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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
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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.
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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
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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
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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-
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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~.
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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
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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?
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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?
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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
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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.
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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 .
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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
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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.
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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.
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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.
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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.
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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.
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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,
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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
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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
Representative terms from entire chapter:
medical education
