settings, the report recommended that technical adjustments be made in the way the Medicare program financed graduate medical education and the way it reimbursed the services of physicians. The report also urged medical schools to reorder their priorities so that primary care teaching and curriculum development were rewarded. As the report noted, physicians in primary care practice responded to community health needs in settings that ranged from solo practice to HMOs; the hospital was no longer a suitable principal focus for the GME experience of such physicians. The committee concluded that "the care provided by future generations of primary care physicians would be enhanced if the GME experience placed greater emphasis on training in primary care outpatient settings." Although the report's effect on public policy was scant, it helped call attention to the need to match the educational system with the realities of medical practice. It received attention from medical schools that were in the process of revising their primary care residency programs, if not from the Congress.55

The Institute of Medicine produced a dizzying array of reports and studies in the Thier years. In the field of health manpower and education, for example, the work of the Institute extended beyond primary care to include multiple studies in the fields of geriatrics, allied health services, and occupational and environmental medicine.56 Often, one study exposed gaps in knowledge or highlighted opportunities that led to the IOM's being asked by a sponsoring agency to do a follow-up study.

At the same time, the IOM responded to numerous requests for assistance from government agencies on studies or projects that the agencies were undertaking themselves. To cite one example, the Institute of Medicine provided scientific advice and oversight for several Centers for Disease Control (CDC) studies of the health of Vietnam veterans. In particular, the CDC wanted to know if exposure to Agent Orange and other herbicides in South Vietnam led to a greater risk of such cancers as Hodgkin's disease and non-Hodgkin's lymphoma. In 1990, the IOM issued a summary report in which it concluded that the CDC Selected Cancers Study made a "useful and important contribution to understanding the relationship between the Vietnam experience and the cancers under study." Such validation was important because an earlier study that had been canceled led to a charge from Representative Ted Weiss (D-N.Y.) that the Reagan administration had deliberately obstructed the study. In such a contested area of public policy as the effects of Agent Orange, with millions of dollars in damages at stake, the public had to be reassured that scientists who performed the investigations were above political



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