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Chapter 2 LOOKING AHEAD: AN AGENDA GROUP ON EDUCATION OF HEALTH PROFESSIONALS This planning and review committee believes that the health needs of the public should provide the context in which the systems for education of health professionals are viewed. Both the health needs and the health professions have changed over the years, and they are expected to continue to evolve (Chapters 4, 6, 10, 11~. The rate of change of national health needs and of the health-care system have been rapid in recent years compared with change in the education system. A new and better match needs to be made between the educational processes for the health professions and society's needs and expectations of those professions. A number of institutions in the United States medical education system have undertaken innovations with goals re sponsive to the public's needs (Chapter 5~. These goals include practitioners who can better meet particular national or local health care needs, more physicians trained in a shorter period of time, more physician- researchers, or "better" physicians. Education for other health professions also has responded to perceived national need--as in the creation of training programs for nurse practitioners, for example, when a shortage of physicians was projected. These innovations in education may derive both from internal and external forces: the creativity, enthusiasm, and skillful leadership of an individual; the push and pull of economic constraints and opportunities; and changes in the social, political, cultural, educational, and scientific climate. External forces, especially economic ones, influence the health professional education systems, but not necessarily in directions such that education of the professional student better promotes the health of the public. This is especially problematic in academic medical centers, which have a broad range of activities encompassing research, care, and training, and in which education does not always have highest priority. There is a continuing need to scan the horizon f or the impact of these forces on the education system, to inform public and private decision-makers of opportunities and of missteps, and to formulate and implement sound policies for health professional education. Therefore ~ the ma jar recommendations __ ~^ lo_ be established. The proposed Agenda Group would provide a mediating _ . force to motivate and support institutions involved in education o: : health professionals to move toward constructive innovations re sponsive to health needs . We make the recommendation of an Agenda Group on Education of Health Professionals in full knowledge of the difficulties previous commissions have had, even when their charge was sharply focused and 15

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they had a mandate from the President or the Congress. but our planning study has led us to the conclusion that the problem of matching education to health needs is involved with so many constantly shifting scientific, economic, social, and political factors that no immediate prescription for reform can be satisfactory, and the best of today's plans will require readjustment later. An Agenda Group on Education of Health Professionals should serve over the next several years to help stimulate and integrate the efforts of the many independent educational and professional organizations that must cooperate if their interests, and those of the public as a whole, are to be harmonized. The Agenda Group would provide a locus for systematic communica- tion among colleges, universities, professional schools, professional organizations, governments, and public interest groups. The Agenda Group also would be a mechanism for scanning for events and trends that might affect health professional education and its responsiveness to national health needs. The Agenda Group als o could commission studies on issues it judged to be of major significance and in need of detailed analysis. In the past two decades, much has been written about the need for reform in medical education, and the charge to this committee was to plan a review of medical education. However, the committee has concluded that the total needs for health care personnel and their education, rather than those only of physicians, must be considered in an integrated fashion. Physicians (allopathic and osteopathic) interact with a variety of other health professionals, and health care is broadly construed. Nurses, midwives,- physician extenders, and dentists, for example,* provide direct health services to patients, and their training has many features and problems in common with that of physicians. Thus, the Agenda Group's sphere is not limited to medical education. Previous studies often have recommended establishment of some sort of national commission with a long-term monitoring function. In the letter of transmittal for this 1965 report1 to the Association of American Medical Colleges, Lowell Coggeshall states: The enormous expansion of medical education, research, and service, especially in the past two decades, has resulted in greater changes than have occurred during any other period in our medical history. The great and growing national concern over the health of our people requires that those responsible for medical education today and in the future turn their attentions to a question of the greatest importance and most far-reaching consequences: Will the methods and practices currently followed in - *The Agenda Group should not dilute its efforts to include all health professionals. Thi s listing provides a suggested start. Consensus on the prof essions to be included should be an early goal of the Agenda Group. 16

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providing health personnel of all categories, together with the programs and facilities in being or planned, be adequate to meet our national needs? During the study, surprising unanimity of concern was found among medical educators, university officials, public officials and others about problems in the field of medical education. Few persons interviewed believe improvements needed are matters of minor adjustment. Most point to the need to take major steps to improve medical education to enable the nation to produce more and better prepared physicians and other health personnel. There is a rather consistent pattern of thought that the quality of education is good, but not fully geared to future needs. Most impressive is the repeated assertion that there is need for some organization (preferably the Association of American Medical Colleges) to assume a more aggressive and correlative role if future needs in the f ield of education f or all health personnel are to be me t . 1 More recently, Carleton Chapman2 concluded that the premedical and preclinical phases of our present scheme of education for medicine are intellectually deficient, wasteful of money and time, and in urgent need of overhaul. Chapman defines conditions under which a national commission might possibly set the educational process on the road to reform, and states that the commission should not be based in government or in a university setting because it should be insulated from partisan and political pressures exerted by government and academe. A 1965 summer workshop noted the startling increases in the number and proportion of children and the elderly, combined with rapidly expanding biomedical knowledge, [which] create wholly new conditions for the practice of medicine. The study reports also stated that It is difficult, moreover, to find a locus within the present organization of medicine and medical education for the many cross-disciplinary activities called for. It is not easy, on the one hand, for any institution to organize for its own alteration; it is even less easy for it to accomplish an alteration in fellow institutions. The solution recommended is that a steering committee for medical education be formed and that it seek to find funds from public or private agencies to assure it a lifetime of a year or more and the services of a small staff. The committee might identify areas where curriculum reform in medical education is essential, and those persons who would be willing to engage in such reform and to solicit funds for the prosecution of the work. In his recent book, 4 Lewis Thomas discusses the governance of universities, and medical schools and teaching hospitals as elements of the university. Who are the decision makers and how does one implement changes that are viewed to be desirable? He identified as factors in medical education the place of most medical schools in the university, the relationships between medical schools and other parts 17

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of the university, such as schools of public health; the role of research in the schools and teaching hospitals; the relative power of the dean and of the heads of departments that bring in large amounts of money compared with those that do not; the relationship of the teaching hospitals to the medical school, to the populations they serve, and to the reimbursers of care. These factors that shape the medical education system, however, do not have the quality of education as a primary concern. Some other force is needed which would have education as its primary concern. Thus we return to the recommendation, made by a variety of groups over a period of time, for a continuing source of independent counsel. The Agenda Group could be an instrument for thinking in detail about the major forces that influence health professional education, ways to preserve valuable parts of current health professional education, and changes in the education systems that would help move the health care system closer to meeting the needs of the public. There have been many recommendations from many sources on how to improve medical education, but very few of the recommendations have been implemented, perhaps because change usually occurs by social consensus. Traditional ways of reaching consensus are being strained and may be breaking down; therefore, it behooves us not to be limited by individual policy outlooks. The Agenda Group might-provide a matrix around which social consensus on education of health professionals could develop. Other issues besides education of health professionals currently share a degree of complexity and national importance which necessitates innovative, interdisciplinary mechanisms for thoughtful review. The Ad Hoc Committee on Government-University Relationships in Support of Science, of the National Academy of Sciences, for example, recently recommended the creation of a Forum on Government-University Relationships.5 The Forum was recommended in an effort to channel tensions among the federal government, the university research community, and university administrators in constructive directions; the goal is to develop a lasting, constructive approach, rather than to redocument the increasing strain in government-university relations. The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research provides an example of success in interdisciplinary handling of complex problems. Its reports6 provided guidelines that already have gained wide acceptance on such thorny issues as informed consent and ethical problems inherent in decisions to forgo life-sustaining treatment. The commissionts impact was such that, since its recent scheduled termination, legislation has been introduced to recreate it. We believe that such groups should have a mandated termination. At the close of the designated period, an active determination of 18

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continuing need and usefulness should be made . Accordingly, we recommend that the Agenda Group should be constituted for no more than five years, and at the outset there should be no commitment by the fenders beyond that period. A preliminary assessment of the Agenda Group ' s ef fectiveness should be made af ter two or three years, and improvements made as needed . At the end of f ive years, af ter critical review of usefulness by, among others, health professionals and their institutions, the group could continue if the sponsors and the members agree that it should. Composition and Qualities of the Agenda Group The Agenda Group should function in the modes of study and inter-institutional cooperation, providing a mechanism for needed perspective and new directions. It could provide an appropriate institutional arrangement for dealing with the social ecology of the health care system, a large industry of which medical education is only a small part. The Agenda Group should be capable both of reflective consideration of issues over time and short-term responses. It should monitor relevant trends and events, suggest new directions, make recommendations for action, and generally be representative of the public's health. The Agenda Group should not be an advocacy group for any of the actors in the health professional education stage, nor for special pleading. It should be as much as possible free from the pressures of representing any particular interest group, and, therefore, should be able to converse with any sector of society in the spirit of free co nmunicat ion and trus t . It i s recommended that appointees to the Agenda Group be a small number of knowledgeable persons of excellent judgment whose goals are to optimize the education of health professionals for meeting the heal th needs of the public . The group would be composed of perhaps six to twelve persons selected on the basis of their personal experience, expertise, broad interest in public affairs, and wisdom, rather than professional or ins titutional af f iliation. In aggregate, the group should be composed of persons who have demonstrated wisdom in matters relevant to higher education in general and health professional education in particular, as well as in matters of public policy and institutional change, and in various social, behavioral, population, and biomedical sciences. The group must be composed of persons with national stature and credibility. Credibility with the profession, the health care system, and the universities is important, but the group' s impact will depend in large measure on the members' credibility with the public, and in their representations to the Congress and the state legislatures. The group's distinction must enable it to mobilize panels of experts to conduct specific studies and to convene workshops or forums. Above all, it is essential that the group be, and be perceived to be, representative of the interests of the American people, not the 19

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interests of the profession of medicine or any other health profession or the institutions of medical or other health professional education. Because the Agenda Group should be a neutral body, it is recommended that nominations to it be made through the Institute of Medicine, whether or not the Institute is involved in its functions and operation. The members should be appointed by the president of the Institute of Medicine from a slate of nominees contributed by health professional groups, education groups, boards of contributing foundations, third-party payers, and representatives of the public interest, among others. The members of the Agenda Group should commit a substantial portion of their time to it and the chairperson should be full time for the first year and at least half time thereafter. Appropriate compensation should be provided. Staggered rotation of group membership is desirable, especially in light of the effort required of each member. A small staff of perhaps two or three professionals would be required, in addition to an executive director, to prepare background materials and reports and to arrange the meetings and other activities of the group. Activities of the Agenda Group The Agenda Group would examine broad issues of population and social changes relating to health and ways in which health professions education could contribute to their accommodation. The group would be a continuing monitor of events, trends, quality, critical thinking, and conceptualization about health professional education both at the national level and the state level. Priority tasks of the Agenda Group would be to def ine appropriate roles in health and health care of physicians, nurses, midwives, physician extenders, and dentists,* as well as tasks and goals of schools to prepare health professionals for these roles. The Agenda Group would have as a major goal the identification of needed changes in health professional education and provision of help in bringing about these changes so as to maximize the possibility of training the wide variety of workers in the health care system to work well together for more effective health care. Extensive consultation and collaboration with leaders of national, regional, and state professional organizations and educational institutions, and with policymakers, will be essential. Periodically, but no less often than after three and five years, the group would report on its findings regarding significant trends having inpact on health professions education, anticipated problems, and approaches to their resolution. While the Agenda Group is developing its long-term work plan, a series of shorter studies could be implemented. This planning committee has identified four targeted studies on medical education . . *See footnote on page 16 e 20

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(Chapter 3) which would address specific problems in improving the education and training of physicians. These studies--on modulating the impacts of financial pressures on education, on the changing role of the physician, on the cultures of the medical education system, and on the science base of medicine, would provide data and analyses for the Agenda Group. The studies could contribute substantially to the eventual solution of problems that already can be identified or anticipated . It is our expectation that other studies will be recommended as the Agenda Group deliberates, especially in view of its expanded scope to include non-physician health professionals. The charge to the Agenda Group is a broad conceptual one, so specif ic committees should be constituted to conduct these shorter targeted studies. The Agenda Group should be instrumental in designating needed expertise and resources for each study committee. Direct participation by one or more Agenda Group members would be valuable but not essential. As appropriate, the special resources of professional organizations* should be called upon. The parallel study of the AAMC, "General Professional Education of the Physician and College Preparation for Medicine, " to be completed in 1984, should prove especially valuable to the suggested studies on the cultures of the medical education system and the science base of medicine. The recent Institute of Medicine study on nursing educations also is highly relevant, especially to the theme "the changing role of the physician." Sponsorship of the Agenda Group The organizational locus of the Agenda Group requires careful consideration, because the group risks being viewed as a competitor by existing entities that have an obvious stake in the issues. The climate of the times and complexity of the issues require unfailing objectivity of assessment, but the group also must be able to involve leaders in medical and health professional schools, in professional organizations and other influential bodies that have particular interest in the issues. Several possibilities come to mind. One place for the Agenda Group would be as a more or less independent body housed in a sponsoring foundation. The amount of responsibility and control of the foundation staff would be a matter for prior agreement. *For example, the American Academy of Nursing, American Academy of Physician Assistants, American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, American Association of Colleges of Pharmacy, American Association of Dental Schools, American Dental Association, American Medical Association, American Medical Student Association, American Nurses Association, American Public Health Association, American Society of Allied Health Professionals, Association of Academic Health Centers, Association of American Medical Colleges, Association of Schools and Colleges of Optometry, Association of Schools of Public Health, Association of University Programs in Health Administration, Committee on Allied Health Education and Accreditation (AMA), National Governors Association, and National League for Nursing. 21

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A second possibility would be a freestanding operation, such as that of the Carnegie Commission on Higher Education, chaired successfully by Clark Kerr for some years. That commission had credibility, and was not viewed as serving particular interest groups. According to Clark Kerr,8 the committed people who served on the commission learned from each other and produced work of much more weight than if the studies had been done by any single individual, no matter how wise. Although the foundation provided a name and funds, it allowed the group complete freedom in its work. Unlike the Carnegie Commission, the Agenda Group for the Education of Health Professionals might be incorporated so that it could establish its own program of issues to study and have both control of and public accountability for its work. In this case, the sponsors of the Agenda Group would be involved initially in delineating the group's mission, but then would sever the formal tie. The Institute of Medicine of the National Academy of Sciences offers other possibilities. The Agenda Group could operate either as a committee of the Institute or as an independent unit housed in the Institute. The Institute charter directs it to examine "policy matters pertaining to the health of the public;" its membership is diverse and expert in the many health-related professions, as well as other relevant disciplines such as economics, law, and ethics. The Institute members could be drawn on for expertise, not only in the Agenda Group, but also on its panels. Review procedures like those in force in the Institute of Medicine and the National Academy of Sciences complex would help assure critical assessments of the reports of ad hoc groups convened by the Agenda Group to deal with specific questions. The way in which the reports of the Agenda Group will be peer reviewed needs to be worked out. On balance, our committee favors the option of an independent body housed in the Institute of Medicine. The potential sponsors providing financial support will undoubtedly want to make their views known regarding the organizational basis of the Agenda Group. Financial Support Regardless of the option selected for the organizational base of the Agenda Group (a foundation, freestanding, or the Institute of Medicine), it is our recommendation that the financial sponsorship come mainly from foundations, with a lesser but meaningful contribution from the federal government.* A single foundation or a consortium of foundations should provide leadership and initial commitment of funds. As discussed earlier, the planning committee believes that the initial commitment should be for five years, a *Whatever role federal and state government play in the future in relation to health care and health professions education, government and the Agenda Group will need each other as informed and critical interlocutors. 22

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period of time that would provide a good test of the usefulness of the enterprise. Because technological, scientific, social, and economic change s are more rapid now than ever before, the need to look ahead in education of health professionals is more critical than in the past. Private foundations traditionally have played a pivotal role in providing financial support for medical education and research and in sponsoring studies in medical education. Our proposed venture provides further opportunity for foundation involvement in educational innovation. Foundation support is particularly important at this time, when substantial support from government agencies appears unlikely. An additional advantage of foundation sponsorship would be its great potential for accelerating implementation of the Agenda Group's recommendations. The offering of grants for model programs could be more persuasive than the logic and rhetoric of the report itself. Flexner, in preparing his 1910 report, visited each medical school in the U.S. at that time.9 Coming from the Carnegie Foundation, he found doors opened to him that might otherwise have been closed, because the foundation name must have evoked "dancing visions of endowment plums."10 . It is estimated that the Agenda Group would cost about $500,000 the first year. Specific targeted studies would require additional funding. If the concept of the Agenda Group is accepted, a workshop should be held with leaders of interested foundations to discuss the project and plan a strategy for its financial support. Implementation of the Agenda Group Recommendations If the Agenda Group is sponsored by several foundations, each should assist in the wide dissemination of reports and implementation of recommendations. Informed leadership opinions should be developed within the affected professions. In addition, the leadership of those segments of society that the medical, nursing, and other health professional schools depend on, such as state governments and components of the federal Department of Health and Human Services, should be involved in both the planning and the follow-up to the work of the Agenda Group. The group's recommendations will stand primarily on their merit, but their implementation can be facilitated beyond the persuasiveness of wise, credible, well-intentioned people. Some of the leaders in medical schools, schools of public health, nursing schools, teaching hospitals, and other relevant institutions might wish to implement needed improvements, but need assistance or support in doing so. The sponsoring foundations, if they find the ideas put forth by the Agenda Group worthwhile, could provide support to follow through on the recommendations. Foundations could ask that their concerned grantees make a major effort to follow the general thrust of the recommendations 23

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of the Agenda Group in order to remain eligible for funding by the foundation in educational and in other areas. There should be special attempts to reach users, the Congress, and others, even before the studies are completed; their comment on the draf t reports could be solicited. This would provide valuable feedback to the study committees and the Agenda Group, and enhance prospects for subsequent implementation. Positive incentives for implementation need to be studied carefully so that the recommendations would appear attractive both from a fiscal point of view and from a desire to shape new consensus among colleagues. Some thought would also have to be given to the factors that are likely to affect the acceptability of innovations in particular settings. What would innovations mean to the prestige and authority of those who must adopt them? What is the intrinsic value to the user of curricular or teaching programs or arrangements that are going to be replaced? How can people who are going to experience a change be involved in the planning and implementation of the innovations? And how can individuals and institutions be motivated to take a leadership role? The sustained dissemination of the reports of the program would be important. Perhaps an advance arrangement for publication of the Agenda Group's reports and other products, as a recognizable series, would be feasible. The Agenda Group should assume responsibility for distribution of its publications to a selected group of people, and the publications should be available to the general public, on request. Forums and press conferences also could provide mechanisms for dissemination. . No matter how good the recommendations of the Agenda Group, their implementation could bring some unintended and undesirable ef feet s . The Flexner report 's consequences provide some examples. To the good, the foundation-sponsored* victory of adoption of a four-year medical school curriculum, the introduction of laboratory teaching exercises, the improvement of the quality of instruction by means of a full-time faculty, the expansion of clinical teaching through the introduction of the clinical clerkship, the incorporation of medical schools into the framework of the universities, and the establishment of research in the teaching program.12 However, unintended effects of the Flexner renc~rt included development of uniformity and rigidity in *The universities responded with alacrity deco the challenge posed by the foundations and the dollars they provided--$78 million from the Rockef eller Foundation alone by 1928 , roughly equivalent to 445 million 1983 dollars; and $154 million by 1936, roughly equivalent to 1.1 billion 1983 dollars. (Dollar figures from Starr, Note 102, p.462; Calculations based on Consumer price indices (CPI) for 1928, 1936, and February, 1983. CPI's were provided by the Bureau of Labor Statistics. ~ Most of this money went to seven schools, a distribution that de termined which schools and which ideals of education would dominate .11 24

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medical school curricula, which lasted for the next 60 years, and a major emphasis on diagnostics and therapeutics and little attention to health maintenance, despite Flexner's warnings that uniformity and rigidity stifled creative work, and that preventive and social medicine were of central importance. Also, after 1910, the number of women entering medicine declined markedly. According to Starr,13 as schools closed and places in medical school diminished, schools started to exclude women; the justification was that they would not continue to practice after marriage. For blacks, the situation was similar--outright discrimination in predominantly white schools accompanied the closing of five of the seven medical schools for blacks that existed in 1910. Casting medical schools on the Johns Hopkins model also removed some of the practical orientation from American medicine and reduced the health manpower available to meet needs, particularly of the rural poor. By 1919, there were about half the number of graduates as in 1900 and it was not until after World War II that their number returned to the level of 1900. While more rigorously educated physicians seems a desirable goal, we can ask retrospectively if the decreased number of doctors was, on balance, beneficial in an era of limited therapeutic possibilities in which physicians' major role was to comfort. Thus, it is important that the Agenda Group monitor the impacts of implementation of its recommendations, to allow for timely corrections. This is particularly important in view of the diversity of U.S. medical schools; a given program or recommendation may not be suitable to all schools. The ability to resist conservative pressure, the wisdom to foresee the consequences of its actions, and the resiliency to meet new problems generated by the ramified effects of its actions, 14 will be invaluable to the Agenda Group. The endorsement of the Agenda Group from the beginning by such groups as the American Medical Association, the American Nurses Association, the American Osteopathic Association, the American Public Health Association, the Association of Academic Health Centers, the Association of American Medical Colleges, the Association of University Programs in Health Administration, the U.S. Department of Health and Human Services, and others who would be at fected by its recommendations would be invaluable to the Agenda Group's aims. Such endorsement would demonstrate what Henry Pritchett called professional patriotism.l5 "By professional patriotism amongst medical men I mean that sort of regard for the honor of the profession and that sense of responsibility for its efficiency which will enable a member of that profession to rise above the consideration of personal or of professional gain." Summary of the Strategic Approach of the Agenda Group If the Agenda Group is to be effective, its members will have to avoid the temptation of thinking that their tactical problem is as straightforward as that of the professional and philanthropic leaders 25

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who pushed for the adoption of the Flexner report recommendations. The situation was fundamentally different at that time: the government was only minimally involved, the professional leadership in the AMA was eager to support the tightening of educational standards, and the small number of major f oundations were in control of the only outside funds that could influence the aspirations of medical schools. Today, by contrast, the foundations are numerous and committed to varying philosophies and approaches. The big money comes from the federal government, whose programs are not always coordinated. Each foundation can supply money only in comparatively small amounts, but their funds can be of great influence as seed money to develop ideas and stimulate discussion. On the encouraging side, there is more general recognition of the importance of the problem, and great pressure to find some solution. There is widespread belief that health programs are a public responsibility, but one which should permit as much local and professional freedom as possible. Education of health professionals is an area in which political and philanthropic leadership is likely to acknowledge the need for some independent review from professional sources--provided that those sources can be made truly independent. An approach toward developing such review is suggested here in the Agenda Group. It involves the following: 1) The selection of an institution with a reputation for independence to take responsibility for organizing the group and providing it with logistical support, but without attempting to control the substance of its deliberations. 2) The selection by that institution of the members of the group. The members should include respected leaders of the academic and professional interests involved, and also experienced leaders in various aspects of public affairs outside the health professions. The members should understand and represent, but still freely criticize, the points of view of the competing interests in the health professions. The professional interests should not be requested to choose representatives as instructed delegates, but should be asked to suggest possible nominees for membership. 3) The Agenda Group members should expect to make its work a major part-time commitment, with meetings several times a year to review the current situation and make projections about future trends and impacts, to reevaluate the various reports on health profession education of earlier years and their practical consequences, to identify topics in need of further data gathering and/or analysis, and to commission appropriate studies. It should have an adequate staff to help it gather data and formulate issues for discussion and proposed resolution. 26

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4) Funds for operation should come from individual donors or foundations which preferably are not committed to particular formulas for health or educational policy, whose support would not give grounds for any suspicion that the group 's conclusions or the selection of its membership from time to time were predetermined by f inancial or political influence. Government support also should be sought, especially at the federal level, and at the state level as well, as appropriate. 5) The group will obviously need to maintain continuous and close liaison with several parts of the federal government and various professional and academic interests--the support of which may be required to carry into effect its recommendations. 6) The four targeted medical education studies (Chapter 3) given high priority by this planning committee, and other targeted studies identified by the Agenda Group, will require combinations of review of available data, data collection, discussion, critical analysis, and recommendations for action. The studies could be conducted under the aegis of the Agenda Group or independently. A decision should be made for each study as to whether it would best be housed in the Institute of Medicine, which would establish a study committee, or set up as an ef fort of a professional organization, a single scholar, a research institute, or some other entity. The planning committee makes the preliminary recommendation that the Institute of Medicine conduct the targeted studies, but suggests that the Agenda Group, once appointed, consider further whether a particular group or individual is better suited to carry out one of The full studies or a component part. Liaison wi th other groups should be established as appropriate, and full participation of the health professions augmented by social scientists, public policy experts, economists, and others, sought as needed. Our hopes for the Agenda Group thus include that it will provide a continuing mechanism for examining change, that it will contribute to a climate leading to improvements in the education of health professionals, and that it will facilitate communication and the more rational resolution of shared problems among the partnership of health professionals. 27

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REFERENCES 1. Coggeshall, L. T. Planning for Medical Progress Through Education. Washington, D.C.: Association of American Medical l Colleges ~ 1965. Chapman, C. B. Should there be a come ission on higher education? Science 20S: 559-562, 1979. . Cope, 0. and Zacharias, J. Medical Education Reconsidered. - Report of the Endicott House Summer Study on Medical Education, July 1965. Philadelphia: J.B. Lippincott Company, 1966. 4. Thomas, L. The Youngest Science: Notes of a Medicine Watcher. New York: Viking Press, 1983. 5. Ad Hoc Committee on Government-University Relationships in Support of Science, Committee on Science, Engineering, and Public Policy. Strengthening the Government-University Partnership in Science. Washington, D. C.: National Academy Press , 1983. 6. President 's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making Health Care Decisions, Volume One. The Ethical and Legal Implications of _ Informed Consent in the Patient-Practitioner Relationship. Washington, D.C.: Government Printing Office, 1982. 7. Institute of Medicine. Nursing and Nursing Education: Public Policies and Private Actions. Washington, D.C.: National Academy Press, 1983. 8. Personal communication to Elena 0. Nightingale, Vice Chair of the Corn~nittee . 9. Flexner, A. The Flexner Report on Medical Education in the United . . , States and Canada. Washington, De C.: Science and Health - Publications, 1960 (original printing, 1910) . 10. Starr, P. The Social Transformation of American Medicine. New York: Basic Books, Inc., 1982, p. 119. 11. Lewis, I. J. and Sheps, C. G. The Sick Citadel: The American Academic Medical Center and the Public Interest. Cambridge, Massachusetts: ~elgeschlager, Dunn and Hain; 1983. Richmond, J. B. Currents in American Medicine. Cambridge, Massachusetts: Harvard University Press, 1969. Reference #10, p. 124-125. 14. Becker, H. S ., Geer, B., Hughes, E. C., and Strauss, A. L. Boys in White: Student Culture in Medical School. Chicago: University of Chicago Press, 1961. 15. Pritchett, H. Introduction. In Reference #9. 28