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Chapter 3 ISSUES FOR TARGETED STUDY The planning committee's efforts were directed toward identifying key topics for targeted study, raising questions, and establishing priorities. Many interesting scholarly questions surfaced, but they are not all presented here. The intent of the studies that are outlined is to identify alternative policy options, to illuminate the practical implications of those options, and to better understand the processes relevant to gaining agreement on and implementation of chosen options. Four sets of questions will underlie the future work of the Agenda Group. 1) What is the shape of the health care system likely to be by the turn of the century? What are the major trends, unmet needs, and areas of obsolescence and redundancy? 2) How should medical and health professional services be adapted to reinforce desirable trends in the health care system and to resist undesirable ones? 3) What are the implications from question 2 for medical education and education of other health professions? 4) What are the factors resisting desired changes and what financial, regulatory, evaluative, and other mechanisms might be employed to achieve those changes? In this chapter, some proposals for targeted studies relevant to these questions are presented. As indicated earlier, because the initial charge to the planning committee dealt with medical education, that is the f ocus here . The targeted studies are presented in the priority order suggested by the planning committee . Within each study, the subtopics also are presented in priority order. As indicated in Chapter 1, caveats about their relative priority are necessary. As the Agenda Group considers its expanded scope, the expertise of its members, the appearance of new reports, the reality of funding possibilities, and changes that take place in the health care system and the larger society, modification of the scope of each study and its priority may be appropriate. Details of methodology, data availability, and necessary resources are not provided here for each suggested study. That information would be a part of detailed study proposals. Some of the studies will require data collection and others will require integration and assessment of completed research projects. Some issues will be amenable to analysis by controlled research methodologies; others will 29

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be less data-based and will require striving toward consensus and inf ormed judgment . The targeted studies and their subtopics, in priority order, are listed here. 1. Financial Pressures on Medical Education c. a. Impact on Students: The Cost of Medical Education b. Impact on Students: Availability of Financial Assistance Impac t on Teaching Hospitals and Medical Schools 2. The Changing Role of the Physician c. a. Desired Qualities in Physicians b. Health Manpowe r Policy Potential New Roles for Physicians 3. The Cultures of the Medical Education System a. Decision Making in the Medical Education System b. Faculty Roles: Fostering Teaching, Research, and Service c. The Professionalization Process for the Physician d. The Teaching Hospital e. The Premedical Syndrome '.. The Science Base of Medicine a. The Science Base of Medicine b. Science Instruct ion c. A Strong Research Establishment Study Issue 1: Financial Pressures on Medical Education Medical education today is rebounding f rom an earlier expansionary era in which increasing the production of health manpower was considered a priority. Government funding resulted in a substantial increase in both the number and size of medical schools. Payment for health services for the poor, aged, and disabled, combined with payment for hospital teaching functions, encouraged hospitals to offer residencies to graduate physicians and clinical experience to medical students. Student loans and scholarships ensured a steady demand f or medical education and lowered f inancial barriers to those who might otherwise have been unable to participate in medical education. In addition, research funding resulted in the development of institutional research capability and research faculty. Now the institutions of medical education, especially the medical schools and the teaching hospitals, must adjust to changing policy and funding environments. The planning committee considered a study of the resultant financial pressures to be of highest priority. While the charge to the committee was to look to the future--10 to 20 years ahead--the 30

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immediate f inancial pressures are perceived to be so intense and of such potentially negative consequences that they must be dealt with. If ignored, their adverse legacy may still be present 10-20 years hence. The specific concerns of the committee, and many others we spoke with, were of two sorts: worries about students and worries about teaching hospi tats . Because tuitions have been rising steadily, and scholarships, low-interest loans, and service payback provisions have become less available, there is fear that low-income students will be prevented by financial barriers f ram becoming physicians , and those low and middle income students who do become doctors will have so great a burden of accumulated debt as to influence decisions about their practice of medicine (Chapters 8, 9, 10, Appendixes C and D). Students are being asked to bear a higher share of the cost of medical education, which raises new questions. Should there be across-the-board subsidies or should available funds be channelled into targeted efforts, such as subsidy programs emphasizing minority and low income groups? With the rapid increase in aggregate supply of physicians and the number of physicians locating in previously underserved communities, will state support of medical education decline? If so, would it be desirable to develop federal-state programs (matching grants) to stimulate state support? The worry about teaching hospitals is that they may collapse because of fiscal pressures--competition from community hospitals, changes in reimbursement schedules, increasing costs of technology and health personnel, and a larger than proportionate share of pat tents who are unable to pay their hospitalization costs (Chapter 10, Appendix B). Balancing the fear that the teaching hospital system will collapse is the fear that it will survive, but with its educational and medical values so subverted to cost containment measures and f inancial strategies that the lessons learned will not be those anyone would choose to teach the next generation of physicians. The current sys tem of f inancing has evolved in a piecemeal fashion. There has been much description of trends in financing sources, but insufficient consideration has been devoted to systematic analysis of the current funding system to determine the appropriate rights and responsibilities of eac~of the payers. The question of who should pay involves value judgments as well as knowledge of behavioral relationships. Currently, no adequate framework for evaluating the important normative issues has been developed. Is the present mix of sources of support for medical education adequate? What are the appropriate responsibilities of the sources of support: students, state and federal government, private and public third party payers, philanthropy, grants for research (including overhead sources), and cross-subsidies from other units of the university? Private third party payers now support medical education, but many are beginning to question their position on this. In any event, increased competition will make it less likely that any payer will be 31

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willing to pay the extra charges of hospitals with major teaching programs. Should medical education be financed by a tax on private insurance premiums? Or by having a rate-setting commission build a tax for medical education in hospital rates? Patient care dollars are an increasingly important source of revenue for medical eduction. What are the pros and cons of cross-subsidies as a method of finance? What kinds of distortions in the medical education process does pressure for cross-subsidies int roduce ? Indirect costs have grown rapidly, and support for indirect costs has been important to academic health centers. Yet further growth in funding of indirect costs will be likely to have an adverse effect on support for direct research costs. What are specific alternative mechanisms for paying for "indirect" activities and the advantages and disadvantages of each alternative? A number of specif ic topics for study relevant to these two sets of concerns have been identif fed . Relevant to the impact on students are analyses of factors af fecting: o the cos t of medical education o the availability and types of f inancial assistance. The impact of the changing financial support structure for teaching hospitals and medical schools would consider such topics as: o educational impact of cost containment measures O availability of residency slots 0 medical practice plans o states' roles in financing. The impact of financial pressures on students is explored in greater detail here than is the impact on teaching hospitals. The latter issue is receiving considerable attention already, as from the Association of Academic Health Centers.l,2 Questions about financing of research activities are presented in our study issue 4, the science base of medicine. Impact on Students: The Cost of Medical Education Tuitions and fees have increased considerably in the last 20 years (Table 2, Chapter 8), yet they seldom cover all educational costs to the institution. To determine the true cost of educating a physician, or a particular kind of specialist, is complex. The numerous streams of money, mixed functions of faculty, student involvement in patient care, and other elements where costs and income are intertwined, make it difficult to determine the level of cost directly attributable to 32

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education. Studies that developed methodologies for estimating education costs include those of the Institute of Medicine and the Association of American Medical Colleges in the 1970s. The Institute study estimated the annual cost of undergraduate education per medical student in 1972-73 to range from $6,900 to $18,650 in 14 schools studied.3 An estimate of 1980 costs per student, calculated by summing federal capitation, state institutional support, and tuition and fees, was $23,044.4 Faculty represent a substantial part of the cost of medical education, and as financial pressures increase, this becomes an obvious area in which to try to economize. The number of faculty members increased at an even greater rate than the number of medical students during the 1960s and 1970s, so that there has been a steady decrease in the ratio of students to faculty. The number of students per full time faculty fell from 1.5 in 1973-74 to 1.3 in 1980-81.5 However, these figures do no necessarily mean that students receive more time from faculty members. The concomitant growth of clinical practice plans may be reducing teaching time. Clinical practice produces revenue that expands with time devoted to such practice, but research income is directly tied to the level of funding. Thus, reductions in funding may have a greater impact on the number of research faculty hired than on the number of clinical faculty. In many types of education, it is assumed that lowering the student/faculty ratio is beneficial to the quality of education. This probably is true up to a point, but one can question whether below a certain point the benefits continue to increase. In an ideal world, one would estimate the optimal student/faculty ratio, the optimal mix of faculty, and the optimal distribution of faculty time in terms of teaching, research, and clinical practice, and move toward that situation. But this is not an ideal world, and medical education is a complex process, and those who must today make faculty hiring decisions have little to fall back on to guide their decisions. It is difficult to devise the research needed to develop guidelines for such decisions. Some obvious difficulties arise from the mix of activities of each faculty member--differences between basic sciences and clinical teaching, overlap or involvement of medical schools with their universities, the similar involvement with patient care institutions, and the problem of developing outcome measures against which to judge differences. Other difficulties arise f ram the various goals of medical education. Academic health centers aim to produce clinicians and researchers, expand the body of medical knowledge, provide health care services, and have many other purposes. Outcome measures therefore must be varied and might include quality of care, career choices of graduates (clinical versus research), specialty choices of graduates, and choice of practice location of graduates. States provide institutional support to medical schools and this helps keep tuition costs to students moderate. State support has grown while federal institutional support has declined; however, state 33

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support has not fully compensated for the decline in federal spending. Federal institutional support through capitation between 1974 and 1978 fell at an average annual rate of about 13 percent; by 1980, state aid was at'the level of only about 6 percent of federal capitation.6 Although reductions that might occur in state expenditures for institutional support may be more severely felt by public than private schools, the impact of Medicaid cuts will be felt across the board. Derzon and Lewin in a recent paper suggested some ways in which states can start looking at their medical education expenditures with a view to reducing costs. Some of these suggestions, such as the use of video and computer assisted instruction and improved management, are useful to more than only the state sector. Others, such as re-examining the state need for additional physician manpower and increased use of the "contract seat" method of purchasing education in private or out4Of-state schools, may be promising approaches for state policy makers. Impact on Students: Availability of Financial Assisistance Policymakers concerned with such matters as the size and composition of the physician labor force, the type of medical care offered to the public, and equity in access to medical education, should be informed thoroughly about the consequences of increased tuition and changes in financial assistance to students. It is important to understand the likely impact of the loss of such programs as the National Health Service Corps scholarship program. The corps was designed primarily to encourage physicians to locate in underserved areas, but also provided substantial support for minority students (Tables 9, 12, 13, Chapter B). If poor and minority individuals no longer enter medicine, there may be a greater impact on underserved areas than elsewhere.7 One way of looking at tuition costs--whether they are in some sense too high--has been to view students' (and their families') input into tuition as an investment and earnings as a return on that investment (Chapter 9~. The rate of return may be decreasing. Tuition is rising; the availability of low cost loans, scholarships, and service payback provisions is decreasing; and physician incomes are rising more slowly than education costs. Tuition increases and reductions in low-cost student support can be expected to have a number of effects. For example, reductions in loan availability may affect high tuition schools more severely than low tuition schools and students with fewer financial resources more than those with greater resources. Tuition increases may drive graduates to practice in the more lucrative areas of the nation and in the better paying specialties. The pool of applicants to medical schools may continue the decline that has already begun, with a possible reduction of quality of student. There may be an especially severe impact on medical schools that educate a great proportion of black or other minority students, such as Meharry and Howard Universities, whose graduates are more likely to practice in underserved areas than graduates of other schools.7 (See Appendixes C and D.) 34

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Research on the impact of increases in tuition and costs on students receiving financial assistance should focus on carefully selected areas of concern, but as a first step a survey of the pertinent information that can be gleaned from the literature on the economics of education would provide a useful base of knowledge.8 For example, education economists are starting to look at the level of debt that people of different income levels are willing to assume. Work by Hansen and Rice and the Congressional Budget Office can be used to expand the information on the effect of loans and the available policy options in education.9-1l Specific areas of research that would produce a useful body of information include: 0 monitoring specialty choice among students with different levels of debt; has a threshold been crossed so that indebtedness inf luences career choices? (See Appendix C). O the difference in effects by race and cultural background, and the impact on access to health care of underserved populations that may result from declining enrollment in medical education of specific cultural, racial, or economic groups o the effects of a shrinking pool of applicants on the quality of students. Studies of this sort could rely, in part, on available data collected by individual schools, the AMA, AAMC, and specialty boards. Characteristics of students (race, level of debt, level of family support, academic background) could be correlated with schools (high tuition versus low tuition) , specialty choice, practice arrangement choice, expected income, etc., to develop information on many of the questions that confront policymakers today. An additional area of useful study would be an investigation of delinquency or default rates in student loan programs. Delinquencies in loan programs that depend on repayment to make further loans obviously suffer a reduced capacity to help students.* In December 1982 the General Accounting Of f ice, responding to a determination that many schools had unacceptably high delinquency rates, ** recommended management actions to improve the situation.12 Although the recent data show schools can lower delinquency rates, this may become more difficult if debt levels and interest rates increase substantially. It is unknown whether there is a correlation between debt and default, between default and institutional policy, between student income level * At Howard University, for example, a relatively large number of students--35 percent--participated in the Health Professions Student Loan (HPSL) program in 1982. ** An HPSL is delinquent if a payment is more than 90 days late. The HPSL delinquency rates, which are determined for each school, ranged up to 40. 9% in 1982.13 35

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and default, between the different loan programs and default, etc. Studies to determine these relationships would be useful in developing policies to reduce default and delinquency rates, and to indicate if failure or delay in repayment warrants further assistance. To the extent that the current political climate is returning to states responsibilities that formerly rested with the federal government, states and the federal government must reconsider their relative roles in medical education. Should physicians be considered a national resource? Should physician manpower policy be developed on a state by state basis? (Between 40 and 50 percent of physicians remain in the state in which they were trained.) If decision-making is to rest increasingly at the state level, the impact of state policies on the local physician supply should be investigated. Changes that are taking place (such as the proposed reduction in the Health Science program of the University of California, tuition increases in public schools, changes in state medical service payback scholarships, and changes in state contract seat arrangements) should be monitored to discover the extent to which they affect both the overall and the local physician supply, and students' decisions on public versus private education. Because political and fiscal pressures differ among states, one can expect differences in their willingness to spend money on medical education, in their willingness to raise tuition, in their willingness to target financial aid to specific population groups, etc. A small number of case studies in selected states could illuminate the understanding of the political, economic, and manpower concerns that drive state policy and the forces that may cause policies to change. Two of the nine states that have passed legislation authorizing the issue of tax exempt bonds to finance loans to students are phasing out their programs.14 Although total appropriations by state governments for medical service payback programs have grown substantially, from a little over $5 million and 1,000 students in 1978 to $13 million and 2,300 students in 1980, these programs do not represent substantial across-the-board student aid. Only three states (Kentucky, Mississippi, and Wyoming) spent more than 61 million in 1980, and 23 stares did not have service payback programs.6 State scholarship aid is also unevenly distributed between public and private schools. Nearly 10 percent of scholarship aid to public schools flows from state governments, but less than 1 percent at private schools. Similarly, state institutional support is directed to public schools to a far greater extent than private schools.6 Research should also look at the comparative costs of some alternative ways of affecting the local supply of physicians. For example, if states want to increase the number of graduates retained in the state, what is an effective mechanism--Area Health Education Center (AHEC) type activities or state health service corps programs? What are the costs to the state of each and which is more cost-effective? 36

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Impact on Teaching Hospitals and Medical Schools Financial pressures on teaching hospitals may affect clinical education. There may be reductions in the size of clinical faculty. There may be reductions in the size of residency programs. Medical schools and teaching hospitals may start to rethink and restructure their relationships with each other. The increased supply of physicians--and specialists--together with broad insurance coverage of health care services, has enabled community hospitals to become direct competitors to teaching hospitals in the provision of sophisticated medical care. Teaching hospitals are therefore competing for patients--especially paying patients--with community hospitals. Teaching hospitals, whose costs are higher than community hospitals because of their patients' severity of illness, special case mix, educational costs, and role in caring for poor and non-paying patients, are developing strategies to maintain their occupancy rates. They are looking at their communities and developing ways of becoming providers of basic medical care for their neighborhood populations, and they are establishing Health Maintenance Organizations to ensure that a group of paying patients will use the hospital. But these strategies are unlikely to provide real f iscal relief for many teaching hospitals, in part because they are of ten located in inner city poverty areas (Appendix By. A less quantif table, but equally important, impact of f inancial pressures on academic health centers is the possible effect of cost pre s sure s on physician behavior . Although cost containment has been a policy theme for many years, there is little evidence that students have been offered thorough formal instruction in the cost of medical care or ways to approach the provision of cost effective care. There is also little evidence that the role models that students observe throughout their education demonstrate significant cost consciousness, but this is changing fairly rapidly. Increasing financial pressures seem to have changed the behavior of these role models; the next generation of physicians will be more aware of the financial impact of their medical decisions on the patient, the hospital, and the health care system as a whole. The challenge is to balance fiscal responsibility with quality care. The effects on teaching hospitals of state policies also deserve investigation because state-level actions affecting the economic welfare of hospitals are continually occurring. State by state monitoring of changes in financing that will affect teaching hospitals will help develop a perspective on the continued ability of those institutions to sustain their contribution to medical education. Medical practice plans have become an increasingly important source of revenue for medical schools (Table 1, Chapter 8) and have been used to finance expansions in clinical faculty. Although the organization of plans differs among schools, all specify the way in 37

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which funds generated by faculty members engaged in patient care are distributed to the school or faculty member. Nedical practice plans have been in place for over twenty years, but concern with the impact of these arrangements has become acute only recently as the search for revenues to replace shrinking government funds has stimulated a greater emphasis on medical practice plans. Many members of our committee, noting that faculty appear to be devoting a large proportion of their time to their clinical practices in order to generate increased plan revenue, expressed concern about two observed effects. First, that teaching activities are becoming secondary to clinical practice and, second, that two tiers of faculty are developing--those who can produce revenue and those who cannot. The latter group includes most research faculty, whose positions may be becoming tenuous since their earnings ability is constrained. Studies have come to differing conclusions as to whether residents represent a loss or gain for teaching hospitals, whether residents should be considered as students, apprentices, or some other status, and whether or how much residents increase the cost of care or decrease productivity in teaching hospitals (chapter 10~. Regardless of the outcome of these differences, a number of things are clear. Residents spend the bulk of their time (roughly 75 percent) in patient care, and are largely (again about 75 percent) funded by hospitals' general operating revenues. Direct costs (i.e., residents' compensation) are only part of the cost of running residency programs. Additional costs include supervision, extra tests and procedures, and space for teaching. It is unclear whether it is these costs or the severity of patients' illnesses or a combination of these and other factors that result in higher patient care costs in teaching hospitals than in others. In 1981-82, there were a total of 73,800 residency positions, 94 percent of which were filled. Recent trends have been for the demand to increase at a higher rate than the number of slots offered; first year slots have declined and are particularly problematic.5,15 A recent Association of Academic Health Centers (AAH0j study suggests pressure by the hospitals to reduce residencies as revenues decline.! However, the new Medicare reimbursement via prospective diagnosis related groups (DRGs) provides extra compensation for teaching costs based on a formula that includes number of residents per bed, which may constitute an incentive to increase residencies.16 Thus, it seems that what will happen to residencies is anyone's guess. It is clear that much time and money has been spent developing methodologies for cost estimation in medical and graduate medical education. It seems questionable whether further effort in that direction is the most useful approach today, when concern is directed toward identifying ways of making medical education more cost effective. For, even if we know educational costs, we do not necessarily know how to produce physicians efficiently. This implies that utility should be a prime consideration in selecting research. Thus, rather than asking broad questions like "how much does medical 38

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education cost?" or "need medical education cost so much?", questions should focus on the components of costs, the contribution of each component to education, the impact of reducing expenditures on any one part, and determining where costs can be reduced without jeopardizing educational goals. In short, if medical schools and their affiliated institutions are looking for ways to reduce costs, and making changes in response to economic pressures, research can help by presenting a menu of cost-containing measures for which the effects of reduced expenditures are known. Educators should then be able to select measures with the most desired, or least undesired, impact. This approach is exemplified by Lewin, who suggests that, since faculty represent the largest single medical school expenditure, studies of faculty costs, through an examination of how faculty spend their time and the revenues they generate, would provide useful information for management, budgeting, and planning.17 A logical approach to performing research useful to decision-makers could use as a base the work begun by the Institute of Medicine in the 1974 report on the Cost of Education in the Health Professions.3 This study examined the cost components of 14 medical schools and noted variations among schools in many of the variables investigated. Further research to discover gross differences in costs among schools and associated educational differences would indicate possible areas of cost reductions and their expected impact. This approach moves away from an emphasis on developing complex cost finding methodologies to arrive at finely tuned cost calculations, toward identification of major cost components, such as faculty, and rough cost estimates. Another approach would group medical schools according to selected characteristics, examine major cost differences (again avoiding complex cost-finding methodologies in favor of concentrating on major blocks of money), and result in pointers to greater cost effectiveness. Characteristics that could be examined include size, to discover if economies of scale exist and if there is an optimal size for medical schools; the proportion of each type of specialist produced, to determine differences in the costs of education of different specialists and if it might be more cost effective for some hospitals to reduce the range of specialties offered; the proportion of graduates selecting careers in biomedical research and the level of research activity, to determine if there are economies of scale associated with research and the training of research scientists that could result in more cost effective ways of conducting these activities, and if there are differences in costs between research intensive and more primary care or clinically oriented schools that could suggest the most economical way of educating a majority of physicians. A number of people have suggested that one approach to finding less cos tly ways of educating physicians could be to investigate differences in the cost of educating medical and osteopathic doctors and differences in cost in foreign and U. S. medical schools. This approach seems dangerous, since many believe that there are major 39

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For many disciplines not strongly represented in typical curricula, and for those which already are established, it is likely that a compelling case could be made for their relevance and importance in medical education for the future (Chapter 6~. However, those departments with a place in the curriculum are reluctant to give up any of their time. One approach is to add more hours of instruction to the educational sequence, but most people believe we have already passed a reasonable limit on those hours. Finding student time for thinking and integration of ideas is most important now. If it is a struggle to f ind a place in the curriculum for the biomedical laboratory-based disciplines, it is all the more cliff icult to include the social/behavioral and the population-based sciences. Molecular biology, for example, is an exciting, productive new discipline, providing powerful tools for research and having easily discernible potential for diagnostic and therapeutic applications. Although a relatively new discipline, it is derivative in part from traditional basic sciences ~ such as microbiology ~ taught in medical school* for decades. The social and behavioral sciences, on the other hand, must open up new places for themselves rather than evolve from old ones. And the population-based sciences typically would have been housed in schools of public health (in those universities that had such schools ~ . They too must forge a new place in the training of physicians . We must fully understand the confounding variables in discussions of what constitutes the science base in medicine. Status, for example, often is linked to a department's share of curriculum time. Giving up time (to make room for.other disciplines) can be viewed as yielding power and status. There also may be a lack of understanding and communication across disciplines.32 (See study issue 3. ~ A useful study would explore ways to promote inter-institutional and inter-disciplinary communication. Case studies of attempts to enhance cross-departmental or cross-institutional understanding of goals, methods, language, and constraints should elucidate productive future directions. During the course of this planning study, a number of such experiments were identified--Morehouse College undertook to educate basic scientists and clinicians about one another's purposes and needs, f or example .42 Participants in some of the combined bachelor-medical degree programs would have insight into opportuni ties for better inter-institutional coordination, as would faculty of Schools of Public Health and Schools of Medicine who share teaching responsibilities . ~ See Chapter 5 . ~ . * The close collaboration of medical school based disciplines (eeg microbiology) and university based disciplines (Beg. ~ physics) was essential to the vigor of the new f ield of molecular biology. It points to the benefit of lowering barriers to communication across institutional and departmental barriers. 59

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The Timing, Sequence, Content, and Integration of Science Instruction Medical education in the U. S. entails four stages: 1) premedical studies in college, 2 j basic science and clinical clerkships in medical school, 3 ~ intensive clinical training as residents in specialty programs, and 4) continuing medical education. Within this continuum are private and public institutions, some emphasizing research, others clinical practice, some with an eye toward community needs, o thers with a more national view. Ideally, it would be a smooth continuum, with each stage building on earlier ones and taking advantage of the particular combination of strengths and goals individuals bring to their education. Di scussions of curricula usually focus on the four years of medical school (or the f irst two years of basic science training ), but pre-pract ice medical educat ion begins in the college years and continues through several years of graduate training. What should be taught, how, and when? Does this vary with the varying goals of medical schools? How early might the language, approaches, and knowledge base of some disciplines be taught and how long might others be deferred? How might this instruction be integrated so as to optimize use of time and resources, and to make tear'. ~ ng most ef fictive? Are scientists, be they in the traditional life sciences, the social and behavioral sciences, or the population-based sciences, conveying only a language and an approach to prepare students for life-long learning, or are they conveying an essential body of facts as well? The rhetoric on this distinct ion varies with t ime and place . Students who enter medical school arrive with diverse academic backgrounds, and they develop a variety of career oh jectives over the following five to eight years. Some start their medical training af ter a very strong undergraduate program in the natural sciences in college, while others have a background in the humanities or social sc fences with only the required minimum of premedical science courses. Many students entering medical school have had a strong liberal education while still others suffer from the current problems of American elementary education and have a poorly developed ability to write reasonable English sentences. Most medical students have as their primary objective careers in medical practice; however, a few aim at careers in academic medicine ei ther as clinical investigators or as basic scientists . Individuals who make each of these different career choices play valuable roles in the society and are needed in the profession. A diverse background of the student body seems desirable botch for the medical schools and for the profession as a whole. What constitutes a reasonable minimum background for entrance to medical school and what level of intellectual diversity should be encouraged f or premedical students in college ? There are certainly some areas of medicine in which it would be important f or s tudents to 60

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have strong backgrounds in molecular biology and genetics, others for which a strong background in chemistry and biochemistry would be desirable, and still others for which backgrounds in sociology, philosophy, economics, computer science, physics, engineering, or management would be extremely useful. The present premedical requirements have remained unchanged for many years. Are they all necessary, either because of the substantive material they contain or the information they provide for the medical school admission process? Are there new requirements which should be added to the premedical program, such as statistics and probability, computer pro`gra~ng, ethics, etc. ? Should there be a requirement for service in the health care system? What criteria can and should be used in establishing such requirements? Students and other critics generally list two complaints about the basic science instruction in medical school--that its relevance to clinical medicine is obscure and that it is overloaded with esoteric facts of importance only to researchers. The basic science faculty indicate they are first and foremost conveying a way of thinking and are teaching essential principles which may at times best be i llustrated by non-cl inical experimental systems, and which can best be understood by in-depth exploration of a research problem. . Teaching in the sciences needs to be assessed as to cognitive tasks. Have the basic science ists articulated for themselves clear goals for their students?32 Are students ready Icy achieve that goal (learn that material) at the time it is presented? Can a cognitive-ta~k approach be used in this setting? Some thought also should be given to the way in which clinical faculty challenge the students to apply their training in science. The responsibility to relate the basic to the clinical is not one s ided . Paradoxically, the information explosion may contribute to its own containment. More knowledge should lead to fundamental understanding so that organizat ion of detail into conceptual frameworks becomes possible. This should ease both teaching and learning. The use of computers, for information management, for teaching, and for problem-solving, undoubtedly will grow in the future. This tool could simplif y teaching and learning, but there is the danger that instead the computer technology will be Created as yet another package of inf ormat ion to be learned--adding to the students ' burden rather than easing it. In this age of computers in the home, grade school, and summer camp, incoming medical students will bring computer facility to their medical education. Are their teachers adequately prepared to use the students' facility to greatest advantage? A recurrent question in medical education is the adequacy with which courses at one level build on material provided in previous study. This question arises with respect to the use which the basic science courses make of college preparation and even more critically wi th respect to the use that clinical training makes of the basic 61

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science courses. Several different experimental programs have been introduced to provide closer integration between the clinical and the preclinical training. Bowever, there is little reliable data as to whether the problem really exists; can and do students make the necessary connections themselves; do faculties know enough of each other's specialty to provide the integration automatically? Bow much success have the new, more integrated programs really achieved? Better integration of science training programs within and among institutions (colleges, medical schools, ant teaching hospitals) might conserve time, one of the scarcest resources in medical education. Willingness to trust another department or institution to convey relevant bodies of knowledge probably will depend on enhanced communication across territorial barriers. Until the life scientists, the social-behavioral scientists, the population-based scientists, and the clinical scientists understand and appreciate the contributions of one another's disciplines, mutual dependence and reinforcement will not be apparent in their teaching. The question of how to reconcile the need to train both private practitioners and academically-oriented researchere/teachers within the same institution also arises. Is there a way to allow multiple pathways through medical school? Can the same basic curriculum fill both the role of graduate school training and professional school training? How can the methods, approaches, and excitement of science be taught rigorously to researchers in such a way as to stimulate students intending a career in practice? what exactly is the role of research in medical education institutions? Should only certain selected schools train our future cadre of clinical investigators? Another aspect of the diversity of the population being educated is the student with advanced training. DO our educational tnstitutions respond adequately to their knowledge and sophistication and build individualized programs for them? What are the barriers to and supports for such individualization? "d do these students devise a career that draws on all facets of their advanced education? For example, what portion of ~PhDs do not do research, and are there correlates or predictors of particular decisions about research, practice, or doing both? When there were a number of medically undereerved segments of our ~ country, and an undersupply of physicians was projected, training programs for a variety of allied health personnel were developed--nurse midwives, nurse practitioners, child health associates, etc. The advantages of upward and lateral mobility tn these psofeselon was noted at that time.44 The allied health professions have Iost some impe tus as the supply of physicians increased . There has been some drift of physicians toward traditionally underserved areas, but inner-city and rural. dwelling Americans still have limited access to health care (Chapters 4 and 11~. And concern about rising health care costs continues to loom large. Thus, there may still be a role for health care personnel with intermediate levels of training. 62

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Diverse entry ant exit options for health professions education should be considered. How readily may students in related educational programo--~chools of medicine, schools of public heal th, graduate schools of arts ant sciences, and Schools of nursing, for example- transfer across programs when it seems well-advised? Should there be structured opportunities for transfer af ter greater experience and maturity have clarified -students' knowledge of their own aptitudes and career aspirations ? Can there be multi-tiered programs so that students can exit from the educational system at varying levels of professional responsibilities, and perhaps re-enter in later years? Might there be trop-out polite for service in the health care system or to devote full time to research pro jects, for example, and thus to glean practical experience (which also helps clarify aptitudes and career goals ~ ? Strong Research Establishment Concern has been expressed that thi s country at present does not have a suf ficient supply of well-trained physician researchers; the problem seems to be growing. Only a small percentage of medical school students intend to pursue a career in research; furthermore, those with an M.D. degree are not an successful an Ph. DO and bit D. -Ph. O.s in competition for grants from NIH. As research fuming declines and reports indicate an undersupply of Medically trained researchers (Chapter 11), a number of questions related to the significance and importance of research to medical education have arisen. How much research is essential to medical education? How large a research f acuity is needed to support this essential element ? What factors hinder and support the production of medical research personnel? How large a pool of medical researchers does the nation want ? Does the existence of research activities in medical schools increase the cost of medical education? Some of the questions have been answered, or partially answered, by existing research. A brief survey of literature revealed the f allowing f indinge: o A 1974 study noted that a 50 percent increase in research essential to education resulted tn a 13 percent cost increase, which was usually offset by an equivalene increase in revenues from research. 45 o The research intensity of a medical school does not af feet the specialty choice of graduates.46 o M.D. graduates with the best academic records are most likely to enter academic or research careers, ant this likelihood is increased by attentlag research-intensive schools.46 o Academic health centers have not been able to compensate fully for cats in federal research funds by attracting funds from other sources.46 63

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o Federal funding af fects both the level of and nature of biomedical research. 46 Concern about the impact of loss of research funds is not new. In 1973 Stan der Frost sounded the alarm, saying, In the last few years . . . we have been taught a bitter lesson. Programs that took years to build can be undercut almost overnight .... Today we are abruptly confronted with a generation of students who for a variety of reasons . . . tend to turn away from science as a satisfying and creative life work. The relative handful who retain interest can only view the future support of science as bleak and uncertain. Many students now in training programs supported by the federal government are unsure f ram month to month how long they will be able to continue .4 7 The alarm belle are ringing even more loudly today, not only for biomedical research but also for the essential research understanding of students in medical school. While there are some who suggest that private industry may fill at least some part of the gap left by the wi thdrawal o f f ede ra 1 f unds ~ doubt is expressed that much help can be expected from that quarter.48 Concern also has been expressed that corporate funding of research might have drawbacks in terms of constraints on academic freedom, free flow of information, diffusion of innovation, And student values. Research faculty, unlike clinical faculty, have no mayor avenue of f inancial support available to them outside of direct research funding, the bulk of which comes from government sources. The implication is that, if faculty are to be cut, researchers who cannot fully support themselve through research awards are most vulnerable. Estimating the impact on medical education of reduces research f unding is complicated by the dif fusion of research and research related activities throughout academic health centers. There are f till-time and part-time research faculty, full-time and part-time clinical faculty who are involved in research, there are research physicians involved in investigations in hospitals, there are medical students with short-term research fellowships, etc. AL the most obvious level, one might assume that because of federal research cute faculty and Ph. D. enrollment will be reduced . Because there are fears that the quality of medical education will suffer if there is a diminution of research activity, and apparently no consensus on the level of research involvement necessary to instill the necessary qualities (ability to absorb the results of research, understanding of deductive processes, scientific curiosity) in students intending to practice clinical medicine, at this time monitoring actions are required to determine how medical schools are reacting to diminishing funds. 64

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Conclusion Most of the issues outlined here pertain not only to physicians but to a wide range of health professions. For example, in such areas as financing of education, qualities sought by a~mi ssions comb ttees, developing curricula, and acquisition of new knowledge through research. Consideration of over health prof essions is integral to successful analysis and policy development. Effective and cost-conscious division of labor and responsibilities in the care of patients, the management of the health care system, and the education of f uture prof essionals in that system require coordination and integration of educational p fanning . 65

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REFERENCES 1. Association of Academic Health Centers. Impact of Changes in Federal Policy on Academic Health Centers. Washington, D.C.: AAl1C, 1982. 2. Ebert ~ R. H. and Brown, S. S. Academic health centers. New England Journal of Medicine 308 :1200-120B, 1983. 3. Institute of Medicine. Costs of Education in the Health Professions . Washington, D. C.: National Academy Press , 1974. Lewin, L. S. and Derzon, R. A. Health professions eduction: State responsibilities under the new federalism. Health Affairs 1 ~ 2 ): 69-85, 1982. S. Medical education in the United States, 1981-19B2. Journal of the American Medical Association 248: 3223-3328, 1982. 6. State Support f or Health Professions Education. Prepared for the Committee on Labor and Human Resources, United States Senate, by the Congressional Research Service of the Library of Congress. Washington, DC: Government Printing Office, 1981. Lloyd, S. M. et al. Survey of graduates of a traditionally black college of medicine . Journal of Medical Education 53: 640-650, 1978. Bradley, J., ed. Medical Education Financing Financing. Policy Analyses and Options for the 1980s. New York: The Urban Institute, 1980. 9. Congressional Budget Of fice. Federal Student Assistance: Issues and Options, Budget Issue Paper for Fiscal Year 1981. Washington, D.C.: Government Printing Of flee , 1980. 10. Rice, L. D., ed. Student Loans: Problems and Policy Alternatives. College Entrance Examination Board, 1917. . 11. Hansen, W. L. Economic growth and equal opportunity: Conflicting or complementary goals in higher education. Aug . 1982 (mimeo ~ . 12. General Accounting Of f ice . Actions Underway to Reduce Delinquencies in the Health Professions and Nursing Student Loan Programs. - GAO/AF)ID-83-7. Washington, D. C.: U. S. Government Printing Of f ice, 19 82. 13. Early, P. Medical loan rules eased but most schools will have Droblems. Washington Post ~ June 6, 1983, p. A-ll. 66

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14. American Medical Student Association. New developments with financial aid programs, p. 7. Unpublished paper. Washington, DC: AMSA, Jan. 3, 1983 . 15. Scarcity of residency slots becoming a worry for medical-~chool graduates. Medical World News, Aug. 2, 1982. 16. Personal communication. N. Seline, Association of American Medical Colleges . 17. Personal communication to the committee. Lawrence S. Lewin, Lewin and Associates, Washington, D. C. 18. Craig, J. The costs of health professional educations. Paper presented to the Southern Regional Education Board Annual Meeting, June 20, 1979. 19. Association of American Medical Colleges. Charges to Working Groups on the Essent ial Knowledge, the Fundamental Skills and the Personal Qualities, Values and Attitudes that Comprise the General Professional Education of the Physician and College Preparation for Medicine. Washington, D.C.: AAMC, 1982. 20. Personal communication to the committee. lair. August Swanson, Director, Division of Academic Af fairs, Association of American Medical Co liege s . 21. Personal communication to Dr. Barbara Filne r. Dr. Barbara Andrew, National Board of Medical Examiners. 22. Institute of Medicine. Community Oriented Primary Care: New Directions for Health Services Delivery. Report of a conference held March 1982. Washington, D. C.: National Academy Press, 1983. 23. IJ. S. Department of Heal th and Human Services. Summary Report of the Graduate Medical National Advisory Committee, Volume I. Washington, D. C.: U. S. Government Printing Of f ice , DENS Pu hi ice t ion No . ~ BRA ~ 81-6 51, 1981. 24. Hadley, J. More Medical Care, Better Health? An Economic Analysis of Mortality Rates. Washington, D.C.: Urban Institute Press, 1982. 25. Thomas, L. The Youngest Science, Notes of a Medicine Watcher. New York: Viking Press, 1982. 26. Andreoli, K. G. "The Future Role of Non-Physician Health Professionals, " 8th Private Sector Conference, Duke University Medical Center, March 13-1S, 1983. 27. Mawardi, B. H. 1956-1965 Career Study Report ~ Case Western Reserve University School of Medicine. Cleveland: Care Western Reserve Uni~rersi ty, 1953 . 67

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28. bIerton, R. K., Reader, G. G., and Kendall, P. L. The Student-Physician, Introductory Studies in the Sociology of Medical Education. Cambridge . Mass.: Harvard University Press, l9S7 . 29. Becker, H. S., Geer, B., Hughes, E. C., and Strauss, A. S. Boys in White: Student Culture in Medical School. Chicago: University of Chicago Press, 1961. 30. Beeson, P. A. Priorities in medical education. Perspectives in Biology and Medicine 25: 673-687, 1982. 31. Lewis, 1. J., and Sheps, C. G. The Sick Citadel: The American Academic Medical Center and the Public Interest . Cambridge, Masse Oelgeschlager, Gunn, and Hain, 1983 e 32. Friedman, C. P. and Purcell, E. F., eds. The New Biology and Medical Education: Merging the Biological, Information, and _ . _ Cognitive Sciences. New York: Josiah Hacy, Jr. Foundation, 1983. 33. Institute of Medicine . Genetic Inf luences on Responses to the Environment. Report of a Conference on Implications of Environmental/Genetic Interactions, sponsored by the Charles H. Revson Foundation, July 10-11, 1980. Washington, D.C.: National Academy Press, 1981. 34. National Research Council, Assembly of Life Sciences, Committee on Maternal and Child Health Research. Maternal and Child Health Research. Washington, D.C.: National Academy of Sciences, 1976. 35. National Academy of Sciences, National Research Council, Assembly of Life Sciences, Division of Medical Sciences, Committee for the Study of Inborn Errors of Metabolism. Genetic Screening: A Study of the Knowledge and Att itudes of Physicians. Washington, D. C.: , National Academy of Sciences, 1975. 36. Institute of Medicine. Health and Behavior: Frontiers of Research in the Biobehavioral Sciences. Report of a Study by a Committee of - the Institute of Medicine. Washington, D.C.: National Academy Press, 1982. 37. Elliott, G.R. and Eisdorfor, E., eds. Stress and Human Health. Report of a Study by a Committee of the Institute of Medicine. New York: Springer Publishing Co., 1981. 38. Institute of Medicine. Alcoholism Alcohol Abuse and Related , Problems : oDDortunitieS for Research. Washington, D.C.: National . . Academy Pre s a, 1980 . 39. Institute of Medicine. Mart juana and Health. Washington, D.C.: National Academy Press, 1981. 40. Commi ttee on Science, Eng ineering, and Public Policy. Report of the Research Brief ing Panel on Ne~lrosclence . Washington, O. C .: National Academy Pre ss, 1983 . 68

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41. Houpt, J.L., et al. The role of psychiatric and behavioral factors in the practice of medicine. American Journal of Psychiatry 137:37-47, 1980. 42. Personal communication to the committee. President, lleharry Medical College. Or . David Satcher, 43. Gellhorn, A. An Evaluative Report of the Interface Programs Supported by the Commonwealth Fund. Prepared for the Commonwealth Fund, Apri 1 1980. 44. Perry, J. W. Career mobility in allied health education. Journal of the American Medical Association 210 :107-110, 1969. 45. Institute of Medicine. Prof ession~, p . 90 . 46. William. A. P. et ^1. _ _ , , ~ C08t~ of Education in the Health Washington, DC: National Academy Press, 1974. The Ef fects of Federal Biomedical Research - Programs on Academic Health Centers. Biomedical Research Panel. Corporation, 1976. Prepared for the President 's Santa Monica, California: Rand 47. Van der Kloot, W.G. The education of biomedical scientists. In W . e t al . The Future of Medical Education. Durham, N. C .: Anlyan, Duke University Press, 1973. 48. The Blue Sheet, Feb. 16, 1983, p. 5. Research Reports. 69 Cherry Chase, Md .: Drug