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Chapter 1
INTRODUCT ION
Medical education in the United States today owes much of its
structure to the implementation of many of the recommendations of the
1910 report by Abraham Flexner.l He decried an abundance of
non-rigorous proprietary schools and held up as a model the
university-based curriculum of Johns Hopkins. Flexner's urging for
reform succeeded so well that medical education and medical practice
henceforth became solidly grounded in the knowledge and methods of
natural science.
Most medical schools now build their curriculum on two years of
basic science and two years of clinical medicine, taught along
disciplinary lines by faculty members who are full-time academics, and
who expect the graduates to go on to further training. Major
departures from that model have been few and far between, limited
largely to development of an interdisciplinary curriculum in the
l95Us, and more recently the problem-based and community-oriented
approaches to medical education.
As medical education settled into a 70-year period principally
spent in adding to its science base, American society was changing all
around it. Many of the changes were related, at least in part, to
medicine's advances, such as a steady expansion in effectiveness
against the infectious diseases--immunizations were developed to
prevent some and antibiotics were found to cure others. New
technologies were developed to improve diagnosis; new drugs and
surgical procedures were introduced to improve treatment; an
understanding grew of risk factors for disease; systems of life
support were perfected to take over for failing organs.
But, as infectious diseases became less of a threat, chronic
diseases moved into the ascendancy; as newborns were led unscathed
through the illnesses of childhood, they lived to incur the diseases
of adulthood, including those related to environmental factors and
personal habits; as techniques improved to sustain life, concern arose
about the quality of that life; and as physicians became more
scientific, complaints were heard that they were less compassionate.
More physicians are being trained than ever before, but the costs of
health care continue to rise steeply and doctors are scarce in the
inner city and rural pockets of poverty.
Since the Flexner report, our country's entire economic and social
system has evolved from one of small scale individualism to organized
corporate and government administration. Health care has become an
industry--one of the largest, now representing 10 percent of the Gross
National Product2 and employing over 7.5 million people, the 450,000
physicians being less than 10 percent of health care personnel.2
Health care decisions no longer derive exclusively from the
relationship between an individual doctor and a patient. The
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doctor-patient relationship is affected by the complex relations
between physicians and the hospitals with which they affiliate, the
growing number of salaried physicians and physicians participating in
group practice arrangements, and the various private medical insurance
programs and federal entitlement programs such as Medicaid and
Medicare. Furthermore, roles and responsibilities of physicians in
relation to other health professionals continue to change as nurses,
physician extenders, and others seek greater professional
responsibilities, and as legislative bodies mandate particular
roles.3
Another force for change has been the growth of the research
programs sponsored by the National Institutes of Health (NIH).
Biomedical research has become a multi-billion dollar enterprise. It
has produced both an explosion of knowledge and a highly
research-oriented faculty in the laboratory-based experimental
disciplines, which are dominant over the population-based sciences and
the behavioral sciences.
Because of an apprehension that our future supply of physicians
would be inadequate, and increasing concern for social justice in our
country, we have more doctors today than ever before, and they are a
more heterogeneous group. Scholarships and low interest loans,
federal laws and enforcement efforts, and increased willingness and
efforts by admissions committees to enroll qualified women and
minorities, have opened the doors of the profession to more students
in general and to women, minorities, and those from less wealthy
families in particular. Medicare and Medicaid legislation has brought
us closer to equity of access to health care, which more and more
people view as a right.4 But recently, in the face of economic
pressures, the trends toward equity in access to the profession and to
health care have slowed.
Institute of Medicine members and others, have expressed doubts
that some aspects of today's health care system are suitably matched
to the preparation of practitioners. Issues that have been brought
forward, and that led the Institute to undertake this review and
planning effort, include the following.
0 The growing numbers of physicians, the expectations of expanded
roles of non-physician health professionals, the desire to assure
equity of access to health careers, and the continued presence of
medically underserved populations (defined geographically,
socioeconomically, or ethnically) raise complex questions which must
be dealt with by educational institutions, governments, and society as
a whole. How may all of these concerns be balanced and integrated to
arrive at a health manpower policy, which would include policies on
admissions . to health professions schools and advanced training
programs; local, state, and federal subsidy and support for medical
education and research; and federal policies relating to immigration,
for example. What will the roles of the various health professions be
in the future, and how should the education system adapt to changes in
role? How do we match numbers and distribution of health
professionals to national needs?
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o How to assure that the medical education system will educate
physicians to be able to address the problems of their patients in the
decades ahead, without unduly prolonging the time and resources
committed to the medical education process. Included here, for
example, are concerns about the aging of the population, the shift in
the burden-of-illness toward chronic disease, the growing importance
of lifestyle and individual behavior in determining health status, and
the importance of primary care physicians in treating mental illness.
An orientation to population-based medicine, so as to see significant
phenomena and to think of impacts and needs beyond those of the
individual patient also is relevant here.
o We are in an era in which information is generated at a rate
never experienced before--a virtual "information explosion.' now
might the education system best prepare physicians to keep abreast of
scientif ic advances--prepare them f or lifelong learning? how can
computers be maximally utilized for the ef f ective management of
information?
o In an era of increasingly bureaucratized health care and
intensively technological medicine, is a special effort required to
preserve the caring function of medical practice--not instead of but
in addition to the scientific and technological strengths of
medicine? How may the objective of caring be translated into
practice; how is it taught and evaluated?
o How to train physicians to balance traditional striving for best
possible care of a patient with economic constraints which also must
be considered; to develop increased sensitivity to economic
consequences of medical decisions on the use of resources and to
search for more cost-effective means of high-quality care.
O How to use the education system to prepare physicians to grapple
with questions about what constitutes best care when technology allows
for extension of life but of greatly compromised quality. Physicians,
individual patients, families, and society as a whole have growing
concern about the need for wise and sophisticated decisions to
deliberately withhold or withdraw these technologies. Ethical,
economic, and personal values all come into play here.
o how to prepare physicians to deal with a public increasingly
conscious of ethical issues in health care--informea consent, clinical
trials, privacy, and the like.
o How can the education system assure continued advances in
knowledge? How best to train a cadre of physician-researchers? Means
to enhance clinical research interfaces between clinical practice and
laboratory research need thoughtful consideration.
o Questions of responsiveness to the community, and possible
conflict of university missions and community missions, arise in many
contexts, but appear especially pressing for academic health centers.
The fear that teaching hospitals and academic health centers will
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collapse under the combined pressures of increased costs, growing
competition from community hospitals, reduced direct and indirect
federal support, and a disproportionately large share of patients who
are unable to pay for their care also must be addressed.
Charge to the Planning Committee
The Institute of Medicine, which has a tradition of viewing events
in the larger perspective when contemplating a new study, wished to
examine these various concerns in the context of societal needs now
and in the future. A request was made to The Pew Memorial trust to
support a planning effort for a comprehensive review of the entire
spectrum of medical education.
It was in the context of an evolving physician role in a highly
complex and changing health care system that the Institute, with the
support of the Pew Memorial Trust, undertook this planning effort. A
committee was appointed to outline the scope and conceptual framework
for a review of medical education.
The work of the committee was 1) to identify the perceived
deficiencies and strengths in the present system for delivery of
health care in the United States, 2) to project future health care
needs in light of projections about the way medicine will be practiced
and organized in the next 10 to 20 years, 3) to identify elements in
the medical education system that have some influence on meeting
present and future health needs, 4) to identify the issues meriting
highest priority for attention, and 5) to agree on the scope and
framework for a significant effort intended to help the education
system be most responsive to future health requirements of society.
This review and planning effort was undertaken with the full
realization that the intrinsic and extrinsic factors which influence
medical education have become so intertwined as to be practically
inseparable. It also was realized that no single person, group, or
institution has the authority to mandate solutions to these major
educational issues, institutional issues, and inter-professional
issues. The committee's intent was to consider responsibly and
rationally the factors relevant to creating a health care system more
in tune with the structure of our society and to suggest some
educational priorities in the establishment of such a system.
Work of the Planning Committee
The 18~ember committee undertook a number of activities in order
to understand more fully the contexts in which medical education takes
place, in which decisions are made about medical education, and in
which health goals for the nation are defined. These activities also
were intended to help identify national, regional, and local concerns
in medical education, to identify further knowledge needed and
feasible approaches to acquiring it, and to help develop priorities
among the many study issues proposed.
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Many persons were consulted informally by the committee and stat f
to get the perspectives of teachers, researchers, clinicians,
students, educational administrators, government administrators, and
foundation administrators, among others. Although too numerous to
name individually, we grater ully acknowledge their valuable
contributions.
A number of previous s tudies were valuable resources . A selec ted
lis t of report s on these studies and other relevant books are included
in Appendix A. Liaison with the current AAh(: s tudy on General
Professional Education for the Physician, described more fully on
pa'ge 7, also was established. The staff of the Association of
American Medical Colleges (ANTIC) provided valuable assistance, which
is gratefully acknowledged.
Consultants and Institute staff prepared background papers on
subjects selected for detailed examination by the committee. These
constitute Part III of this report.
Two workshops were convened by the committee--one on Teaching
Hospitals and Medical Education and the other on Financing Medical
Education. Summaries of those workshops and lists of participants are
in Appendix B.
With the support of the Josiah Stacy, Jr. Foundation, ~ small
conference on The Changing Cost of Medical Education and the impact on
the Mix of Students was conducted. The purpose of this conference was
to assist the Institute's planning committee in its identification and
selection of issues for study. Following the 1 1/2-day conference,
a list of study topics was distributed to the participants. They were
asked to review the list, add to it if appropriate, and to make
judgments on relative priorities. The conference summary, a report on
the participant responses about priorities for study, and a list of
participants are in Appendix C.
Visits were made to two U.S. medical schools: Meharry Medical
College was chosen to learn about and highlight issues in the
recruitment and education of minority student;. The University of
Indiana School of Medicine was chosen as an example of a state-
supported school. We were especially interested in its reported
succes s in integrating a number of campuses into the medical education
program. In addition, the Vice-Chair of the come ittee, while in
Israel, took advantage of the opportunity to visit the 1sen Gurion
University of the Ne.gev health Sciences (:enter (an example of a
co~nmunity-based school) and the Hadassah Medical School of Hebrew
University . Appendix 1) contains reports on the f our visits.
In order to learn more--in a very preliminary way--of the variety
of structures for medical education systems, and how other countries
deal with their health manpower needs in the context of medical
education, an informal survey of some other countries was made. A
letter of inquiry sent to medical/scientific officers in Washington,
D.C. embassies and a tabulation of responses are in appendix b. This
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survey enabled the committee to identify issues which might be
followed up selectively in greater depth, if the Agenda Group decides
case studies from abroad would provide useful perspective. One
example is the comparative benefits (and problems) of highly selective
entrance requirements for medical school (e.g., United States) vs.
Open admissions (e.g., Italy). Another topic for possible follow-up
and international dialogue is the use, in countries with shortages, of
"excess" health personnel from other countries.
The planning committee assessed the information gleaned from these
various sources in light of their own experiences and knowledge of the
published literature. Discussions during six meetings over a 12-month
period led to the recommendations that constitute Parts I and
II of this report.
Rationale for an Integrated Look at Major Issues
The first question the committee had to resolve was whether
another major study of medical education would be worthwhile.
Considerable doubt was encountered about the value of a series of
studies on medical education. There were those who adjured us, in
effect, "if it ain't broke, don't fix it." They viewed the health
care and medical education systems as fundamentally sound and feared
that marginal alterations could inadvertently damage the whole.
Others, who perceived a need to improve the health care system,
expressed skepticism about the ability of the medical education system
to influence it. Many other people questioned the need for yet
another study of the same subject, and pointed out that the time was
at hand for implementation of what we already knew, not more study.
Still others considered the subject of medical education too narrow
for meaningful analysis.
Some believe that the American health care system and American
medical education are the best in the world. The education system
provides technically competent, honest, responsible physicians. But
specif ic system-wide inadequacies exist today, such as steadily rising
health care costs and the persistence of medically underserved
populations.6
And even if the system were optimal for the present, it would not
necessarily be optimal for the future. In the not-too-distant future,
with the population aging and the rise of chronic disease, maintenance
of maximal possible function, rather than cure, is likely to be the
physician's best effort (Chapters 4, 6~.7 Multiple interacting risk
factors', rather than straightforward cause-effect relationships, will
have greater roles in determining health status.~9
Such trends must be accommodated within medical education, but
time is needed until the effect of educational changes will be seen at
the level of the health care system. Typically there is a five- to
eight-year period from the beginning of medical school studies to
entry into independent practice (Appendix F). Thus, the committee
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concludes that an integrated look at the medical education system
together with education of non-physician professionals who deliver
health care, from the perspective of the nation's health care needs in
the next 10 to 20 years, could provide timely guidance to those who
would make the changes. However, the committee also deems it
essential to preserve those parts of the system that have worked well
over time and that are likely to continue to be fruitful.
To what extent can changes in the educational process be used to
solve some of the present concerns centered in the health care
system? Although educational changes alone will not solve these
problems, it is likely that they will have some effect. By formal
course work, by implicit and explicit messages in the words and
actions of clinician-teachers, and by informal discussions with
mentors and colleagues at many stages of the education process,
physicians and other health professionals can learn about care
alternatives, career alternatives, and the social implications of one
choice over another. Enhancement of awareness of these choices would
contribute to the solution of some of the complex and longstanding
problems of the health care system.
Is there need for further study? Since Flexner's time, many
studies on medical education have been published--some by individuals,
some by professional organizations, and some by special committees or
commissions (Appendix A). These have dealt with modification and
improvement in the design and management of premedical, general
medical, post-MD (graduate medical), and continuing medical education
programs.
Recently, the American Medical Association (AMA), in Future
Directions for Medical Education,1O examined the concepts and
principles governing education for medical practice. However, this
report, which offers valuable analysis of medical school and teaching
hospital concerns, cautions that it has not addressed in depth "cost
and f inancing of medical education; changing ethical principles
resulting from new knowledge and technology; interrelationships
between government agencies and higher education; . . . expectations
of society concerning physician competence; methodologies for
evaluating clinical performance; and need for cohesive long-range
planning nationally for all levels of medical education."
The Association of American Medical Colleges (AAMC) and the Macy
Foundation Study Group on Graduate Medical Education completed reports
on GME--Graduate Medical Education: Proposals for the Eightiesl1
and Graduate Medical Education, Present and Prospective: A Call for
Actibr~l2~-
An AAMC study on 'General Professional Education of the Physician
and College Preparation for Medicine' (GPEP) is in progress and will
be completed in 1984.13 Working groups of the GPEP study have been
considering the knowledge and skills physicians must have, as well as
the desired personal qualities, values , and attitudes (see Chapter
3~.14 An important component of the charge to these working groups
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is the identification of faculty actions that develop and foster the
requisite attributes. Several recommendations for actions (by faculty
and others) have been advanced by the working groups,l5~16,l7
following a series of regional meetings and deliberations of the
working groups. The Project Panel will work on means of
implementation of these recommendations during the second
year-and-one-half of the three-year study. The AAMC is especially
well-suited to look at issues related to internal operations of the
medical schools--admissions, for example. Since it is the
organization that represents the schools, it is likely that its
recommendations will be given serious consideration.
There have been a number of manpower studies relevant to medical
education. The Graduate Medical Education National Advisory Committee
(GMENAC) 1980 reportl8 was concerned with aspects of supply and
distribution of physicians, as were On the Status of Health
Professions Personnel in the U. S., Third Report to the President and
Congress, -Y On the Status of Medical School Faculty and Clinical
Research Manpower 1968-1990, and Personnel Needs and Training for
~ . _
Biomedical and Behavioral Research, 1981 Report . Al Of related
interest is the recent Institute of Medicine study report Nursing and
Nursing Education: Public Policies and Private Actions, which
considers the need for federal support of nursing education, means to
enlarge the supply of nurses in underserved areas, and reasons for
individual career choices by nurses.22 -
Similar topics also have been explored in special conferences.
The Institute of Medicine sponsored a conference on Clinical
Investigations in the 1980s: Needs and Opportunities, which looked
into research manpower needs. .A recent Macy conference on
Teaching the New Biology went into such issues as teaching methods,
evaluation methods, and curriculum goals.24 A conference on
Financing Medical Education, at the New York Academy of Medicine,
probed "The Cost for Students and the Implications for Medical
Practice."
And there have been many articles each year on almost all of the
issues of concern here in publications such as the Journal of the
American Medical Association, the New England Journal of Medicine, and
l
the Journal of Medical Education.
Committee Conclusions
The committee has concluded that a major effort is indeed
warranted, employing recent reports and ongoing studies as valuable
resource s. However, it does not recommend that another broad study of
medical education be undertaken. Rather, it is the committee's
recommendation that an institutional mechanism more consonant with
current decision-making processes be created. This mechanism would
provide a forum for discussion by all concerned constituencies; a
means to filter and sort major concerns relevant to education of
health professionals; and a basis on which to identify areas that
require action.
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The most important reason for proposing a new approach is the
committee's agreement with comments that medical education is too
narrow a focus. We agree. Our charge was to plan a study of medical
education, and most of the effort in this planning phase emphasized
the education of physicians. But the answer to almost every question
we asked ourselves depended on decisions about issues such as who
would be responsible for aspects of health care of the well elderly
and of the chronically ill, who will be advising about
health-promoting behavior, and who will be teaching people how to
change their behavior ?
The first step in rethinking the education system must be a look
into the future--in as open a manner as possible and with a minimum of
assumptions--to assess what the role of the physician should be. This
inevitably leads to a need to project the role of other health
professionals--nurses and social workers, to name but two--because
physicians do not work alone. Thus, our proposal is to monitor the
educational agenda of the health professions in a coordinated manner,
and to undertake an early examination of optimal allocation of roles
and responsibilities.
The committee also believes that the perspective this ef fort would
have is extremely important. The interests and needs of the general
public served as the starting point in this planning effort, rather
than the needs of the health professions as viewed by the health
professions. A group bringing together a broad spectrum of health
prof essions would be able to question common assumptions and achieve
consensus on professional roles and prerogatives. The participation
of professional organizations is essential, but the group in its
entirety must not be allied with any particular professional interest ;
it should be as free as possible from the pressures of representing
any particular interest group, and therefore be able to converse with
any sector of society in the spirit of free communication and trust.
A crucial concern would be how to promote implementation of
recommendations (judged by the proposed group to be feasible and
promising), whether generated by the group or stemming from other
studies. Insight into how to promote and sustain specific reasonable
improvements will be important. Without the leverage of money or
regulation, power to implement changes must derive from the shedding
of light, from the persuasiveness and intellectual rigor of the
presentation of the problems and approaches to their resolution.
Proposed Plan
The ma jar recommendation of this committee is that an Agenda Group
on Education of Health Professionals be established to deliberate on
how the health professions education system helps or hinders progress
toward f uture health goals of our country; to consider the social ~
economic, political, scientific, and educational f orces in our society
that act on health professions education; to tell when these forces
can be enlisted to implement constructive changes in the education
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system; and of equal importance to caution when those forces are
acting to undermine a valuable aspect of health professions
education. The committee's recommendation is that the Agenda Group
-
have a broad mandate and broad perspective, encompassing a range of
health professions, and that it should have assurance of at least a
five-year continuity.
Although the Agenda Group would depend heavily upon data generated
from a variety of sources, it is the committees further
recommendation that as needed the Agenda Group identify specific
targeted studies that would help it meet its mandate. These studies
could be conducted under the aegis of the Agenda Group, or
independently of it. In either case, the Agenda Group would
coordinate and integrate the studies, and would seek means to
implement recommendations derived from them.
During the deliberations of the planning committee, four medical
education issues for early attention came to the fore. Listed in
priority order, they follow.
1. Financial Pressures on Medical Education
2. The Changing Role of the Physician
3. The Cultures of the Medical Education System
4. The Science Base of Medicine
These topics focus on medical education, as does the entirety of
this report, because the initial charge to the planning committee
encompassed only medical education. However, as indicated earlier, it
is the strong recommendation of the committee that the scope of the
Agenda Group activities be expanded to include other health
professions. Accordingly, the Agenda Group might modify the four
suggested studies to include other health professions within their
framework. It is our expectation that the information and conclusions
brought forth by each of these studies would be most useful if the
studies are conducted as a coordinated set of activities; sequencing
would be necessary for some studies--how large the science base of
medicine is, f or example, will depend on the role of the physician--
other studies could be conducted in parallel. It also is our
expectation that as the Agenda Group deliberations proceed, with a
scope expanded beyond medical education to include health professions
education, additional priority topics for study will be identified.
The priority sequence presented here, which was determined by a
vote of the planning committee, should not be considered immutable.
Several caveats accompany the priority. First is the realization that
the expansion of the scope of the Agenda Group beyond medical
education to health professions education may change the relative
priorities. Secondly, the Agenda Group may wish to modify priorities,
in light of the expertise its members provide and the actual timing of
its activities--what studies are then available, what developments
have occurred since completion of this planning report. The overall
theme of the Agenda Group is the interplay of the education systems
with their multi-faceted environments. An environment can change
quickly, and the priorities should be responsive to these changes.
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Additionally, the interest of funding sources may proscribe strict
adherence to the suggested priority sequence. This sequence is not
intended to be rigid . It is intended to provide helpf ul guidance .
The four medical education issues were chosen for different
reasons, and their study will serve a number of different purposes.
Financial pressures is a topic relevant to the long-range view of the
Agenda Group, but it also is of immediate concern. The intent of this
s tudy would be to examine the consequences of current f iscal crises
and policies and to work toward short-term solutions while also
assessing the lessons for long-term policy. The three other themes
are closely related to one another and to f inancial pressures. They
would help the Agenda Group (and the larger community of educators and
policymakers) look toward the future, learn from the past, and
illuminate how decisions are made within the education system. Two
major public policy questions for each of these priority topics, as
selected by the committee, are enumerated below. Chapter 3 presents
these and other questions in greater detail.
Financial Pressure on Medical Education
1) Should available funds for students be channeled into targeted
efforts, such as subsidy programs emphasizing minority and low income
groups?
2) Is the present mix of sources of support for medical education
adequate and what are appropriate responsibilities (including such
issues as payment of indirect costs) of each source (students, state
and federal government, private and public third party payers,
philanthropy, grants for research, and cross-subsidies from other
units of the university) ?
The Changing Rule of the Physician
1) What are the implications for the future role of physicians of
the increasing supply of physicians, increase in number and proportion
of elderly, scientific advances, changes in burdens of illness,
increased interest in health promotion and disease prevention, and
changes in numbers and kinds of non-physician providers?
2) What outcome measures can be used to evaluate quality of
physician performance? Valid outcome measures would be needed to
determine which selection procedures and which innovative approaches
to medical education are most likely to produce physicians well suited
to their various future roles.
The Cultures of the Medical Education System
Behind each of these issues are questions of power and decision-
making wi thin the educat ion sys tem.
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l) What are the implications for educational values and messages
of the organization and financing of academic medical centers?
2) How do the values and priorities implicit in the traditional
socialization process by which a medical student becomes a physician
relate to the shifting goals of medical education?
The Science Base of Medicine
1) What is the Science base needed for the future practice of
medicine and what is the general education required of future
physicians?
2) When in the educational sequence should particular aspects of
the science base be taught--and how can better integration of the
teaching in the several institutions involved be achieved?
The committee believes that all of these topics deserve priority
consideration and clarification; some will need new research; all
require thoughtful attention and considered action. The topics differ
considerably in terms of their susceptibility to various research
methodologies. For some, there are existing instruments and
experimental designs that can be applied so as to minimize threats to
reliability and validity. In many cases, qualitative research methods
can be applied, but in others, the lack of a clear conceptual
framework inhibits more formal inquiry.
The basis for these recommendations and more details about the
proposed studies are presented in the following chapters. The Agenda
Group is discussed in Chapter 2. The medical education study issues
are presented in Part II (Chapter 3~.
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REFERENCES
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.
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3. Roemer, M. I. An Introduction to the U.S. Health Care System.
New York: Springer Publishing Company, 1982.
4. Jonsen, A. R. The Rights of Physicians: A Philosohica1 Essay.
Andrew W. Mellon Foundation, June 1978.
5. Table 67, Reference #2.
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7. Institute of Medicine. The Elderly and Functional Dependency.
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8. Institute of Medicine. Healthy People, The Surgeon General's
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papers. DHEW (PHS) Publication No. 79-55071A. Washington, D.C.:
U. S. Government Printing Of f ice, 1979.
9, Tnot] tilt" Of M-d ~ nine. Health and Behavior
Frontiers of Research
in the Biobehavioral Sciences . Washington, D. C.: National Academy
. .
Press, 1982.
10. American Medical Association. Future Directions for Medical
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11. Association of American Medical Colleges. Graduate Medical
Education: Proposals for tt~ Ii. Washington, D.C.:
~;= _ is, 1980.
12. Josiah Macy Jr. Foundation. Graduate Medical Education Present and
Prospective: A Call for Action. Report of the Macy Study Group.
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14
Representative terms from entire chapter:
health professions
