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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 295

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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 296

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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 297

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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? 298

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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 299

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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 300

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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