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Appendix B-1
TEACHING HOSPITALS AND MEDICAL EDUCATION
Workshop, October 21, 1982
1 ) What do metical schools expect teaching hospitals to provide ?
2) What to teaching hospitals expect from medical schools?
3 ~ Mat does the public expect ?
4 ~ What ts the reward system in teaching ho~pital~edical school
associations, and how do you deal with it?
Participants
Charles Sanders, M.D., Chair, Executive Vice President for Science and
Administration, E.R. Squibb ant Sons, Inc., Princeton, New Jersey
Douglas Collins, M.D., Private Practice in Internal Medicine, Caribou, Maine
Jeptha Dalston, Executive Director, University of Michigan Hospitals, Ann
Arbor, Michigan
Barbara Filner, Ph.D., Study Director, Inatitute of Medicine, Washington, D.C.
Ruth Hanft, M.A., Vice President, Delta Corporation, Washlagton, D.C.
George Harrell, M.D., Vice President for Medical Sciences, Emeritus,
Pennsylvania State University, Hershey, Pennsylvania
Philip Lee, M.D., Professor of Social Medicine ant Director, Institute for
Health Policy Studies, University of California, San Francisco
Leah Lowensteln, Moo., D.Phil~., Dean and Vice President, Jefferson Medical
College, Thomas Jefferson University, Philadelphia, Pennsylvania
Elena Nightingale, M.D., Ph.D., Senior Scholar-in-Residence, Institute of
Medicine, Washington D.C.
Morton Rapoport, M.D., Vice Chancellor and Chief Executive Officer, Unlveraity
of Maryland Medical System, Baltimore, Maryland
Julius Richmond, M.D., Professor of Health Policy, Harvard Medical School,
Boston, Massachusetts
Frederick Robbins, M.D., President, Institute of Medicine, Washington D.C.
Walter Rosenblith, Ing. Rad, Institute Professor' Massachusetts Institute
of Technology, Cambridge , Massachusetts
Mitchell Spellman, M.D., Ph.D., Dean for Medical Services and Professor of
Surgery, Harvard Medical School, Boston, Massachusetts
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Teaching Hospitals and Medical Education
The workshop considered the expectations teaching hospitals and
medical schools have of one another, how well those expectations are
met, and whether or not the institutional reward systems reinforce
desires aspects of the teaching hospital~edical school association.
O It is unclear whethe ~ or not most schools have articulated their
educational goals. To the extent that they hare, it is not
clear that the goals have been rethought in the context of ma jar
changes pot-World War II, such as the overwhelming presence of
high technology in teaching hospitals, and the even more recent
expectation that some community health needs will be dealt with
in the hospital.
o Teaching hospitals have adopted a business-oriented thinking,
using such terms an "market-share" and the hospital becoming a
"cash cow" f or the hospital~edical school association. ~ In Ann
Arbor, the university hospital has decided to move toward a
subspecialization emphasis, in order to remain competitive.
The educational goals of the medical school are no longer
leading the hospital . In s rate schools and their af f iliated
hospitals, additional non-educational driving forces are derived
from state legislatures, which may put limits am QlE slots or
further direct hospital decisions through reimbursement
constraints.
O The thinking about the teaching hospital~medical school
relationship should distinguish between intrinsic factors ant
external constraints--the latter should not be allowed to
dominate thinking about the former. Concern about reimbursement
policy, especially, tends to overwhelm' and to a certain extent
distort, thinking about what should or could be expected in
these institutional associations.
O Finally, it must be remembered that there is diversity in the
medical school-teaching hospital association, so generalized ions
should be made with caution, if at all. There is a spectrum of
medical schools, with research orientation at one end, community
orientation at the other, and most schools in the middle. There
are differences between academic health center tertiary care
hospitals (research oriented) and patient care oriented
community hospitals, between private and public hospitals; the
VA system is yet another variation, as are ambulatory care
settings.
Bearing this context (alla these cautions) in mint, the workshop
agreed that in general, research, teaching, and patient care of the
highest quality are expected from the teaching hospital by the medical
school. Some participants thought that research and teaching were
more important than care, but others thought that care had primacy,
and the research and teaching were derivative from that. In addition,
understanding for the values and objectives of medical education is
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expected from the teaching hospital. This is not always present--as
exemplified by teaching hospital faculty making derogatory remarks
about community practitioners, although most of the medical students
ant resitents prevent will, in fact, practice in the community.
Medical schools also expect teachlog hospitals to underwrite some
educational costs, via reimbursement for patient care. Resources
provided include instructors and instructions, space and physical
facilities for research (and care), patients, graduate training ~lots,
and f inancing for those slots.
Do medical schools need tertiary care hospitals? The workshop
thought yes, such hospitals are necessary, but they are not
sufficient. Students should experience other care environments as
well. It is important to think of the training of physicians as
taking place in a chain of institutions, no single element of which
will meet all of the expectations of the medical schools. (And the
residency experience possibilities also must moderate the expectations
regarding necessary experiences during the four years of medical
school. ~
The discussion of the other questions put before the workshop was
less intense. Prestige, as exemplified by the presence of volunteer
faculty, and stimulation, challenge, and fun in interactions with
students, were identified as what the hospital expects from the
medical school. In subsequent committee discussion, Bob Tranquada
added to the list cheap manpower (from medical students and residents.
As to what the public expects ~ excellence and leadership in the
development of new clinical methodologies f or diagnosis and treatment
of disease were suggested.
Finally, in the workshop discussion of the reward system, prestige
and beds were mentioned. There was co discussion, in this context, of
salary.
In subsequent committee discussion, Doug Collins underlined the
need for medical schools to define their goals and stick to them a
little better, rather than being led away from them by the teaching
hospitals, but Bob Tranquata said, "it is no contest . " Walter
Rosenblith remarked that he too was impresses with the shift in power
balance toward the hospital, but Fred Robbins questioned whether there
had really been a shift--rather, the reality might just be more
apparent than it had been previously.
Al Tarlov pointed out that at Chicago, the hospital in owned by,
and indeed run by the medical school, but he added it may be
atypical. Problems in such a situation include efficiency and everday
practice behavlour--this system is less attractive to patients. As
teaching hospitals despond to the economic realities, they will be
more technological and more narrowed in patient mix, and thus will be
less useful in medical education. At the same time, hospitals also
are moving to assume new responsibilities that are relevant to medical
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education: long-term care centers, ambulatory care centers, geriatric
centers. Hetical schools will have to look at corporate restructuring
in the hospital incus try, ant to some restructuring themselves.
Walter Rosenblith noted that the motivations seem to be
centrifugal, pulling the hospital and medical school further and
further apart. It's important for the ION planning study to suggest a
mechanism to think through changes in teaching hospitals. From an
educational perspective, the hospitals can' t be viewed in isolation as
a self-contained unit seeking f fecal stability (or survival ).
The committee also discussed the problem of integrating Pros into
associations similar to those of teaching hospitals with medical
schools. HMOs require large volume, ef f icient operas ions, which are
not usually considered to be compatible with educational goals.
Several examples of "failures" in attempts to use pros for teaching
were cited--the ~0 costs went up, and they couldn't afford to
continue to provide educational opportunities. However, successful
examples also were mentioned--in cases where the university paid the
HMO for teaching, or when the teaching was limited to residents ~ that
is, excluding medical students ~ .
Questions for further study include:
1 ) Who has responsibility for educational planning at the teaching
hospital? What are the goals around which planning should take place?
What is the balance of emphasis among research, Beaching, ant care now,
and might a different balance better foster educational goals? How
would decisions be made about allocat ion of resources ~ time, dollars,
space, trained personnel, patients, teaching and care. ~
2) What is the role of tertiary care hospitals in medical education? How
much diversity of care environments should students be exposed to ? Are
particular experiences in one or another particular setting essential
at a part icular stage of training?
3) How can the whole issue of reimbursement be kept in perspective? How
should training costs be factored in?
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Appendlc B-2
FINANCING MEDICAL EDUCATION
Workshop, October 2l, 1982
What do we know about future phy~lcian supply and temant? Are
current projections (GMENAC, HRA) useful? what are the
problems with them? If these projection methodologies are not
useful, what sorts of methodologies hold promise ? Mat future
activity might develop better methodologies and/or pro Sections.
2) What sources of support for financing medical education are
likely in the future? How will sources affect the nature of
medical education? What are the major gaps in knowledge? What
future activity might help to fill those gaps?
Part icipant s
Frank Sloan, Chair, Ph.D., Professor of Economics, Vanderbilt University, and
Director, Health Policy Center, Vanderbilt Ins t itute for Public Policy
Studies, Nashville, Tennessee
Nancy Ahern, Staff Officer, Institute of Medicine, Washington D.C.
Gerard Anderson, Ph.D., Project Officer, Study of Graduate Medical Education,
DdHS, Washington, D.C.
Karen Davis, Ph.D., Professor of Health Services Administration, The Johns
Hopkins University, Baltimore, Maryland
Mary Fruen, Ph.D., Health Policy Consultant. Washington, D.C.
Ruth Hanft, M.A., Vice President, Delta Corporation, Washington, D.C.
Jesse Hilton, Ph.D., Chief, Modeling ant Research, Bureau of Health
Prof essions, DENS, Washington, I). C.
Elena Nightingale, M.D., Phil., SenSor Scholar-in-Resitence, Institute of
Medicine, Washington, D. C.
Nora Piore, IS.A., Senior Program Consultant, The Commonwealth Fund, New York,
New York
Freter~ick Robbins, M.D., President, Institute of Medicine, Washington, D.C.
Walter Rosenblith, Ing. Rad., Institute Professor, Massachusetts Institute
of Technology, Cambridge, Massachusetts
Michael ZubRoff, Ph.~., Professor and Chairman, Department of Community and
Family Medicine, Dartmouth Medical School, ant Professor of Health
Economics, Amos Tuck School of Business Administration, Dartmouth College,
Hanover, New &mpshire
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Manpower Pro jections ant Financing of Medical Education
The workshop considered two broad sets of questions, the first
dealing with current knowledge about supply and demand projections,
and the second concerning presene and future sources for f inancing
medical education.
Projections of physician supply and demand are seen as important
in that they affect a number of decisions including financing
decisions by state legislatures, and medical student's speciality
choices .
There was general agreement in the workshop that there will be
substantial increase in the supply of physicians, regardless of what
particular modeling technique is used. Rather than carrying out more
studies to get the "right" number for a projected surplus, the
workshop suggested the following areas for further study by the IOM or
other organizations:
1) Identif ication of public policies that would help direct the
increase in physician supply to meet certain needs, such as
care of home-bound elderly, low~income children, and other
underserved groups.
2) Improved estimates of various surgery ratios and procedure
rates, as these are important components of estimating
physician supply.
3)
Further study of access to health care (and health personnel)
in medically unterserved areas, and possible consequences of an
overall surplus of physicians.
4) a look at expected responses to a surplus, with distinctions by
age , rice, and sex, e .g ., what are young doctors likely to to
differently from older doctors?
5) Examination of specific groups of providers and the patients
they serve, e.g., probability of an inadequate supply of black
physicians even if there is an overall surplus of 70,000 MDs.
Subsequently, there was some discussion among planning committee
members as to how accurate the existing projections are, and how
accurate they can be. The consensus was that the supply figures for
1990 are fairly well known, since most of the new entrants are already
in-the pipeline. Eselmating requirements or needs is much more
difficult, as is estimating needs within various specialities. Al
Tarlov states that a mathematical model does exist and data to plug in
are available, but the motel is highly sensitive to assumptions which
are essentially social, entailing values and politics. He added that
the state-of-the-art in medical practice and the predictability of
social preference in health subraces are such that estimating for any
f uture year is bound to be guesswork. For social planning, a simple
physician-to-population ratio, for example, probably is better than
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the sophisticated model, with motiflcation9 made as medical knowledge
and social change Cove forward. For Acade~lc purposes' to try to
understand the medical profession and the health care system, motels
for projecting need are useful.
Gus Swanson, director of academic affairs, AAMC, salt that
downward adjustments in supply are aireaty occurring. This year, for
the first time since 1952, there is an expected decilne of 100 in
number of f irst-year medical students . Fewer opportunities in
graduate education also are expected.
With regard to medical education financing, the workshop
participants stated that recent bents in financlag are fairly clear,
and are likely to continue . Research funds will be falling, with
increasing pressure for revenues from affiliated hospitals. Tuition
is holding it's own, maybe going up slightly, but it is typically only
a small piece of the total medical school budget. Increased reliance
on thirt-party reimbursement is expected. Left unanswered is the
broad issue of what is the "right" payment for medical education and
from which source, e.g., how much should students be paying, and how
much should state funds be used? The group suggested that the IOM
committee court provide leadership in identifying alternative sources
of support.
In subsequent planning committee discussions, Bob Tranquada notes
the existence of a whole set of organizational questions, i .e ., where
control will flow from. Cy Leventhal pointed out that health care
requires a substantial amount of research expend! Cures, and the
interaction between education and research in essential. Gus Swanson
remarked that the trend for increasing reliance on income from
practice plans represents a potential threat to the educational system.
Frank Sloan doted a number of research questions related to
financing that had not been addressed--by the workshop or the planning
committee. He noted that federal research dollars were less
available, which might mean fewer and/or smaller grant-what will be
the impact on metical Schools and medical education? Also, with
research dollars available from industry, and profit linked to patents
a real potential, what will this do to relations among faculty and
sharing of research f indings?
Al Tallow generalized the concerns to "the perversion of values
and effort in teaching." Certain curricular changes, for example,
Sight not be made because they would disturb the flow of revenues from
the hospital. (Equivalent revenue would not be available from
ambulatory settings. ~ He suspects a study would document a dramatic
effect of financing on medical education and on medical practice
subsequently--and lead to a call f or restructuring of the f lasncing.
How might a study best be carried out?
301
Representative terms from entire chapter:
teaching hospitals
