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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Suggested Citation:"3. Issues for Targeted Study." Institute of Medicine. 1983. Medical Education and Societal Needs: A Planning Report for Health Professions. Washington, DC: The National Academies Press. doi: 10.17226/729.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

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

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

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

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

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

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

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

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

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

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

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

differences in the quality of education offered--for a true cost comparison, an identical, or at least very similar, product is needed.* Craig in 1979 made a suggestion that should be considered seriously today: a detailed analysis of the costs and activities of a small number of schools followed by experiments to develop norms for various inputs. 18 Craig suggested this procedure as a prerequisite to revolutionizing educational payment systems; however, the research component of the exercise alone could be used to indicate areas for cost containment in schools that exceed the norms. An initial step toward a study aimed at developing cost ef fective faculty mix or size is to determine the appropriate variables and measures to be used. A one- or two-day conference of leaders in the different aspects of medical education would be a first move toward conceptualizing such a study, defining its parameters, developing hypotheses, and suggesting appropriate outcome measures. A study should look at the different financial arrangements of practice plans to determine whether some arrangements are more effective than others in structuring incentives that constrain tendencies to allow clinical practices to override teaching to the detriment of educational goals. Financial factors In the demand for residencies also deserve investigation. Does the level of debt incurred in the first stage of medical education relate to the length of specialty training chosen?--in other words, as debt rises are shorter residency specialties chosen? This could be studied as part of an inquiry into the impact of debt levels. Study Issue 2: The Changing Role of the Physician This theme was selected because, although it is not possible to predict with absolute certainty the demands on the medical profession 10 to 20 years from now, it is necessary to prepare for change and develop the ability to deal with change. There are trends underway both in the health care system and in society at large that are likely to have significant impact (Chapters 4, 6, 11) . Because of the long period required for a physician's training, we must begin to consider the implications of these trends--implications for the role of the physician and appropriate education for that role. *Some members of the committee suggest that it might be productive to look at foreign medical schools that, at a lower cost than domestic schools, graduate high-quality physicians. The purpose of this investigation would be to discover how a good physician can be educated less expensively. Geoffrey H. Bourne, Vice Chancellor of St. George's University School of Medicine in Granada, West Indies, in a letter in Education on September 23, 1981, argues persuasively against assuming that all foreign schools produce inadequately prepared physicians. To support his contention he cites both the clinical preparation given students in his school and their success in various examinat ions . 40

The trends that appear to be significant include demographic changes, particularly the aging of the U.S. population and the shift to the sunbelt and to smaller metropolitan areas; changes in patterns of disease to be treated or prevented, such as the shif t in the burden of illness away from infectious disease and toward chronic disease; changes in delivery systems, such as increased use of health maintenance organizations and group practices; changes in numbers and kinds of providers, such as non-physician health personnel, and other alternatives to the traditional office-based, fee-for-service practice by individual physicians; an increased supply of physicians, with a growing proportion of women and minorities, who as groups are distinguishable in their practice choices and patterns from the predominant white male group of physicians; steadily rising health costs with growing reluctance on the part of federal, state, and local governments and other payers to sustain these costs; an increased business orientation (competition for patients and acute awareness of costs) on the part of hospitals and physicians; advances in the knowledge base and technology for diagnosis, treatment, and prevention of disease; increased use of computers for the management of records, the storage and retrieval of information relevant to clinical care, and perhaps also a direct role in clinical decision-making itself; a shift in the doctor-patient relationship toward a more active role on the part of the patient and a less authoritative role for the physician, and other altered expectations on the part of both patients and physicians (Chapter 4,6~. All of these trends can be expected to produce changes in traditional physicians' roles. Some may be merely quantitative--for example, a greater amount of time may be spent with each patient as each physician sees fewer patients. However, there also may be profound qualitative changes in the role of the physician. For example, with financial resource limitation assuming great importance, the criterion of the greatest benefit to the individual patient may no longer be the dominant basis for decision-making by the physician. A number of study topics integrating the trends enumerated above provide an opportunity to explore in depth the changes in professional education predicated by the changes in professional roles. These studies emerged from committee discussions and background materials, and are presented in order of priority set by the committee: 0 identifying, selecting for, and nurturing desired qualities in physicians 0 health manpower policy 0 potential new roles for and changing demands on the physicians (e.g.,.as health educators, as care providers for the elderly or chronically ill) and division of labor among health professionals o educating physicians to be researchers. 41

The first three will be discussed below. The issue of educating physicians to be researchers will be addressed in study issue 4, the science base of medicine. Desired Qualities in Physicians Are there qualities, such as honesty, curiosity, and skepticism, that are required in all those seeking a career in medicine, regardless of whether patient care, research, administration, or some other activity is their major responsibility? The AAMC study on the "General Professional Education of the Physician and College Preparation for Medicine" has a working group on Personal Qualities, Values and Attitudes that is charged to describe desirable traits that students should develop during college preparation for medicine and during medical school, to assess how faculties might best select students who possess the capability to develop these traits, and to consider how faculties can foster the development of these traits in college and medical school.l9 The findings of this working group should be available in approximately one year and should be a helpful for further work in this field. Other resources that might be used, bearing in mind possible cultural differences, include the experiences and evaluations of the student selection process at, among others, Ben Gurion University of the Negev Center for Health Sciences. This community-oriented primary care school lists nine mayor characteristics particularly looked for in the interviewing process; these include integrity and a sense of responsibility, as well as community orientation and tolerance of ambiguity (Chapter 5, Appendix D). Some personal characteristics may be taught after entry into medical school, but others, perhaps, must be well-formed by the inception of the education process. Questions to be addressed include: What are the desired qualities, and how can they be detected in applicants? There are varied and more or less elaborate testing and interview processes in place to screen candidates at several stages of medical education--admission to medical school, appointment to residency slots. How relevant are these screening procedures; how predictive are they? Gan the selection process be validated? (See Chapter 7.) Aspects of medical education that-reinforce particular personal qualities must be identified. How much malleability exists in young adults with respect to critical personality characteristics? How can characteristics be influenced? How are messages about desirable and undesirable qualities transmitted? Are the messages correctly perceived? What happens when mixed messages are received? Can critical stages or processes in the education continuum be identified for nurturing desirable and unlearning undesirable qualities? There are reports, for example, that the medical education process dampens 42

enthusiasm for learning. There are systematic efforts to assess factual knowledge, but what are the possibilities for enhancing the use of evaluation of and feedback on more personal aspects of performance by college pre-medical students, by medical students, by residents, and by faculty at all stages of the education process? Perhaps physicians in practice also should be included in the evaluation and feedback so that it is viewed as an expected part of an effective continuum. Should someone ill-suited to the practice of medicine, but with potential for outstanding performance as a clinical researcher, for example, be admitted to medical school ? How can we better understand and shape career decisions? For example, will prospective researchers change their minds and go into practice (or vice versa), or should there be ways to restrict career choices based on personal qualities? Perhaps of greatest importance, how can desired values and attitudes be taught, modeled, and learned? How can appropriate role models be selected for faculty within the cultures of the medical school and clinical teaching settings ? A number of innovative medical educational programs have attempted to nurture particular qualities in future physicians. An assessment of the value and success of representative innovative programs is timely (Chapter 5~. A review of innovative programs by a study committee would seek to make explicit the goals of the programs, agree on outcome measures, and evaluate the outcomes. Intended and unintended effects, both desirable and undesirable, would have to be determined. Information on decision processes also would be sought--how are decisions made about retention or termination of new programs, who decides, and what factors sway the decision? ~ See Study Is sue 3 . ~ The first task will be agreeing on outcome measures by which the effectiveness of the innovations can be assessed. Most difficult of all, and most essential, will be developing consensus around measures of quality in clinical activities. A Delphi approach to agreement on such measures might prove fruitful. This could be carried out as a 2- to 3-day workshop. The AAMC20 has done some exploration of soft measures, which might provide a starting point for the enumeration of measures by the Delphi process. The National Board of Medical Examiners also has developed methodology to assess communication skills21 (as an educational tool, rather than as a certification test ~ . Once having agreed upon outcome measures, it would be possible to compare cohorts of physicians who have followed different pathways through their medical education. Further topics to be explored by a committee would include the question of transfer of successful innovative programs--what can be transferred, what should be transf erred , and how to encourage appropriate transfer without starting a slide toward homogeneity. Nurturance of innovations in the medical education system which seem to address specific societal health needs also should be explored (Chapter 5~. 43

Periodic meetings with an international group of medical educators involved in educational activities tied to meeting national health care needs (e.g., community-oriented primary care), 22 in Australia, Israel, the Netherlands, and elsewhere might be particularly fruitful to the U.S. because of the diverse set of problems and environments with which we must deal (Chapter 5, Appendixes D, E). These small conferences also might provide a forum at which to inquire into the desirability and feasibility of using our excess health manpower to assist other countries in meeting their health care needs. It has often been suggested that a national service obligation be considered f or the youth of our country . This might coincide with a program of service at home or abroad, as part of medical education. An interna- tional forum for discussion would be invaluable in this regard as well. Health Manpower Policy The increasing supply of physicians in respect to other health professionals, modifications in roles of non-physician health care personnel, scientific advances, and changing demographic patterns and burdens of illness, may well lead physicians into new roles. Although techniques for forecasting manpower requirements have become more sophisticated, improvements have been offset by increasing complexity of the health manpower situation and a rapidly changing health care system. It is necessary to integrate manpower needs across all the professions, including allopathic and osteopathic physicians, nurses and nurse practitioners, dentists, optometrists, podiatrists, psychologists, and social workers. Connections should be made across the health professions in identifying and resolving manpower-related problems at entry points into the professions. For example, there are a shrinking applicant pool and declining enrollments in dental schools. A decreased demand for dental services, because of families facing financial constraints and lacking insurance coverage, and because of the success of preventive programs, probably account for these trends. A decline in applications to medical school also may be imminent. What kind of cross-over occurs, and how may each profession assure continuing high quality of entrants in the face of these trends? Ultimately, the long-term requirements f or each profession's services must be translated into the number of available training positions (residencies in each specialty, for example). Connections must be made between specialty-specific requirements, supply, training positions, entering class size, and immigration laws. Especially challenging will be the development of an acceptable policy for funding medical and graduate medical education in the approaching era in which the economics of the health services system will undergo radical transformation. We note the following important developments (Chapters 4, 11~: 1. The supply of health professionals will continue to outgrow the U. S. population into the l990s. The physician supply will expand by one-third in this decade.23 44

2. The requirements for health professional services cannot be estimated satisfactorily for the l990s because the determinants are largely unpredictable technological advances and social, economic, and political factors. 3. Profound changes in the structure of the health care system will modify substantially supply/requirements relationships in the l990s. These changes will be made possible by the marked expansion in health manpower and the progressive move toward contractual medicine. . The marked increase in the number of women physicians in the last decade and their distinct practice patterns (as a group) must be considered in planning for the future. We believe that a national health manpower policy should be developed to meet these changes (Chapter 11~. A health manpower policy is critically important for long-range funding of medical and other health profession schools and teaching hospitals, to provide reliable information to high school and college students concerning opportunities in the health professions, and to provide useful information for long-range planning of the health services industry. Our supply of health researchers also is a crucial component of manpower policy. This will be addressed in study issue 4, the science base of medicine. - Establishment of a national health manpower policy requires a sustained illumination of the issues through data collection and analysis, integration across all health professions, effective participation by both the private sector and governments, and the development of consensus. We recommend that there be a continuing effort to collect and analyze data, making available biennial profiles of the manpower situation and two- to ten-year forecasts. One function of a national health manpower policy effort would be to create likely scenarios, identify what data are needed to construct the scenarios, and how they can be collected. Scenarios that integrate manpower with demand and need would be particularly instructive. Delineation of policies to finance health manpower would have profound effects on a number of f actors in education, such as faculty behavior, f lexibili ty of approach, etc. (Chapter 11~. The available evidence supports the hypothesis that the demand for medical education, as measured by the number of students applying to medical school , is directly related to the economic returns from the investment. However, this concept is based on aggregate numbers and relatively old data. It would be useful to develop and estimate models of individual choice in order to improve our understanding of the influence of socioeconomic characteristics, and family and educational background, as well as economic costs and returns. A scenario that allowed market forces to operate on an open admissions policy to medical schools might be useful to create and analyze. 45

Research on physicians' specialty choice has suggested that prospective earnings play a negligible role. However, a recent study calls these findings into question on the basis that their estimates of future earnings may have been biased (Chapter 9~. This issue needs to be investigated further with more recent data, building on advances in modeling individual choice behavior, to give us a better understanding of the extent to which financial pressures will affect future specialty distribution of physicians. In addition, it will be desirable to consider the data in the context of a number of broad socio-economic-political issues, such as: What are the special needs of certain populations--blacks and Hispanics, the urban and rural poor, and the elderly? What are the comparative benefits of present high and low patterns of utilization? How can the reimbursement system or other mechanisms be used to bring demand for medical services in line with need? What is the outcome of health services as measured in socially relevant terms, i.e., in terms of the functioning of the patients and their productivity? What are the appropriate roles for government? It should be emphasized that while a national policy is desirable, one body does not control it, because ours is a decentralized system. State-controlled institutions constitute 60 percent of the nation's medical schools. States will have to determine their health manpower needs, the dis tribution of existing providers by location and specialty, the inflow and outflow of health professionals, and the return rates on funds for health professions training. State legislatures, facing increased budgetary pressures, will want guidance on future levels of medical and other health professional school enrollments. They will be greatly assisted by having available national data for purposes of comparison, and for projections about possible migration of physicians. Specialty societies also will want to compare their assessments with national statistics. The American Board of Medical Specialties recently released the statement: "The ABMS believes that a continuing study of physician manpower should be conducted. Directed toward fact-finding and dissemination of information, this study should be primarily the responsibility of the private sector wi th the collaboration and assistance of the federal government." Two crucial concerns to be kept in mind in the f iscalization of manpower policies, however, are that quality of education needs to be systematically maintained and that policies based on the belief that more doctors mean higher health care costs, which we cannot afford, may be detrimental to the health of the population. 24 We also want to keep in mind other means to affect manpower supply. Professional schools, by their formal and informal programs of instruction, can influence the individual career decisions which in aggregate give our national manpower supply its detailed shape and characteristics. The development and successful implementation of a national health manpower policy--for practitioners as well as for researchers, academicians, and administrators--requires that a broad constituency 46

be involved f row the outset . This will include medical schools, other health professions schools, and professional organizations, as well as state and federal governments. A health manpower policy can only be implemented successfully through broad consensus, developed by all sectors that have a role to play. Po tential New Roles for Physicians Wi th changing patterns of health and disease and an increasing supply of physicians to interact with a variety of health care providers, the division of labor among health professionals may undergo major shifts. Two areas in which shifts might occur and therefore should be studied so that changes are made for improved patient care are related to delivery of patients' health education and of primary care. According to Lewis Thomas, medicine first focused on diagnosis. There was insufficient knowledge to do anything about the conditions that were described, but the prognosis and description of diseases, once identif led, could be accomplished. The second phase of medicine was that of therapeutics. This coincided with the tremendously expanding science base and the Flexnerian revolution, but also resulted in an increase of distance, both physical and psychological, of the patient from the physician.25 We are entering into a third stage, that of health promotion, health maintenance, and disease prevention. Traditionally, the conceptual role of the physician has been illness-related rather than health-oriented. Behavioral responsibilities have been a traditional component of the nursing role--pain management, patient education, and f amity counseling . Public health specialists also are concerned wi th health promotion/disease prevention, but usually not in direct patient interac Lions . Should physicians take on more of a role (and be trained) as health educators? Is health promotion/health education the business of physicians ? Should health promotion/disease prevention be an integral part of health care or a separate function of, for example, health departments or public health personnel? Should education about lifestyle and health be done person to person; and by whom? Should efforts be directed to a population via mass communication? What combinations of approaches are likely to be effective? Regardless of alternative practices, or first contacts with other health~profe~sionals, will a role remain for physicians in rendering advice on health-related behaviors or for validating advice of other professionals? Physicians are as effective as others in inducing changes in health-related behaviors, but is the cost too high? Whether health promotion/di~ease prevention/health education can or should be imparted in the traditional physician system is a question that can and should be the subject of research. 47

Decisions about reimbursement for preventive services will undoubtedly influence the speed and direction in which the medical profession moves with respect to health education. A public policy analysis, to identify the health professionals who will provide the requisite services wi th the optimal combination of availability, effectiveness, and cost, is recommended. This analysis would include critical assessment of such issues as prestige, educational competence, the costs and benefits of training, the aptitudes of those selected to be trained, and the willingness of the different health professions to take on the role of health educator. An important question for the future, related also to health manpower policies, is who should deliver primary care? The primary care physician specialties include family practice, obstetrics/ gynecology, pediatrics, and general internal medicine. In the 1960s, in the wake of the proclaimed shortage of providers of primary care, a variety of non-physician providers were educated. Some studies indicate that non-physician health professionals, independently, can provide quality primary care, but many questions remain about the division of labor, supervision, and patient choice . The role of the non-physician practi tioners in counseling, health education, and patient advocacy services also is of interest .26 The numbers of primary care physicians continue to grow; will they expand their traditional roles into those of other professionals ? What will be the impacts of such trends on health manpower and on quality and costs of care? Study Issue 3: The Cultures of the Medical Education System Patterns of authority and complexity in medical schools and at f iliated universities have changed profoundly in the past three decades. Changing pat terns of financing and the changing allocation of faculty time to teaching, practice, administration, and research demand a careful tracking and evaluation in the years ahead. We need to understand how the component parts of the educational system shape the practitioner, the health care system, the researcher, the teacher, and the administrator. A better understanding of the cultures of the medical education system will enable us to learn where decisions necessary for implementation of change are made or blocked, where and how improvements can be made and sound recommendations implemented to influence the development of future physicians to meet future health care needs. Decisions to start or terminate innovations in the education process as a whole, in introducing and establishing new fields (Chapter 5, 6) or eliminating those that have outlived their usefulness, would benefit from an appreciation of the social organization and functioning of the medical education system. As social organizations, medical schools and teaching hospitals have distinctive characteristics, patterns of authority and power, and expectations of behavior. There are at least three cultures within 48

medicine--primary care physicians, technically-oriented subspecialists, and those concerned with public head th. The students, faculties, and institutions of the medical education system also can each be thought of as a culture which shapes the expectations, attitudes, and practicer of the physicians in this country. The way in which faculty define the purposes of medical education and priorities within it, formally and informally, provides a set of influential messages to students that eventually impinge on medical practice. Some of this influence is intended and explicit and viewed as part of the professionalization process. But at other times, individuals are acting on false perceptions or are being influenced inadvertently. The student culture, for example, develops its own style, ideas, and preferences. It also is important to understand the sub-culture of resident physicians. They spend more time with students than any clinical faculty, and the education system depends on them, yet they have no control over the system. There are major differences in the cultures of medical schools and schools for educating health professionals that physicians must interact with. An example is the difference between schools of medicine and of public health in reference to income, way of life, and political view. In general, physicians are wealthier, more conservative politically, and resist government intervention, but public health professionals' culture includes acceptance of lower personal income and a close working relationship with government. A closer study of the cultures in the health field could facilitate mutual understanding, better collaborative relationships, and insights as to where changes are needed and how to bring them about. Of critical importance is an understanding of responsibilities and ethical duties various health professionals should have and how to make these consistent with the relevant cultures. The following study topics are presented in order of the priorities that emerged from the committee 's discussions based in part on the background papers in Part III of this report. o Decision-making in the medical education system 0 Faculty roles: fostering teaching, research, and service o The professionalization process o The teaching hospitals Decision-making in the Medical Education System At each stage of medical education, there are persons or committees with power to include or exclude, to shape, redirect, encourage or discourage the student or physician. Three crucial points are that 1) we are very uncertain about the criteria that should govern admissions decisions (Chapter 7 ); 2 ~ performance evaluation during the education process generally is weak when it comes to anything other than objective measurement of science 49

knowledge; and 3) many leverage points are not used or are used poorly in the very circumstances that faculty should exert more control--that is, during the clinical professionalization process (clerkship and residency). Why are faculty powers sometimes not exercised to exclude clearly undesirable persons; how could they be used positively to include and encourage persons who would be good physicians? These questions go beyond the culture of the faculty to the culture of the institutions in which training takes place. What are the best ways of initiating and implementing constructive change? What are the internal forces, including sources of power and decision-making processes, and the external forces shaping education-related decisions? What are the organizational attributes of schools recognized as the most successful in reaching an explicit goal? How can educational values be protected in the face of conflicting priorities and responsibilities (such as the fiscal health of a teaching hospital)? These questions relate to the desired personal characteristics for medicine and their selection (discussed earlier in this chapter). Our concern is In having a medical education system evolve toward a flexible and adaptable one that prepares physicians to meet society's health care needs equitably and ethically, and that is able to reset priorities as these needs evolve. Among those involved are federal and state governments, state lobby groups, foundations, and public interest groups, all of whose leverage derives from funding for teaching, research, clinical care, through scholarships, loan programs, research grants, capitation, reimbursement for care, and the like. Participants from the health care system include professional societies and organizations, insurance firms, practicing physicians, and other health professionals. The consumers of care--the patients-- also have a role. To gain an understanding of the cultures of the medical education system, studies of the norms and values of medical education and the f orces that maintain them should be done, covering the system from pre-medicine to practice circumstances and norms. For example, a study is recommended of the hierarchical value structure of the medical education system in selected schools. The study would include identification of factors (in addition to dollars) that contribute to power and prestige in the schools and clinical settings; the position of the health institutions within the university structure (where applicable) and the influences of the university on the medical education power structure; the relationships of curriculum time and place to power and prestige (Chapter 6~. One format would employ a social scientist and a health profession&l, working as a team, to conduct site visits and interviews with key people in medical schools and hospitals selected to be representative of a genre (e.g., private, research oriented or community, primary care oriented). An analytical summary of the decision-making hierarchy of medical education establishments could then be used to identify levers for change within the institutions and the kinds of outside pressures that have major impact on them. 50

Case studies that ref lect some of the cultural dimensions of medical education also would be instructive. For example, a study of committees on promotion could examine the processes of appointment, organizational structure, modes of work, and decision~aking. Studies of the introduction and long term adjustment of fringe disciplines or f ields within the established power structure in specific schools would be useful to other schools considering similar changes (Chapter 6~. Examples for case studies are : psychiatry (going back to the 1930s); geriatrics, as a prospective model--what is happening now? what are its near term and long term prospects?; family medicine--what pressures resulted in its introduction? which schools successfully integrated family medicine? why do most high-prestige schools not have a department of family medicine? if physicians who are in family practice have limited contact with students, where are the role models for the students to come from? Faculty Roles : Fostering Teaching, Research, and Service The role of research in medical schools and academic health centers has grown strong since World War II. Only more recently have practice plans grown in importance. Laboratory basic science research and clinical faculty lead in prestige and rewards. The growth and strength of the biomedical research effort has had significant influence on medical school organization, power hierarchy, curriculum, priorities, and student selection. Funds for research, directly and indirectly, supported medical schools. In many schools, research became the primary component of the culture, with population-based social and behavioral research in secondary positions, if present at all. In some institutions this led to such distortions as medical education and teaching becoming by-products rather than primary goals of the schools. The fruits of biomedical research have provided scientif ically based improvements in health care, but at some cost to the process of education for the practice of humanistic medicine. How can a proper balance be attained among teaching, service, and research when teaching is underfinanced? How can quality and productivity be assessed for non-researchers? What are the equivalents of scholarly publications for teachers or clinicians? Medical school and teaching hospital faculty are operating in a system that usually gives low priority and few rewards for teaching, except for personal rewards that come from students themselves. Furthermore, a faculty member's identity is likely to be aligned with a department, rather than with the school, hospital, or university. In such an environment, how might rewards be structured and communications enhanced to promote educational values? During the course of this planning study, we heard anecdotal evidence of experiments in rewarding teaching, and in helping clinicians, behavioral scientists, and biomedical scientists become better role models for students and understand one another's needs, advantages, constraints, and contributions. Meharry Medical College, 51

Case Western Reserve University, Indiana University, and Ben-Gurion University are examples of such approaches. Do these efforts help the institution build a balanced and integrated education for their students? Preliminary data from Case Western Reserve indicate that their graduates are knowledgeable about behavioral impacts on health, use their knowledge in practice, and are comfortable with communicating and relating to patients as people.27 A systematic cataloging and assessment of such efforts would help identify key elements of successful efforts and barriers to and supports for shaping an education system that maximizes intended, socially useful messages and minimizes unintended messages. There is a growing awareness of fraud in biomedical research which makes it imperative that we grapple with the problems of research data fabrication and the inadequacy of our traditional supervisory approaches in preventing deceptions. The essence of scientif ic inquiry is respect for truthful pursuit of knowledge irrespective of outcome. Recently publicized cases establish that what has been assumed inviolate is not, and that our methods of education require prompt re-examination if the values of science are to be preserved. The environment for the education of both clinicians and researchers will otherwise not be conducive to building the integrity both require. Li ttle research has been done since the 1950s and early 1960s on how medical schools work as social organizations or on student or faculty attitudes to the educational experience.~8~29 Studies of schools selected for their different cultures or different career preferences of students would illuminate the informal processes of medical education, and help to identify levers for change. In addition, experiments in faculty. education and sharing of views are called for, both within and across schools. Another part of the study might be to explore the educational planning process in different schools. The Professionalization Process of the Physician During the course of their education, physicians-in-training acquire a set of facts, a knowledge of resources, an approach to problem-solving, a set of values and attitudes, and a personal style of interacting with patients and professional colleagues. Expecta- tions for interactions with patients, colleagues, and society at large also are shaped. Paul Beeson, 30 among others, has pointed out that highly motivated, bright, and hard-working students 'given the opportunity to spend time in a setting of clinical medicine, with access to books and journals, " will learn on their own. "We must be careful about a ttributing the good pert ormance of a young doctor to special features of the educational system from which he or she has emerged.' Rather than the formal instruction, it may be informal exchanges among students, residents, and faculty, and the tutelage implicit in the actual behavior of the teachers (in interactions with patients, other 52

physicians of more junior and senior rank, and nursing staff and other non-physician health professionals) that have greatest educational impact. Most of the observations of role models for physicians occur in clinical settings, and the significance of those settings in the professional development of the physician should be explored. Clinical training, for the most part, has been centered in tertiary care university teaching hospitals. Recently, clinical clerkships and residency programs have been offered in a variety of settings, such as nursing homes , health maintenance organizations, industrial and workplace health sites, group and individual practices in the community, community mental health centers, and rehabilitation hospitals. It has been assumed that these varied experiences will be more relevant to subsequent practice and that will temper an overdependence on high technology and its high cost tests and procedures. There also is the suggestion that warmer, more personal doctor-patient relationships will be observed outside of the traditional academic setting. A review and summary of different models for clinical training, and an assessment of their success, would be of value. Success might be measured by a variety of outcomes, including performance on national boards (NBME, Part II or specialty boards), patient outcomes, satisfaction of the trainees, and patient satisfaction. An analysis of the problems in establishing programs in these several settings also would be valuable--consideration of the costs, administration, quality control, and liability issues, for example. Longitudinal studies of attitudes and correlation of experiences with major changes in attitudes could be done. Surveys of residents should be conducted with follow-up as they enter into practice, to gain information on their attitudes about patients, approaches to care, colleagues (physicians and other health professionals), and their perceptions of the adequacy (and deficiencies) of their prior education. By appropriate choice of those to be surveyed, the impact of the clinical setting (inextricably linked to the impact of role models who have chosen to work in those settings) could be determined. What factors influence career choices? Most medical students become practitioners, but a subset of medical students and residents will be researchers, teachers, and adminis trators. There is concern about the declining supply of physician researchers. What is an adequate supply ; when is the decision made to be a researcher/ teacher; is early exposure to such activi ties cri t teal ; how can you be taught,to do them well? How effective has the Medical Scientist Training Program been? A school or program in which faculty show little interest in geriatrics is unlikely to stimulate constructive interest in the elderly. A school or program whose faculty exhibits, in their behavior, an overriding commitment to research conveys the importance of research. These questions can be generalized to almost any career choice and are related to the manpower study above, and to Chapters 6, 9, and 11. 53

The Teaching Hospitals For a long time, schools of medicine held a dominant post Lion in the ecological system of health care. They attracted patients for procedures or diagnositic activities that could not be provided by community hospitals. They also were the locus of specialists who possessed significantly more training and newer information than their colleagues in the practicing community. Howeve r, over the past decade, that ecological balance has been seriously altered. Over the past few years, the f low of federal dollars to medical schools has diminished.l,2~3l In this same interval, a variety of cost-containment activities for hospitals have been applied. As a consequence, clinical departments in U.S. medical schools were propelled into a series of coping activities. Professional practice income was seen as the source for transfusions to a body of medical education made anemic through the loss of federal funds. Medical education is poised for drastic re-examination; either the teaching hospitals must change their essential character, or the mix of hospitals classified as teaching hospitals, expecially for the purposes of training residents, must change. The former alternative appears less likely than the latter. Each portends significant environmental upheaval in the institutions. The scope of re-examination and the anticipated reorientation are major. For example, physician trainees will need greater exposure, not to the traditional intellectual ferment of the teaching hospital, but to the community health setting. Continuity of care for the patients and breadth of exposure for trainees will become the focal points. If the teaching hospital fails to become an active participant in designing and controlling the educational process, it will assume a limited status as the site of specialty rotation for those whose major educational-experiences will be elsewhere. Such an outcome would be most unfortunate because the nature of medical education requires physicians to undergo an intense curriculum centered upon the acquisition of scientific and technologic knowledge. The teaching hospital is and should be where both come together for patient, senior caretaker, and trainee alike. The teaching hospital is a changing environment, one in which cost effectiveness will become an important partner of scientific inquiry and intellectual ferment. There will be growing pressure for the institutions to search for sources of income in addition to patient care revenue that may be used to of f set the expenses inherent in delivering education, undertaking research, and exploring the f rontiers of technology . The numbers of those engaged in educat ion and research will necessarily shrink, but if their role is to be preserved, alternative sources of support are essential, and successful searches must be encouraged. Care of the aged and of the medically indigent will demand more of the resources available. The success of the teaching hospital in fostering managed care for these patients will in large measure 54

dictate the overall reasonableness of the quality, continuity, and expense of care available in a system where dependence on public financing remains very important. Teaching hospitals face the problem of cannibalizing their own product--the more they train specialists and the more the country is convinced that the number of physicians is growing faster than the population or its demand for their services, the lesser will be the system's dependence on the major teaching hospital--its graduates now staff the community hospitals--its trainees may accomplish their training through rotations outward, a lesson learned early by the more recently developed medical schools and their af f iliated institutions but resisted mightily by the more traditionally established teaching centers. Physician trainees will come to the teaching hospital and its network of the future more for the purposes of learning how to manage what is available, than to participate in the development of more sophisticated technologic interventions. An enlightened vision of what medical care can be has been the expectation of the trainee and of the world in conceptualizing the teaching hospital; this image will be very difficult to maintain when cost effectiveness is the mandate, especially during the time that newly determined sources of revenue are not yet readily apparent. If the system tightens and fewer students enter residency and fellowship programs, it is obvious that the nature of medical practice for the established staff member of teaching hospitals will be altered and in ways that may at best be inconvenient for a time. The conceptually appealing solution of multi-institutional rather than vertical integration of training programs is still at variance with the tradition of independence and the traditional requirements of numerous specialty boards for program approval. The teaching hospital has concentrated on "doing things right," and now the question is whether we are "doing the right things." A very different series of debates, frustrations and challenges are upon our institutions. Recent studies and writings have reviewed the problems of academic health centers, the financial dilemmas of the teaching hospitals, and some of the attempts at coping with the fiscal problems The focus has been on those issues that loom largest--the economic pressures and pressures for relevance to community needs. What the impacts of the economic pressures will be on the clinical education of medical students and residents should be thoroughly studied. The alterations.in the mix of clinician workers and researchers, the emergence of community hospitals as primary providers of care, the need to extend clinical teaching beyond the teaching hospitals, the decreasing number of residency slots--these are but a few of the problems that should be approached realistically, with quality and appropriateness of physician education as a primary concern, rather S5

than development of coping mechanisms to maintain the status quo of medical schools and academic health centers. At the very least, methods for monitoring impacts of economic pressures on the medical education system should be devised. The Premedical Syndrome The premedical syndrome is one adverse outcome of perceptions about the culture of medical school. Premedical students are variously said to shun difficult courses, to select too few or too many courses in particular disciplines, and to be excessively aggressive, competitive, and/or studious. Where does their inf ormation about the best way to get into medical school come from? How can the behavior of admissions committees be altered to match stated goals? How successful are early admission programs in altering college students' behaviors? What role, if any, might college counselors and faculty play in reinforcing desirable behavior and dampening undesirable behavior? Is there any agreement on what is, in fact, to be encouraged? How could communication be improved between the institutions involved in each stage of education? What messages are perceived and passed on as senior students in college and in medical school report back on their medical school and residency interviews? What communications occur amongst faculties and administrators at the several institutions, including teaching hospitals? Study Issue 4: The Science Base of Medicine During their education, physicians must learn the ways of science as well as a specific body of knowledge. The knowledge base is called upon frequently by practitioners in making decisions about diagnosis, treatment, and prevention of disease. The scientific method, an analytic approach to problem-solving, and a critical skepticism in evaluating data are needed both for the appropriate application of old knowledge and f or a continuing assessment of new hypotheses and experimental data as they are generated. The study theme the science base of medicine was selected because of concerns that we are moving toward a medical education that will not adequately prepare students in science. A number of pressures have been identified: the vast increase in knowledge in the traditional laboratory-based sciences; instructional time devoted to non-scientific topics such as ethics or cost containment; a diminution in the mathematics training of incoming students (the lack of common sense about numbers); and a trend toward fewer and fewer laboratory experiences, and increased difficulty in obtaining support for research. Furthermore, the changing burden of illness, the changing demography of the U.S. population, and advances in knowledge in the social, behavioral, and population-based sciences 56

have brought these non-traditional sciences within the bounds of the science base of medicine, and they too are demanding time in the curriculum (Chapter 6~. We have encountered considerable difference of opinion as to the reality and magnitude of the particular concerns expressed above, but there is unanimity in expressing an underlying concern--that physicians be adequately prepared in the methods of science to enable them to continue to evaluate the validity and significance of reports of new diagnostic and analytic tests, new drugs, new therapies, and the like. Three major questions will provide a focus for analysis. These questions emerged from committee discussions, the background papers, and some relevant independent activities such as the Macy Foundation sponsored conference "Teaching the New Biology:"32 o what is the current and projected science base for the practice of medicine? o what should the timing, sequence, and content of science teaching be? How could the separate components of the educational process be better integrated? o how can we maintain a strong research establishment? The Science Base of Medicine In many areas of practice, the physician must integrate observations and data spanning a range from the submicroscopic level through physiology and individual variation to the ecological environment of the patient. Knowledge in fields as diverse as genetics and behavioral sciences is evolving rapidly, and boundaries between disciplines are becoming less clear. The methods and data being generated in these fields today are widely generalizable, both in practice and research settings. It is likely that they will find increasingly broad application. Creative approaches in these fields will be enhanced by cross-fertilization among them. But especially in areas where knowledge is expanding rapidly, there is evidence that physicians are inadequately prepared. The science of genetics, for example, plays a central role today in the generation of new knowledge. The genetic manipulation of experimental organisms (microbes, insects, or animals) provides a powerful tool in the hands of a diverse array of investigators. It allows for experimental designs that will provide new understanding of the growth and development, the function and malfunction, and the death of cells, tissues, organs, organ systems, and organisms. Almost every physician in practice, regardless of specialty or patient population, will have to directly apply the findings and teachings of genetics. There is an ever-increasing list of inherited chromosomal aberrations and single or multiple gene mutations that lead to 57

malformations or metabolic disorders. These must be recognized and acted upon--they may require treatment, they may complicate the course of response to treatment of other health problems, and they also raise questions the patient wishes to ask (e.g., about having children). There also is a growing awareness of the genetic predisposition to adverse ef fects of environment or occupational chemicals33 or to certain dietary habits. Rapid advances in recombinant DNA research, the manipulation and transfer of genes, suggest a role of growing importance in future health care. The clinical importance of genetics is indisputable. It has been calculated, for example, that about 30 percent of children in hospitals are there because of a genetically determined or influenced disorder.34 Yet there is evidence that physicians are inadequately prepared in this science.35 Another example is provided by the behavioral sciences. Knowledge in recent years has been steadily increasing, for example, about the anatomy, physiology, biochemistry, pharmacology, pathology, and behavioral aspects of the nervous system. Recently acquired insights into neuroregulators offer great promise for clinical medicine. Insight into such behavioral concerns as psychosocial risk factors for cardiovascular disease, mental illness, substance abuse, and other health problems, and the significance of biological rhythms for sleep disorders, pharmacokinetics, and such health relevant problems as occupational accidents in shif t work all point to the clinical importance of the behavioral sciences. 36-40 Here, too there are indications that physicians are inadequately prepared.41 (See Chapter 6. ~ An adequate background in quantitative problem-solving and an understanding of the limitations and possibilities inherent in population-based research also are essential to physicians. New drugs, devices, and health maintenance programs, for example, require quantitative analysis of outcomes from trial populations to determine their usefulness and their possible hazards. The individual practitioner must be alert both to the problems and the potentials in all such situations. Can mathematical common sense be developed so that statistical fluctuations are not misinterpreted--preventing both exaggerated claims for the success of new modalities and false worries about impending epidemics of rare diseases or environmental health hazards, for example. A sense of skepticism must be developed during their training so that physicians will be able to analyze new claims critically while not ignoring valuable clues from rare events. How then to adequately educate students to the full science base of medicine? First, there must be agreement on what that science base is. To what.extent does it include the population-based sciences, such as epidemiology, the behavioral sciences, and the social sciences? How do we assure timely integration of other fields that emerge in the future? (See Chapter 6.) Before drawing conclusions about what the full science base of medicine will be in the future, it will be necessary first to pro ject what the physician's role will be . This is addressed in study issue 2 and Chapter 4. 58

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

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

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

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

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

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

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

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

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

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

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

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