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Appendix D~1 SUMMARY OF.VISIT TO MISCARRY MEDICAL COLLEGE On September 23' 1982, committee member David Satcher, President of Meharry Iledical College in Nashville, Tennessee, was host to a visit from some members of the Institute of Medicines Committee to Plan a Comprehensive Review of Medical Education in the United States. Institute of Medicine participants included cay Andreali, Elena Nightingale, ~ Tariov, and Frank Sloan from the committee and Barbara Filner, Study Director. The Meharry participants included a number of administrators and faculty members concerned with student af fairs, institutional management, and basic and clinical sciences. (See Attachment 1 for a complete list. ~ A List of questions from the IOM committee had been distributed beforehand to help guide the discussion (Attachment 2~. In brief, the discussions dealt with the national importance of Heharry as an institution training black physicians (ant other health professionals ~ ~ the goals of Meharry for itself as an institution and for its students, selection of students and their academic performance, and financial concerns of students, among other issues. Background Information Meharry Medical College, a private school establishes in 1876, has trained 40 percent of the black physicians (and dentists) in this country. Forty-six percent of the black faculty members in U.S. medical schools are Meharry graduates. The other well-established predominantly black metical school in the U.S. is Howard IJniversity, which has a special relationship to the Congress of the U.S. (as a source of "state. support). Two new schools are the Morehouse School of Medicine, which opened in 1978 with a two-year basic poetical science program and was licensed for a full four-year M.~. program starting with the class entering in 1981, and the Charles R. Drew Postgraduate Medical School/UCLA Medical Program, which first-enrolled students in the IS. D. program in 1981. There are four health-related schools at Meharry: Medicine, Dentistry, Graduate (biochemistry, microbiology, pharmacology, and biomedical sciences as established doctoral program, and physiology being developed), arut Allied Health (dental hygiene, medical technology. health admintotration, nurse practitioner) . Enrollment at the Medical School was 481 in the 1981-82 academic year, accounting for about half of the student body of 965 in all four schools. The medical school entering class in 1982 numbered BO, down sharply from the 124 of recent years, in order to improve the student/bed ratio for clinical experiences ant to improve the faculty/~tudent ratio. Fif ty percent of the medical students are from the southeast, but 33 states, the Distrlet of Columbia, Virgin Islands, and Canal Zone were represented in the 1981 entering class. Forty-f tve percent of 309

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the students went to historically black colleges. Thirty-six percent are women. There is considerable age diversity in the entering class, with some members in their late 30~. Meharry students are from low-income families; 85 percent receive f inancial assistance tn some fore. Average family income is SI5 .000 per year. Tuition and fees amount to about S8IOO annually. On average, MC AT scores are relatively low, but attrition rates are not high and students pass state licensing exams after graduation. Some Meharry students are no educationally disadvantaged that they would not have been admitted to other medical schools. Sixty percent of Meharry graduates become primary care physicians. In the last ten years, about 75 percent located their practices in traditionally medically underserved areas (inner cities and rural areas ) . The Importance o f Meharry A number of reasons f or the cant inued need f or predominantly black medical schools and for Meharry in particular (in addition to Howard, Drew, ant Morehouse ~ were discussed . The Institute of Medicine committee members present thought that a convincing case had been made. Why a predominantly black medical school? 1. Most predominantly white medical schools do not have a strong commitment to train black physicians. Admissions of blacks have been declining in recent years and there are no assurances for the future. (It was suggested that the Baske decision hat a great deal to do with this decline. )* Even at present levels, the l].S. medical schools do not train sufficient black physicians to meet national needs. (For whites, the M.I)./patient ratio is 1/8,000; for blacks, the ratio is 1/15,000. Among U.S. physicians, 3.3 percent are black and the recent trend has been for the percentage to get smaller.) 2. It is important that there be predominantly black medical schools to be recogulsed as centers of excellence and thereby validate the standing of all black health professionals. Without this institutional recognition, highly capable individuals who are black can be regarded by colleagues as the exception rather than the rule. A black student attending a predominantly white medical School must deal with special pressures as a black. These pressures derive from high visibility, a responsibility to be a civil rights advocate, and the need to be aggressive in order to be included in - *However, applications from black students are down, and this parallels the trend in applications from white students. 310

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inf ormal academic and social experiences Some black students do not want this additional burden and will handle the academic and emotional challenges of medical education more successfully (or more comfortably) in a predominantly black school. 4. In majority institutions, blacks are more likely to be assimilated than integrated; the black graduates of these schools are lees likely than graduates of predominantly black schools to make career choices that reflect black community needs (e.g., service to medically underse rved areas ~ . 5. Black medical schools play an important advocacy role--for availability of financial assistance funds and for research on the health problems of particular importance to black populations. Why Meharry? 1. It successfully trains students to meet the health care needs in many uncle rserved areas . 2. Part of its student body is composed of students who would have had difficulty being admitted elsewhere and it successfully trains students who are considered high ri sk. Meharry has learned how to teach the (apparently) least qualif fed student ant/or to identify predictors of success other than cognitive test scores. 3. It is important as a symbol with deep historical and emotional . ties to the black community and the nation. '. . Problems such as the f inancial pressures and limited access to patients have been a positive stimulus in that they have forced innovative programs to be developed. The pressures, and thus the creativity, are not likely to go away soon. (The community emphasis and Mound Bayou pilot program, which served as a model for Tufts University Neighborhood Health Center project, grew out of the need to increase student access to clinical experiences, and to satisfy the health care needs of a unique and restricted black communi ty. MeharrY's Goals The goals for Meharry for the next five years are financial stability, accountability, and academic excellence . Financial stability efforts involve better management (in part through accountability) throughout Meharry ant continued fundraising efforts. Accountability will be enhanced by making routes of communication clear, management and star f development, setting goals, and providing rewards and recognition. The approach to academic excellence includes vigorous recruitment of faculty interested in research (space is not a problem), providing faculty development funds for stare-up research (from Commonwealth and 311

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MacArthur grants), keeping the enterlag class down to 80 until there are four clinical beds available per student (the current ratio is one bed per student), rewarding good teaching and counseling faculty on how to improve teaching, and attracting a core group of students with high cognitive Lest scores to serve as pace-setters. As a beginning, foci for growth probably wilt! be selected, rather than attempting to develop strong research and teaching programs throughout. Among the possible "themes" that would be of particular importance to the black community, but that would have relevance to and be recognized by the entire population, are hypertension and aging. Sickle cell research as part of a more general program on birth defects was mentioned as another possible area for emphasis. Selection of Students; Their Academic Performance MCAT scores tend to be at the low end of the range for U.S. medical school students, but in Meharry 's experience over the years, these students do succeed in becoming physicians, and some with low MCAT scores are outstanding. MCAT scores are not equally predictive for all students; in their judgment, a black student whose score is 7-S is no greater risk than a majority student with a score of 10, but they noted that this has to be documented. There was some concern that MCAT scores (and their correlates ~ tend to drive the system rather than the needs and goals of Meharry. The Liaison Committee on Medical Education (LCME) of the AKA/AAMC, which is responsible for accreditation, judges a school in part by National Board scores. Because MCAT scores are good predictors of Part I Board scores, accreditation concerns have led to more emphasis on MCAT scores and less emphasis on qualities that have to be Judged sub jectively (motivation, energy, perseverance, etc. ~ and/or that reflect the goals of Meharry (e.g., commitment to the co~unit~r~. A Special Medical Program provided an alternative admissions pathway. Students who successfully completed the program were then admitted to the medical school (second year) even though their MCATs were "unacceptable." Their Meharry course grades hat to be at the median level for the "regular" class. In the first ten years of the program, 135 of 150 students (15 each year) successfully completed the medical curriculum, and several graduated with honors (membership in Alpha Omega Alpha Honor Society). The program features a slower pace (15 months to complete 9 months of the traditional program), counseling on learning skills, and frequent personal contact with a particular mentor (faculty member or Dean). The students were selected by the Medical School Admissions Committee conjointly with Dr. Charles W. Johnson, Dean of the Graduate School during the 1967 - 1971 period, who also was professor of Microbiology in the Medical School. He reports that this selection was somewhat idiosyncratic and it is difficult for him to pin down exactly what contributed to his impression of a students ability to 312

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"make it." Among the items mentioned were being the first in a family to graduate from college, the parents' professions (e.g., postal clerks are a plus), and the number of siblings. Student Finances The cost of aid is going up ant the amount of aid available i. going down. Thin hits Meharry particularly hard because 85 percent of i t s s tudent body rece ive f inancial aid . Among the past sources and present prospects for f inancial assistance were: Nat tonal Health Service Corps: Meharry once led the country in number of students "enlisted"; this year there were only 4 slots open, and there may be no new entrants after that. Military Health Professional Scholarships: This year there were 80 available nationwide, but no student at Meharry received one . Health Professions Loans: The interest rate went f ram 7 percent to 9 percent; Meharry decreased its default rate last year f row 65 percent to 38 percent, but the new government standard is 5 percent and they don't think they will soon be able to meet that . Health Education As sistance Loan Program: Three years ago these loans were at 13 percent simple interest; as of October 1981, the interest is compound and set at 3 percent above 90-say Treasury notes . (The f irst set of loans at the new formula were at 21 percent. ~ Work Study: This dropped from $70,000 last year to g40, 000 this year at {teharry. National Student Defense Loans: The college expects student applications f or about S500, 000 in loans. Meharry is currently experiencing an 11 percent delinquency rate, within acceptable limits. Student indebtedness is increasing rapidly. Apart from potentially barring some students from starting or completing their medical education, the f inancing also inf luences subsequent career decisions . Graduates tend to select three-year residency training programs rather than longer ones, ant they seek out residencies that lend themselves to moonlighting arrangements. It also was pointed out that of Gentiles large extended families pool their resources to send a student to Ned teal schoo 1 . The " f amity" will expec t a re turn on the i r inve ~ tment in the form of free medical care once the student sets up a practice. Addi tional Observations Biomedical Scientists: It was repeatedly pointed out that tSeharry is deeply committed to training biomedical scientists and/or stimu- 313

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rating young blacks to pursue a health research career. A program of Her study for college students helps to accomplish the latter goal. Faculty Recruitment: The last decade saw considerable expansion and modernization of the building at Meharry, and they are not being used at their full capacity yet. lathe need now in for Brained and committed people to use these facilities. (Salaries at Meharry are at the low end of the average range for the region, according to AAMC data. ~ Curriculum: The curriculum is, for the most part, traditional. Innovations derive from necessity. more than from a concern with curriculum per ~e. Electives at Vanderbilt and other schools are available. Manpower Needs: It was pointed out that great care must be taken when developing or applying policy because "ma jority" data do not always reflect the situation for the black population. For exampl e, there is a continuing need for black primary care physicians and specialists, although according to the projections of the GMENAC report, the total number of physicians trained in several specialties will be adequate or even an oversupply for the country. Special Financial Pressures: A letter from Dr. David Satcher President, Meharry Medical College, describes special financial pressure on minority medical schools (Attachment 3~. 314

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At tachmene 1 Visit to bleharry Medical College September 23, 1982 lleharry Participants Dr. Davit Satcher, President Dr. Charles W. Johnson, Vice President for Academic Af fairs Execut ive Management Commi t tee Academic Council Dr. F. Jones Dr. I. Arinze Dr. R. Hardy Jackie Wilson Paul Dandridge 315

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At tachment 2 Institute of Medicine Committee to Plan a Comprehensive Review of Medical Education QUESTIONS FOR VISIT TO MEHARRY September 23, 1982 The schoo 1 5. 1. What do you view as the role of Meharry in the community and in the nation? 2. What sort of faculty and students to you want and how successful are you in attracting them? 3. What do you view as an appropriate role for research at Meharry? What are the problems and opportunities in obtaining a desired level of support ? What is the minimum level of research support required ? What i s needed f or Meharry to continue as a f inancially viable institution? How are the educational decisions made? what is the power structure; what role do students have in these decisions? 6. What is your approach to teaching the basic sciences ant clinical knowledge? What is the relation between the basic sciences and clinical f aculties? 7. How are public health, health promotion and disease prevention, the social and behavioral sciences ~ problems of aging, and the quantitative Sciences incorporated into the education at Meharry? As a historically black institution 1. What is your mix of students ant what special educational and f inancial problems do you face related to that mix? Is this changing (for better or worse), how to you cope, ant what are your future concerns ? 2. What are the problems related to being an institution with a large minority enrollment (e . g., the recently resolved issue of access to patients ~ ? 3. What special awareness do you have as a school training minority physicians--e."., attitudes toward patients and the health care system; specialty needs, type ant location of practices? What sort of transfer of perspective might be achieved via student ant/or faculty exchanges with other medical schools? 316

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Students I. What kinds of students are you looking for--do you actively recruit (e.g., women, whites, selected minority/ethnic groupo)? 2. How do you assess applicants~~do you assess your selection process? 3. What are the problems your students face in financing their medical education? What is the projected impact of changes in relevant f eteral programs ? 4. What postgraduate training do your graduates seek, and where? 5. How to they fare on boards, in getting residencies, and in their subsequent career? Are they distinguishable from graduates of other medical schools in the type and place of their practice (or other important career decisions) ? 6. Do you try to inf luence your students toward certain career decisions, e.g., to practice in a medically underserved area, to train as primary care physicians ? What are the factors in their education that you use to encourage them in the desired direction? 7. What proportion of your students do establish practices in medically underservet areas? Other 1. What issues would you like to raise in the context of the Institute of Medicine planning study? 317

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At tachment 3 Special Financial Pressures on Minority Medical Schools David Satcher, President, Meharry Medical College March 3t, 1983 INTRODUCTORY REMARKS Two predominantly black medical schools in this country, Meharry Medical College and Howard University, have educated more than 50 percent of all black physicians and dentists. In addition, more than 40 percent of black physicians currently on the faculty of medical schools throughout this country are Meharry graduates. Since Howard University, because of its land-grant status, receives special appro- priation from the federal government, it will not be discussed specifically here. Meharry Medical College, as a private institution, has s truggled f inancially since i t s f ounting in 1876 . Abraham Plexner commented on the f inancial. plight of Meharry in 1909 when he recom- mended that increased local and national support be brought to bear upon this institution which had contributed greatly despite limited resources . To a great extent, Meharry ' s f inancial ~ truggle has been inherent in the mission of the institution. Meharry was founded to respond to the unmet needs of former slaves and their offspring for medical education and medical care . In carrying out this mission, Meharry has responded to the needs of a constituency that has been basically poor. Until this day, most of Meharry's graduates have been first general ion co liege graduates . Likewise, Meharry has maintained a special concern for low income ant unterserved communities throughout it's history. H ISTORY OF F INANC IAL PRESSURE In order f or Meharry to educate blacks from low income families, it has been necessary to maintain a tuition thee has been signif icanely lower than that of other private medical schools. In 1979-80 the median income of the families of students at Meharry was approximately $10,000. Meharry's tuition at that time was S5,500. Today, Meharry's tuition is 67,500 and the median income of the families of our students is approximately S16,500. Yet despite Meharry's low tuition (as pointed out by the Robert Wood Johnson Foundation Report of 1980) tuition constitutes a higher percentage of Meharry's budget than it does at other institutions. In 1979-80, tuition accounted for 23 percent of Meharry's budget, whereas it counted for less than 15 percent of the budget of the average priorate schools in this country. The obvious reason that Meharry's tuition, while low, accounts for such a large percentage of it 's budget is that the institution has received relatively low funding from other sources. For example, funds f rom research to Meharry have consistently accounted for less 318

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than 10 percent of the institutions budget as has funds from practice income . Meharry ' s f acuity has nester hat the Strong biomedical research orientation as have the faculties of other medical schools in this country. Because of the bacicBround of our students the importance of teaching has always been greater at Meharry. Meharry ' ~ faculty, residents, and students have always however been involved in the provision of care to populations. However this care has consistently been provided to patients in low income communities where patients have been unable to pay, or patients have relied heavily upon reimbursement from medicaid and Medicare which has been basically cost-based. Thus Meharry 's experience in delivering care in North Nashville, in Tuskegee, Alabama, in Mound Bayou, Mississippi, and at Provident Hospital in Baltimore have all been very important experiences f or teaching and orientation of our students; but they have not been income producing. The outcome of Meharry's experience however is clear in that 75-80 percent of our graduates have elected to practice in underserved, rural and inner-city communities. The price of course has been the lack of significant funds from practice. By the same token, Meharry has not received signif leant gif ts from private individuals. This again relates to the fact that bleharry' s alumni are for the most part f irst generation college graduates ant do not come f rom families or communities with great resources. TRANSITIONAL EXPERIENCE Meharry 's f inancial plight improved signif icantly in the early to middle 1960's. The passage of Medicaid and Medicare legislation certainly improved Heharry ' s f inancial plight in the delivery of medical care despite the limitations of these programs. By the same token, the availability of capitation for medical schools with an emphasis OF primary care ant minority enrollment was of great benefit to Meharry. Then, of course, the coming of the National Health Service Corps Scholarships in 1972 was quite significant for Meharry-~where at one time 80 percent of the medical students were on National Health Service Corps Scholarships. These programs were as natural for Meharry as the great NIH Research Grants were for other institutions. The fact that our students were already committed to practicing in underserved communities meant that the guidelines for the National Health Service Corps Scholarships were natural to our population. At the same time, however, negative forces began to impact upon Meharry in the early 1970's. Among other things, one~way integration hat started to take effect where black physicians and black patients were able to go to hospitals where they previously had not been able to go ant they took advantage of this opportunity as they should have. However, integration in the other direction with white physicians and patients coming to Meharry did not take place until very recently and still only to a small degree. Added to this, of course, was the fact that in the late 1970' s decisions were made which affected Meharry adversely including decisions to decrease and ultimately cut out National Health Service Corps Scholarships and capitation for medical schools . While there decisions af fected all institutions adversely, their impact upon Meharry was especially critical .

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UNIQUE FINANCIAL NEEDS OF MEHARItY HE:DIC~ COLLEGE AND OTHER MINORITY INSTITUTIONS TODAY - Today then' with the loss of the National Health Service Corps Scholarship, the loss of institutional capitation, decrease in the availability of loans, and the new guidelines for reimbursements for Medicaid and Medicare, Meharry ' ~ f inancial plight ts especially critical. Since much of these changes came about because of the GHENAC Report and other studies projecting a surplus of physicians by L990, it is worthwhile to point out that the same study said there would be a deficit of black physicians who now constitute less than 3 percent of the total despite the fact that almost 12 percent of the population in this country is black. Meharry and other predominantly minority institutions desperately need some legislation or initiative in this country that is specif ically responsive to the unique contribution and the unique needs of these institutions. Among other things Meharry needs the availability of student support in the form of scholarships ant loans that is responsive to the backgrounds of our students and their commitment for service in underserved communities. Also consistent with this mission, Meharry needs support to develop a special prepayment plan f or medical care that is geared to the low income population that other payment plans tend to not only ignore but to consciously exclude. Certainly health maintenance approaches could be very important for these populations where health promotion and disease prevention are so greatly needed. Likewise, Meharry and other predominantly minority institutions need to benefit from incentive programs for practice in under~er~red communities. That is especially true now where large debts might tend to drive students not only away from primary care careers but away from practices in underserved communities. lrhus again that which is natural for Meharry and her students will be adversely affected. Finally, Meharry and similar institutions need funding for research into some of the special problems of unterservet communities. It is certainly the posture of the current Me.harry a/ministration that research is as important f or Heharry as is education and service. In fact, the future of quality education and service that ts responsive to the unique needs of Meharry and it's communities depends upon research that i-s relevant to unsolved problems and unanewered questions in these communities and for these populations. Hopefully funding for the prevention of cardiovascular diseases, better understanding and prevention of the rising rate of cancer in blacks, nutritional problems, high infant mortality, birth defects ant other problems will become increasingly available to all institutions but especially to institutions like Meharry that have for so long been dedicated to dealing with these problems in the fore of service delivery. While there should be no doubt about the ability of bleharry and similar institutions to survive the present f inancial pressures, it is time for special steps to be taken in this country to minimize those pressures where they are not only unnecessary, but where they are inconsistent with what we states as our goals for health care and medical educat ion. 320

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Appendix D-2 SUMMARY OF VISIT SO INDIANA UNIVERS ITY SCHOOL OF MEDICINE On November 22, 1982, Elena Nightingale, Vice Chair of the Committee, and Barbara Filner, Study Director, visited Indiana University School of Medicine in Indianapolis. They met with Steven C. Beering , A. D., Dean of the Medical School and Director of the Medical Center; George T. Lukemeyer, M.D., Executive Associate Dean; Morris Green, Men., Chairman of Pediatrics; Alan Fischer, M.D., Chairman of Community Medicine; and Be~rerley E. Hill, Ed.I). ~ Director of the Medical Educational Resources Program. In general, Drs. Night ingale and Filner had the impression of a thriving enterprise, one which toad the firm support of the state (its residents and legislators), and which had a high morale within its own institutions . Background The medical school is a statewide system with nine campuses. Students are dispersed among these campuses for the f irst two years of medical school and then go to Indiana University Medical Center in Indianapolis for the third and fourth year. The eight schools outside Indianapolis are pare of pre-existing universities (Notre Dame, Purdue, Indiana State, and Ball State) and have at filiations with hospitals in those communities. There are about 20 f irst year students at each of the eight campuses. There are 290 f lest year medical students (down from 305 last year), about 98 percent of whom are residents of Indiana. For this entering class,- 32 percent were women and 6 percent were black. (The state ' s population is 11 percent black. ~ About 75 percent of the students have financial aid, one form of which is a research assistantship. (There are 80 students in the research program now.) In-state tuition is S3, 000 per year; for out~of-state reeldents, it is $7, 200. Indiana also has an M.D.-Ph.D. combined degree program in four locations. There have been about 600 graduates since it was started in 1958. The graduates are similar to the M.D. graduates in their subsequent careers . About 10 percent of the M. 0. -Ph. D. ~ and aboue 6 percent of the M.D.s have full-time acatemic/research poaltion~ in such places as medical schools, pharmacautlcal companies, and the Na tional Institutes of Health. The Dean of the Medical School also runs the graduate medical education program. There are 260 f irst year positions and a total of 1, 000 resident positions in 107 af f iliatet hospitals in the state ~ all directed through the Dean' s of fice. About 65 percent of the medical school graduates do their graduate training in Indiana. About 75 percent of the physicians who have their graduate medical education in the state establish their practice within a 50 mile radius of that hospital . 321

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About 21 percent of the graduatlag class choose family practice residency training' and those students are from the top of the class. There is a statewide network of training programs, with a total of 240 positions (80 slots for each of the three years of training). Half of the graduates of the residency programs establish a practice in towns with population. under 30,000, and half of that group are in towns with populations under 10,000. The Statewide System Dr. Beering's judgment is that the dispersed system is successful academically and has positive impact on the communities involved. He said that it is not possible to distinguish among the third year students based on where they were the previous two years. As an example of impact on the community, he mentioned that in the ten years that Evansville has had a school ~ the number of physicians increased f ivef old; previously there were no specialists in the community and now there is a great variety available. He also thought that the school had helped the community hospitals at tract "e legant " doctors . The two year program statewide ts responsible for Beaching- 1st year: biochemistry, microbiology, gross anatomy, histology, physiology, behavioral science, neurobiology , introduction to emergency medicine, and electives. 2nd year: pharmacology, general pathology, medical genetics, systemic pathology, history taking, ant physical diagnosis. Even though each school was located on a university campus, as the statewide system developed, Dr. Beering found it preferable to establish a separate faculty for each school rather than to use the faculty in the graduate departments already present on that campus. Students have an introduction to clinical aspects of medicine both the f irst and second year of school. These are not only in the affiliated hospitals, but also in teaching nursing homes, V.A. hospitals, and house calls. The thlrt year curriculum is set by the school. The fourth year is entirely elective, but is decided upon after close consultation with a faculty advisor. She school emphasizes amal1 group interactions between faculty and students, and including patients rather than blackboards or compueere. They also hire actors to simulate patlenes. The educational cost is about S4, 000 per student . This does not include the cost of resources for research, service, etc. Quality teaching is given a fair amount of emphasis. First of all, classes are kept small. First year classes have labs or discussion sessions with 20 students; second and third year classes have 4 or 5 students per faculty member; and fourth year electives are one on one. Furthermore, teaching ts one of the criteria for 322

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promotion and tenure. (Among the five categories of research, teaching, committee work, community service, and [for clinical faculty] care, two must be excellent and all must be satisfactory.) There also are awards for outstanding teachers. In Indianapolis, the Dean also is the Director of the Medical Center (and its hospitals) and the chairs of the major clinical departments in the medical schools are the chiefs of the departments in the hospitals. The department chairs report to an executive committee at each school, which reports to the Dean. All major departments also have a business manager reporting to the chair. (Nationwide, about 30 medical school deans also are the hospital directors. ~ As reported by the Dean, the faculty are quite happy at Indiana University. This is reflected in their low turnover rate (3 percent). They have outside support for their research, equipment requests that are met by the Dean, support to attend national and international meetings, and encouragement to be active in professional societies. The number of endowed chairs has increased from 3 to 39 in the last ten years. Television Network The medical school uses its television network for 1) continuing education at sites throughout the state, 2) patient education, and 3 ~ medical student instruction. They produce their own programs and broadcast programs produced elsewhere. The CME component is called Medical Television Network, and is picked up at 54 hospitals (in 26 cities), 3 clinics and 2 industrial sites statewide. Broadcast hours are 10:30 a.m.-2:30 p.m. and 6:00 p.m.-10:00 p.m., Monday through Friday. There is a special theme, e.g. mental health, which is emphasized in the programming for each four week block. There is the potential to reach 90 percent of the practicing physicians in the state. Estimates are that as many as 5,500 of the 6,600 physicians in the state actually take advantage of the universities' continuing medical education program (which prominently features the TV network, but is not limited to it). Home programming is geared to administrators as well. Some of the programs are live panel shows in which viewers can call in questions. The Patient Television Network broadcasts 20 hours per week. A health promotion/wellnese theme is planned for the future. At present, programs help patients interact with their physicians (e.g. how to answer questions) ant to deal with their disease. For medical student education, closed circuit systems are used in lecture rooms to provide clo~e-up views of demonstration materials. 323

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Other Observations . . I. The trend at Indiana University Medical Center has been toward more patients in general and those patients are older and have multiple problems (5-7 diagnoses now rather than the 2-3 of ten years ago). There also is a trend for the clinical faculty to put in more and more time seeing their own patients (as part of the practice plan) rather than teaching house staff. 2. Alumni donate about 33 million each year. Dr. Beering works at maintaining contact, e.g. by alumni receptions at all ma jor national medical meeting. 3. The statewide system, including schools and hospitals, is a half billion dollar operation. 4. The school no longer accepts junior college students, for the most part, because they are not thought mature enough. 5. Dr. Lukemeyer salt he would like to see a "real" premedical college program, including humanism and ethics. 6. They are trying to reverse the trend away from laboratory experience in the basic science years at medical school. 7. A grant has been obtained to provide all entering medical students with a "home" computer for their use in their room. 324

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Appendix D-3 SUMMARY OF VISITS TO BEN GI]RION UNIVERSITY CENTER FOR HEALTH SCIENCES AND HAr)ASSAH MEDICAL SCHOOL On December 6 and 7, 1982, Elena Nightinale, vice-chair of the committee, visited the Ben Gurion University Center for Health Sciences in Beer Sheva, Israel; on the 8th ant 9th, she met with several people at the Hadas~ah Medical School of Hebrew University in Jerusalem. The purposes of both visits were to obtain information f row these two schools on their current medical education programs; to obtain views of a variety of faculty members ant students on the content and quality of the educational program at the school; and to explore how those interviewed felt the program succeeded in preparing s tudents for careers in medicine in accordance with the goals of the particular schools. Major problems and issues of concern in medical education in Israel were also discussed. Elena Nightingale reported on the Institute of Medicine planning study on medical education in the United States and described some of the enamor concerns of the committee that were under consideration. The integration of planning for health manpower in the plan for education of physicians and other health professionals was also discussed. 1. Visit to the Ben Gurion University Center for the Health Sc fences . The School and the Center for Medical Education . The essential features of the school are described by Segall* and summarized in Chapter 5. The students, faculty, ant administrative staf f demonstrated deep commitment to the creation of an innovative, but lasting, institution. The dedication and commitment of all concerned was most impressive; however, there has been insufficient Dime to determine whether the program is a success. Only two classes have been graduated thus far, and even though approximately half the f irst class and perhaps a third of the second, have elected to remain in the Negev and to deliver primary care prior to further residency training, career choice after realdency will be important in assessing whe titer the goal of educating community-oriented, science baset ~ humanistic primary care physicians is being reached. An important feature of this medical school that is different from schools in the U. S. is its intimate relationship to the Kupat Hutim, the Seek fund of organized labor. This organization actually pays for most of the overhead, the buildings, ant the facilities at the medical school and is in direct competition with the Ministry of Health. They have mate some progress at the local level for working together, but this remains a ma jor problem, particularly because the Kupat Hulim is *Segall, A., M. Prywes, D.E. Benor, and 0. Susekind, University Center for Health Sciences, Ben Gurion University of the Beget, Beersheva, Israel: An Interim Perspective, Reprinted from Public Health Papers--70--World Health Organization, Geneva, Switzerland. 325

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responsible for all delivery of sick care, whereas the Ministry of Health is responsible for preventive care. Conceptually, it is difficult to separate the two in the delivery of primary care, the main goal of the medical school training program. The Center of Health Sciences of the Ben Gurion University of the Negev was founded by Dr. Moshe Prywes. He states thee the school is "the scene of the concerted effort to change the orientation of health care. The direction of change is away from the impersonal (the hospital and the disease ~ and towards that demanded by the public ~ the community and the person) . It is being accomplished by f undamentally changing the education of health personnel. Changes are being implemented and mediated by a coordinating consortium of in region and Ben Gurion University of the Negev care and/or welfare agencies that plans and evaluates the process and progress of change for which each agency is responsible . ' Dr. Prywes continues, "The university hospital is to serve the regional network of hospital affiliated community oriented primary care clinics. Curricular innovation uses the concept of the natural history of disease in basic science and clinical teaching. Teaching takes place, not only in the wards, but also in outpatient and primary care clinics and in the facilities for occupational health, rehabilitation, and public health."* This medical school is one of the first community oriented, primary care schools. In their worts, public health oriented community medicine is their first priority. The school aims to bring together medical care, medical education, and Helical research. Or. Prywes believes that government, the university, and society can work closely together, and that the main prescription for coexistence to that of a consortium, rather than of domination of one system by another. Much has been published about this medical school. It has been the focus of interest, both in Israel and abroad, and its graduates' careers will be closely followed. Dr. Moshe Prywes, the driving force behind the new metical school, has recently retired from being the dean and is now the director of the new Center for Medical Education. The Center for Medical Education was establishes to provide an organizational framework for a scientific study of methods, techniques, and tactics in medical education, particularly in the selection of students, in curriculum development, in program= evaluation, in student evaluation, teacher training, and profeselonal socialization of medical and paramedical students. The Center brings together members from Ben Gurion, as well as from other medical schools in Israel who are interested in its activities and wish to be a part of the Center. *Prywes, M. Community medicine. The "first-born. of a marriage between medical education ant medical care. In Health Policy ant Education 1, Elsevier Scientific Publishing Company, Amsterdam, The Netherlands, 1980. 326

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The Medical School of the Ben Gurion University was established in 1974 with the purpose of educating a new kind of physician. In Israel, medical manpower is a problem. There is a high doctor-to-population ratio, but many of the doctors were specialized, practiced solo, and many of the primary care practitioners came as immigrants from a variety of nations and with highly varied expertise and training. The purpose of this school was to educate doctors who would identify with community health problems, utilize community resources, and promote community health services. They were expected to be able to work with and to lead a multiprofessional health team and to possess those personal qualities that enables them to of fer their services while reflecting humane, considerate, and respectful attitudes towards their patient s . The Curriculum Ben Gurion, as well as the other three medical schools in Israel, have a seven year curriculum. lye Etest six years include subjects that here would be covered in the last two years of college, plus the basic sciences and clinical disciplines of our medical schools. The seventh year is an internship year, which must be completed before the doctor of medicine degree is awarded. Before medical school, students comple te the equivalent of our high school plus one year . They are eighteen years old at the time of graduation. Then, both boys and- girls enter military service--boys serve for three years and girls for twenty months. 1r is af ter military service is completed that the seven year medical school curriculum is begun. This is an important point in that both at Hatassah ant at Ben Gurion, the faculty interviewed were convinced that the tine spent in military service was crucial in developing maturity ant crystallizing what the young people wanted to to with their futures, and in providing an opportunity for them to relate to people and to provide service and act as members of teams, sometimes as leaders, sometimes as followers, and assume responsibility for themselves and for others. This enables faculty to have a better idea of the personal qualities of the applicants to medical school, and the students are more mature when they enter. About ten percent of medical students in larael enter prior to their military service. These are the people who were going to be doctors in the mliltary. These students, according to the faculties of both medical schools visited, do not do as well as their classmates who have completed military service. They apparently show more anxiety about examinations, are less well able to relate to patients, are more insecure, etc . This was interesting because the maturing process during military service is not one that we would wish to duplicate in the United States, but perhaps some analogue of service might be found for all applicants to medical school. National service would provide a time to mature as well as provide a proving ground for those personal qualities necessary for medicine. In the United States, most students are about 21 years old when they start medical school--aboue the age of Israeli students after their military service--but most students in the United States have spent the ir entire lives in an academic Butt log ;~,~.i 'padre not Id opportunities to work in service-related programs or assume much responsibility. 327

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The seven year curriculum includes clinical teaching from the f irst day of the f ire t year . The amount of clinical teaching increases in each year, whereas the amount of basic science decreases each year, but neither component of -medical education is eliminated to tally at any point during the training period . There is much emphasis on social studies and on behavioral sciences and on the public health aspects of medicine including social, socioeconomic, and ethnic cultural facets of health and disease. In talking to the various people on the faculty, there was total agreement that a primary goal is to teach students to learn on their own and to continue to be self-teachers for the rest of their lives. Another point on which there was agreement was that research and the science base for medicine are very important and are not second order priorities. Each student is required to do a research project prior to graduation. Many students elect to do pro jects in public health and epidemiology, either in the Beer Sheva Hospital or in some of the outlying communities. Many try to relate their research to the medical needs of the people that they hopefully will serve. The curriculum is called the "spiral" curriculum; the four components of this spiral, basic sciences, behavioral sciences, clinical medicine, and public health, f ore one integrated system' and all four parts are present at the outset ant continue together until the last year. The inter-tepartmental cooperation that is required seems to be obtainable at Ben Gurion as is the large amount of time spent in teaching by the faculty. Perhaps one of the factors that makes this spiral curriculum possible is that the class size is limited to 50. Therefore, teaching in small groups is much more practical than in those medical schools that have several hundred students per class. Another aspect of this school that is quite different from the schools in the U. S . is that there are no f inancial restrictions. Students do nor bear the cost of the medical education and neither does the medical school. It is largely paid for by the government and by the labor union's sick fund. Selection Process for Medical Students The most interesting feature of the Ben Gurion program is the selection process for medical students. High school graduates take an examination that is roughly equivalent to an IQ test. A cut off point comparable to that of most professional schools is determined. Beyond that, a passing grade of 80 or above is required on two of the f ive subjects in which achievement tests are given at the end of high school. For students who pass these two inn' ial screens (approximately 400 per year), the academic record is put aside ~ and selection is mate entirely on the basis of interviews. The interviews are conducted by four people, two of whom are not physicians. The two non-physicians may be nurses, social workers, psychologists, or people from the community. A basic assumption is that all candidates who reach the interview have the cognitive potential for successful study in the Ben Gurion Medical School. Interviewers look for nine major character- istics: personal integrity, empathy, a clear, stable self-identity, 328

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tolerance of ambiguity, decisiveness, insight, intellectual level, a community orientation, ant a sense of social responsibility. Pressure is exerted towards identifying these characteristics an they have manifested themselves in real life. What have you done?" is the concrete question, and not What do you believe ?" Af ter two rounds of interviews, the admissions committee makes the f inal selection. One consequence of this process is that some of the students who would not have a chance for admission to the traditional medical schools in Israel because of their academic records, do have a chance o f being admitted to Ben Gurion. Out of a total enrollment of 270 students, about 16 have to repeat the year, and 6 leave after 1 year. So far, Or. Prywes and the dean, Dr. Naggan, report that the graduates of Ben Gurion are doing well in their residencies, but only two classes have been graduated. The school is evaluating the graduates, the admissions procedures, and the total educational program. Some Issues in Education One question to be raised in whether the educational process at Ben Gurion produces a generally well-educatet person, and whether it is in f act important to be such to practice primary care . Teaching of the humanities is a problem because of the logistics of interacting with the rest of Ben Gurion University. Another question is whether there is fostering of an adequately intellectual environment at Ben Gurion and whether academic accomplishment is relevant to it. Most of the faculty felt that their educational program stimulates a love of learning; the concepts of self-learning and self-evaluation are major goals. lathe students are taught how to read scientific articles and how to evaluate their contents critically. Much of their education comes f ram readings in the original literature in addition to textbooks. Lectures are minimized as teaching devices, and small group discuselons are emphasized. In the words of Moshe Prywes, the key to medical education at Ben Gurion in relevancy and responsibility . The students are educated towards the goal of becoming change agents once they are in practice in the community. It is hopes that the quality of primary care in the Negev will be improved because of the presence of the graduates of the Beer Sheva school. There is a physician surplus in Israel, and the need for four and perhaps soon five medical schools in Israel is a question of interest to the committee. Dr. Naggan, who is now the teen of the Ben Gurion University Medical School, thought that it is almost impossible to plan or make projections for health manpower in Israel. In 1979, half of the physicians practicing in Israel were immigrants. Only one quarter were graduates of Israeli medical schools no that the medical schools in Israel influence only one quarter of the total health manpowe r . Another area of concern was the role of research in the medical school. Adequate research capability becomes a problem in the face of the heavy service and teaching loads for the faculty. Dr. Naggan 329

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tries to encourage research, but the lack of faculty time and the relatively small faculty are problems, so collaboration with researchers in other schools, and collaborations among the different basic science departments within the- school are encouraged to facilitate research. There is the probability of having to select areas for research strength, perhaps related to community health needs, rather than trying to have active research programs in a broad array of f ields. Faculty promotions are based on excellence in teaching and service, though research is encouraged. The need to create a place for research was viewed by some faculty members as a temporary disadvantage. Problems also emerge when a medical school takes the responsibility for delivery of health services and becomes not only a medical school, but the administrative home for organization of nursing, ancillary services, etc. 2. Vis it to the Hadassah Medical School of Hebrew University Elena Nightingale net wi th the head of the curriculum committee, Dr. Guttman, and with several other faculty members including the director of the student/teacher committee. The Hadassah Medical School is a traditional one patterned af ter German medical schools and the Johns Hopkins model. The selection of medical students pays strong attention to academic achievement and interviews are important, but less so than at Ben Gurion. There is a lot of competition for spaces in the Hadassah biedical School. Graduates do quite well in obtaining residency programs . The group at Hadassah was part icularly interested in the ma jar issues for study in the Institute of Medicine project. It became apparent that they are interested in very much the same issues and would welcome opportunities for greater interaction with the United States. They also are extremely concerned with the selection process for medical students and with the possibility of a mismatch between the selection and the education of doctors and future needs in health care. Dr. Ellensweig, who is also a member of the National Center for Public Health, is interested in conduct ing a study on the needs for health services for the Israeli population ant how to educate people to deliver these services. He ant Dr. Tulchinsky would be interested in a bipartite working conference of about 12 to IS participants to be held in Israel where issues of common concern with the U. S. could be discussed in depth. 330