Part I.
Introduction

Archival information, including three program evaluations conducted by outside consultants, case studies, directories, and minutes, were collected, synthesized, and summarized. These many and varied sources of information came together to tell a most provoking and stimulating story.

The idea of writing about the legacy and experiences of the Pew Health Policy Fellowship Programs was first articulated several years ago by the Pew Health Policy Program Advisory Board. Under the direction of Marion Ein Lewin, the Program Office began negotiating with outside consultants and writers. Logistical difficulties postponed the production for several years, and it was not until August 1995 that the project took off. It was at that time that the process of gathering information about the various Pew Health Policy Fellowship Programs began.

Over the next year, 25 telephone and focused, in-depth, face-to-face interviews with key individuals were conducted to enlarge the range of perspectives (see Appendix A), roundtable discussions and focus groups were held at a November 1995 Pew Networking Dinner at the institute of Medicine in Washington, D.C. and at the Association for Health Services Research (AHSR) annual meeting in Atlanta in June 1996, and the manuscript was circulated among several program directors and alumni for feedback. Detailed archival information, including three program evaluations conducted by outside consultants, case studies, directories, and minutes, were collected, synthesized, and summarized. Ultimately, these many and varied sources of information came together to tell a most provoking and stimulating story.

The Program Office, in consultation with the program directors, envisioned—and ultimately produced—a report that would capture some of the history of the Pew Health Policy Fellowship Programs, include the curriculum from each of the program sites, and report on interviews with program directors regarding specific issues. Questions included the following: How had the programs evolved over time? What lessons and insights have been learned? How were the program directors able to make an innovative and often unconventional training program work within the traditional academic environment? The report was also to include



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The Lessons and The Legacy of the Pew Health Policy Program Part I. Introduction Archival information, including three program evaluations conducted by outside consultants, case studies, directories, and minutes, were collected, synthesized, and summarized. These many and varied sources of information came together to tell a most provoking and stimulating story. The idea of writing about the legacy and experiences of the Pew Health Policy Fellowship Programs was first articulated several years ago by the Pew Health Policy Program Advisory Board. Under the direction of Marion Ein Lewin, the Program Office began negotiating with outside consultants and writers. Logistical difficulties postponed the production for several years, and it was not until August 1995 that the project took off. It was at that time that the process of gathering information about the various Pew Health Policy Fellowship Programs began. Over the next year, 25 telephone and focused, in-depth, face-to-face interviews with key individuals were conducted to enlarge the range of perspectives (see Appendix A), roundtable discussions and focus groups were held at a November 1995 Pew Networking Dinner at the institute of Medicine in Washington, D.C. and at the Association for Health Services Research (AHSR) annual meeting in Atlanta in June 1996, and the manuscript was circulated among several program directors and alumni for feedback. Detailed archival information, including three program evaluations conducted by outside consultants, case studies, directories, and minutes, were collected, synthesized, and summarized. Ultimately, these many and varied sources of information came together to tell a most provoking and stimulating story. The Program Office, in consultation with the program directors, envisioned—and ultimately produced—a report that would capture some of the history of the Pew Health Policy Fellowship Programs, include the curriculum from each of the program sites, and report on interviews with program directors regarding specific issues. Questions included the following: How had the programs evolved over time? What lessons and insights have been learned? How were the program directors able to make an innovative and often unconventional training program work within the traditional academic environment? The report was also to include

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The Lessons and The Legacy of the Pew Health Policy Program The Pew Health Policy Program was the first Trusts-initiated program, and it represented Pew's desire to play a more active role in the programs that it sponsored. interviews with fellows and alumni sharing their experiences in pursuing midcareer, fast-track doctorate and postdoctorate education. In describing the field, the report would illustrate the importance of health services and health policy research and the role that the Pew Health Policy Program (PHPP) has played in this arena, as well as in the areas of leadership training and health policy development. Finally, the report was to describe the next generation of such programs and how and where they might be developed and funded. A report such as this was deemed important because the PHPP experience was an especially rich one due to the various formats of graduate training in health policy that the program helped to develop. The original thinkers hypothesized that differentiating between these programs would help guide future programs and identify aspects that were replicable and transferable. THE BIRTH OF THE PEW HEALTH POLICY PROGRAM By 1994, the Pew Charitable Trusts had eight signature scholarship programs. The Pew Health Policy Program (PHPP) was the oldest of the eight programs and the first with a national scope.1 In many ways PHPP, which was established in 1982 and which selected its first fellows in 1983, was a crucial experiment for the Pew Charitable Trusts, because, until the establishment of PHPP, Pew grants had predominantly been distributed in Pennsylvania. When PHPP was designed, the operating philosophy of the Pew Charitable Trusts was strikingly different from what it had been during the development of earlier signature fellowship programs. PHPP was the first Trusts-initiated program, and it represented Pew's desire to play a more active role in the programs that it sponsored. The Pew Charitable Trusts developed their own programmatic initiatives and, together with the institutions selected to run the programs, helped to shape the process (Hamilton, 1995). Traditionally, the Pew Charitable Trusts had focused on supporting the ''bricks and mortar'' endeavors in health and education. Rapid growth, however, in both the assets and the interests of the Pew Charitable Trusts during the 1970s, combined with significant changes in the nation's health care delivery, research, and funding systems, influenced the Pew Charitable Trusts to change their focus toward program building and human development. With the establishment of PHPP, Pew aimed to enrich the content of a subject area that was suffering from limited academic recognition and 1   The seven other signature scholarship programs were: The Pew Scholars Program in the Biomedical Sciences/Latin American Fellows; Pew Fellowships in the Arts; Pew National Arts Journalism Program; Pew Economic Freedom Fellowships; Pew Global Security Initiative; Pew Evangelical Scholars; and Pew Scholars in Conservation and the Environment.

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The Lessons and The Legacy of the Pew Health Policy Program student interest. PHPP was created to stimulate the development of the nation's health policy through the development of multidisciplinary educational programs that would prepare fellows for leadership roles in health policy. PHPP was created to stimulate the development of the nation's health policy through the development of multidisciplinary educational programs that would prepare follows for leadership roles in health policy. The Pew Charitable Trusts invited a Health Advisory Group of nine experts in health care to assist them in developing their programmatic initiatives. Eight members of this advisory group were academicians, and the ninth person was a physician representing the foundation community (see Table 1). The Health Advisory Group recommended that Pew sponsor one to three programs in health policy and suggested the incorporation of several different educational models (i.e., master's degree programs, doctoral programs, and combined on-job/on-campus doctoral programs). The development strategy included assembling several consultants who would be charged with designing a request for proposal (RFP), selecting the appropriate institutions to receive the RFP, reviewing the responses and recommending the best institutions proposing the best programs, and developing a strategy to evaluate the programs (Hamilton, 1995). Table 1. Health Advisory Group Membership, The Pew Charitable Trusts, 1980 Robert W. Berliner, M.D. Yale University School of Medicine New Haven, Connecticut Hilary Koprowski, M.D. Director Wistar Institute of Anatomy and Biology Philadelphia, Pennsylvania Thomas W. Langfitt, M.D. Vice President of Health Affairs University of Pennsylvania Philadelphia, Pennsylvania Irving M. London, M.D. Harvard-MIT Program for Health Science and Technology Cambridge, Massachusetts Vernon B. Mountcastle, M.D. Director Department of Physiology Johns Hopkins University School of Medicine Baltimore, Maryland Ray D. Owen, Ph.D. Vice President, Student Affairs and Dean of Students Division of Biology California Institute of Technology Pasadena, California Frederick C. Robbins, M.D. Office of the Dean School of Medicine Case Western Reserve University Cleveland, Ohio Timothy R. Talbot, Jr., M.D. President Fox Chase Cancer Center Philadelphia, Pennsylvania Kerr L. White, M.D. Deputy Director Director of Health Sciences The Rockefeller Foundation New York, New York

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The Lessons and The Legacy of the Pew Health Policy Program Ultimately, 15 academic institutions with health centers and four nonacademic health centers that were conducting high-quality programs in health policy-related areas were selected to receive the RFP. All 19 organizations sent proposals. Four university programs, each of which proposed a unique educational model, and one nonacademic center-based site providing independent programming and support services to the university sites received funding. The proposals from the institutions selected to receive funding are briefly described here. RAND Corporation/University of California at Los Angeles (RAND/UCLA) Four university programs, each of which proposed a unique educational model, and one nonacademic center-based site providing independent programming and support services to the university sites received funding. RAND and UCLA proposed a jnt venture in the Los Angeles area. The proposal contained three components: the Health Policy Fellowship Program, a 3-year interdisciplinary program leading to a PhD in policy analysis at RAND or the PhD in health policy at UCLA; the Policy Career Development Program, a 1-year nondegree program aimed at improving the individual's ability to critically evaluate health policy studies and to collaborate knowledgeably with professionals from varied disciplines; and the Medical Student Policy Seminar, a 10-session lecture and discussion series designed to introduce medical students to health policy issues early in their training. Boston University/Brandeis University (BU/Brandeis) Boston University and Brandeis also proposed a joint venture. The proposal contained three specific elements: the Pew Scholars Program, an intensive 2-year, post-master's, multidisciplinary program leading to a PhD in health policy, offered at both universities; the Pew Fellows Program, which included a 2-year seminar program to raise the level of health resource management skills of upper-level corporate and government managers (called senior fellows), and a 2- to 3-year commitment of selected midcareer-level corporate staff to focus on improving access to health care services through the implementation of cost-containment strategies within selected communities (called mid-level fellows). University of California San Francisco (UCSF) UCSF proposed a two-component program designed to meet needs at various levels. The first component was the

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The Lessons and The Legacy of the Pew Health Policy Program Pew Health Policy Research Program, which offered two distinct programs: a 2-year postdoctoral fellowship aimed at augmenting research skills, particularly methodological and statistical skills, and improving the fellows' ability to work effectively in both large and small interdisciplinary research studies requiring significant cooperation, and a 2-year pre-doctoral fellowship providing broader exposure to health policy issues in a multidisciplinary environment and encouraging research on health policy-related topics that would result in a dissertation. The second component was the Pew Health Policy Management Program, offering a 2-year term of diverse management experiences in hospitals, the School of Medicine, and other UCSF professional schools and participation in the Health Policy Research Seminar. University of Michigan The University of Michigan proposed a 2- to 3-year, nonresidential on-job/on-campus doctoral program providing 20 4-day sessions and two 4-week sessions for health services policy makers and administrators and offering doctoral-level training without requiring fellows to leave their current employment for extended periods of time. The program was to be housed in the School of Public Health, and those participants who completed the program received a doctorate in public health. American Enterprise Institute (AEI) Over time, various changes took places. The American Enterprise Institute provided a two-component effort designed to support the basic aims of PHPP: (1) a program for state officials offering nine seminars over a 2-year period focusing on new cost-containment strategies for state and local governments and (2) semiannual 3-day seminars for fellows and faculty from the four university-based programs to expose fellows to policy leaders on national and regional levels. Changes to the Programs The programs are described as they were originally designed during the period of initial funding. Over time, various changes took place. For example, one entire program (RAND/UCLA) was not refunded after the program's first 11 years; however, fellows matriculating in the Fall of 1990 were funded through July 1993. (As will be discussed further,

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The Lessons and The Legacy of the Pew Health Policy Program Three evaluations contracted out first in 1985, then in 1990, and finally in 1995 guided the evolution of PHPP. the RAND program continued to thrive past the termination of Pew funding.) Boston University, one of the partner institutions at the BU/Brandeis site dropped out at the same point. The site and administration of the program office also changed after 5 years. Finally, some programmatic elements at each site were either dropped or became self-financed.2 VAGUE GOALS THAT ALLOWED FOR REFLECTIVE ORGANIZATIONAL LEARNING The purpose of PHPP was clear: To stimulate the development of multidisciplinary health policy education programs that will equip a cadre of leaders with the required skills to deal effectively with the nation's complex current and future health policy issues. In spite of this clear purpose, a review of the available archives and discussion records reveals an absence of performance measures or benchmarks to gauge the progress or success of PHPP. Although the goals and objectives were not explicit, three evaluations contracted out first in 1985, then in 1990, and finally in 1995 guided the evolution of PHPP. The data obtained from the comprehensive and instructive evaluations by William Richardson (1985, 1990) and Ed Hamilton (1995) formed the foundation for this report. Eight performance indicators used in those evaluations greatly influenced the progress and development of the individual programs: The interdisciplinary strength of the curricula The richness of the health policy-related research and policy analysis environments accessible to fellows The existence of a nurturing orientation and structured mentoring function and the quality of the fellows The impact of the program on local, state, and national scenes The degree to which Pew funding has had a capacity-building influence within the universities housing the programs The ability of the fellows to routinely secure appointment to appropriate health professional positions having a significant health policy content The impact of the fellowship experience on the fellow's career paths The degree to which grantees' programs complement rather than duplicate each other 2    The evolution of the programs will be described in further detail in Part II.

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The Lessons and The Legacy of the Pew Health Policy Program To decipher the legacy of PHPP, the programs will be examined on each of these levels. A few other factors found to play critical roles in the successful growth and development of these programs are also described. HISTORY AND ORIGINS OF DEVELOPMENT PHPP was established in response to several challenging environmental needs. First, the nation's health care system was becoming increasingly competitive, complex, customer focused, and community oriented, generating the need for an ever larger pool of highly qualified health policy professionals. Second, Pew realized that the key players at the forefront of resolving and reshaping the future of the U.S. health care system would need to represent a spectrum of disciplines and perspectives. Pew realized that the key players at the forefront of resolving and reshaping the future of the U.S. health care system would need to represent a spectrum of disciplines and perspectives. The objective of the program was to develop and support a unique program of advanced training and education in health policy that would attract talented young and midcareer professionals interested in preparing for leadership roles in policy development at the highest levels of government and industry. The program envisioned that these future health policy leaders would come from a variety of disciplines—including medicine, public health, other health professions, law, management, social sciences, economics, and political science—but that all would benefit from multidisciplinary training in policy research and analysis, hands-on-experience, and management. Multidisciplinary learning would ideally enable the Pew fellows to function in the world of health policy with an ability to work not only with each other but with professionals from many fields. It was further envisioned that these programs should be formulated in a way that would support and supplement the advanced health policy training and education activities that were being undertaken at various universities and institutes, building on existing efforts at a few selected institutions of excellence. The request for proposals was not prescriptive regarding the type of educational experience to be provided or its format, content, length, or cost. It did, however, indicate that programs should draw from the perspectives of a variety of disciplines. As Stuart Altman of Brandeis University recalled: If you go back to the very beginning, one of the things that was very impressive and very unique about the original solicitation, that I have never seen before and have never seen since, was the fact that a small group of advisers to Pew said that there are

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The Lessons and The Legacy of the Pew Health Policy Program important issues that are likely to develop in health care over the next few years, rather than the foundation saying what they are. Therefore, the small group of institutions that were selected to train people were allowed to (a) indicate what they believe[d] [were]going to be some of the major health care problems that this country would face over the next decade and (b) how they could design a training program to help individuals meet those needs. Granting the individual universities the creative freedom to create programs that best fit their institutions and their perspectives resulted in several very different kinds of training centers and a rich diversity of health policy professionals. The program evaluations were subsequently used to tighten and improve the programs. Today, PHPP fellows have been able to take leadership positions throughout the health care system at strategic levels and locations. The incredibly broad scope of PHPP fellows has elevated their influence, impact, and effectiveness as policy engineers and change agents. PROGRAM DESCRIPTIONS University of California at San Francisco Granting the individual universities the creative freedom to create programs that best fit their institutions and their perspectives resulted in several very different kinds of training centers and a rich diversity of health policy professionals. The UCSF program, jointly sponsored by the university's Institute for Health Policy Studies in the School of Medicine and the Institute for Health and Aging in the School of Nursing, initially offered three types of 2-year fellowships: predoctoral, postdoctoral, and management. Following the first 5-year funding cycle, however, predoctoral and management fellowships were discontinued in favor of strengthening the postdoctoral program. At the same time, the postdoctoral program was expanded to include some midcareer fellows, people who entered the program from an employment setting as opposed to postdoctoral fellows who entered the program directly from a graduate degree program or residency. The program was made more flexible so that 1-year and part-time fellowships could also be offered. Part-time fellowships were typically for 20 to 40 percent of a full-time fellowship for a period of 2 years. The program offers multidisciplinary training in applied collaborative health services and health policy research through apprenticeship models. Fellows learn to think broadly and work collaboratively with people from a variety of disciplines and then develop a base of skills that can be applied to health policy issues at various levels of government and in the private sector. The faculty from the two institutes serve as teachers, mentors, and research preceptors

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The Lessons and The Legacy of the Pew Health Policy Program to the fellows. Additional faculty are drawn from other departments and units at UCSF. The incredibly broad scope of PHPP follows has elevated their influence, impact, and effectiveness as policy engineers and change agents. From its inception, the UCSF Pew fellowship program has been unique in that it is housed in and cosponsored by organized research units (ORUs) of the university rather than departments: the Institute for Health Policy Studies and the Institute for Health and Aging. The ORUs are designed to facilitate cross-departmental and cross-school research, but they do not have formal teaching responsibilities or sponsor degree programs. Furthermore, the majority of the faculty in these two ORUs are supported entirely by outside grants and contracts. The two Institutes have more than 65 faculty, and fellows have the opportunity to work directly with policy analysts and researchers from a wide range of disciplines and interests on a large number of important projects. The interdisciplinary nature of these institutes also makes their position unique. Both settings draw upon faculty from a wide range of disciplines, including sociology, economics, psychology, political science, medicine, nursing, pharmacy, dentistry, law, public health, and bioscience. The role of key people in the development and evolution of the UCSF postdoctoral program cannot be overstated. In particular, the role of its founder, Phil Lee, as program champion is widely acknowledged, as cited by Hal Luft: Phil Lee's commitment to training, to doing health policy and health policy research, and incorporating a wide range of people with different backgrounds and expertise was crucial [to the development of the UCSF program].... Many of the faculty come out of a multidisciplinary background and believe that good integrative health policy research and policy analysis is something that is valued and good to do, and this gave us an opportunity, in a sense, to reproduce. The development of the UCSF doctoral program was based on a strongly held belief that excellent health services research can often be better accomplished through a team effort involving people of different backgrounds who understand each other's assumptions and perspectives on the world. Thus, the program was designed as a model in which social scientists would learn to work with health professionals and health professionals would learn to work with social scientists. If physicians or other health professionals really wanted extensive research skills, they were encouraged to enroll in a master's of public health or doctoral program. At UCSF, there was no preexisting set of courses to serve as a basis for the program. There were excellent, but

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The Lessons and The Legacy of the Pew Health Policy Program small, programs in sociology, medical anthropology, and health psychology, but there was little institutional support for a new PhD program in health policy on this campus, nor did the faculty think that such a program should be developed. Instead, they supported a "learning by doing" model, widely used in both the medical and nursing schools at UCSF, that enabled the fellows to gain facility with the methodology needed to conduct sound, policy-relevant research. The course work and hands-on research experience resulted in the development of an effective network for fellows that included academicians, health professionals, and policy makers (UCSF Report, 1994). At UCSF, there was no preexisting set of courses to serve as a basis for the program. Instead, they supported a "learning by doing" model, widely used in both the medical and nursing schools at UCSF. In an effort to make the Pew Health Policy Program at UCSF self-sufficient, its faculty implemented major steps toward institutionalizing the training approach. A series of new formal courses has been developed, and the curriculum has been greatly enriched. The issues surrounding the difficulties of institutionalizing the fellowship program without financial support will be discussed later. However, UCSF has made a commitment to exploring new avenues of funding. Faculty have worked collaboratively to identify new funding sources and have been quite successful (UCSF Report, 1994). University of Michigan At the University of Michigan, another new and innovative advanced training model emerged. A nontraditional, nonresidential Pew health policy doctoral (DrPH) program was created. The program has been sponsored by the Department of Health Services Management and Policy in the School of Public Health at the University of Michigan. Every 2 years, the program selects approximately 10 to 15 health policy makers from across the nation. These Pew fellows hold graduate degrees or the equivalent in public health, medicine, law, or business and have at least 5 years of experience in health policy positions. The PHPP at Michigan was designed for individuals who were seeking doctoral-level education to enhance their ability to function in the health policy arena. The program is offered in an on-job/on-campus (OJ/OC) format, which allows the doctoral students to continue working full time while pursuing their degree. The OJ/OC format was initiated at the University of Michigan in the early 1970s and has been extremely successful. It began as a single master's program in health services administration and has evolved into a total of seven different graduate-level programs at the

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The Lessons and The Legacy of the Pew Health Policy Program School of Public Health (Michigan Report, 1994). John Griffith stated that although Michigan had experimented with this type of nonresidential training before PHPP, the real challenge was transferring it to the doctoral level. Bill Weissert explains how Michigan met and continues to meet the challenge: We had an innovation here that dates back 25 years, which is this midcareer weekend program where people come in and take 2 years of the same courses. That was a proven idea that worked and cranked a huge number of people out into the health management community. So, we extended that to the health policy community with this [doctoral] program. And, I think it's a good idea. And, it gets better every year. That's how it developed. It was basically an incremental change over a proven program that was and is unique in the country. It was innovative at the time and continues to be innovative. The work experiences brought to the classroom by the students provide a unique opportunity to integrate both the theoretical and practical sides of policy. Participants meet once each month for a 4-day weekend session in Ann Arbor. The weekend comprises 30 hours of classroom work, and the fellows are expected to spend an additional 20 to 25 hours on independent work between monthly sessions. During the third year of the program the students meet for three weekend sessions, scheduled several months apart, as part of a series of activities and services designed to support their work on the dissertation. Added to the responsibilities of a full-time job, the Michigan full-time doctoral program offers an intense experience that only very carefully selected students are able to sustain for the full 2 years of course work plus 2 to 3 years spent on the dissertation. At the same time, however, the work experiences brought to the classroom by the students provide a unique opportunity to integrate both the theoretical and practical sides of policy. The OJ/OC format complements the DrPH's practitioner orientation quite well. It does not require students to leave the world of practice and action to acquire skills that are ultimately meant for that world. This contrasts with the traditional PhD programs, whose principal aim is to prepare future teachers and researchers and whose students therefore benefit from being immersed full time in the academic and research environment for which they are being prepared (Michigan Report, 1994). RAND/University of California at Los Angeles The RAND/UCLA program evolved out of a long-term relationship between the University of California at Los Angeles and the RAND Graduate School of Policy Studies.

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The Lessons and The Legacy of the Pew Health Policy Program One of the major challenges faced by the RAND/UCLA program, like most multidisciplinary programs, was how not to include the whole world of health policy in the curriculum. sion, One of the major challenges faced by the RAND/UCLA program, like most multidisciplinary programs, was how not to include the whole world of health policy in the curriculum. and we deal with everything from the NIH process of awarding grants to drug regulation. The one on health care has modules that deal with the hospital side and now the managed care side. That has worked well. Another thing that was unique (and one never knows just how unique one's own program is, as you only hear about the others) was that the exercises were in the form of short policy exercises: a short policy memo, a presentation, etc., all oriented toward current problems which captures the fellows.... The workshop model was a modification of part of the curriculum at the RAND Graduate School. It's oriented toward health and has become more stylized. That basic model was there, and what we tried to do was to apply it to health policy programs. Student integration at RAND was strong, and Al Williams attributed this in part to the fact that the workshops were open to people outside the Pew program. Integrating Pew and non-Pew fellows in the workshops led to a more diverse student body that enriched class discussions. Al Williams attributes much of the success in bringing students together to the integrated seminars and the small size of the RAND program. One of the major challenges faced by the RAND/UCLA program, like most multidisciplinary programs, was how not to include the whole world of health policy in the curriculum. Kate Korman elaborated on this point: Initially, the curriculum was pretty enthusiastic, far-reaching, even overreaching. One course was eliminated after 2 years because it was just too much. The students couldn't learn everything. This was challenging, because as parts of courses or whole courses were cut out or restructured, some faculty found their role changed. However, the program design was much too ambitious in the beginning. Yet, RAND continued to try and reach the whole multifaceted world of health policy by bringing in guest speakers for regular colloquia. This way the students were able to get some exposure to all areas of health policy. This technique was used, in various ways, by all of the PHPP and was cited as a great strength. According to the Richardson (1990) evaluation, the UCLA program was weakened over time because of the loss of several senior faculty. This point, however, did not come out in the recent interviews (see Appendix A). Richardson (1990) reported that despite the rich mix of research projects at RAND and UCLA, students expressed concern about their inability to gain access to a research project that was compatible with their own interests and professional goals, and complaints about the lack of access to faculty mentors grew over

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The Lessons and The Legacy of the Pew Health Policy Program time. In Richardson's (1990) evaluation, fragmentation was listed as a major weakness, existing as a result of the difficulty of matching a diverse mix of students with faculty or projects that reflected each fellow's interests. On the contrary, Kate Korman rated the relationships between faculty and students as one of the long-run strengths of the program, and explained that the collaborative student-faculty research projects led to close relationships: Over time very strong bonds were created between faculty and students, since the students were not just faces in the classroom but integral members of research teams with faculty team leaders.... There was a lot of camaraderie, and our faculty showed up for every award ceremony or whatever.... Lots of support. Furthermore, Joan DaVanzo, a RAND/UCLA doctoral alumna who started out at RAND and then graduated from UCLA, cited the work project requirements as a bonding experience between the fellows and the faculty: Working on the projects allows you to get to know the professors in a different way. As a student you know a professor is a professor and you are both locked into that role, then you're thrown on a project with a professor and all of a sudden they are more collegial. You're not just one of the graduate students anymore. You have access to them in a different way. Being able to switch the role is very important when you are a student. Like Joan DaVanzo, several other RAND doctoral fellows started out at one of the two jointly sponsored institutions and then switched over to the other institution to complete the degree. This flexibility was cited as one of the most innovative and unique aspects of the program. DaVanzo described RAND as supplying the necessary depth in quantitative skills and economics, with UCLA providing the equally necessary breadth in health, epidemiology, and public health: ''The combination was invaluable," she said. RAND supplied the necessary depth in quantitative skills and economics and UCLA provided the equally necessary breadth in health, epidemiology, and public health: The combination was invaluable. Terry Hammons, a RAND alumnus considered the work projects a great strength of the midcareer program for another reason: the reality focus. This concept comes up again and again with the Pew fellows, whether they are doctoral, postdoctoral or midcareer fellows. To most, PHPP was fully representative of the health policy world, with health policy leaders teaching in a relevant, timely, and applicable manner. Hammons explained that the workshops and seminars were always structured in the context of real-world application: The second part of our program was working on real projects, and I thought in contrast to my experience in graduate school, for example, these workshops and seminars were more effective

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The Lessons and The Legacy of the Pew Health Policy Program than traditional graduate education (I did economics at MIT [Massachusetts Institute of Technology]). Most important were the projects. I was fortunate enough to be involved in four and a half really wonderful projects during the year I was there. They were real projects, such as helping DHHS [U.S. Department of Health and Human Services] understand what academic medical centers were going through and how to make policy that related to graduate medical education, research and training, and so forth and that was appropriate for the nation's goals but that took into account what academic medical centers could do and were doing. Kathleen Eyre, another RAND midcareer alumna, underscored Hammons' emphasis on the value of being able to apply newly learned skills to specific on-the-job projects. She also considered the work projects to be a great strength of the RAND midcareer program. However, she would have liked to have seen more general discussions of the big-picture health policy issues. She explains that there was a lack of regular, organized, high-level discussions on, for instance, health reform, which was the hot topic of the time: We just didn't have opportunities to take cuts at the big picture. That's the major criticism I would have of the midcareer program. I don't know if it was because of time constraints. I think some of it was that and some of it was that the focus was one giving you your basic skills. That was the most useful part of the program. I think being able to put that in context would have been useful as well. The tension between breadth and depth is not uncommon in fast-paced multidisciplinary programs, and because it was cited by most PHPP directors and fellows, this tension is probed further, later in the report. University of California at San Francisco The tension between breadth and depth is not uncommon in fast-paced multidisciplinary programs. The UCSF program's shift to a postdoctoral focus was based on a desire to take advantage of the interaction among several groups of advanced doctoral and postdoctoral students (Pew fellows and others) at UCSF and to contribute to that interaction (Richardson, 1990). This fellow-fellow and fellow-faculty interaction was nurtured throughout the fellowship and was considered a great strength of the program. Hal Luft discussed how the process of integrating Pew fellows among all students was facilitated by the flexibility of Pew funding. He stressed the importance of treating all fellows (Pew fellows and others) equally. Equality among the students fostered integration and collaboration, whereas separation would have led to a divisive elitism.

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The Lessons and The Legacy of the Pew Health Policy Program [There was] a conscious strategy of using Pew funds to supplement other fellowship funds so we [had] people who were fully funded by Pew and others who basically got $1,000 all mixed together in the same classes. We did not ... establish a pecking order. We set a standard for fellowship applicants and said this is what all our applicants have to meet, and then once they were in that acceptable pool, who we give what kinds of dollars to out of what pot will partly depend on the constraints of the pot.... Everybody is on equal footing. That integration worked very well. Cross-fertilization Of individuals who had worked in the policy arena and other health care professionals is what the Pew Charitable Trusts hoped to accomplish with PHPP. The aspect of mixing physicians with social scientists was one of the greatest challenges and one of the greatest rewards of the UCSF program. The program typically enrolled five postdoctoral fellows per year, drawing from a national pool of applicants to create a mix of medical and nonmedical doctorates. Physicians came primarily from preventive medicine and primary care specialties, with the PhDs typically drawn from among individuals with social science backgrounds. The Pew program at UCSF also took advantage of the opportunity of bringing together clinicians and PhDs already committed to health policy and health services research with physicians completing their clinical fellowship. Integrating these two groups served a dual purpose. The Pew fellows' experiences were further enriched by exposure to other key players in the health policy world, and the purely clinical fellows' experience was broadened and enriched with policy-relevant training. Hal Luft discussed this unique interaction: The clinicians attend the Pew seminars, get involved with a faculty member's research project, and are basically integrated into the fellowship program, although paid by someone else. These are people who might have otherwise been doing bench research on pulmonary function. They are now doing work on risk adjustment models and health care costs of AIDS, etc., exactly the kinds of things Pew fellows do. This kind of cross-fertilization of individuals who had worked in the policy arena and other health care professionals is what the Pew Charitable Trusts hoped to accomplish with PHPP. Collaboration and communication between various players in the health policy arena can lead to more effective and appropriate policies. Carroll Estes considered the aspect of mixing physicians with social scientists as one of the greatest challenges and one of the greatest rewards of the UCSF program. The commitment of UCSF faculty has been maintained throughout the program, and many fellows cited this as the greatest strength of the UCSF program. Fellows were pleased that the faculty had top-level policy influence and real-world perspectives, were committed to teaching and being supportive, and treated the fellows as peers (Richard-

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The Lessons and The Legacy of the Pew Health Policy Program son, 1990). Hal Luft and Carroll Estes both underscored this sentiment, stating that most of the faculty treated and truly believed that the fellows were more like colleagues than students. Outside evaluators cited UCSF's research and policy environment as a "tremendous" strength of the program. Richardson (1990) stated that all faculty were intricately involved in a range of activities at the local, state, and national levels, including high-priority areas such as AIDS policy, physician reimbursement, and policies related to aging. The UCSF program believed that its goal was not merely to train competent researchers and practitioners but to ensure that graduates be effective and relevant participants in the health policy process. The UCSF program believed that its goal was not merely to train competent researchers and practitioners but to ensure that graduates be effective and relevant participants in the health policy process, and so it considered supervised field placements in public-and private-sector organizations a valuable "learning-by-doing" part of the fellowship program, especially for midcareer fellows (UCSF Annual Report, 1992). Mark Legnini, a postdoctoral alumnus, recalled the benefits of the learning-by-doing educational model: [The most innovative aspect of the Pew program is] the emphasis on networking and getting involved in the politics and the art of doing things rather than just plugging people into existing research projects and making sure they have a job. For alumna Lisa Bero, the field placements were a vital part of her training and posttraining placement: [The program] positioned me for doing a lot of international work. I had my first contact with the World Health Organization while I was a Pew fellow. That rocketed me into doing international health policy work which was great. I got a real jump start on that through the fellowship. Early on the lack of physical space for fellows was a problem and precluded some valuable interaction between faculty and fellows and among fellows. Close proximity to peers and mentors, a seemingly simple logistical issue, is one of the strongest integrative and bonding forces. Hal Luft describes the situation at UCSF: In general, one of the biggest challenges early on was space. When we were located in our old site, on the main campus, there wasn't even enough room for faculty. So there was no Place for the postdocs. They were banging out in weird and bizarre places. They were often off site in office space that had been provided, but this hindered interaction. When we moved 5 years ago, we provided real office space for all the fellows as part of the unit. They were integrated with the faculty, with the unit. [It] works a lot better.

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The Lessons and The Legacy of the Pew Health Policy Program Whereas an appropriate core curriculum is necessary, a health policy training program must also be flexible enough to allow it to adapt to the unique needs of individual follows. Like fellows from the other program sites, the UCSF postdoctoral fellows discussed at length the tension between depth and breadth. However, unlike the RAND fellows, at UCSF the feeling was that depth was often sacrificed for breadth (Richardson, 1990). Fellows also cited the lack of structure and guidance in establishing fellow-mentor relationships early in the program, although this situation was said to improve over time. As the program evolved, the fellow-mentor relationships and career planning services became more formalized (see Appendix C for specifics on the Fellow-Mentor Relationship Guidelines at UCSF). UCSF program directors concluded that the optimal amount of structure depends on the needs of individual fellows. Whereas an appropriate core curriculum is necessary, a health policy training program must also be flexible enough to allow it to adapt to the unique needs of individual fellows (UCSF Annual Report, 1992). In a multidisciplinary program such as the PHPP, where fellows come into the program with many different perspectives and experiences, faculty really need to have the capacity and commitment to cater to each fellow. Lisa Bero stated that the UCSF faculty mastered this approach, and she cited this ability as one of UCSF's greatest strengths: The most unique aspect [of the UCSF program] was that it was very tailored to the individual fellow. Every fellow came into the program with different experiences. We had some core courses, but most were tailored to the individual and the faculty spent a lot of time talking to each fellow to find out what specifically were our needs at the beginning. It was a needs assessment. We were asked: where do you want to go? And what do you need to do that? And then efforts were made to give the fellows what they needed to get where they wanted to be. This individual attention was by far the strongest point. Boston University/Brandeis University Raskin and colleagues (1992) discuss the BU/Brandeis program's greatest challenge: the idea of a 2-year accelerated doctoral program. This concept was new to Brandeis and Boston universities, and required a different pedagogical approach. Some of the faculty believed that the best way to produce good policy makers in health policy was to get researchers to learn skills quickly and get them ''out there" doing policy research. Many believed that candidates with a master's degree could attain the necessary research skills that could be used on an applied research dissertation within a 2-

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The Lessons and The Legacy of the Pew Health Policy Program to 3-year period. Stan Wallack discussed the way that the Heller School at Brandeis University approached the 2-year curriculum challenge: [One] thing that was key in terms of our 2-year curriculum and our very high success rate was the focus on problem solving and learning how to get to an answer. The seminar led by Jon Chilingerian was very critical in getting people to work together and to see studies of successes. How does someone who is in political science move ahead on an entire project and complete it? How does an economist go ahead and do it? Our educational process or approach was pragmatic, using the procedures as any business or person would adopt in solving a problem. Being exposed to this process from the beginning of the program to the end is very important. It is very difficult but very important for students to see at the outset how they get from where they are starting to the end. This road map became a backdrop for students, one they could put hooks into as they moved along. For those students who were very focused and self-directed, the 2-year time frame was found to be manageable. Jonathan Howland, in the unique position of having been a Pew fellow at BU and then subsequently a program director, reflected on his doctoral experience and how the time pressures worked to his benefit: I thought it was great that we could essentially design our own curriculum and decide what tools we wanted to get. One of the reasons I thought that was so great was that the program enabled me to study epidemiology, which is what I wanted to do, and I was free from taking a whole lot of required courses and able to pursue the courses that were really of interest to me. That was really nice. The other thing that was really nice was that I was able to ... [do] my course work and dissertation at the same time. There are very few programs that would have allowed me to do that. It was a fast-track program. Jonathan Howland and Steve Crane discussed not only the benefits of a fast-track, flexible program but also the potentially negative aspects. For instance, people fall through the cracks and get their doctorate without having acquired the necessary tools. The lack of structure associated with the BU program worked for some but not for others, which meant that students needed to be self-motivated. For those students who did not identify a dissertation topic early on in the process and preferred to be exposed to broad social policy perspectives, it was very difficult for them to complete the requirements in the 2-year time frame. Steve Crane explained how determining program structure was a learning experience for the program directors as well as the fellows:

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The Lessons and The Legacy of the Pew Health Policy Program The [BU] program wasn't as assertive with the students in saying you must take this and this. We weren't sure what the "musts" should be. As we went along in the program and we saw what students did, we saw then what we needed to do and towards the end we probably had a much better sense of what we needed to do in terms of requirements than we had in the beginning. Jonathan Howland recommends that future fast-track, loosely structured programs develop some sort of mechanism to ensure that people get the necessary skills without taking away all sense of control. A minimum skill set requirement was one example that he offered. This issue will be addressed further later in this report. Another issue found to have a substantial impact on the completion rate was the lack of funding for the third year. This meant that the fellows had to secure other sources of funding for the additional time required to complete the dissertation. When funding ceased, many students had to take jobs, which distracted them from their dissertation work. A Brandeis survey found that many students complained that after the 2 years they were no longer linked with the program and felt isolated. Following the 2-year funding period, students would have liked to have been able to keep in touch with faculty and other students for dissertation support. The greatest strength reported by the Brandeis fellows was the support of the well-known and highly respected faculty. Raskin and colleagues (1992) found that some students saw the Pew program as creating rigidity in the pacing of the curriculum. Since the Pew fellows were expected to complete their dissertations within 2 years, they were forced to think about their proposals prior to the Qualifying Examination, which is administered in January of the second year. The delay of the Qualifying Examinations until students had been in residence for a year and a half was viewed as a significant hurdle by the Pew fellows. Their schedule required them to assemble a dissertation committee early on in the process and conduct a literature review prior to taking the exams. This fast track obligated students to make decisions about how they used their time. They often missed the special seminars and colloquiums offered at the school and felt disconnected from some excellent learning opportunities at the Heller School. In addition, networking with other students, a valuable resource, was limited. Boston University faculty and fellows alike cited the involvement and dedication of several faculty and program directors as a major strength of the program. Steve Crane described how several key people, Diana Chapman Walsh, Sol Levine, and Dick Egdahl, worked to build and define the BU Pew Health Policy Fellowship Program. The whole BU

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The Lessons and The Legacy of the Pew Health Policy Program program was modeled on Diana Chapman Walsh's program in the University Professors Program (UPP), where she ultimately became a mentor. According to Steve Crane, "UPP was the educational home for the BU Pew Doctoral Program, and Diana was the intellectual inspiration." Sol Levine was the academic director at BU and a leading national expert on medical sociology. He was the faculty member who bridged the gap between students, UPP, and BU. Steve stated that it was Sol who "made it happen at the academic level" by focusing on the importance of change and emphasizing values, policy, and "the quest to do what was right and good. Sol was always there for the students at BU and Brandeis, and they loved him." Debbie Ward, a BU alumna, reflected upon her memories of Diana Chapman Walsh and Sol Levine: Diana Walsh constructed several important bridges at the Health Policy Institute at BU. One was to the business community, where she had done extensive work and where her understanding of business imperatives was quite a bit more sophisticated than that of we run-of-the-mill capitalist scorners. The second bridge built by Diana was specifically for the women in the program. Diana had a feminist care which exhibited itself in her humor as well as her intellectual and personal pursuits. All the women at Pew in my day were grateful for that.... Sol Levine was a grand facilitator. He used his rolodex and his prodigious memory to send us to the vast resources of Boston and beyond. In my case, he sent me to the great urban historian, Sam Bass Warner and to Mike Miller whose course in sociology of poverty led me to the text I still have students use: Beeghley's Living Poorly in America. Sol made us remember that we were in a great university setting, not only budding policy wonks ("Wonk," as I recall it, was not a word in use during my Pew days). At Brandeis, fellows are trained too focus on critiquing understanding, and finding solutions to problems through integrated problem-solving techniques. Similarly, the greatest strength reported by-the Brandeis fellows in Richardson's 1990 evaluation and during the interviews was the support of the well-known and highly respected faculty. The Institute for Health Policy was in a unique position as a leading health care and research center; thus, key faculty and research staff were available to assist Pew doctoral students in the pursuit of their PhDs (Raskin et al., 1992). The multidisciplinary training approach was another strength of the Brandeis program cited by alumni. Health policy issues are often approached from several different paradigms: economics, political science, and sociology. At Brandeis, on the other hand, fellows are trained to focus on critiquing, understanding, and finding solutions to problems through integrated problem-solving techniques. The multi-

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The Lessons and The Legacy of the Pew Health Policy Program disciplinary approach was not unique to Brandeis; rather, it was a cornerstone of the PHPP vision. Approaching health policy from a variety of disciplines brings about a deeper understanding of the related issues and consequences of policy. This style of advanced graduate training is relatively unique and will be discussed further later in this report. COMMON THEMES The programs were applicable to the real world and the research and work projects were focused on current health care issues and problems. The strengths and weaknesses discussed above in no way encompass an exhaustive list. Rather, those issues highlighted above were those mentioned most often during the interviews. However, several common themes emerged from the interviews, themes that transcended the different program structures. First, most fellows and faculty emphasized the importance of having a strong, well-known, committed faculty. As will be discussed later in the report, excellent faculty may be one of the greatest recruitment tools that a university can employ. Even beyond that, however, the use of a strong and dedicated teaching faculty with one foot in the world of academia and research and the other foot in the world of health policy making and development is the best way a university can ensure a successful program and produce future leaders. The Pew programs were able to offer as faculty leaders in the field of health policy. A second common theme that emerged from the interviews is the "reality focus" of the Pew programs. Almost all of the fellows commented on how the programs were applicable to the real world and how the research and work projects were focused on current health care issues and problems. All of the programs except the Michigan program, whose fellows were already engaged in full-time employment in the health field, required their fellows to become involved with ongoing research projects either internally or outside the university. Many of these work projects or internships led to publications or job placements for the fellows. For the Michigan fellows and the RAND midcareer fellows, the educational experience was easily translated into immediate on-the-job applications. This feature of PHPP situated the programs in a class by themselves, and the fellows and faculty considered this feature a great strength. The multidisciplinary nature of the PHPP curricula will be discussed in Part II, however, it should be noted that every person interviewed emphasized that this aspect of the Pew program was one of its greatest strengths. Incorporating many disciplines and perspectives into health policy cur-

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The Lessons and The Legacy of the Pew Health Policy Program There is a strong consensus that the multidisciplinary approach remains the most effective way to train health policy professionals. ricula acknowledges that health care problems are not unidimensional and that effective change cannot be achieved without a thorough understanding of the multiple aspects of a given issue. The Pew Health Policy Program trained fellows to view health care problems through many different lenses. The ultimate strength of PHPP can thus be described as a training approach that gave future health policy leaders the ability to understand and speak fluently in the many languages of health policy development. Although the PHPPs had common strengths, no weaknesses were common to all programs. There was frequent discussion about the tension between breadth and depth inherent in a multidisciplinary curriculum; however, some programs focused more on giving the fellows a broad training in health policy, whereas other programs zeroed in on certain perspectives or disciplines and rarely looked at the big picture. In both cases, fellows and faculty mentioned the gaps and weaknesses in the approach. Nonetheless, there was a strong consensus that the multidisciplinary approach remains the most effective way to train health policy professionals.