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MEDICAL EDUCATION AND SOC IETAL NEEDS:
A PLANNING REPORT FOR THE HEALTH PROFESSIONS
Report of a study by
a committee of the
INSTITUTE OF MEDICINE
Division of Health Sciences Policy
July 1983
National Academy Press
Washington, D . C .
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NOTICE The project that is the subject of this report was approved by
the Governing Board of the National Research Council, whose members
are drawn from the councils of the National Academy of Sciences, the
National Academy of Engineering, and the Institute of Medicine. The
members of the committee responsible for the report were chosen for
their special competences and with regard for appropriate balance.
This report has been reviewed by a group other than the authors
according to the procedures approved by a Report Review Committee
consisting of members of the National Academy of Sciences, the
National Academy of Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National
Academy of Sciences to enlist distinguished members of the appropriate
professions in the examination of policy matters pertaining to the
health of the public. In this, the Institute acts under both the
Academy's 1863 Congressional charter responsibility to be an advisor
to the federal government and its own initiative in identifying issues
of medical care, research, and education.
This study was supported by The Pew Memorial Trust.
2101 Constitution Avenue, N.W.
Washington, D.C. 20418
(202) 334-3300
Publication No. IOM-83-02
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CONTENTS
Commi t tee
Study Staff
Pref ace
Acknowledgements
Part I: Introduction and Ma jor Recommendation
. INTRODUCTION
Charge to the Planning Committee
Work of the Planning Committee
Rationale for an Integrated Look at Major Issues
Commit tee Conclusions
Proposed Plan
References
2. LOOKING AHEAI): AN AGENDA GROUP ON EDUCATION OF
HEALTH PROFESSIONALS
Composition and Qualities of the Agenda Group
Activities of the Agenda Group
Sponsorship of the Agenda Group
Financial Support
Implementation of the Agenda Group Recommendations
Summary of the Strategic Approach of the Agenda Group
References
Part Il: Priority Medical Education Issues
3 . IS SUES FOR TARGETED STUDY
Study Issue 1: Financial Pressures on Medical Education
Impact on Students: The Cost of Medical Education
Impact on Students: Availability of Financial Assistance
Impact on Teaching Hospitals and Medical Schools
Study Issue 2: The Changing Role of the Physician
Desired Qualities in Physicians
Health Manpower Policy
Potential New Roles for Physicians
Study Issue 3: The Cultures of the Medical Education System
Decision~aking in the Medical Education System
Faculty Roles: Fostering Teaching, Research and Service
The Professionalization Process for the Physician
The Teaching Hospital
The Premedical Syndrome
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Study Issue 4: The Science Base of Medicine
The Science Base of Medicine
Science Instruction
A Strong Research Establishment
Conclusion
References
Part III: Background Papers
4. THE PHYSICIAN' S ROLE IN A CHANGING HEALTH CARE SYSTEM
Stephen J. Williams, Elena 0. Nightingale, Barbara Filner
5. INNOVATIVE MODELS OF MEDICAL EDUCATION IN THE UNITED STATES
TODAY: AN OVERVIEW WITH IMPLICATIONS FOR CURRICULUM AND
PROGRAM EVALUATION
Jane S. Takeuchi, Nina M. Smith, Allyn M. Mortimer
6 . INFUS ION OF NEW FIELDS INTO MEDICAL EDUCATION
Barbara Filner, Victoria Weisfeld, Delores L. Parron
7. MEDICAL SCHOOL ADMISSIONS
Mary A. Fruen
8 . HOW TI1E MEDICAL STUDENT F INANCES EDUCATIONAL EXPENSES
Mary A. Fruen
9. THE INFLUENCE OF ECONOMIC FACTORS ON MEDICAL STUDENTS'
CAREER CHOICES
Sunny G. Yoder
10. FINANCING ME: DICAL EDUCATION
Jessica Townsend
11. PHYSICIANS FOR THE FUTURE-WHAT ARE THE NEEDS?
Nancy C. Ahern, Alvin R. Tarlov, Frank A. Sloan
Appendixes
A. BIBLIOGRAPHY
B. WORKSHOP SUMMARIES
1. Teaching Hospitals and Medical Education
2. Financing Medical Education
C. TOM/JOSIAH MACY, JR. FOUNDATION WORKSHOP ON
CHANGING COSTS OF MEDICAL EDUCATION AND THE
IMPACT ON THE MIX OF STUDENTS
1. Summary of Issues and Suggested Studies
2. Responses to Summary
3. Participants
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D. REPORTS ON VISITS TO MEDICAL SCHOOLS
1. Meharry Medical College (with letter from Dr. David
Satcher, President, on Special Financial Pressures on
Minority Medical Schools)
2. University of Indiana Medical School
3. Ben Gurion University Medical School
and Hadassah Medical School
E. MEDICAL EDUCATION ABROAD
1. Letter Requesting Information
2 . Summit ry of Responses
F . TYP ICAL PATTERN OF HE:DICAL EDUCATION IN THE UNITED STATES
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TABLES
Chapter 4
Table 1 Past and projected U.S. population, selected years,
1930 to 2000
Table 2 Live births and age specific birth rates, U.S.,
selected years, 1950 to 1979
Table 3 Age-adjusted death rates by cause, U.S., selected
years, 1950 to 1979
Table 4 Life expectancy at birth and at age 65, U.S.,
selected years, 1950 to 1980
Table 5 Limitations of activity and use of health care
resources by selected age groups, U.S., 1980, and
projections for 2000
Table 6 Number and percentage of office visits by the 20
most common principal diagnoses, U.S., 1970
Table 7 Discharges and days of care, non-federal short-stay
hospitals, according to first-listed diagnosis, U.S.,
1979
Table 8 Gross national product and national health
expenditures, U.S., selected years
Table 9 Per capita physician visits, by source of care and
patient characteristics, U.S., 1980
Table 10 Short-stay hospitals and beds by type, U.S., 1979
Table 11 Percentage of hospitals and hosptial beds under
propietary ownership, U.S., selected years, 1960
to 1980
Table 12 Number of medical group practices and physicians
and group practice by type of practice, U.S.,
selected years
Table 13 Number and population rates of physicians, U.S.,
selected yeas, 1950 to 1980 and projections for
1990 and 2000
Chapter 7
Table 1 Medical 'school applicant data, 1961/62 to 1980/81
Table 2 Medical school first-year enrollment data, 1968/69
to 1982/83
Table 3 Premedical grade point average distribution among
first-year medical students, 1966/67 to 1981/82
Chapter 8
Tabled Sources of medical school support, selected years,
1960/61 to 1980/81
Table 2 U.S. medical schools median tuitions and fees,
first-year students, 1960 to 1981
Table 3 Indebtedness of graduating medical students reporting 203
debt, selected years, 1971 to 1982
Table 4 Patterns in medical student finances, selected years, 204
1963/64 to 1977/78
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Table 5 Source of medical student loan funds and amount of
scholarship f unds expended, selec ted years, 1963
to 1973
Table 6 Amounts of loans and scholarship funds, 1975/76,
by source
Table 7 Sources of loans and scholarship funds, 1978/79
through 1980/81, by source
Table 8 Comparison of federal student loan programs available
to medical students
Table 9 NHSC scholarship awards, school years 1973/74 through
1982/83
Table 10 Medical school first-year enrollment data, 1960/61
through 1980/81
Table 11 Family income distribution among students in medical
school, 1963 and 1975
Table 12 Comparison of National Health Service Corps
scholarship recipients and total medical student
population, 1980/81
Table 13 Medical school s with the greatest number of National
Health Service Corps award recipients for the 1981/82
school year
Chapter 9
Table 1
Table 2
Table 3
Table 4
Alternative estimates of net present value of medical
education
Net present value of investment in medical education
compared with alternative occupations, 1976
Trends in medical school applicants, tuition and fees,
and physician incomes, 1977 to 1982
Numbers of physicians and mean net income from
practice, by specialty, 1976 to 1981
Chapter 11
Table 1 Enrollment of f irst-year medical students, 1965
to 1982, allopa~chic schools
Table 2 Enrollment of first-year medical students in
osteopathic schools, 1965 to 1982
Table 3 Numbers of initial licenses issued by state boards
of medical examiners, selected years, 1960 to 1981
Table 4 Foreign medical graduates participation in graduate
medical education, 1979 to 1981
Table 5 Physician supply pro jected by GMENAC, and U. S.
population, 197 8, 1990, and 2000
Ta ble 6 Physician Supply pro jected by Bureau of Health
Professions, and U. S. population, 1980, 1990,
and .2000
Table 7 Growth in numbers of active health professionals,
1965 to 1980
Table 8 Comparison of pro jections of physician supply and
requirements for 1960 and 1975
Table 9 Trends in hours of work, patient visits, and visits
per hour of work of MDs, 1970 to 1980
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INSTITUTE OF MEDICINE
Division of Health Sciences Policy
Committee to Plan a Comprehensive
Review of Medical Education in the United States
WALTER A. ROSENBLITH, Ing.Rad., CHAIRMAN, Institute Professor,
Massachusetts Institute of Technology, Cambridge, Massachusetts
ELENA 0. NIGHTINGALE, M.D., Ph.D., VICE-ChAIkt~N, Senior Scholar-in-
Residence, Institute of Medicine, National Academy of Sciences,
Washington, b.C.
KATHLEEN G. A~DRLULI, D.S.~., Executive Director of Academic Services,
Professor of Nursing, The University of Texas Health Science Center
at Houston, Houston, Texas
SUSAN D. BLOCK, M.D., Director of Psychiatry Primary Care Training,
Department of Psychiatry, Cambridge Hospital, Cambridge,
Massachusetts
H. DOUGLAS COLLINS, M.D., Private Practitioner of Internal Medicine,
Caribou, Maine
RUTH T. GROSS, M.D.. Katharine Dexter and Stanley McCormick Professor
of Pediatrics, Stanford University School of Medicine, Stanford-
Children~s Ambulatory Care Center, Children' s Hospital at Stanford,
Palo Alto, California
ROBERT L. HILL, Ph.D., James B. Duke Professor and Chairman,
Department of Biochemistry, Duke University Medical Center, Durham,
North Carolina
CYRUS LEVINTHAL, Ph.~., William R. Kenan, Jr. Professor of Biophysics,
Department of Biological Sciences, Columbia University,
New York, New York
ChA=ES E. LEWIS, Al; ., Sc.~., Professor of Medicine and Chief,
Division of Internal Medicine and Health Services Research, UCLA
Center for Health Services, Los Angeles, California
DON K. PRICE, Professor, John F. Kennedy School of Government,
Harvard University, Cambridge, Massachusetts
DAVID C. SABISTON, Jr., M.D., James B . Duke Professor and Chairman,
Department of Surgery, Duke University Medical Center, Durham, forth
Carolina
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CHARLES A. SANDERS, M.D., Executive Vice President for Science and
Administration, E.R. Squibb and Sons, Inc., Princeton, New Jersey
DAVID SATCHER, M. D., Ph. D., President, Meharry Medical College ,
Nashville, Tennessee
FRANK A. SLOAN, Ph.D., Professor of Economics, Vanderbilt University
Director, Health Policy Center, Vanderbilt Institute for Public
Policy Studies, Nashville, Tennessee
ROSEMARY A. STEVENS, Ph. D., Professor of History and Sociology of
Science and Chairman, Department of History and Sociology of Science
University of Pennsylvania, Philadelphia, Pennsylvania
ALVIN R. TARLOV, M.D., Professor of Medicine and Head, General Internal
Medicine, University of Chicago, Chicago, Illinois
ROBERT E. TRANQUADA, M.~., Chancellor/Dean, University of Massachusetts
Medical School, University of Massachusetts Medical Center,
Worcester, Massachusetts
HERMAN A. TYROLER, M.D., Alumni Distinguished Professor, Department of
Epidemiology, School of Public Health, University of North Carolina,
Chapel Hill, North Carolina
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INSTITUTE OF MEDICINE
President
Frederick C. Robbins, }1.~.
Division of Health Sciences Policy
Enriqueta C. Bond, Ph.D., Director
Study Staff
Barbara Filner, Ph.D., Study Director
Nancy Ahern, B.S., Staff Officer
Allyn Mortimer, B.S., Research Associate
Jane Takeuchi, Phil., Staff officer
Jessica Townsend, M.A., Consultant
Sunny Yoder, B.A., Staff Officer
Nina Smith, Administrative Assistant
Cynthia Howe, B.A., Administrative Secretary
Papers prepared by
Delores Parron, Ph.D., Institute of Medicine, Division of Mental
Health and Behavioral Medicine
Victoria Weisfeld, M.P.~., Institute of Medicine, Division of Health
Promotion and Disease Prevention
Mary Fruen,-Ph.D.' Consultant
Stephen Williams, Sc.D., Professor of Health Services Administration,
Graduate School of Public Health, San Diego State University,
San Diego, California
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PREFACE
As its charter states, "the Institute of Medicine shall be
concerned with the protection and advancement of the health of the
public," including "education for the health and medical professions
and sciences." Thus, numerous Institute studies during the past
decade have related, directly or indirectly, to diverse aspects of
medical education, the health professions, and health manpower, all in
the context of societal needs. Clearly, medical education has been an
Institute-wide concern and not just the concern of the members in
academic medicine or in academic administration.
The current Institute president, Dr. Frederick C. Robbins,
conceived the idea of a comprehensive review of medical education in a
contemporary setting and was fortunate in finding The Pew Memorial
Trust willing to support such an effort. Given the many studies and
reviews carried out by national commissions and professional medical
associations, it seemed appropriate to proceed in stages. Thus the
task was cast as one of planning whether such a review should be
conducted and, if so, how. ~
As the committee's work progressed, it became increasingly clear
that a ready-made solution to this complex problem was not in the
cards. The consensus at which we finally arrived reflects our
conviction that the task at hand is one that will need continued
attention. Thus it will be required that the health professions learn
to better adapt their educational agendas to continued progress in the
sciences and related technologies as well as to societal needs and
expectations and, last but by no means least, changes in resource
allocations that take only little account of what consequences they
may have for education.
With no illusion that the "problematique" of medical education at
the end of this century could be approached in the manner that had
been so successful when the century was young, the Institute president
assembled a committee from a broad range of disciplines and
professions. Two-thirds of the committee members had gone through the
personal experience of a medical education. Because the chairman
lacked such experience, it was indispensable to have him associated
with a vice-chairman who had practiced medicine and done biomedical
research. Dr. Elena Nightingale, an Institute Senior Scholar in
Residence, was ideally suited to play that role. She and the study
director, Dr. Barbara Filner, set a high standard of thoughtfulness,
flexibility, and hard work, a standard that the entire committee
appreciated and adopted.
Walter A. kosenblith
Chairman
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ACKNOWLEDGEMENTS
It is with pleasure and deep gratitude that we particularly
acknowledge the wise counsel of Or. John k. Evans, Chairman, Allelix
Inc.; Dr. David A. hamburg, President, Carnegie Corporation of hew
York; Dr. Julius B. Richmond, Professor of Health Policy, Harvard
University Medical School; and br. James B. Wyngaarden, Director,
National Institutes of Health. Their willing and generous guidance
and encouragement at pivotal points in this project enabled us to fine
a direction through a tangle of complex questions and ideas.
Drs. Steven C. Beering, President, Purdue University, David
Satcher, President, Meharry Medical College, Moshe Prywes, Dean
Emeritus, University Center for Health Sciences, Ben Gurion University
of the Negev, and Lechaim Naggan, Dean, University Center for health
Sciences, Ben Gurion University of the ~egev, made it possible for us
to gain a first-hand appreciation of some of the problems that medical
educators face and of the dedication, courage and creative talents
that can forge idealistic yet practical solutions. Their
contributions to the study were invaluable and their warmth and
hospitality to committee and staff will not be forgotten.
Dr. Frederick C. bobbins, President, Institute of Medicine, was
the inspiration and driving force for the entire enterprise--we thank
him for his unfailing interest and support.
Nancy Ahern, Dr. Jane Takeuchi, Jessica Townsend, and Sunny Yoder
made key contributions in the preparation of background papers and
throughout the course of the study, especially in thinking through
issues in need of further study.
Allyn hortimer and Nina Smith were our able researchers and
librarians. We are grateful to Cindy Howe and Nina Smith for their
dedication and capable support and thank Linda DePugh for cheerfully
assisting them in every crunch.
We also are indebted to many persons and organizations too
numerous to name here, for providing information and advice.
Finally, we would have accomplished nothing without the study
director, Dr. Barbara Filner. Her contributions to this
effort--substantively, logistically, and in every other way, were
immeasurable.
Elena (J. Nightingale
Vice-Chairman,
for the Committee
xii
