(Reuter, 1996a). These advances (testing and improving new kinds of heart surgery, developing new drugs, testing of advanced technology, like MRI, for example) are supported by an infrastructure that depends on the GME mission (Blumenthal and Campbell, 1996). They often owe their conceptualization and application to practice to scientists, medical care givers, and educators at our teaching hospitals. Concentrations of patients, drawn to teaching hospitals because of unusual clinical problems, and the lessons and experiences they provide are also important contributors. With the opportunities in time and resources afforded by teaching hospitals and medical schools, scientists and patients produce the observations and clinical research, through trials and case studies, that advance the understanding of disease and its diagnosis and treatment (Goldfarb 1996; Schroeder et al., 1989). Cooperation with private industry in these endeavors, which has greatly expanded over the last decade, strengthens the U.S. domestic and export pharmaceutical and medical device industries (Blumenthal et al., 1996).

New ideas arising from clinical research are communicated across the country, contributing to needed improvements in a national standard of health care and the development of a consistent approach to care (Pew Health Professions Commission, 1995). Teaching programs, by communicating information and by example, help to create a better standard of practice in their own communities as well. Geographic variations in practice patterns, overuse of technologies, and quality problems in the delivery system have been identified through the efforts of investigators in academic health centers. The existence of an effective network of teaching institutions committed to addressing these issues should be encouraged.

As medicine evolves, different types of personnel are needed. New training programs and new kinds of expertise and professionals develop in the environment created for research and educational purposes. GME keeps clinicians current with progress in health care, and, when new knowledge could be delivered more effectively through new disciplines and specialties, GME helps to create them and train the necessary personnel. Exceptional, complex services are also made available. The GME mission enables the creation of, and its trainees help with the staffing levels needed by, these kinds of care, which are primarily found in teaching hospitals (Jones and Smith, 1997). Although a competitive health care environment is forcing needed reductions of redundancies in expensive services and overcapitalization through mergers and closures (Blumenthal et al., 1996; Gold, 1996), a leaner, reoriented system will still need GME and its support to continue the contributions to health care noted here.

By virtue of their location, tradition, and the educational mission, teaching hospitals provide care with less than the usual concern about the sources, or likelihood, of payment for their services. The populations cared for are disproportionately disadvantaged. The 286 major teaching hospitals provided about $2.5 billion in charity care in 1994, for example, which was 45 percent of



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