and California Legislature for all residents in UCSF-Fresno residency training programs, proposed changes in all enrollment categories are subject to review and approval by the UCSF GME Enrollment Committee. This includes proposed increases or decreases in existing programs, proposed establishment of new programs, or proposed closure of programs.

C. UC Los Angeles - Charles R. Drew University of Medicine and Science

The Charles R. Drew University of Medicine and Science (Drew) is a private, non-profit corporation with a Board of Trustees that is separate and distinct from the UC Board of Regents. Drew conducts education and research programs in south central Los Angeles in collaboration with the Martin Luther King, Jr. County Hospital, also known as King-Drew Medical Center. State General Funds are provided to Drew under two separate contracts, each administered by UC. Funding for a budgeted enrollment of 170 Drew residents is provided as part of this arrangement. In 2001-02, enrollment at King-Drew Medical Center totaled 302 residents. For purposes of these standards, Drew residents are classified as Category IIIA (i.e., the 170 state-supported positions in first board programs); Category IIIB (i.e., non first board enrollments beyond 170); and Category IV (i.e., Drew residents in second board programs). Consistent with long-standing reporting practices and these standards, Drew enrollments are reported separately from those at UCLA and are not subject to the campus-based enrollment limit.

Future requests for growth in the number of state supported positions (i.e., beyond the 170 Category IIIA positions) must be submitted to the campus GME Enrollment Committee for review, approval, and (if approved) inclusion in the UCLA campus budget submitted by the Chancellor to the Office of the President. Because the governance structure for Drew is separate from that of UC, and because King-Drew Medical Center is the accredited entity for Drew residency programs, proposed changes in program size do not require approval by UCLA. Given that state support for 170 Drew residents flows through the UC budget, and that UC is required to report on all categories of Drew GME enrollments, the University requests that proposed changes (i.e., increases or decreases) in enrollment in Drew programs be submitted for review by the UCLA GME Enrollment Committee. As a result of any such review, the UCLA committee will provide a letter to Drew indicating that UCLA either "endorses" or "does not endorse" the growth proposed.

D. UC Davis - Affiliated Family Practice Programs

UC Davis sponsors its own UC-based family practice program, located at UCDMC in Sacramento. In addition, UC Davis is affiliated with eight non-University based programs, including a newly established rural program in Marysville/Yuba City. These programs serve the health needs of the people of northern California, and have particular dedication to medically underserved communities. Five of these programs are long-standing affiliates that initially contributed to increases in the campus-budgeted enrollment (see definition of Category IIIA). Since 1980, enrollment in these five programs has grown from 85 to 118 residents. Three new affiliates with an additional 52 residents in training have also been added, thereby bringing enrollment in UC Davis-affiliated family practice programs to a total of 170 trainees in 2001-02.

Consistent with these standards and definitions, enrollments are reported as part of UC's state-supported and non-state supported enrollments. Growth in these programs is not subject to campus-based enrollment limits. Given the long-standing relationship between UC Davis and the five affiliated programs with enrollments that contributed to the campus's budgeted enrollment, and in view of the State's interest in the growth of family practice programs over the past decade, it is important that the UC Davis GME Enrollment Committee be informed about enrollments as well as proposed growth. The University therefore requests that proposed changes (i.e., increases or decreases) in enrollment in these programs be submitted for review by the UCD GME Enrollment Committee. As a result of any such review, the UCD committee will provide a letter to the affiliated program indicating that UCD either "endorses" or "does not endorse" the proposed change.