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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 viii x xi xii 1 4 4 6 8 9 13 15 19 20 21 22 23 25 28 29 30 32 34 37 40 42 44 47 48 49 51 52 54 56

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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 iv 56 57 60 63 65 66 70 107 148 175 198 224 243 261 286 295 302 302 305 307

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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 v 302 309 321 325 331 331 333 359

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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 71 72 73 73 74 76 77 79 80 81 82 91 177 178 179 199 202 V1

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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 vii 206 207 209 211 212 214 215 217 218 229 231 236 237 262 263 264 264 266 267 268 277 278

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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 viii

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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 x

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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 xi

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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