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Appendix F TYPICAL PATTERN OF MEDICAL EDUCAT ION IN TB UNITED STATES Summary Prepared by Allyn M. Mortimer TV CONTI==G MEDIC EDUCATION 1 n l FOREIGN t1ED$nA, GRADUATES IS. and -IS. citizens attend - g medical school abroad) . III GRADUA" }SEDUCE EDUCATION - , ' 1 Ply PATENT! PRDGRA25S (I. S. citizens stteDd~g medical school abloom) EDUCATION 359 S PRICE E[)lOCATION

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I PREMEDICAL EDUCATION Tradit tonally f our years Awarded baccalaureate degree At graduation between 21-23 years old Most medical school applicants and entrants ma jored in one of the sciences as undergraduates, frequently in an area of biology or chemistry o Recommended college courses: natural and physical sciences, English, f o reign language, social sciences, mathematics o In 1981-82, 19 schools of fered accelerated programs that combined undergraduate and medical studies leading to the M. D. degree in six years or less. . 360

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11 MEDICAL EDUCAT ION Traditionally four years (148 weeks, excluding vacations) Awarded M. O. degree At graduation between 25-27 years old Range of expenses for f irst year students, 1980-81: private schools tuft ion/f ees other public schools tui t ion/ f ees tuition/fees other 32, 863-$14, 85S 2,400- 9,475 487- 5,665 (resident) 1, 087- 26 ~ 321 (nonresident 3,000- 8,000 Mean education debt of graduating seniors - $18, 102 1982: tuition range up to 319, OOO/year (George Washington University ~ o 1980-81 applicants-acceptance ratio, 2 ~ 1 o Total enrollment in 126 medical schools, 1980-81 - 65, 497 o First year students - 17, 204 (2SZ women, 14Z minorities) o Full-time faculty-stutent ratio: preclinical ~ 4.9: 1 (1979-80) cl inical - 1. 7: 1 ( 197 9-80 ~ M. D. curriculum: 2 years basic sciences; 2 years clinical experience (patient care), including 5-12 week clerkships in internal medicine, surgery, obstetrics-gynecology, pediatrics, psychiatry, ant others (family medicine, etch. Final year, average of 16 weeks required clerkships and courses; 25 weeks devoted to elective courses, clerk- ships ~ or both. Use of national boards for student evaluation: 58 schools required students to pass Part I of examination at end of basic science sequence.; 47 schools require Pare II, testing clinical knowledge, to be pasted to graduate. 0 1981-82, 94 schools offered combined M.D./Ph.D. degree o In 1973 as many as 19 U. S. medical schools had 3 year M.D. programs; by 1981-82, only 2 U. S. medical schools have a regular 3 year program; 14 schools have an optional 3 year program. 361

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III GRADUATE MEDICAL EDUCATION (GME:) Years of residency training vary with choice of specialty. Standard sequence def ined by board eligibility requirements in each specialty. Usually from 3-7 years in training. Medical specialty boards certify physicians who have completed required GME and passed certificate examinations (23 specialty boards). Nationwide mean resident stipends (1979-80~: 1st year post-M.D. = 314,811 2nd year post-M.~. ~ 15,832 3rd year post-M.D. ~ 16,749 4th year post-~.D. - 17,626 5eh year post-M.~. - 1B,495 6th year post-~.D. ~ 19,494 In 1980-81, 22: women, 4.9Z blacks, and 19.8: foreign medical graduates (40: U. S . citizens ~ were in residency positions in U. S. accredited training programs. 1S,535 first post-graduate year positions offered, 1981-82; number decreased to 17, 602 in 1982-83. O In 1980-81, 51% of residents being trained in primary care: internal medicine (440 programs), family practice (380 programs), pediatrics (249 programed, obstetrics-gynecology (30S programs). July 1980, 4, 588 accredited residency programs. O Programs tended to be located in highly populated regions of the country (1/4 located in Hiddle-Atlantic region). Institutions involved in GME: hospitals (l,414~; ambulatory clinics state medical examiner' ~ of f ices; blood banks; mental health agencies. In 1979, 93X of U. S. medical school graduates responding to AAMC survey declared their intent to become certif let by a specialty board . 75% of all U. S. physicians licensed through National Board of Medical Examiners; 25: licensed through FLEX ~ Federation Licensing Examination) promoted by the Federation of State Medical Boards. (License to practice medicine vested in states; upon graduation from accredited medical school or upon completion of one year graduate training, licensing laws and regulations permit licensing . 362

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ALTERNATE PATHWAYS TO GRADUATE MEDICAL EDUCATION FORE IGN MEDICAL GRADUATES To obtain certif icate to participate in U. S . graduate medical education programs, gradua te has to: fulf ill requirements for licensure in country where school is located, and pass Education Commission for Foreign Medical Graduates exam. The number of foreign medical graduates in residency training in U. S. decreasing during the pant several yearn. In 1980, 19.8X of residents were foreign medical graduates compared to 24.5: in 1977. The number of foreign medical graduates who are U.S. citizens increased from 4,229 (35X) in 1979 to 4,790 (39.61) in 1980. FIFTH PATHWAY PROGRAMS Provides clinical experience to U. S. students of certain foreign medical schools who have completed premedical education in the United States and have completed all but the internship year or social service components, or both, of the foreign metical education. Training includes courses and rotations through 5 to 6 clinical services. Students are required to pass an examination designated by medical school offering year of supervised clinical training. For 1980-81 academic year, 2,850 applicants for fifth pathway clerkships received by medical schools; 616 accepted;~541 enrolled; and 468 successfully completed program. 363

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IV CONTINUING MEDICAL EDUCATION (CME) Purpose: to help physicians maintain and update knowledge and skills used to practice medicine. There are 26 states and territories with legislation concerning CME requirements for reregistration of the license to practice medicine Twenty states have written regulations and a program in operation. AMA Publishes course list in J. AMA annually (medical societies, voluntary health agencies, medical schools, hospitals, and other institutions and organizations provide CME courses). Physician's Recognition Award given by AMA: purpose to encourage physicians to engage in CME and to provide recognition to those who do: in 1981, 103,342 physicians held valid Physician's Recognition Award certificates (150 hours of CME needed to qualify). Estimated $500 million spent on CME annually by U.S. physicians, medical schools, hospitals, medical societies, industry, and government . ~ In 197 7, cost of CME to participant per day between $26-650~. Physician's gross income (net income plus practice expenses) in 1980 - $135,300; in 1970 - 666,100. 364 .

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SOURCES: Lewin, L. S . and Derzon, ~ ~A. Health professions education: State responsibilities under the new federalism Health Af fairs l: 69-85, 1982. Ebert ~ R.H. Ref lections on academic health centers ~ prepared for the National Academy of Sciences, 1982. 81st Annual Report on Medical Education in the U. S. 1980-81. JAMA 246:2911-2988, 1981. Graduate medical education: Proposals for the eighties. J. Med. Ed. 56: (part 2), 1981. U. S. Department of Health and Human Services. Third Report to the President and Congress on the Status of Health Professions Personnel in the United States DHHS . Publication No. (BRA) 82-2. Washington DC: U. S. Government Printing Of f ice, 1982. Glandon, G.L. and Werner, J.L. Physicians' practice experience during the decade of the 1970s. J. AMA 244: 2514-2518, 1980. Medical School Admission Requirements 1982-83. Washington Association of American Medical Colleges, 1981. 365

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