DISCLAIMER

The following is a preliminary report of actions taken by the House of Delegates at its June 2021 Special Meeting and should not be considered final. Only the Official Proceedings of the House of Delegates reflect official policy of the Association.

AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES (J-21 Special Meeting)

Report of Reference Committee [C]

Tracey L. Henry, MD, MPH, Chair

1 Your Reference Committee recommends the following consent calendar for acceptance: 2 3 RECOMMENDED FOR ADOPTION 4 5 1. Council on Medical Education Report 1 – Council on Medical Education Sunset 6 Review of 2011 House Policies 7 2. Council on Medical Education Report 3 – Optimizing Match Outcomes 8 (Resolution 304-I-19) 9 3. Council on Medical Education Report 4 – Study Expediting Entry of Qualified 10 IMG Physicians to US Medical Practice 11 12 RECOMMENDED FOR ADOPTION AS AMENDED 13 14 4. Council on Medical Education Report 2 – Licensure for International Medical 15 Graduates Practicing in U.S. Institutions with Restricted Medical Licenses 16 (Resolution 311-A-19) 17 5. Council on Medical Education Report 5 – Promising Practices Among Pathway 18 Programs to Increase Diversity in Medicine 19 6. Resolution 305 – Non-Physician Post-Graduate Medical Training 20 7. Resolution 309 – Supporting GME Program Child Care Consideration During 21 Residency Training 22 8. Resolution 310 – Unreasonable Fees Charged and Inaccuracies by the American 23 Board of Internal Medicine (ABIM) 24 9. Resolution 318 – The Impact of Private Equity on Medical Training 25 10. Resolution 319 – The Effect of the COVID-19 Pandemic on Graduate Medical 26 Education 27 28 RECOMMENDED FOR REFERRAL 29 30 11. Resolution 304 – Decreasing Financial Burdens on Residents and Fellows 31 12. Resolution 314 – Standard Procedure for Accommodations in USMLE and 32 NBME Exams 33 Reference Committee C (J-21) Page 2 of 30

1 RECOMMENDED FOR REAFFIRMATION IN LIEU OF 2 3 13. Resolution 308 – Rescind USMLE Step 2 CS and COMLEX Level 2 PE 4 Examination Requirement for Medical Licensure 5 14. Resolution 311 – Student Loan Forgiveness 6 7 8 Amendments 9 10 If you wish to propose an amendment to an item of business, click here: 11 Submit New Amendment Reference Committee C (J-21) Page 3 of 30

1 RECOMMENDED FOR ADOPTION 2 3 (1) COUNCIL ON MEDICAL EDUCATION REPORT 1 – 4 COUNCIL ON MEDICAL EDUCATION SUNSET REVIEW 5 OF 2011 HOUSE POLICIES 6 7 RECOMMENDATION: 8 9 The Recommendation in Council on Medical Education 10 Report 1 be adopted and the remainder of the report be 11 filed, with the exception of H-260.978, “Salary Equity for 12 Laboratory Personnel,” which is reaffirmed. 13 14 HOD ACTION: Council on Medical Education Report 1 15 adopted and the remainder of the report filed, with the 16 exception of H-260.978, “Salary Equity for Laboratory 17 Personnel,” which is reaffirmed. 18 19 The Council on Medical Education recommends that the House of Delegates policies 20 listed in the appendix to this report be acted upon in the manner indicated and the 21 remainder of this report be filed. (Directive to Take Action) 22 23 Your Reference Committee heard limited, supportive testimony on this item. Testimony 24 from the Pathology Section Council requested that H-260.978, “Salary Equity for 25 Laboratory Personnel,” be reaffirmed rather than rescinded. Particularly during the 26 COVID-19 pandemic, the increased need for laboratory testing underscores the need for 27 highly skilled lab personnel who develop and run these tests is critical to maintaining 28 equitable access to timely, accurate lab results needed both by our care teams and our 29 patients. The Council on Medical Education agreed with the amendment, as does your 30 Reference Committee, which therefore recommends that Council on Medical Education 31 Report 1 be adopted as drafted, with the exception of H-269.978, which is to be reaffirmed. 32 33 (2) COUNCIL ON MEDICAL EDUCATION REPORT 3 – 34 OPTIMIZING MATCH OUTCOMES (RESOLUTION 35 304-I-19) 36 37 RECOMMENDATION: 38 39 Recommendations in Council on Medical Education 40 Report 3 be adopted and the remainder of the report be 41 filed. 42 43 HOD ACTION: Council on Medical Education Report 44 3 adopted and the remainder of the report filed. 45 46 1. That our AMA reaffirm Policies D-310.977, “National Resident Matching Program 47 Reform,” H-200.954, “US Physician Shortage,” and D-305.967, “The Preservation, Reference Committee C (J-21) Page 4 of 30

1 Stability and Expansion of Full Funding for Graduate Medical Education.” (Reaffirm HOD 2 Policy) 3 4 2. That our AMA encourage the Association of American Medical Colleges, American 5 Association of Colleges of Osteopathic Medicine, National Resident Matching Program, 6 and other key stakeholders to jointly create a no-fee, easily accessible clearinghouse of 7 reliable and valid advice and tools for residency program applicants seeking cost-effective 8 methods for applying to and successfully matching into residency. (Directive to Take 9 Action) 10 11 Your Reference Committee received supportive testimony in favor of adoption of this item, 12 including online testimony posted by the Academic Physicians Section, Resident and 13 Fellow Section, and Medical Student Section. As noted in the second recommendation of 14 the report, creation of a clearinghouse to assist applicants applying for residency programs 15 will help transparency and simplicity in the Match process and serve to decrease the 16 financial burden and other barriers to a successful match. This report also highlights our 17 AMA’s advocacy and leadership on this issue (through the Coalition for Physician 18 Accountability and other organizations) and our efforts to continue to change and improve 19 the Match. For these reasons, your Reference Committee recommends adoption of 20 Council on Medical Education Report 3. 21 22 (3) COUNCIL ON MEDICAL EDUCATION REPORT 4 – 23 STUDY EXPEDITING ENTRY OF QUALIFIED IMG 24 PHYSICIANS TO US MEDICAL PRACTICE 25 26 RECOMMENDATION: 27 28 Recommendations in Council on Medical Education 29 Report 4 be adopted and the remainder of the report be 30 filed. 31 32 HOD ACTION: Council on Medical Education Report 4 33 adopted and the remainder of the report filed. 34 35 1. That American Medical Association (AMA) Policy D-255.980 (1), “Impact of Immigration 36 Barriers on the Nation’s Health,” that reads, “Our AMA recognizes the valuable 37 contributions and affirms our support of international medical students and international 38 medical graduates and their participation in U.S. medical schools, residency and 39 fellowship training programs and in the practice of medicine” be reaffirmed. (Reaffirm HOD 40 Policy) 41 42 2. That our AMA encourage states to study existing strategies to improve policies and 43 processes to assist IMGs with credentialing and licensure to enable them to care for 44 patients in underserved areas. (Directive to Take Action) 45 46 3. That our AMA encourage the Federation of State Medical Boards and state medical 47 boards to evaluate the progress of programs aimed at reducing barriers to licensure— 48 including successes, failures, and barriers to implementation. (Directive to Take Action) 49 Reference Committee C (J-21) Page 5 of 30

1 4. That Policy D-255.978, “Study Expediting Entry of Qualified IMG Physicians to US 2 Medical Practice,” be rescinded, as having been fulfilled by this report. (Rescind HOD 3 Policy) 4 5 Your Reference Committee received supportive testimony in favor of adoption of this item, 6 including online testimony posted by the Academic Physicians Section and the 7 International Medical Graduates Section. Proposed and enacted state licensure and 8 credentialing models, such as those described in the report, may enable physicians to be 9 quickly credentialed and licensed so that they may help address national or international 10 pandemics or state/ regional medical emergencies. Additionally, the state models 11 presented may support additional states’ efforts to assist international medical graduates 12 with credentialing and licensure. For these reasons, your Reference Committee 13 recommends adoption of Council on Medical Education Report 4. Reference Committee C (J-21) Page 6 of 30

1 RECOMMENDED FOR ADOPTION AS AMENDED 2 3 (4) COUNCIL ON MEDICAL EDUCATION REPORT 2 – 4 LICENSURE FOR INTERNATIONAL MEDICAL 5 GRADUATES PRACTICING IN U.S. INSTITUTIONS 6 WITH RESTRICTED MEDICAL LICENSES 7 (RESOLUTION 311-A-19) 8 9 RECOMMENDATION A: 10 11 Recommendation 1 in Council on Medical Education 12 Report 2 be amended by addition and deletion, to read 13 as follows: 14 15 1. That our American Medical Association (AMA) 16 advocate that qualified international medical graduates 17 have a pathway for licensure by encouraging 18 encourage state medical licensing boards and the 19 member boards of the American Board of Medical 20 Specialties to develop criteria that allow 1) completion 21 of medical school and residency training outside the 22 U.S., 2) extensive U.S. medical practice, and 3) evidence 23 of good standing within the local medical community to 24 serve as a substitute for U.S. graduate medical 25 education requirement for physicians seeking full 26 unrestricted licensure and board certification. 27 (Directive to Take Action) 28 29 RECOMMENDATION B: 30 31 Recommendations in Council on Medical Education 32 Report 2 be adopted as amended and the remainder of 33 the report be filed. 34 35 HOD ACTION: Council on Medical Education Report 36 2 adopted as amended and the remainder of the 37 report filed. 38 39 1. That our American Medical Association (AMA) encourage state medical licensing 40 boards and the member boards of the American Board of Medical Specialties to develop 41 criteria that allow 1) completion of medical school and residency training outside the 42 U.S., 2) extensive U.S. medical practice, and 3) evidence of good standing within the 43 local medical community to serve as a substitute for U.S. graduate medical education 44 requirement for physicians seeking full unrestricted licensure and board certification. 45 (Directive to Take Action) 46 47 2. That our AMA amend Policy H-255.988 (12), “AMA Principles on International Medical 48 Graduates,” by addition to read as follows: Reference Committee C (J-21) Page 7 of 30

1 Our AMA supports …12. The requirement that all medical school graduates complete at 2 least one year of graduate medical education in an accredited U.S. program in order to 3 qualify for full and unrestricted licensure. State medical licensing boards are encouraged 4 to allow an alternate set of criteria for granting licensure in lieu of this requirement: 5 1) completion of medical school and residency training outside the U.S., 2) extensive 6 U.S. medical practice, and 3) evidence of good standing within the local medical 7 community. (Modify Current HOD Policy) 8 9 3. That our AMA amend Policy H-275.934 (2), “Alternatives to the Federation of State 10 Medical Boards Recommendations on Licensure,” by addition to read as follows: 11 2. All applicants for full and unrestricted licensure, whether graduates of U.S. 12 medical schools or international medical graduates, must have completed one 13 year of accredited graduate medical education (GME) in the U.S., have passed 14 all state-required licensing examinations (USMLE or COMLEX USA), and must 15 be certified by their residency program director as ready to advance to the next 16 year of GME and to obtain a full and unrestricted license to practice medicine. 17 State medical licensing boards are encouraged to allow an alternate set of 18 criteria for granting licensure in lieu of this requirement for completing one year of 19 accredited GME in the U.S.: 1) completion of medical school and residency 20 training outside the U.S., 2) extensive U.S. medical practice, and 3) evidence of 21 good standing within the local medical community. (Modify Current HOD Policy) 22 23 4. That our AMA amend Policy H-160.949 (6), “Practicing Medicine by Non-Physicians,” 24 by addition and deletion to read as follows: 25 Our AMA … (6) opposes special licensing pathways for “assistant physicians” 26 (i.e., those who are not currently enrolled in an Accreditation Council for 27 Graduate Medical Education of American Osteopathic Association training 28 program, or have not completed at least one year of accredited post-graduate US 29 medical education in the U.S). (Modify Current HOD Policy) 30 31 5. That our AMA amend Policy H-275.978 (5), “Medical Licensure,” by addition to read 32 as follows: 33 Our AMA … (5) urges those licensing boards that have not done so to develop 34 regulations permitting the issuance of special purpose licenses, with the 35 exception of special licensing pathways for “assistant physicians.” It is 36 recommended that these regulations permit special purpose licensure with the 37 minimum of educational requirements consistent with protecting the health, 38 safety and welfare of the public; (Modify Current HOD Policy) 39 40 Your Reference Committee heard testimony in support of this report and its recognition of 41 the needs and dedication of international medical graduates (IMGs). Regarding the first 42 recommendation of the report, testimony noted concern for how “good standing” is being 43 defined; however, your Reference Committee believes it will be addressed in the 44 development of the criteria requested in this report. Testimony also questioned the 45 meaning of “extensive U.S. medical practice” if an IMG is without a license or board 46 certification. Therefore, your Reference Committee has offered amended language of the 47 first recommendation “…to advocate that qualified international medical graduates have a 48 pathway for licensure…”. Your Reference Committee recommends that Council on 49 Medical Education Report 2 be adopted as amended. Reference Committee C (J-21) Page 8 of 30

1 (5) COUNCIL ON MEDICAL EDUCATION REPORT 5 – 2 PROMISING PRACTICES AMONG PATHWAY 3 PROGRAMS TO INCREASE DIVERSITY IN MEDICINE 4 5 RECOMMENDATION A: 6 7 Recommendation 1 in Council on Medical Education 8 Report 5 be amended by addition and deletion, to read 9 as follows: 10 11 1. That our AMA recognize some people have been 12 historically underrepresented, excluded from, and 13 marginalized in medical education and medicine 14 because of their race, ethnicity, disability status, sexual 15 orientation, and gender identity, socioeconomic origin, 16 and rurality, due to structural racism and other systems 17 of oppressionexclusion and discrimination. (New HOD 18 Policy) 19 20 RECOMMENDATION B: 21 22 Alternate Recommendation 5 in Council on Medical 23 Education Report 5 be adopted in lieu of 24 Recommendation 5, to read as follows: 25 26 5. That our AMA amend Policy H-200.951, Strategies for 27 Enhancing Diversity in the Physician Workforce by 28 addition and deletion to read as follows: 29 30 Our AMA (1) supports increased diversity across all 31 specialties in the physician workforce in the categories 32 of race, ethnicity, genderdisability status, sexual 33 orientation, /gender identity, socioeconomic origin, and 34 rurality persons with disabilities; (2) commends the 35 Institute of Medicine (now known as the National 36 Academies of Sciences, Engineering, and Medicine) for 37 its report, "In the Nation's Compelling Interest: Ensuring 38 Diversity in the Health Care Workforce," and supports 39 the concept that a racially and ethnically diverse 40 educational experience results in better educational 41 outcomes; and (3) encourages the development of 42 evidence-informed programs to build role models 43 among academic leadership and faculty for the 44 mentorship of students, residents, and fellows 45 underrepresented in medicine and in specific 46 specialties; (4) encourages physicians to engage in 47 their communities to guide, support, and mentor high 48 school and undergraduate students with a calling to 49 medicine; (5) encourages medical schools, health care Reference Committee C (J-21) Page 9 of 30

1 institutions, managed care and other appropriate groups 2 to adopt and utilize activities that bolster efforts to 3 include and support individuals who are 4 underrepresented in medicine by developing policies 5 that articulating articulate the value and importance of 6 diversity as a goal that benefits all participants, 7 cultivating and funding programs that nurture a culture 8 of diversity on campus, and recruiting faculty and staff 9 who share this and strategies to accomplish that goal; 10 and (6) continue to study and provide recommendations 11 to improve the future of health equity and racial justice 12 in medical education, the diversity of the health 13 workforce, and the outcomes of marginalized patient 14 populations. (Modify Current HOD Policy). 15 16 RECOMMENDATION C: 17 18 Alternate Recommendation 6 in Council on Medical 19 Education Report 5 be adopted in lieu of 20 Recommendation 6, to read as follows: 21 22 6. That our AMA amend Policy H-60.917, Disparities in 23 Public Education as a Crisis in Public Health and Civil 24 Rights by addition to read as follows: 25 3. Our AMA will encourage the U.S. Department of 26 Education and Department of Labor to develop policies 27 and initiatives in support of students from marginalized 28 backgrounds that 1) decrease the educational 29 opportunity gap; 2) increase participation in high 30 school Advanced Placement courses; and 3) increase 31 the high school graduation rate. (Modify Current HOD 32 Policy) 33 34 RECOMMENDATION D: 35 36 Council on Medical Education Report 5 be amended by 37 addition of a ninth Recommendation, to read as follows: 38 39 9. That our AMA advocate for funding to support the 40 creation and sustainability of Historically Black College 41 and University (HBCU), Hispanic-Serving Institution 42 (HSI), and Tribal College and University (TCU) affiliated 43 medical schools and residency programs, with the goal 44 of achieving a physician workforce that is proportional 45 to the racial, ethnic, and gender composition of the 46 United States population. (Directive to Take Action)

Reference Committee C (J-21) Page 10 of 30

1 RECOMMENDATION E: 2 3 Council on Medical Education Report 5 be amended by 4 addition of a tenth Recommendation, to read as follows: 5 6 10. That our AMA work with appropriate stakeholders to 7 study reforms to mitigate demographic and 8 socioeconomic inequities in the residency and 9 fellowship selection process, including but not limited 10 to the selection and reporting of honor society 11 membership and the use of standardized tools to rank 12 applicants, with report back to the House of Delegates. 13 (Directive to Take Action) 14 15 RECOMMENDATION F: 16 17 Recommendations in Council on Medical Education 18 Report 5 be adopted as amended and the remainder of 19 the report be filed. 20 21 HOD ACTION: Council on Medical Education Report 22 5 adopted as amended and the remainder of the 23 report filed. 24 25 Council on Medical Education Report 5 amended by 26 addition of an eleventh Recommendation, to read as 27 follows: 28 29 11. That our AMA establish a task force to guide 30 organizational transformation within and beyond the 31 AMA toward restorative justice to promote truth, 32 reconciliation, and healing in medicine and medical 33 education. 34 35 1. That our AMA recognize some people have been historically underrepresented, 36 excluded from, and marginalized in medical education and medicine because of their 37 race, ethnicity, sexual orientation, and gender identity due to structural racism and other 38 systems of oppression. (New HOD Policy) 39 40 2. That our AMA commit to promoting truth and reconciliation in medical education as it 41 relates to improving equity. (New HOD Policy) 42 43 3. That our AMA recognize the harm caused by the Flexner Report to historically Black 44 medical schools, the diversity of the physician workforce, and the outcomes of 45 minoritized and marginalized patient populations. (New HOD Policy) 46 47 4. That our AMA work with appropriate stakeholders to commission and enact the 48 recommendations of a forward-looking, cross-continuum, external study of 21st century 49 medical education focused on reimagining the future of health equity and racial justice in Reference Committee C (J-21) Page 11 of 30

1 medical education, improving the diversity of the health workforce, and ameliorating 2 inequitable outcomes among minoritized and marginalized patient populations. (New 3 HOD Policy) 4 5 5. That our AMA amend Policy H-200.951, Strategies for Enhancing Diversity in the 6 Physician Workforce by addition and deletion to read as follows: (4) encourages medical 7 schools, health care institutions, managed care and other appropriate groups to adopt 8 and utilize activities that bolster efforts to include and support historically 9 underrepresented groups in medicine, by developing policies that articulateing the value 10 and importance of diversity as a goal that benefits all participants, cultivating and funding 11 programs that nurture a culture of diversity on campus, and recruiting faculty and staff 12 who share this and strategies to accomplish that goal. (5) continue to study and provide 13 recommendations to improve the future of health equity and racial justice in medical 14 education, the diversity of the health workforce, and the outcomes of minoritized and 15 marginalized patient populations. (Modify Current HOD Policy) 16 17 6. That our AMA amend Policy H-60.917, Disparities in Public Education as a Crisis in 18 Public Health and Civil Rights (3) by addition to read as follows: Our AMA will support 19 and encourage the U.S. Department of Education to develop policies and initiatives to 1) 20 increase the high school graduation rate among historically underrepresented students 21 2) increase the number of historically underrepresented students participating in high 22 school Advanced Placement courses and 3) decrease the educational opportunity gap. 23 (Modify Current HOD Policy) 24 25 7. That our AMA amend Policy D-200.985 (13), “Strategies for Enhancing Diversity in 26 the Physician Workforce,” by deletion to read as follows: (a) supports the publication of a 27 white paper chronicling health care career pipeline programs (also known as pathway 28 programs) across the nation aimed at increasing the number of programs and promoting 29 leadership development of underrepresented minority health care professionals in 30 medicine and the biomedical sciences, with a focus on assisting such programs by 31 identifying best practices and tracking participant outcomes; and. (Modify Current HOD 32 Policy) 33 34 8. That our AMA reaffirm Policy D-200.982, “Diversity in the Physician Workforce and 35 Access to Care.” 36 37 Your Reference Committee received supportive testimony in favor of adoption of this item, 38 including online testimony posted by the Academic Physicians Section and friendly 39 amendments, proffered by the Medical Student Section, American Academy of Family 40 Physicians, and the New York and Texas delegations, respectively, to support the 41 sustainability of institutions of higher education serving minority populations, mitigate 42 inequities in the selection of medical students for honor societies, and further refine and 43 strengthen Policy H-200.951, “Strategies for Enhancing Diversity in the Physician 44 Workforce.” An amendment from the Minority Affairs Section was considered, but your 45 Reference Committee believed that it was not germane to the report. In the spirit of 46 intersectionality, amendments were also accepted to include people with disabilities and 47 from rural locations in the first resolve. It was also recommended that the Department of 48 Labor be added to the sixth resolve as they also oversee initiatives in public education, 49 and the three clauses in the policy were reordered to enhance readability. Our AMA has Reference Committee C (J-21) Page 12 of 30

1 evidenced, particularly over the past few years—with the development of the Center for 2 Health Equity and the recent release of the strategic plan on health equity—a significant 3 change in its awareness of, leadership on, and commitment to racial justice and equity 4 within the medical profession and society as a whole. The recommendations put forth by 5 this report, along with the amendments noted, will only accelerate that advocacy and 6 action and represent a critical step towards rectifying the harmful past actions that the 7 medical profession as a whole and organized medicine have perpetrated on communities 8 of color. The impact of the byzantine legacy of the Flexner Report, in particular Chapter 9 14 entitled “The Medical Education of the Negro,” must be addressed and reconciled to 10 ensure that future physicians are aware of structural factors that are impeding their 11 patient’s health outcomes. For these reasons, your Reference Committee recommends 12 that Council on Medical Education Report 5 be adopted as amended. 13 14 (6) RESOLUTION 305 – NON-PHYSICIAN POST- 15 GRADUATE MEDICAL TRAINING 16 17 RECOMMENDATION A: 18 19 The first Resolve of Resolution 305 be amended by 20 deletion, to read as follows: 21 22 RESOLVED, That our American Medical Association 23 believe that healthcare trainee salary, benefits, and 24 overall compensation should, at minimum, reflect 25 length of pre-training education, hours worked, and 26 level of independence and complexity of care allowed 27 by an individual’s training program (for example when 28 comparing physicians in training and midlevel 29 providers at equal postgraduate training levels) (New 30 HOD Policy); and be it further 31 32 RECOMMENDATION B: 33 34 Alternate Resolve 2 in Resolution 305 be adopted in lieu 35 of Resolve 2, to read as follows: 36 37 RESOLVED, That our AMA amend policy H-275.925 38 “Protection of the Titles ‘Doctor,’ ‘Resident’ and 39 ‘Residency’,” by addition and deletion to read as 40 follows: 41 42 Our AMA: (1) recognizes that when used in the 43 healthcare setting, specific terms describing various 44 levels of allopathic and osteopathic physician training 45 and practice (including the terms “medical student,” 46 “resident,” “residency,” “fellow,” “fellowship,” 47 “physician,” and “attending”) represent the completion 48 of structured, rigorous, medical education undertaken 49 by physicians (as defined by the American Medical Reference Committee C (J-21) Page 13 of 30

1 Association in H-405.951, “Definition and Use of the 2 Term Physician”), and must be reserved for describing 3 only physician roles; (2) will advocate that 4 professionals in a clinical health care setting clearly 5 and accurately identify to patients their qualifications 6 and degree(s) attained and develop model state 7 legislation for implementation; and (3) supports and 8 develops model state legislation that would penalize 9 misrepresentation of one’s role in the physician-led 10 healthcare team, up to and including the level of 11 make it a felony to for misrepresenting oneself as a 12 physician (MD/DO); and (4) support and develop model 13 state legislation that calls for statutory restrictions for 14 non-physician post-graduate diagnostic and clinical 15 training programs using the terms “medical student,” 16 “resident,” “residency,” “fellow,” “fellowship,” 17 “physician,” or “attending” in a healthcare setting 18 except by physicians. (Modify Current HOD Policy); and 19 be it further 20 21 RECOMMENDATION C: 22 23 The third Resolve of Resolution 305 be amended by 24 addition and deletion, to read as follows: 25 26 RESOLVED, That our AMA study and report back to the 27 House of Delegates, by the 2022 Annual Meeting, on 28 curriculum, accreditation requirements, accrediting 29 bodies, and supervising boards for undergraduate, 30 graduate, and postgraduate clinical training programs 31 for non-physicians and the impact of non-physician 32 graduate clinical education on physician 33 undergraduate and graduate medical education 34 (Directive to Take Action); and be it further 35 36 RECOMMENDATION D: 37 38 Policy H-310.916 be reaffirmed in lieu of the fourth 39 Resolve of Resolution 305. 40 41 RECOMMENDATION E: 42 43 The fifth Resolve of Resolution 305 be amended by 44 deletion, to read as follows: 45 46 RESOLVED, That our AMA partner with the 47 Accreditation Council for Graduate Medical Education 48 (ACGME) to create standards requiring Designated Reference Committee C (J-21) Page 14 of 30

1 Institutional Officials to notify the ACGME of proposed 2 training programs for physicians or non-physicians 3 that may impact the educational experience of trainees 4 in currently approved residencies and fellowships 5 (Directive to Take Action); and be it further 6 7 RECOMMENDATION F: 8 9 The eighth Resolve of Resolution 305 be amended by 10 deletion, to read as follows:

11 RESOLVED, That our AMA oppose non-physician 12 healthcare providers from holding a seat on the board 13 of an organization that regulates and/or provides 14 oversight of physician undergraduate and graduate 15 medical education, accreditation, certification, and 16 credentialing when these types of non-physician 17 healthcare providers either possess or seek to possess 18 the ability to practice without physician supervision as 19 it represents a conflict of interest. (Directive to Take 20 Action) 21 22 RECOMMENDATION G: 23 24 Resolution 305 be adopted as amended 25 26 HOD ACTION: Resolution 305 adopted as amended as 27 follows: 28 29 The first Resolve of Resolution 305 adopted, to read 30 as follows: 31 32 RESOLVED, That our American Medical Association 33 believe that healthcare trainee salary, benefits, and 34 overall compensation should, at minimum, reflect 35 length of pre-training education, hours worked, and 36 level of independence and complexity of care 37 allowed by an individual’s training program (for 38 example when comparing physicians in training and 39 midlevel providers at equal postgraduate training 40 levels) (New HOD Policy); and be it further 41 42 Alternate Resolve 2 in Resolution 305 referred. 43 44 The eighth Resolve of Resolution 305 referred. 45 46 RESOLVED, That our American Medical Association believe that healthcare trainee 47 salary, benefits, and overall compensation should, at minimum, reflect length of pre- 48 training education, hours worked, and level of independence and complexity of care Reference Committee C (J-21) Page 15 of 30

1 allowed by an individual’s training program (for example when comparing physicians in 2 training and midlevel providers at equal postgraduate training levels) (New HOD Policy); 3 and be it further 4 5 RESOLVED, That our AMA amend policy H-275.925 “Protection of the Titles "Doctor," 6 "Resident" and "Residency",” by addition and deletion to read as follows: 7 Our AMA: 8 (1) recognize that the terms “medical student,” “resident,” “residency,” “fellow,” 9 “fellowship,” “physician,” and “attending,” when used in the healthcare setting, all 10 connote completing structured, rigorous, medical education undertaken by 11 physicians, as defined by the Centers for Medicare and Medicaid Services, and 12 thus these terms must be reserved only to describe physician roles; (2) advocate 13 that professionals in a clinical health care setting clearly and accurately identify to 14 patients their qualifications and degree(s) attained and develop model state 15 legislation for implementation; (3) supports and develop model state legislation 16 that would penalize misrepresentation of one’s role in the physician-led 17 healthcare team, up to and including to make it a felony to misrepresent oneself 18 as a physician (MD/DO); and (4) support and develop model state legislation that 19 calls for statutory restrictions for non-physician post-graduate diagnostic and 20 clinical training programs using the terms “medical student,” “resident,” 21 “residency,” “fellow,” “fellowship,” “physician,” or “attending” in a healthcare 22 setting except by physicians. (Modify Current HOD Policy); and be it further 23 24 RESOLVED, That our AMA study and report back, by the 2022 Annual Meeting, on 25 curriculum, accreditation requirements, accrediting bodies, and supervising boards for 26 graduate and postgraduate clinical training programs for non-physicians and the impact 27 of non-physician graduate clinical education on physician graduate medical education 28 (Directive to Take Action); and be it further

29 RESOLVED, That our AMA work with relevant stakeholders to assure that funds to 30 support the expansion of post-graduate clinical training for non-physicians do not divert 31 funding from physician GME (Directive to Take Action); and be it further 32 33 RESOLVED, That our AMA partner with the Accreditation Council for Graduate Medical 34 Education (ACGME) to create standards requiring Designated Institutional Officials to 35 notify the ACGME of proposed training programs for physicians or non-physicians that 36 may impact the educational experience of trainees in currently approved residencies and 37 fellowships (Directive to Take Action); and be it further 38 39 RESOLVED, That policy H-310.912 “Resident and Fellow Bill of Rights,” be amended by 40 addition and deletion to read as follows: 41 B. Appropriate supervision by qualified physician faculty with progressive 42 resident responsibility toward independent practice. With regard to supervision, 43 residents and fellows should expect supervision by physicians and non- 44 physicians must be ultimately supervised by physicians who are adequately 45 qualified and which allows them to assume progressive responsibility appropriate 46 to their level of education, competence, and experience. It is neither feasible nor 47 desirable to develop universally applicable and precise requirements for 48 supervision of residents. In instances where clinical education is provided by non- Reference Committee C (J-21) Page 16 of 30

1 physicians, there must be an identified physician supervisor providing indirect 2 supervision, along with mechanisms for reporting inappropriate, non-physician 3 supervision to the training program, sponsoring institution or ACGME as 4 appropriate. (Modify Current HOD Policy); and be it further 5 6 RESOLVED, That our AMA distribute and promote the Residents and Fellows’ Bill of 7 Rights online and individually to residency and fellowship training programs and 8 encourage changes to institutional processes that embody these principles (Directive to 9 Take Action); and be it further 10 11 RESOLVED, That our AMA oppose non-physician healthcare providers from holding a 12 seat on the board of an organization that regulates and/or provides oversight of 13 physician undergraduate and graduate medical education, accreditation, certification, 14 and credentialing when these types of non-physician healthcare providers either 15 possess or seek to possess the ability to practice without physician supervision as it 16 represents a conflict of interest. (Directive to Take Action) 17 18 Your Reference Committee heard testimony in support of this resolution, which contains 19 eight resolves. Your Reference Committee is sensitive to the concerns related to the 20 impact of non-physicians on graduate medical education. The Council on Medical 21 Education provided recommendations to address the various pieces of this resolution. 22 Your Reference Committee appreciates the expert guidance of the Council and all who 23 contributed to the testimony. 24 25 Resolve 1: Given that the salaries of health care trainees are under the purview of the 26 programs/institutions, your Reference Committee recommends that the first resolve be 27 deleted. 28 29 Resolve 2: Your Reference Committee is sensitive to the use of terms like “fellow” and 30 “fellowship” which are used in a variety of contexts, many of them non-medical. Also, 31 “resident” and “residencies” for non-physicians exist in other countries. Your Reference 32 Committee offered amendments to the first clause to provide clarity, as well as to support 33 the AMA definition of a physician. Amendments to the third clause and the addition of a 34 fourth clause support model state legislation in keeping with AMA policy and the AMA’s 35 Truth in Advertising campaign. 36 37 Resolve 3: Your Reference Committee recognizes the value of studying this issue and 38 appreciates the Council on Medical Education’s willingness to do so. It was recommended 39 that a report back date is best determined by the Council and should not be included in 40 this language. Also, your Reference Committee recommends including undergraduates in 41 this study. As such, your Reference Committee recommends the third resolve be adopted 42 as amended. 43 44 Resolve 4: Your Reference Committee recognized that AMA policy advocates that funds 45 to support the expansion of post-graduate clinical training for non-physicians do not divert 46 funding from physicians. Your Reference Committee was informed that the AMA 47 Advocacy team is actively engaged in these efforts; therefore, it is recommended that 48 Policy H-310.916, “Funding to Support Training of the Health Care Workforce,” be 49 reaffirmed in lieu of the fourth resolve. Reference Committee C (J-21) Page 17 of 30

1 2 Resolve 5: Your Reference Committee deliberated on the best way to address proposed 3 training programs for physicians or non-physicians that may impact the educational 4 experience of trainees in currently approved residencies and fellowships. It was clarified 5 that the request in this resolve is already reflected in the Accreditation Council for 6 Graduate Medical Education common program requirements, which include a standard to 7 address this issue. Your Reference Committee, accordingly, recommends that the fifth 8 resolve be deleted. 9 10 Resolve 6: Your Reference Committee appreciates the author’s language to amend policy 11 H-310.912, “Residents and Fellows’ Bill of Rights,” to clarify the role of physicians as 12 supervisors. Your Reference Committee recommends that the sixth resolve be adopted 13 as amended. 14 15 Resolve 7: Your Reference Committee acknowledged the importance of the Resident and 16 Fellows’ Bill of Rights and its dissemination such that residency and fellowship training 17 programs embody these principles. It was noted that the AMA has promoted this policy 18 through AMA MedEd Update and other mechanisms. Your Reference Committee 19 recommends that the seventh resolve be adopted. 20 21 Resolve 8: Your Reference Committee appreciated the concern for non-physician health 22 care providers holding a seat on an oversight board and the conflict of interest it may pose. 23 However, your Reference Committee is aware of boards in which a non-physician seat is 24 valuable (e.g., institutional review board, hospital medical quality board, or medical 25 specialty board). Given the complicated existing systems, your Reference Committee 26 recommends that the eighth resolve be deleted. 27 28 While some testimony supported referral of this nuanced resolution, your Reference 29 Committee felt it was sufficient to address the various pieces at this time. In sum, your 30 Reference Committee recommends that Resolution 305 be adopted as amended. 31 32 Policy recommended for reaffirmation: 33 H-310.916, “Funding to Support Training of the Health Care Workforce” 34 35 1. Our American Medical Association will insist that any new GME funding to 36 support graduate medical education positions be available only to Accreditation 37 Council for Graduate Medical Education (ACGME) and/or American Osteopathic 38 Association (AOA) accredited residency programs, and believes that funding made 39 available to support the training of health care providers not be made at the 40 expense of ACGME and/or AOA accredited residency programs. 41 42 2. Our AMA strongly advocates that: (A) there be no decreases in the current 43 funding of MD and DO graduate medical education while there is a concurrent 44 increase in funding of graduate medical education (GME) in other professions; and 45 (B) there be at least proportional increases in the current funding of MD and DO 46 graduate medical education similar to increases in funding of GME in other 47 professions. 48 Reference Committee C (J-21) Page 18 of 30

1 3. Our AMA will advocate to appropriate federal agencies, and other relevant 2 stakeholders to oppose the diversion of direct and indirect funding away from 3 ACGME-accredited graduate medical education programs. 4 5 (7) RESOLUTION 309 – SUPPORTING GME PROGRAM 6 CHILD CARE CONSIDERATION DURING RESIDENCY 7 TRAINING 8 9 RECOMMENDATION A: 10 11 Resolution 309 be amended by addition and deletion, to 12 read as follows: 13 14 RESOLVED, That our American Medical Association 15 convene work with a group of interested stakeholders 16 to examine the need investigate solutions for 17 innovative childcare policies and flexible working 18 environments for all health care professionals (in 19 particular, medical students and physician trainees) 20 residents in order to promote equity in all training 21 settings. (Directive to Take Action) 22 23 RECOMMENDATION B: 24 25 Resolution 309 be adopted as amended. Reference Committee C (J-21) Page 19 of 30

1 RECOMMENDATION C: 2 3 The title of Resolution 309 be changed, to read as 4 follows: 5 6 SUPPORTING CHILD CARE FOR HEALTH CARE 7 PROFESSIONALS 8 9 HOD ACTION: Resolution 309 adopted as amended with a 10 change in title to read as follows: 11 12 SUPPORTING CHILD CARE FOR HEALTH CARE 13 PROFESSIONALS 14 15 RESOLVED, That our American Medical Association convene a group of interested 16 stakeholders to examine the need for innovative childcare policies and flexible working 17 environments for all residents in order to promote equity in all training settings. (Directive 18 to Take Action) 19 20 Your Reference Committee heard unanimous supportive testimony for this resolution. 21 AMA policy supports flexible working environments to accommodate childcare needs. 22 Testimony from the Council on Medical Education recommended referral for further study; 23 however, other testimony pointed out the timely need for equitable childcare support for 24 physician trainees and medical students as well as the full health care team, and the desire 25 for the AMA to investigate solutions. This goal can be accomplished through working with 26 interested stakeholders. As such, your Reference Committee recommends that 27 Resolution 309 be adopted as amended. 28 29 (8) RESOLUTION 310 – UNREASONABLE FEES CHARGED 30 AND INACCURACIES BY THE AMERICAN BOARD OF 31 INTERNAL MEDICINE (ABIM) 32 33 RECOMMENDATION A: 34 35 Resolution 310 be amended by addition and deletion, to 36 read as follows: 37 38 RESOLVED, That our American Medical Association 39 work with the American Board of Medical Specialties 40 Boards (ABMS) and its member boards to reduce 41 financial burdens for physicians holding multiple 42 certificates who are actively participating in continuing 43 certification through an ABMS member board, by 44 developing opportunities for reciprocity for certification 45 requirements as well as consideration of reduced or 46 waived fee structures. in general, and American Board 47 of Internal Medicine (ABIM), specifically, to require the 48 ABIM stop charging physicians with two or more board 49 certifications, who participate in Maintenance of Reference Committee C (J-21) Page 20 of 30

1 Certification (MOC) with a board other than the ABIM, a 2 fee to accurately list their current board status in the 3 ABIM Directory. (Directive to Take Action). (Directive to 4 Take Action)

5 RECOMMENDATION B: 6 7 Resolution 310 be adopted as amended. 8 9 RECOMMENDATION C: 10 11 The title of Resolution 310 be changed, to read as 12 follows: 13 14 UNREASONABLE FEES CHARGED BY ABMS MEMBER 15 BOARDS 16 17 HOD ACTION: Resolution 310 adopted as amended with a 18 change in title to read as follows: 19 20 UNREASONABLE FEES CHARGED BY ABMS 21 MEMBER BOARDS 22 23 RESOLVED, That our American Medical Association work with the American Board of 24 Medical Specialties Boards (ABMS), in general, and American Board of Internal Medicine 25 (ABIM), specifically, to require the ABIM stop charging physicians with two or more board 26 certifications, who participate in Maintenance of Certification (MOC) with a board other 27 than the ABIM, a fee to accurately list their current board status in the ABIM Directory. 28 (Directive to Take Action) 29 30 Your Reference Committee heard testimony in support of amended language to this 31 resolution, to include the support of the American Board of Internal Medicine, as offered 32 by the Council on Medical Education. AMA policy supports the reduction of unnecessary 33 burdens on individuals holding multiple certifications and discourages fee structures aimed 34 at financial gain. Your Reference Committee was made aware that the American Board of 35 Medical Specialties (ABMS) Standards are currently in a Call for Comment period, with a 36 recommendation aimed at developing reciprocity between member boards for 37 requirements to reduce the burden on diplomates of multiple boards. The amended 38 language would allow our AMA to comment as well on the impact of multiple fees to 39 practicing physicians by all member boards of the ABMS, including ABIM. The committee 40 developed language to allow the AMA to work with both the ABMS and its member boards 41 directly, to increase the odds of a successful outcome. Therefore, your Reference 42 Committee recommends that Resolution 310 be adopted as amended with a change in 43 title. 44 45 (9) RESOLUTION 318 – THE IMPACT OF PRIVATE EQUITY 46 ON MEDICAL TRAINING 47 48 RECOMMENDATION A: Reference Committee C (J-21) Page 21 of 30

1 2 Resolution 318 be amended by addition and deletion, to 3 read as follows: 4 5 RESOLVED, That our American Medical Association 6 work with relevant stakeholders including specialty 7 societies and the Accreditation Council for Graduate 8 Medical Education to study the level of financial 9 involvement and influence private equity firms have in 10 graduate medical education training programs and 11 report back to the House of Delegates, at the 2021 12 Interim Meeting with possible concurrent publication of 13 their findings in a peer-reviewed journal. (Directive to 14 Take Action) 15 16 RECOMMENDATION B: 17 18 Resolution 318 be adopted as amended. 19 20 HOD ACTION: Resolution 318 adopted as amended. 21 22 RESOLVED, That our American Medical Association work with relevant stakeholders 23 including specialty societies and the Accreditation Council for Graduate Medical Education 24 to study the level of financial involvement and influence private equity firms have in 25 graduate medical education training programs and report back at the 2021 Interim Meeting 26 with concurrent publication of their findings in a peer-reviewed journal. (Directive to Take 27 Action) 28 29 Your Reference Committee heard mixed testimony on this item. Online testimony posted 30 by the American Society of Hematology raised the specter of Hahnemann, when 550 31 trainees were suddenly stuck in limbo without new training sites or a clear pathway to 32 independent practice, not to mention the impact on faculty and staff, along with the 33 surrounding community losing a safety-net hospital. Subsequently, a $55 million winning 34 bid for those GME-funded training positions came from a consortium of hospitals—the 35 direct result of private equity interfering in GME. Additional testimony noted an ongoing 36 study on the impact of private equity and corporate investors on medical practice by the 37 Council on Medical Service, but medical education is not likely to be encompassed in the 38 subsequent CMS report. Testimony by the Council on Medical Education, while 39 recognizing the urgency of this issue, noted that a sound and well researched study cannot 40 be accomplished by November and requested amending the resolution to delete the time- 41 certain requirement. In addition, your Reference Committee noted that peer-reviewed 42 journals have various manuscript style requirements, and acceptance for publication of an 43 incomplete study cannot be guaranteed. Furthermore, the House of Delegates may wish 44 to review the findings before recommending publication and may find it desirable for 45 publication in other than a peer-reviewed journal. Your Reference Committee therefore 46 recommends that Resolution 318 be adopted as amended. 47 Reference Committee C (J-21) Page 22 of 30

1 (10) RESOLUTION 319 – THE EFFECT OF THE COVID-19 2 PANDEMIC ON GRADUATE MEDICAL EDUCATION 3 4 RECOMMENDATION A: 5 6 The first Resolve of Resolution 319 be amended by 7 addition and deletion, to read as follows: 8 9 RESOLVED, That our American Medical Association 10 work with the Accreditation Council for Graduate 11 Medical Education (ACGME) and other relevant 12 stakeholders to advocate for provide additional, 13 equitable compensation and benefits for 14 compensation, such as moonlighting, hazard pay, 15 and/or additional certifications for residents and 16 fellows who are redeployed to fulfill service needs that 17 may be are outside the scope of their specialty training 18 (Directive to Take Action); and be it further 19 20 RECOMMENDATION B: 21 22 The second Resolve of Resolution 319 be amended by 23 deletion, to read as follows: 24 25 RESOLVED, That our AMA urge ACGME to work with 26 relevant stakeholders including residency and 27 fellowship programs to ensure each graduating 28 resident or fellow is provided with documentation 29 explicitly stating his/her board eligibility and identifying 30 areas of training that have been impacted by COVID-19 31 that can be presented to the respective board certifying 32 committee (Directive to Take Action); and be it further 33 34 RECOMMENDATION C: 35 36 The third Resolve of Resolution 319 be amended by 37 addition and deletion, to read as follows: 38 39 RESOLVED, That our AMA urge ACGME and specialty 40 boards to consider reducing replacing minimums on 41 case numbers and clinic visits with revised more 42 holistic measures to recognize resident/fellow learning, 43 indicate readiness for graduation and board 44 certification eligibility, especially given the drastic 45 educational barriers confronted during the COVID-19 46 pandemic. (Directive to Take Action) 47 48 RECOMMENDATION D: 49 Reference Committee C (J-21) Page 23 of 30

1 Resolution 319 be adopted as amended. 2 3 HOD ACTION: Resolution 319 adopted as amended. 4 5 RESOLVED, That our American Medical Association work with the Accreditation Council 6 for Graduate Medical Education (ACGME) and other relevant stakeholders to provide 7 additional benefits for compensation, such as moonlighting, hazard pay, and/or additional 8 certifications for residents and fellows who are redeployed to fulfill service needs that are 9 outside the scope of their specialty training (Directive to Take Action); and be it further 10 11 RESOLVED, That our AMA urge ACGME to work with relevant stakeholders including 12 residency and fellowship programs to ensure each graduating resident or fellow is 13 provided with documentation explicitly stating his/her board eligibility and identifying areas 14 of training that have been impacted by COVID-19 that can be presented to the respective 15 board certifying committee (Directive to Take Action); and be it further 16 17 RESOLVED, That our AMA urge ACGME and specialty boards to consider replacing 18 minimums on case numbers and clinic visits with more holistic measures to indicate 19 readiness for graduation and board certification eligibility, especially given the drastic 20 educational barriers confronted during the COVID-19 pandemic. (Directive to Take Action) 21 22 Your Reference Committee received supportive testimony on this item. Online testimony 23 posted by the Georgia delegation highlighted the long-term consequences of the 24 pandemic on graduate medical education and the nation’s future health care workforce. 25 Both the Academic Physicians Section and Council on Medical Education, while in support 26 of the spirit of this item, proffered revisions to the language to clarify specific aspects, such 27 as the need for equitable compensation for trainees compared to other health care 28 professionals who provided additional services during the pandemic. The Council on 29 Medical Education also testified that Resolve 2 is encompassed by Resolve 3, and 30 therefore recommended its deletion. Your Reference Committee agrees with this and 31 other helpful editorial and substantive suggestions, and therefore recommends that 32 Resolution 319 be adopted as amended. Reference Committee C (J-21) Page 24 of 30

1 RECOMMENDED FOR REFERRAL 2 3 (11) RESOLUTION 304 – DECREASING FINANCIAL 4 BURDENS ON RESIDENTS AND FELLOWS 5 6 RECOMMENDATION: 7 8 Resolution 304 be referred. 9 10 HOD ACTION: Resolve 3 of Resolution 304 referred. 11 Remainder of Resolution 304 adopted as amended, 12 to read as follows: 13 14 RESOLVED, That our American Medical Association 15 work with the Accreditation Council for Graduate 16 Medical Education (ACGME) and other relevant 17 stakeholders to advocate for additional ways to 18 defray costs related to residency and fellowship 19 training, including essential amenities and/or high 20 cost specialty-specific equipment required to 21 perform clinical duties (Directive to Take Action); 22 and be it further 23 24 RESOLVED, That our AMA work with relevant 25 stakeholders to define “access to food” for medical 26 trainees to include overnight access to fresh food 27 and healthy meal options within all training hospitals 28 (Directive to Take Action); and be it further 29 30 RESOLVED, That the Residents and Fellows’ Bill of 31 Rights be prominently published online on the AMA 32 website and be disseminated to residency and 33 fellowship programs (Directive to Take Action); and 34 be it further Reference Committee C (J-21) Page 25 of 30

1 RESOLVED, That the AMA Policy H-310.912, 2 “Residents and Fellows’ Bill of Rights,” be amended 3 by addition and deletion to read as follows: 4 5 5. Our AMA partner with ACGME and other relevant 6 stakeholders to encourages training programs to 7 reduce financial burdens on residents and fellows by 8 providing employee benefits including, but not 9 limited to, on-call meal allowances, transportation 10 support, relocation stipends, and childcare services 11 teaching institutions to explore benefits to residents 12 and fellows that will reduce personal cost of living 13 expenditures, such as allowances for housing, 14 childcare, and transportation. (Modify Current HOD 15 Policy) 16 17 RESOLVED, That our American Medical Association work with the Accreditation Council 18 for Graduate Medical Education (ACGME), the Association of American Medical 19 Colleges (AAMC), and other relevant stakeholders to advocate that medical trainees not 20 be required to pay for essential amenities and/or high cost or safety-related, specialty- 21 specific equipment required to perform clinical duties (Directive to Take Action); and be it 22 further 23 24 RESOLVED, That our AMA work with relevant stakeholders including the AAMC to 25 define “access to food” for medical trainees to include 24-hour access to fresh food and 26 healthy meal options within all training hospitals (Directive to Take Action); and be it 27 further 28 29 RESOLVED, That our AMA work with relevant stakeholders to ensure that medical 30 trainees have access to on-site and subsidized childcare (Directive to Take Action); and 31 be it further 32 33 RESOLVED, That the Residents and Fellows’ Bill of Rights be prominently published 34 online on the AMA website and be disseminated to residency and fellowship programs 35 (Directive to Take Action); and be it further 36 37 RESOLVED, That the AMA Policy H-310.912, “Residents and Fellows’ Bill of Rights,” be 38 amended by addition and deletion to read as follows: 39 5. Our AMA partner with ACGME and other relevant stakeholders to encourages 40 training programs to reduce financial burdens on residents and fellows by 41 providing employee benefits including, but not limited to, on-call meal 42 allowances, transportation support, relocation stipends, and childcare services. 43 teaching institutions to explore benefits to residents and fellows that will reduce 44 personal cost of living expenditures, such as allowances for housing, childcare, 45 and transportation. (Modify Current HOD Policy) 46 47 Your Reference Committee heard unanimous testimony in support of the sentiment of this 48 resolution. Testimony noted the burdens placed upon trainees who have been asked to 49 purchase essential equipment, uniforms, or other attire without being reimbursed, as well Reference Committee C (J-21) Page 26 of 30

1 as support to advocate for benefits for trainees including meal allowances, transportation 2 support, and childcare services. Testimony also expressed concern for the financial 3 impacts on hospitals and programs in order to implement such expanded services, as well 4 as funding for graduate medical education overall. AMA policy is supportive of eliminating 5 barriers to student and resident debt, healthy food options in hospitals for staff and 6 patients, and the childcare needs of physicians and trainees. The Council on Medical 7 Education requested that this resolution be referred to give them the opportunity to explore 8 this topic further and then formulate recommendations on ways to reduce financial 9 burdens on trainees while also maintaining equity both among trainees and equity among 10 all healthcare workers. As such, your Reference Committee recommends that Resolution 11 304 be referred. 12 13 (12) RESOLUTION 314 – STANDARD PROCEDURE FOR 14 ACCOMMODATIONS IN USMLE AND NBME EXAMS 15 16 RECOMMENDATION: 17 18 Resolution 314 be referred. 19 20 HOD ACTION: Resolution 314 referred for decision. 21 22 RESOLVED, That our American Medical Association collaborate with medical licensing 23 organizations to facilitate a timely accommodations application process (Directive to Take 24 Action); and be it further 25 26 RESOLVED, That our AMA, in conjunction with the National Board of Medical Examiners, 27 develop a plan to reduce the amount of proof required for approving accommodations to 28 lower the burden of cost and time to medical students with disabilities. (Directive to Take 29 Action) 30 31 Your Reference Committee heard largely supportive testimony on this item and believes 32 that advocating for disability inclusion in medicine is an important role for our AMA. Online 33 testimony posted by the Council on Medical Education and Academic Physicians Section 34 called for edits to both Resolves 1 and 2, to indicate specifically the licensing organizations 35 in question (in Resolve 1) and to change the focus of Resolve 2 to require the boards’ 36 adherence to the Americans with Disabilities Act. The National Board of Medical 37 Examiners (NBME) posted a lengthy defense of its practices—for example, that 38 accommodations may affect exam standardization and comparable validity of examination 39 results—and recommended not adopting Resolution 314. Other testimony posted by 40 individuals and the Medical Student Section, however, disputed the NBME’s claims and 41 provided compelling anecdotal data to suggest that medical students with disabilities face 42 undue burdens in attaining needed accommodations for these required examinations. The 43 Council on Medical Education also notes that some of these issues could be integrated 44 into a currently scheduled report for the November meeting on trainees with disabilities. 45 Due to the complexity of issues surrounding these examinations, questions about legal 46 implications, and the importance of this issue, your Reference Committee recommends 47 referral of Resolution 314. Reference Committee C (J-21) Page 27 of 30

1 RECOMMENDED FOR REAFFIRMATION IN LIEU OF 2 3 (13) RESOLUTION 308 – RESCIND USMLE STEP 2 CS AND 4 COMLEX LEVEL 2 PE EXAMINATION REQUIREMENT 5 FOR MEDICAL LICENSURE 6 7 RECOMMENDATION: 8 9 Policy D-295.988 be reaffirmed in lieu of Resolution 308. 10 11 HOD ACTION: Policy D-295.988 reaffirmed in lieu of 12 Resolution 308. 13 14 RESOLVED, That our American Medical Association work to rescind USMLE Step 2 CS 15 and COMLEX Level 2 PE examination requirements and encourage a “fifty-state 16 approach” by all individual state medical societies to engage with their respective state 17 medical boards on this issue. (Directive to Take Action) 18 19 Your Reference Committee heard supportive testimony for this resolution as well as 20 testimony regarding reaffirmation of AMA Policy D-295.988, “Clinical Skills Assessment 21 During Medical School,” in lieu of the resolution. Your Reference Committee noted that 22 the USMLE Step 2 CS examination was suspended on March 16, 2020 and formally 23 discontinued on January 26, 2021. Also, the NBOME COMLEX-USA Level 2 PE 24 examination was suspended on March 20, 2020 and postponed indefinitely on February 25 11, 2021. Your Reference Committee noted the concern and uncertainty about the future 26 of COMLEX-USA. Policy D-295.988 supports that both these exams be replaced with 27 either an LCME-accredited or a COCA-accredited medical school-administered 28 examination of clinical skills. Your Reference Committee believes that current policy 29 effectively addresses this concern and therefore recommends that Policy D-295.988 be 30 reaffirmed in lieu of Resolution 308. 31 32 Policy recommended for reaffirmation: 33 D-295.988, “Clinical Skills Assessment During Medical School” 34 35 1. Our AMA will encourage its representatives to the Liaison Committee on Medical 36 Education (LCME) to ask the LCME to determine and disseminate to medical 37 schools a description of what constitutes appropriate compliance with the 38 accreditation standard that schools should "develop a system of assessment" to 39 assure that students have acquired and can demonstrate core clinical skills. 40 41 2. Our AMA will work with the Federation of State Medical Boards, National Board 42 of Medical Examiners, state medical societies, state medical boards, and other key 43 stakeholders to pursue the transition from and replacement for the current United 44 States Medical Licensing Examination (USMLE) Step 2 Clinical Skills (CS) 45 examination and the Comprehensive Osteopathic Medical Licensing Examination 46 (COMLEX) Level 2-Performance Examination (PE) with a requirement to pass a 47 Liaison Committee on Medical Education-accredited or Commission on Reference Committee C (J-21) Page 28 of 30

1 Osteopathic College Accreditation-accredited medical school-administered, 2 clinical skills examination. 3 4 3. Our AMA will work to: (a) ensure rapid yet carefully considered changes to the 5 current examination process to reduce costs, including travel expenses, as well as 6 time away from educational pursuits, through immediate steps by the Federation 7 of State Medical Boards and National Board of Medical Examiners; (b) encourage 8 a significant and expeditious increase in the number of available testing sites; (c) 9 allow international students and graduates to take the same examination at any 10 available testing site; (d) engage in a transparent evaluation of basing this 11 examination within our nation's medical schools, rather than administered by an 12 external organization; and (e) include active participation by faculty leaders and 13 assessment experts from U.S. medical schools, as they work to develop new and 14 improved methods of assessing medical student competence for advancement 15 into residency. 16 17 4. Our AMA is committed to assuring that all medical school graduates entering 18 graduate medical education programs have demonstrated competence in clinical 19 skills. 20 21 5. Our AMA will continue to work with appropriate stakeholders to assure the 22 processes for assessing clinical skills are evidence-based and most efficiently use 23 the time and financial resources of those being assessed. 24 25 6. Our AMA encourages development of a post-examination feedback system for 26 all USMLE test-takers that would: (a) identify areas of satisfactory or better 27 performance; (b) identify areas of suboptimal performance; and (c) give students 28 who fail the exam insight into the areas of unsatisfactory performance on the 29 examination. 30 31 7. Our AMA, through the Council on Medical Education, will continue to monitor 32 relevant data and engage with stakeholders as necessary should updates to this 33 policy become necessary. 34 35 (14) RESOLUTION 311 – STUDENT LOAN FORGIVENESS 36 37 RECOMMENDATION: 38 39 Policy H-305.925 be reaffirmed in lieu of Resolution 311. 40 41 HOD ACTION: Policy H-305.925 reaffirmed in lieu of 42 Resolution 311. 43 44 RESOLVED, That our American Medical Association study the cause for the unacceptably 45 high denial rate of applications made to the Public Health Services Student Loan 46 Forgiveness Program, and advocate for improvements in the administration and oversight 47 of the Program, including but not limited to increasing transparency of and streamlining 48 program requirements; ensuring consistent and accurate communication between loan Reference Committee C (J-21) Page 29 of 30

1 services and borrowers; and establishing clear expectations regarding oversight and 2 accountability of the loan servicers responsible for the program. (Directive to Take Action) 3 4 Your Reference Committee is supportive of the intent of this resolution; that said, 5 testimony was mixed testimony on this item. Online testimony posted by the Council on 6 Medical Education and Academic Physicians Section called for reaffirmation of current 7 (and in-depth) AMA policy on the Public Service Loan Forgiveness (PSLF) Program— 8 specifically, Policy H-305.925—along with incorporating specific asks of the resolution 9 (e.g., the “reasons for denial and transparency”) into a Council report on medical student 10 debt scheduled for a future House of Delegates meeting. Testimony from the Medical 11 Student Section and American Academy of Pediatrics, in contrast, called for adoption as 12 written. All those providing testimony, however, agreed that this is an important topic for 13 AMA study and advocacy. As the Council on Medical Education’s study is slated for 14 release in 2021, your Reference Committee believes that the most expeditious and 15 efficient course of action is incorporation of the “reasons for denial and transparency” of 16 the Public Health Services Student Loan Forgiveness program into the forthcoming 17 Council report and reaffirmation of AMA Policy H-305.925 in lieu of Resolution 311. 18 19 Policy recommended for reaffirmation: 20 H-305.925, “Principles of and Actions to Address Medical Education Costs and 21 Student Debt” 22 23 … 20. Related to the Public Service Loan Forgiveness (PSLF) Program, our AMA 24 supports increased medical student and physician benefits the program, and will: 25 (a) Advocate that all resident/fellow physicians have access to PSLF during their 26 training years; (b) Advocate against a monetary cap on PSLF and other federal 27 loan forgiveness programs; (c) Work with the United States Department of 28 Education to ensure that any cap on loan forgiveness under PSLF be at least equal 29 to the principal amount borrowed; (d) Ask the United States Department of 30 Education to include all terms of PSLF in the contractual obligations of the Master 31 Promissory Note; (e) Encourage the Accreditation Council for Graduate Medical 32 Education (ACGME) to require residency/fellowship programs to include within the 33 terms, conditions, and benefits of program appointment information on the PSLF 34 program qualifying status of the employer; (f) Advocate that the profit status of a 35 physicians training institution not be a factor for PSLF eligibility; (g) Encourage 36 medical school financial advisors to counsel wise borrowing by medical students, 37 in the event that the PSLF program is eliminated or severely curtailed; (h) 38 Encourage medical school financial advisors to increase medical student 39 engagement in service-based loan repayment options, and other federal and 40 military programs, as an attractive alternative to the PSLF in terms of financial 41 prospects as well as providing the opportunity to provide care in medically 42 underserved areas; (i) Strongly advocate that the terms of the PSLF that existed 43 at the time of the agreement remain unchanged for any program participant in the 44 event of any future restrictive changes…. Reference Committee C (J-21) Page 30 of 30

1 Mister Speaker, this concludes the report of Reference Committee C. I would like to thank 2 Derek Baughman, MD; Joanne Loethen, MD, MA; Russyan Mark Mabeza; Joseph M. 3 Maurice, MD; Mark Milstein, MD; and Carl G. Streed Jr., MD; and all those who testified 4 before the committee, as well as staff persons Amber Ryan, Tanya Lopez, Fred Lenhoff, 5 and Kim Lomis, MD.

Derek Baughman, MD Joanne Loethen, MD, MA American Academy of Family Missouri State Medical Association Physicians

Russyan Mark Mabeza, Medical Student Joseph M. Maurice, MD California Medical Association American Association of Gynecologic Laparoscopists

Mark J. Milstein, MD, FAAN Carl G Streed, Jr., MD, MPH, FACP American Academy of Neurology Massachusetts Medical Society

Tracey L. Henry, MD, MPH, MS, FACP American College of Physicians Chair